ECMO Group Research Articles

The Impact of Venoarterial and Venovenous Extracorporeal Membrane Oxygenation on Cerebral Metabolism in the Newborn Brain.

BackgroundExtracorporeal membrane oxygenation (ECMO) is an effective therapy for supporting infants with reversible cardiopulmonary failure. Still, survivors are at risk for long-term neurodevelopmental impairments, the cause of which is not fully understood.ObjectiveTo elucidate the effects of ECMO on the newborn brain. We hypothesized that the cerebral metabolic profile of neonates who received ECMO would differ from neonates who did not receive ECMO. To address this, we used magnetic resonance spectroscopy (1H-MRS) to investigate the effects of venoarterial and venovenous ECMO on cerebral metabolism.Methods41 neonates treated with ECMO were contrasted to 38 age-matched neonates.ResultsAll 1H-MRS data were acquired from standardized grey matter and white matter regions of interest using a short-echo (TE = 35 milliseconds), point-resolved spectroscopy sequence (PRESS) and quantitated using LCModel. Metabolite concentrations (mmol/kg) were compared across groups using multivariate analysis of covariance. Elevated creatine (p = 0.002) and choline (p = 0.005) concentrations were observed in the grey matter among neonates treated with ECMO relative to the reference group. Likewise, choline concentrations were elevated in the white matter (p = 0.003) while glutamate was reduced (p = 0.03). Contrasts between ECMO groups revealed lower osmolite concentrations (e.g. myoinositol) among the venovenous ECMO group.ConclusionNeonates who underwent ECMO were found to have an abnormal cerebral metabolic profile, with the pattern of abnormalities suggestive of an underlying inflammatory process. Additionally, neonates who underwent venovenous ECMO had low cerebral osmolite concentrations as seen in vasogenic edema.

Effects of Additional Intra-aortic Balloon Counter-Pulsation Therapy to Cardiogenic Shock Patients Supported by Extra-corporeal Membranous Oxygenation.

Extra-corporeal membranous oxygenation (ECMO) has been applied in patients with cardiopulmonary failure. One critical drawback of peripheral ECMO is an increase in left ventricular (LV) afterload which could be counterbalanced by the combination of intra-aortic balloon counter-pulsation (IABP) therapy. We hypothesized that an add-on therapy with IABP could improve outcomes in patients receiving ECMO support. We included patients (>18 years old) from 2002 to 2013 requiring ECMO support due to cardiogenic shock in a medical center. A total of 529 patients (227 ECMO alone and 302 combined IABP plus ECMO) were included. The mortality rates at 2 weeks (48.5 vs. 47.7%) after ECMO implantation were not different between the two groups (ECMO vs. combined group). After adjustment for propensity score and potential confounders, the odds ratios of outcomes within 14 days (combined group vs. ECMO) for poor LV systolic function, high preload, multi-organ failure and mortality were not different. The results remained similar for subgroup analysis. Compared with ECMO alone, combined IABP and ECMO treatment did not improve outcomes in patients with circulatory failure.

Acupressure for post-operative nausea and vomiting: A pilot randomised controlled trial

Results: Four RCTs have been conducted in patients with acute lung failure; all of which concluded with no difference in all-cause mortality. One trial reported higher survival in the ECMO group at 6 months post-intervention. Medical and technological advancements around the year 2000 introduced clinical heterogeneity that prevented meta-analyses of the four RCTs. There were no completed RCTs in cardiac failure or cardiac arrest. We found two RCTs recruiting patients with cardiac arrest and two RCTs recruiting patients with acute lung failure. Conclusion(s): ECMOuse in patientswith acute respiratory failure remains inconclusive. ECMO use in cardiac failure or arrest is a new area with no completed RCTs available. We recommend matching and combining of ongoing RCTs with RCTs conducted after the year 2000.

Extracorporeal membrane oxygenation for critically ill adults.

