ECMO Support Research Articles

ECMO in Cardiogenic Shock: Time Course of Blood Biomarkers and Associated Mortality.

Veno-arterial extracorporeal membrane oxygenation (va-ECMO) is a temporary life support for severe cardiogenic shock, gaining time for organ recovery, permanent assistance, or transplantation. In this work, we aimed to investigate the trends of blood biomarkers over the period of ECMO support and their role in patient outcome. This retrospective study comprised patients receiving va-ECMO support over the period of 14 years at a tertiary university center. Of 435 patients, 62% (268/435) survived to discharge, and the most frequent adverse event was hemorrhage (46%), followed by thrombosis (25%). Deceased patients had increased blood levels of C-reactive protein, procalcitonin, and white blood cells during the whole observation period, with higher peaks compared with survivors. The multivariable model identified hemorrhage (HR 1.73, p = 0.005) and higher levels of procalcitonin (HR 1.01, p = 0.001) as independent risk factors for death. In our population of critically ill patients receiving va-ECMO support, deceased patients had increased inflammatory biomarkers during the whole observation period. Patients having higher values of procalcitonin and experiencing bleeding events showed an increased risk for mortality. Further studies focusing on inflammation in ECMO patients, clarifying its role in patient outcome and potential therapeutic interventions, are warranted.

Outcomes of Pediatric Patients with Sepsis Managed on Extracorporeal Membrane Oxygenation: An Analysis of the Extracorporeal Life Support Organization Registry

AbstractExtracorporeal membrane oxygenation (ECMO) support is increasingly used for refractory septic shock. There is a lack of data on the outcomes of children requiring ECMO support for refractory septic shock. Our study objective was to describe the variables associated with survival, risk factors for mortality, and outcomes of children requiring ECMO support for refractory shock. This was retrospective registry study of 340 international centers contributing data to the ELSO Registry, analyzing children <18 years who received ECMO with septic shock, severe sepsis, sepsis, systemic inflammatory response syndrome, toxic shock syndrome, shock associated with infection, and septicemia from any organism from 1990 to 2015. Outcomes were analyzed by categorizing the data into survivors and nonsurvivors. Logistic regression models were used to describe the association of dependent variable and multiple independent variables. A total of 1,928 patients were identified who met the inclusion criteria. In total, 744 (38.5%) of the cohort survived. Survivors in this cohort tend to have a longer duration of ECMO (230 vs. 201 hours, p = 0.005) and shorter time from intubation to ECMO cannulation (87 vs. 116 hours, p = 0.0033) when compared to nonsurvivors. Survivors were also noted to have higher pH, higher serum bicarbonate, higher saturations, and higher systolic, diastolic, and mean arterial pressures compared to nonsurvivors. These results suggest that early initiation of ECMO therapy for refractory sepsis is associated with better patient outcomes. ECMO is unlikely to recover patients once circulatory and metabolic collapse has developed.

Infections complicating extracorporeal membrane oxygenation in patients with traumatic injuries

IntroductionExtracorporeal Membrane Oxygenation (ECMO) has increasing utility in adult patients with traumatic injuries. There is currently limited data on the pathogens complicating a trauma patient's ECMO course, making empiric antibiotic decisions difficult. This study aims to characterize the types of infection among patients with traumatic injuries on ECMO. MethodsA chart review was performed on all trauma patients at Brooke Army Medical Center receiving ECMO between February 2013 and July 2021. Charts were reviewed to identify pathogens by culture site as well as time to infection following cannulation. ResultsTwenty-one trauma patients underwent ECMO during the study period. The majority of patients were men (90%) with a median age of 30 [IQR 27–38], and a median ECMO course of 9.8 days [IQR 3.9–14.1]. Motor vehicle crashes (81%) accounted for the majority of mechanisms of injury. Of the 24 infections, the majority were respiratory (n = 13, 58/1000 ECMO days) followed by skin and soft tissue (n = 6, 26/1000 ECMO days), blood stream (n = 4, 18/1000 ECMO days), and urinary tract (n = 1, 5/1000 ECMO days). Gram-negative bacteria were the most commonly isolated organism from all sites and at all time periods following cannulation. Multi-drug resistant organisms accounted for 35% (n = 9) of infections and were independent of time from cannulation. Discussion/ConclusionThis is the first study to describe infections in trauma patients requiring ECMO support. We observed majority Gram-negative infections regardless of culture site or time after cannulation. Thus, with infection in this population, empiric antibiotics should have broad spectrum coverage of Gram-negative organisms.