Extracorporeal membrane oxygenation (ECMO) is a form of life support that targets the heart and lungs. Extracorporeal membrane oxygenation for severe respiratory failure accesses and returns blood from the venous system and provides non-pulmonary gas exchange. Extracorporeal membrane oxygenation for severe cardiac failure or for refractory cardiac arrest (extracorporeal cardiopulmonary resuscitation (ECPR)) provides gas exchange and systemic circulation. The configuration of ECMO is variable, and several pump-driven and pump-free systems are in use. Use of ECMO is associated with several risks. Patient-related adverse events include haemorrhage or extremity ischaemia; circuit-related adverse effects may include pump failure, oxygenator failure and thrombus formation. Use of ECMO in newborns and infants is well established, yet its clinical effectiveness in adults remains uncertain. The primary objective of this systematic review was to determine whether use of veno-venous (VV) or venous-arterial (VA) ECMO in adults is more effective in improving survival compared with conventional respiratory and cardiac support. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid) and EMBASE (Ovid) on 18 August 2014. We searched conference proceedings, meeting abstracts, reference lists of retrieved articles and databases of ongoing trials and contacted experts in the field. We imposed no restrictions on language or location of publications. We included randomized controlled trials (RCTs), quasi-RCTs and cluster-RCTs that compared adult ECMO versus conventional support. Two review authors independently screened the titles and abstracts of all retrieved citations against the inclusion criteria. We independently reviewed full-text copies of studies that met the inclusion criteria. We entered all data extracted from the included studies into Review Manager. Two review authors independently performed risk of bias assessment. All included studies were appraised with respect to random sequence generation, concealment of allocation, blinding of outcome assessment, incomplete outcome data, selective reporting and other bias. We included four RCTs that randomly assigned 389 participants with acute respiratory failure. Risk of bias was low in three RCTs and high in one RCT. We found no statistically significant differences in all-cause mortality at six months (two RCTs) or before six months (during 30 days of randomization in one trial and during hospital stay in another RCT). The quality of the evidence was low to moderate, and further research is very likely to impact our confidence in the estimate of effects because significant changes have been noted in ECMO applications and treatment modalities over study periods to the present.Two RCTs supplied data on disability. In one RCT survival was low in both groups but none of the survivors had limitations in their daily activities six months after discharge. The other RCT reported improved survival without severe disability in the intervention group (transfer to an ECMO centre ± ECMO) six months after study randomization but no statistically significant differences in health-related quality of life.In three RCTs, participants in the ECMO group received greater numbers of blood transfusions. One RCT recorded significantly more non-brain haemorrhage in the ECMO group. Another RCT reported two serious adverse events in the ECMO group, and another reported three adverse events in the ECMO group.Clinical heterogeneity between studies prevented meta-analyses across outcomes. We found no completed RCT that had investigated ECMO in the context of cardiac failure or arrest. We found one ongoing RCT that examined patients with acute respiratory failure and two ongoing RCTs that included patients with acute cardiac failure (arrest). Extracorporeal membrane oxygenation remains a rescue therapy. Since the year 2000, patient treatment and practice with ECMO have considerably changed as the result of research findings and technological advancements over time. Over the past four decades, only four RCTs have been published that compared the intervention versus conventional treatment at the time of the study. Clinical heterogeneity across these published studies prevented pooling of data for a meta-analysis.We recommend combining results of ongoing RCTs with results of trials conducted after the year 2000 if no significant shifts in technology or treatment occur. Until these new results become available, data on use of ECMO in patients with acute respiratory failure remain inconclusive. For patients with acute cardiac failure or arrest, outcomes of ongoing RCTs will assist clinicians in determining what role ECMO and ECPR can play in patient care.

Case report: the first case of laparoscopic ureteric re-implantation in a solitary urinary system

s / International Journal of Surgery 12 (2014) S13eS117 S21 patients can exhibit thoracic pathologies, which require surgical intervention. We evaluated the outcomes and complications of these thoracic procedures. Methods: Retrospective analysis of clinical variables for consecutive patients undergoing ECMO treatment during a 4 year period. Results: 70 patients underwent ECMO with an age range of 18-74 (median 54 years). 54.6% had at least one complication relating to ECMO.11 patients (15.7%) required thoracic surgical intervention whilst on ECMO, their duration of ECMO ranging 2-28 days (median 16 days). The mean ICU stay was 41.4 days (range 13-61 days). A total of 10 isolated intercostal chestdrains were inserted, with a bleeding rate of 10% (significant haemothorax). Three patients underwent thoracotomy/VATs for evacuation of empyema/haemothorax. Two of these 3 patients (66.7%) developed significant bleeding requiring re-exploration/ packing, however none died. In-hospital mortality in the 11 patients was 27.3%, similar to the total ECMO group (p1⁄40.28). Conclusions: A small but significant proportion of ECMO patients require thoracic surgical intervention, which carries the risk of major bleeding, especially with interventions such as thoracotomy/ VATs. However, in-hospital mortality rates are acceptable for this high-risk patient population, and are not related to thoracic surgical intervention.

Lessons learned from extracorporeal membrane oxygenation as a bridge to lung transplantation

Abstract Extracorporeal membrane oxygenation (ECMO) has been used infrequently as a bridge to lung transplantation due to lack of consensus and data regarding the benefits of such a strategy. We present data from the United Network of Organ Sharing (UNOS) database on the outcomes of patients bridged to lung transplantation with ECMO. We used the UNOS database to analyze data between January 1, 2000 and December 31, 2011. During this time 14,263 lung transplants were performed, of which 143 (1.0%) were bridged using ECMO. Patients on ECMO as a bridge to lung transplantation were compared to those transplanted without prior ECMO support. Demographics, survival rates, complications, and rejection episodes were compared between the two groups. The 30-day, 6-month, 1-year, 3-year, and 5-year survival rates were 69%, 56%, 48%, 26%, and 11%, respectively, for the ECMO bridge group and 95%, 88%, 81%, 58%, and 38% respectively, for the control group (p ≤ 0.01). The ECMO group incurred higher rate of postoperative complications, including airway dehiscence (4% vs. 1%, p ≤ 0.01), stroke (3% vs. 2%, p ≤ 0.01), infection (56% vs. 42%, p ≤ 0.01), and pulmonary embolism (10% vs. 0.6%, p ≤ 0.01). The length of hospital stay was longer for the ECMO group (41 vs. 25 days, p ≤ 0.01), and they were treated for rejection more often (49% vs. 36%, p = 0.02). The use of ECMO as a bridge to lung transplantation is associated with significantly worse survival and more frequent postoperative complications. Therefore, we advocate very careful patient selection and cautious use of ECMO.

(671) - Extracorporeal Membrane Oxygenator Bridge To Ventricular Assist Device Implantation for Patients in Profound Cardiogenic Shock Achieves Stabilization and Improved Results

In patients requiring left ventricular assist device (LVAD) support, acuity of presentation has been shown to be a predictor of outcomes. Those in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) 1 status demonstrating a mortality risk of 14% with an interval improvement in mortality of 17% with each successive INTERMACS level. (3) INTERMACS 1 status patients are difficult to stratify for viability of long-term support with LVAD and beyond. Even in the absence of contraindication to LVAD, institution of LVAD in a shocked patient is associated with high morbidity and mortality. In such situations, interest is growing in the utilisation of veno-arterial extracorporeal membrane oxygenator (VA-ECMO) as a bridge-to-bridge support for these critically unwell patients. We conducted a retrospective review of all consecutive patients implanted with LVAD at a single quaternary referral centre from January 2010 to June 2013. 53 patients presented requiring LVAD. All patients received third-generation devices. Of these, 48 were implanted as bridge-to-transplantation, 3 were implanted as destination therapy, and 1 as a bridge-to-decision. 36.5% (n=19) required urgent pre-VAD ECMO due to cardiogenic shock. There was 1 in hospital death in the ECMO group (1/19 [5.2%]) and 1 in the LVAD group not requiring ECMO (1/34 [2.9%]p=0.33). This is despite the ECMO group having a higher presenting APACHE 3 score (mean 66 +/- 11.533 vs. 52.485 +/- 6.103, p=0.021) and higher incidence in pre-operative haemofiltration (31.6% vs. 6.1%, p=0.0156) and ventilatory support (75% vs. 13.8%, p=0.0001). The incidence of RV failure was 46.2% (n=24, 12 per group). There were no differences between groups in bleeding, return to theatre, inotrope use, nitric oxide use or ventilator support. These results suggest that, despite presenting more acutely unwell, patients supported on VA-ECMO as bridge to longer term VAD support have outcomes which are comparable with those not requiring ECMO prior to LVAD. The ECMO bridge to LVAD support can stabilize high risk INTERMACS 1 status patients with an improved outcome after LVAD implantation compared to published outcomes in these ‘crash and burn’ patients.