ECMO Support in Refractory Cardiogenic Shock: Risk Factors for Mortality.

Veno-arterial extracorporeal membrane oxygenation (va-ECMO) is a specialized temporary support for patients with refractory cardiogenic shock. The true value of this potentially lifesaving modality is still a subject of debate. Therefore, we aimed to investigate the overall in-hospital mortality and identify potential risk factors for mortality. We retrospectively analyzed the data of 453 patients supported with va-ECMO over a period of 14 years who were admitted to intensive care units of a tertiary university center in Austria. We observed in-hospital mortality of 40% for patients with refractory cardiogenic shock. Hemorrhage, ECMO initiation on weekends, higher SAPS III score, and sepsis were identified as significant risk factors for mortality. Hemorrhage was the most common adverse event (46%), with major bleeding events dominating in deceased patients. Thromboembolic events occurred in 25% of patients, followed by sepsis (18%). Although the rates of complications are substantial, a well-selected proportion of patients with refractory cardiogenic shock can be rescued from probable death. The reported risk factors could be used to increase the awareness of clinicians towards the development of new therapeutic concepts that may reduce their incidence.

Post-heart transplant outcomes according to age and ECMO support: implications for New Heart Allocation System in Korea

Post-heart transplant outcomes according to age and ECMO support: implications for New Heart Allocation System in Korea

Impact of Initial Operative Urgency on Short-Term Outcomes in Patients Treated with ECMO Due to Postcardiotomy Cardiogenic Shock.

The outcomes of patients with PCS and following ECMO therapy are associated with several preoperative risk factors. Our aim was to compare clinical presentation, ECMO-related data and in-hospital outcomes of patients treated with ECMO due to PCS after cardiac surgery, in regard to elective or emergent cardiac surgery procedures. Between April 2006 and October 2016, 164 consecutive patients that received VA-ECMO therapy due to PCS were identified and included in this retrospective cohort study. The patients were divided into groups based on the urgency of the initial procedures performed: elective group (ELG; n = 95) and an emergency group (EMG; n = 69). To compare the unequal patient groups, a propensity score-based matching (PSM) was applied (ELG, n = 56 vs. EMG, n = 56). The EMG primarily received ECMO intraoperatively (p ≤ 0.001). In contrast, the ELG were needed ECMO support more frequently postoperatively (p < 0.001). In-hospital mortality accounted for 71% (n = 40) in the ELG and 76% (n = 43) in the EMG (p = 0.518). Outcome data showed no major differences in the (abdominal ischemia (p = 0.371); septic shock (p = 0.393): rhythm disturbances (p = 0.575); emergency re-thoracotomy (p = 0.418)) between the groups. The urgency of the initial procedures performed is secondary in patients suffering PCS and following ECMO. In this regard, PCS itself seems to trigger outcomes in cardiac surgery ECMO patients substantially.

One hundred ECMO retrivals before and during the Covid-19 pandemic: an observational study

ObjectivesPatients with severe acute respiratory distress syndrome may require veno-venous extracorporeal membrane oxygenation (V-V ECMO) support. For patients in peripheral hospitals, retrieval by mobile ECMO teams and transport to high-volume centers is associated with improved outcomes, including the recent COVID-19 pandemic. To enable a safe transport of patients, a specialised ECMO-retrieval program needs to be implemented. However, there is insufficient evidence on how to safely and efficiently perform ECMO retrievals. We report single-centre data from out-of-centre initiations of VV-ECMO before and during the COVID-19 pandemic. Design & settingSingle-centre retrospective study. We include all the retrievals performed by our ECMO centre between January 1st, 2014, and April 30th, 2021. ResultsOne hundred ECMO missions were performed in the study period, for a median retrieval volume of 13 (IQR: 9–16) missions per year. the cause of the acute respiratory distress syndrome was COVID-19 in 10 patients (10 %). 98 (98 %) patients were retrieved and transported to our ECMO centre. To allow safe transport, 91 of them were cannulated on-site and transported on V-V ECMO. The remaining seven patients were centralised without ECMO, but they were all connected to V-V ECMO in the first 24 hours. No complications occurred during patient transport. The median duration of the ECMO mission was 7 hours (IQR: 6–9, range: 2 – 17). Median duration of ECMO support was 14 days (IQR: 9–24), whereas the ICU stay was 24 days (IQR:18–44). Overall, 73 patients were alive at hospital discharge (74 %). Survival rate was similar in non-COVID-19 and COVID-19 group (73 % vs 80 %, p = 0.549). ConclusionIn this single-centre experience, before and during COVID-19 era, retrieval and ground transportation of ECMO patients was feasible and was not associated with complications. Key factors of an ECMO retrieval program include a careful selection of the transport ambulance, training of a dedicated ECMO mobile team and preparation of specific checklists and standard operating procedures.

Lack of volume-outcome association in ECMO bridge to heart transplantation.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as a bridge to cardiac transplantation. As the 2018United Network for Organ Sharing(UNOS) heart allocation policy change elevated waitlist status for patients receiving mechanical circulatory support (MCS), we aimed to determine if a center's annual heart transplant volume was associated with ECMO-support duration and posttransplant outcomes. Adults heart transplant candidates between January 1, 2011, and December 31, 2021, were isolated in the UNOS database. VA-ECMO use was identified at the time of listing for transplant. Average annual transplant volume was calculated by the center, with stratification as high (≥20 cardiac transplants, high volume center [HVC]) or low (<20 cardiac transplants, low volume center [LVC]) volume centers. Results are reported as mean(interquartile range) or n(%). In total, 543 patients at HVCs and 275 at LVCs were listed for transplant supported with VA-ECMO. Those listed at HVCs were more likely to be supported by intra-aortic balloon pump (103[19%] vs. 32[11.6%], p = .008) and inotropes (267[49.2%] vs. 106[38.5%], p = .004) at time of listing. Patients at HVCs received ECMO support for 6[4-9] days, compared to 8[4-15] days at low-volume centers (p = .030), and but were cannulated a similar time before listing (2[1-5] vs. 3[1-7] days, p = .517). There were no differences in rates of transplant (p = .2126), waitlist mortality (p = .8645), delisting due to clinical deterioration (p = .8419), or recovery (p = .1773) between groups. Among transplanted patients, there were no differences in support duration (6[4-8] vs. 6[4-10], p = .187), or time from registration to transplant (5[2-20] vs. 7[3-22] days, p = .560). Posttransplant survival did not vary (p = .293). LVCs can successfully bridge patients to transplant with VA-ECMO and achieve comparable outcomes to HVCs.

Abstract 9777: Percutaneous Ambulatory Biventricular Support With Protekduo and Impella: A Community Hospital Experience