(329) - The Prevalence of the Frailty Syndrome in Advanced Heart and Lung Failure

s S125 in the increased use of ECMO as a bridge to transplant to minimise waitlist mortality. There is limited data on the use of ECMO prior to LTx in paediatrics and physical outcomes are not well documented. This study aims to evaluate the short-term physical outcomes of pts bridged to LTx via ECMO. Methods: A retrospective analysis was performed of all paediatric pts at a tertiary hospital (n= 4, median age= 13) who underwent bilateral sequential lung transplant (BSLTx) following ECMO support. Indications for transplant included cystic fibrosis (n= 1), acute lung injury (1) and pulmonary vascular disease (2). All pts participated in a supervised, intensive outpatient (OP) exercise rehabilitation program for 1 hour, 3 times a week for 1-3 months. 6 minute walk test (6MWT) results were compared post rehabilitation to a paired cohort of 6 paediatric pts who underwent BSLTx without the need for ECMO pre LTx. Results: Survival at 3 months was 100% for both groups. All pts were female. ECMO support (VA n= 2, VV n= 2) was for a median of 18 days (range 2-35). Median time spent in OP rehabilitation for both groups was 72.5 days (ECMO range 37-80, control 42-77), p= 0.67. 6MWT results on discharge from OP rehabilitation tended to be higher in the ECMO group: median 520m (range 351-557) vs non-ECMO: median 476m (339-503), p= 0.13. All pts progressed to high level physical ability, denoted by jogging or running independently post rehabilitation. Conclusion: The use of ECMO as a bridge to LTx was not shown to be detrimental to short-term physical outcomes based on 6MWT distance. According to available literature, 5/10 pts (3 ECMO, 2 control) achieved a 6MWT distance within the range for healthy paediatrics. Future challenges will include the increasing use of ECMO, in particular, ambulatory circuitry, and the effect of this on short and long-term physical outcomes post paediatric LTx.

(326) - Is MFI Value a Solid Ground to Listing Unacceptable HLA Antigens

s S125 in the increased use of ECMO as a bridge to transplant to minimise waitlist mortality. There is limited data on the use of ECMO prior to LTx in paediatrics and physical outcomes are not well documented. This study aims to evaluate the short-term physical outcomes of pts bridged to LTx via ECMO. Methods: A retrospective analysis was performed of all paediatric pts at a tertiary hospital (n= 4, median age= 13) who underwent bilateral sequential lung transplant (BSLTx) following ECMO support. Indications for transplant included cystic fibrosis (n= 1), acute lung injury (1) and pulmonary vascular disease (2). All pts participated in a supervised, intensive outpatient (OP) exercise rehabilitation program for 1 hour, 3 times a week for 1-3 months. 6 minute walk test (6MWT) results were compared post rehabilitation to a paired cohort of 6 paediatric pts who underwent BSLTx without the need for ECMO pre LTx. Results: Survival at 3 months was 100% for both groups. All pts were female. ECMO support (VA n= 2, VV n= 2) was for a median of 18 days (range 2-35). Median time spent in OP rehabilitation for both groups was 72.5 days (ECMO range 37-80, control 42-77), p= 0.67. 6MWT results on discharge from OP rehabilitation tended to be higher in the ECMO group: median 520m (range 351-557) vs non-ECMO: median 476m (339-503), p= 0.13. All pts progressed to high level physical ability, denoted by jogging or running independently post rehabilitation. Conclusion: The use of ECMO as a bridge to LTx was not shown to be detrimental to short-term physical outcomes based on 6MWT distance. According to available literature, 5/10 pts (3 ECMO, 2 control) achieved a 6MWT distance within the range for healthy paediatrics. Future challenges will include the increasing use of ECMO, in particular, ambulatory circuitry, and the effect of this on short and long-term physical outcomes post paediatric LTx.

Board 330 - Research Abstract Simulation-Based Assessment of ECMO Clinical Specialists (Submission #442)

Introduction/Background Extracorporeal Membrane Oxygenation [ECMO] is a life-saving measure with significant risks of morbidity and mortality for critically ill patients in cardiac or pulmonary failure. Clinical specialists in the management of ECMO patients provide continuous bedside monitoring and are the first line of defense in recognizing and responding to acute and potentially catastrophic events. However, since such events are infrequent and unpredictable, an ECMO specialist with many years of experience may never have encountered one. The purpose of this study was to create simulated scenarios of critical events to enhance the training of ECMO specialists. A second goal was to assess their performance in recognizing and responding to the simulated events. The hypothesis was that more experienced individuals would outperform the less experienced. The simulations provided a hands-on, real-time approach to the challenging and complex nature of bedside ECMO emergencies. Methods Eight scenarios, designed to reflect acute events an ECMO specialist would be expected to manage included hyperventilation, air entrainment, ventricular tachycardia, hypovolemia causing venous occlusion, agitation with arterial occlusion, pneumothorax, bleeding and hemodilution. The scenarios were created and piloted by perfusionists, critical care physicians and the ECMO nurse coordinator. These scenarios represent events that have occurred while a patient was on ECMO support. Twenty five ECMO clinical specialists consented to participate in this IRB-approved study. The subjects were oriented to the manikin and the study format and participated individually. They had five minutes to complete each scenario and an in-depth debriefing was held at the Conclusion of the session. The sessions were captured on an audiovisual system. Two trained raters scored for completion of key actions and assessed a global score. Results All twenty five participants completed the scenarios. Thirteen (52%) had less than one year of experience on the ECMO team. The generalizability coefficients were moderate for both the checklist (0.41) and global scores (0.43). Large proportions of variance were attributable to the Person x Task (P x T) interaction, suggesting that performance in one scenario was poorly predicted by performance in another. Relatively little variance was attributable to the rater, or associated interactions, indicating the raters were reasonably consistent in the assignment of scores. The standardized inter-rater reliability coefficient were comparable for the checklist scores (r=0.72) and the global scores (r=0.70). For the ANOVA of both the checklist and global scoring, the group (experience) by scenario interaction was not significant indicating that any performance differences between ECMO groups were reasonably consistent across scenarios. There was a main effect attributable to group by checklist (F=4.3, p<0.05) and global score (F=8.4, p<0.015) indicating that the more experienced ECMO group outperformed the less experienced group. Participants with >1 year experience (mean=77.5, SD=17.9) outperformed those with <=1 year experience (mean=73.1, SD=14.1) by checklist scoring as well as in their global score [>1 year: (mean=7.2, SD=1.5) versus <=1 year: (mean=6.6, SD=1.4)]. There was also a main effect attributable to scenario based on checklist scores (F=6.9, p<0.01), as well as the global rating (F=4.1, p<0.01) indicating that the scenarios were not of equal difficulty. Conclusion ECMO simulation scenarios were created for acute skills training and evaluation of ECMO clinical specialists. Regarding reliability, the study revealed a great deal of task specificity, which is not unexpected with a heterogeneous group of tasks to be accomplished. Construct validity was supported by the experienced specialists outperforming the less experienced. It was also supported by participant feedback following the sessions. In their evaluations, the participants felt that the simulation scenarios were realistic, represented events that could occur in practice and were appropriate for training. These preliminary data support the simulation of ECMO critical events for training and evaluation of clinical specialists.

A multicenter study of primary graft failure after infant heart transplantation: Impact of extracorporeal membrane oxygenation on outcomes

Primary graft failure is the major cause of mortality in infant HTx. The aim of this study was to characterize the indication and outcomes of infants requiring ECMO support due to primary graft failure after HTx. We performed a retrospective review of all infants (<1 yr) who underwent Htx from three institutions. From 1999 to 2008, 92 infants (<1 yr) received Htx. Sixteen children (17%) required ECMO after Htx due to low cardiac output syndrome. Eleven (69%) infants were successfully weaned off ECMO, and 9 (56%) infants were discharged with a mean follow-up of 2.3 ± 2.5 yr. Mean duration of ECMO in survivors was 5.4 days (2-7 days) compared with eight days (2-10 days) in non-survivors (p = NS). The five-yr survival rate for all patients was 75%; however, the five-yr survival rate was 40% in the ECMO cohort vs. 80% in the non-ECMO cohort (p = 0.0001). Graft function within one month post-Htx was similar and normal between ECMO and non-ECMO groups (shortening fraction = 42 ± 3 vs. 40 ± 2, p = NS). For infants, ECMO support for primary graft failure had a lower short-term and long-term survival rate vs. non-ECMO patients. Duration of ECMO did not adversely impact graft function and is an acceptable therapy for infants after HTx for low cardiac output syndrome.

First 24-h SNAP-II score and highest PaCO2 predict the need for ECMO in congenital diaphragmatic hernia

Background/PurposeEarly clinical predictors for the use of ECMO in patients with congenital diaphragmatic hernia (CDH) are lacking. We sought to evaluate the first 24-h SNAP-II score and highest PaCO2 as predictors of ECMO support and in-hospital mortality in neonates with CDH. MethodsRetrospective review of 47 consecutive neonates with CDH admitted to our institution from January 2007 to December 2010 was performed. Covariates of ECMO use including SNAP-II score and highest PaCO2 within the first 24 h of NICU admission were evaluated. ResultsOf the 47 infants in this study, 24 patients were supported with ECMO. The ECMO group had a higher incidence of pulmonary hypertension, higher PaCO2, and higher 24-h SNAP-II scores. Only the SNAP-II score and not highest PaCO2 predicted mortality following multivariate adjustment. ConclusionsThe first 24-h SNAP-II score and highest PaCO2 may provide some prognostic value in identifying neonates who undergo ECMO support; however neither measure was independently associated with the use of therapy. Only the SNAP-II score was associated with in-hospital mortality following multivariate adjustment. Additional study is needed to validate these results in a larger data set.

The Effect of Extremity Vascular Complications on the Outcomes of Cardiac Support Device Recipients

To assess the effect of extremity vascular complications (EVC; including ischemia and vessel trauma) on the outcomes of patients receiving cardiac support devices (CSD; including ventricular assist device [VAD] and extracorporeal membrane oxygenation [ECMO]). Institutional review board-approved, retrospective review of a prospectively maintained database of all temporary and permanent CSD recipients from 7/1/10 to 6/30/12. Patient demographics, procedural data, and outcomes were analyzed. The primary endpoint was all-cause mortality at 30 days post-CSD initiation. Of 208 patients who received CSDs, 31 (14.9%) experienced EVC: 13 (8.9%) of the 146 permanent VADs, 10 (26.3%) of the 38 temporary VADs, and eight (33.3%) of the 24 ECMO patients. The 30-day mortality was significantly higher for temporary VAD patients who experienced EVC versus those that did not (80.0% vs 35.7%; P = .03). However, 30-day mortality was not significantly impacted by EVC in the permanent VAD (15.4% EVC vs 4.5% without EVC; P = .15) and ECMO patients (50.0% vs 68.75%; P = 1.00). Preinitiation peripheral arterial disease and cardiogenic shock did not significantly differ between the CSD groups. Outcomes for CSD subgroups following the occurrence of EVC are shown in Table. In temporary VAD recipients, the development of extremity vascular complications results in higher 30-day mortality and more frequent withdrawal of care. In contrast, extremity vascular complications in the permanent VAD and ECMO groups did not significantly impact mortality or withdrawal of care. This prognostic data may be useful in the management of these challenging patients.TableOutcomes for 31 cardiac support device (CSD) recipients who experienced extremity vascular complications (EVC)Permanent VADTemporary VADECMOCSD recipients experiencing EVC13108OutcomesAny vascular procedure, n (%)7 (53.9%)9 (90.0%)6 (75.0%)Revascularization, n (%)5 (38.5%)4 (40.0%)2 (25.0%)Amputation, n (%)0 (0.0%)1 (10.0%)1 (12.5%)Withdrawal of care, n (%)3 (23.1%)8 (80.0%)4 (50.0%)Time to death after EVC, days (± SEM)60.14 ± 21.4815.38 ± 2.3415.20 ± 7.2130-day mortality after EVC, n (%)2 (15.4%)8 (80.0%)4 (50.0%)ECMO, Extracorporeal membrane oxygenation; SEM, standard error of the mean; VAD, ventricular assist device. Open table in a new tab

Effect of venovenous extracorporeal membrane oxygenation on the heart in a healthy piglet model

BackgroundCardiac function is important for patients treated by venovenous extracorporeal membrane oxygenation (VV ECMO), but data about the effect of VV ECMO on the heart in nonneonates is absent. We studied the effect of VV ECMO on cardiac performance, cardiomyocyte and mitochondria in an animal model.MethodsTwelve farm piglets were randomly assigned into two groups: control group and ECMO group. In the ECMO group, ECMO cannulaes were placed and ECMO was instituted. Hemodynamics was recorded at baseline, 1 hour after induction, and every 4 hours thereafter, to assess the cardiac performance. All animals were monitored for 24 hours and were euthanized and myocardium was harvested. Myocardial histology, ultrastructure of cardiomyocyte and mitochondria were observed, and activities of mitochondrial complexes I-V were measured, to assess the effect to cardiomyocyte and mitochondria.ResultsHemodynamics were stable in each group of animals throughout the experiment. Interstitial edema, disorderd and dissolved of focal myofilament, morphological deformations of mitochondria were observed in the ECMO group. The activities of mitochondrial complexes were decreased in the ECMO group, and complex I and IV reached significance.ConclusionsVV ECMO therapy is associated with changes of ultrastructure and function of cardiomyocyte and mitochondria, inducing myocardium injury. However, the injury was mild and had no effect on the cardiac performance for healthy piglets.

Continuous Renal Replacement Therapy (CRRT) Attenuates Myocardial Inflammation and Mitochondrial Injury Induced by Venovenous Extracorporeal Membrane Oxygenation (VV ECMO) in a Healthy Piglet Model

In this study, we investigated the myocardial inflammation and mitochondrial function during venovenous extracorporeal membrane oxygenation (VV ECMO) and further evaluated the effects of continuous renal replacement therapy (CRRT) on them. Eighteen piglets were assigned to the control group, ECMO group, and ECMO+CRRT group. Myocardial inflammation was assessed by the activity of myeloperoxidase (MPO), myocardial concentrations, and mRNA expression of TNF-α, IL-1β, and IL-6; mitochondrial function was assessed by activities of mitochondrial complexes I-V. VV ECMO elicited a general activation of serum and myocardial inflammation and significantly decreased the activities of mitochondrial complexes I and IV. After being combined with CRRT, serum and myocardial concentrations of IL-1β and IL-6, myocardial mRNA expression of IL-6, and the activity of MPO were decreased significantly; the activities of mitochondrial complexes were increased. We conclude that myocardial inflammation was activated during ECMO therapy, inducing mitochondrial injury; moreover, CRRT reduced myocardial inflammation and partially ameliorated mitochondrial function.

Skin microvascular morphology and hemodynamics during treatment with veno-arterial extra-corporeal membrane oxygenation

To explore the potentials of microcirculatory assessments for predicting outcome of patients treated with extra corporeal membrane oxygenation for cardiogenic shock. Eight patients with acute cardiogenic shock treated with ECMO and eight healthy controls were examined with skin vital microscopy and laser Doppler perfusion measurements. Three patients died on ECMO (group 1). Five patients were successfully weaned off ECMO (group 2). Four patients were discharged from hospital and one died after successful weaning from bleeding complications. Patients surviving ECMO (group 2) had microcirculatory findings comparable with healthy controls. Patients in group 1 showed major skin microvascular pathology: pericapillary bleedings (n = 1), pericapillary dark haloes (n = 2) and capillary micro thrombi (n = 1). As compared with survivors they had lower functional capillary density (FCD) (n = 3), higher heterogeneity of functional capillary density (n = 3) and significantly reduced capillary mean flow-categorical velocity (n = 2). Laser Doppler measurements in group 1 had non-significant lower laser Doppler flux values as compared with survivors and controls. Skin microvascular pathology as detected with video microscopy (pericapillary bleedings or haloes, micro-thrombi/capillaries with "no flow", low FCD with high spatial distribution heterogeneity or low mean flow-categorial velocity) seems to be associated with poor prognosis.

818 ABO Blood Group Antigen Sensitization of Infants Exposed to Mechanical Circulatory Support (MCS)

formed via bilateral mini thoracotomies, the others via clamshell incisions. Size reduction of lung allografts was undertaken in 5 ECMO and 4 nonECMO cases, respectively. 5 patients were taken off ECMO intra-operatively; the other patients were weaned off ECMO within 48 hours post-operatively. 2 recipients experienced complications due to ECMO cannulation: a wound infection at the ECMO cannulation site and a compartment syndrome, both of which were treated successfully. 3-months survival was 100%. By 12 months post-transplantation, 1 patient in the ECMO group died due to multi-organ failure following initial primary graft dysfunction, and 1 patient in the nonECMO group died due to a fungal sepsis. Conclusions: Lung transplantation can be safely undertaken in children using ECMO. In experienced centers, the use of pre-transplantation ECMO may not generally be a survival disadvantage in children.

The Microcirculation Is Unchanged in Neonates with Severe Respiratory Failure after the Initiation of ECMO Treatment

Purpose. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is known to improve cardiorespiratory function and outcome in neonates with severe respiratory failure. We tested the hypothesis that VA-ECMO therapy improves the microcirculation in neonates with severe respiratory failure. Methods. This single-center prospective observational pilot study took place in an intensive care unit of a level III university children's hospital. Twenty-one-term neonates, who received VA-ECMO treatment, were included. The microcirculation was assessed in the buccal mucosa, using Orthogonal Polarization Spectral imaging, within 24 hours before (T1) and within the first 24 hours after initiation of ECMO treatment (T2). Data were compared to data of a ventilated control group (N = 7). Results. At baseline (T1), median functional capillary density (FCD), microvascular flow index (MFI), and heterogeneity index (HI) did not differ between the ECMO group and the control group. At T2 the median FCD was lower in the control group (median [range]: 2.4 [1.4–4.2] versus 4.3 [2.8–7.4] cm/cm2; P value <0.001). For MFI and HI there were no differences at T2 between the two groups. Conclusion. The perfusion of the microcirculation does not change after initiation of VA-ECMO treatment in neonates with severe respiratory failure.

Surgical Procedures for Patients Receiving Mechanical Cardiac Support

Mechanical cardiac support devices are used for patients with cardiopulmonary failure. We reviewed our institutional experience with noncardiac surgical procedures (NCPs) in patients supported by ventricular assist devices (VADs, n = 198) or extracorporeal membrane oxygenation (ECMO, n = 165) between July 1998 and June 2010. In total, 64 NCPs were performed in 55 VAD patients and 14 NCPs in 14 ECMO patients. Thirty-day mortality was higher for the VAD compared with the ECMO group (25 vs 86%; P < 0.001) and was greater for emergent compared with nonemergent procedures (58 vs 19%; P < 0.001). Excluding tracheostomy, no patients died within 30 days of a nonemergent procedure. Kaplan-Meier survival showed a trend toward worse survival after NCP in ECMO patients, but NCP did not alter survival in VAD patients. Fewer VAD patients were bridged to heart transplantation when NCP was required, and time from device implantation to transplant was significantly longer than for patients without NCP. In summary, this is the largest series of NCPs on VAD support and the only series on ECMO. Mortality is substantial for ECMO patients. Selected procedures can be performed safely in VAD patients but will delay heart transplantation.

Percutaneous Cannulation for Extracorporeal Life Support

Extracorporeal life-support systems are valuable tools to treat patients with acute cardiopulmonary failure in intensive care facilities, and are highly suitable for the interhospital transfer of critically ill patients to specialized centers. This article reviews the cannulation strategies and associated vascular complications in our institution. Between January 2004 and December 2009, 464 extracorporeal life-support systems were implanted via percutaneous cannulation at our institution. The type and incidence of adverse events related to the percutaneous access to femoral, subclavian vessels and the jugular vein were retrospectively analyzed. The primary focus was on bleeding and limb ischemia. 464 patients (340 male, 124 female) with isolated pulmonary or combined cardiopulmonary failure were connected to extracorporeal gas exchange systems. Most patients (n = 196) were connected to a PECLA system; 158 patients to a veno-arterial ECMO. Use of a veno-venous ECMO system was necessary in 110 cases. Thirty-two patients (6.9 %) suffered bleeding complications after cannula insertion, predominantly after PECLA placement (3.9 %). After implantation, limb ischemia developed in 15 cases (3.2 %), mostly in the veno-arterial ECMO group (n = 13). Demographic data and cannula size show no significant difference between patient groups with and without ischemic complications ( P = 0.57). A prophylactic fasciotomy was performed in the 15 cases with limb ischemia. Survival was independent of ischemic (leg) complications. With proper vessel visualization, exposure and cannulation, and accurate cannula placement, optimal flows and minimal complication rates can be achieved, rendering percutaneous extracorporeal life support a safe procedure.