Introduction: With the advent of percutaneous MCS devices, like the Abiomed ® Impella TM LVAD and Livanova ® ProtekDuo TM RVAD, patients with biventricular failure necessitating ECLS can be transitioned to a fully ambulatory femoral-free BIVAD configuration. Case: A 60-year-old man presented with atrial fibrillation. He underwent TTE revealing EF &lt;20%. After cardiac cath ruled out ischemic cause, he underwent TEE with plan for cardioversion. Upon induction, he suffered a PEA arrest and VA- ECMO support promptly ensued, per ECLS protocol, with b/l femoral cannulation. An Impella TM CP LVAD was also inserted to provide unloading and further support. After 2-days with b/l groin ECMO cannulation with femoral percutaneous LVAD, the patient awoke, displaying adequate urine output and following of basic commands. Transition was made from femoro-femoral cannulation to percutaneous right-IJ ProtekDuo TM RVAD attached to a Quadrox-i ® oxygenator for ECMO support, along with transition of femoral Impella TM CP to a robust axillary Impella TM 5.5 LVAD (Figure). This configuration decannulated the groins, permitting the patient to work with physical therapy. Discussion: Transition to groin-free configuration with percutaneous BIVAD apparatus implementing the ProtekDuo TM RVAD with Impella TM 5.0/5.5 axillary LVAD has only been reported at a large cardiovascular institute in Germany. That case series highlighted how percutaneous ambulatory BIVAD allowed for rapid extubation, early mobilization, and minimal complications 1 . Herein, we demonstrated the first presumed community-hospital experience with this underreported mechanical circulatory support combination promoting a pathway to rehabilitation and eventual transplantation. Conclusion: This report showcases the feasibility of adapting percutaneous ambulatory BIVAD with a combined ProtekDuo TM /Impella TM groin-free apparatus in the community-hospital setting.

Abstract 10437: Venoarterial Extracorporeal Membrane Oxygenation Rescue Therapy in Vasoplegic Shock Due to Calcium Channel Blocker Overdose: 5 Year Single Center Experience

Introduction: Over 15,000 incidences of Calcium Channel Blocker (CCB) overdose were reported by the American Association of Position Control Centers (AAPCC) in 2020, resulting in 45 deaths from pure CCB overdose and 176 deaths from multidrug overdose involving CCBs. We present a single-center experience on the use of VA ECMO in the management of refractory hypotension due to CCB toxicity. Hypothesis: VA ECMO is effective and can be life-saving in vasoplegic shock from drug overdose Methods: We retrospectively reviewed our ECMO registry in the last 5 years to identify patients who were started on ECMO support for refractory hypotension due to drug overdose. Results: We found 5 patients who were started on VA-ECMO for drug overdose, all involving CCBs. Mean age was 60. They had persistent lactic acidosis and hypotension after fluid resuscitation, requiring escalating doses of vasopressors until they were on or near the maximum. All patients were started on hyperinsulinemia euglycemic protocol and 3 patients received methylene blue. The mean time to intubation was 11.2 ± 4.14 hours. An echocardiogram demonstrated intact systolic function in all patients. VA-ECMO was started within 11.2 ± 4.5 hours of admission. Pressor requirements quickly improved on ECMO support. Average time on ECMO was 69 ± 48.6 hours. 4 of 5 patients improved quickly and were extubated within 10 days (mean: 4.88 ± 2.95). In these 4 patients, the length of ICU stay was 8.5 ± 3.87 days, and hospital stay was 11.75 ± 2.06 days. One patient had a protracted course due to renal failure, pneumonia, and concern for North-South Syndrome. Cannulation was switched to subclavian/axillary approach, but that was complicated by left arm ischemia and switch to VV-ECMO after 44 hours of VA-ECMO. She was discharged after a 46-day hospital stay. Conclusions: VA-ECMO support is effective and lifesaving in patients with refractory shock from CCB toxicity. Early referral to ECMO capable center should be considered in these patients.

Textbook outcome in lung transplantation: Planned venoarterial extracorporeal membrane oxygenation versus off-pump support for patients without pulmonary hypertension.

Planned venoarterial extracorporeal membrane oxygenation (VA ECMO) is increasingly used during bilateral orthotopic lung transplantation (BOLT) and may be superior to off-pump support for patients without pulmonary hypertension. In this single-institution study, we compared rates of textbook outcome between BOLTs performed with planned VA ECMO or off-pump support for recipients with no or mild pulmonary hypertension. Patients with no or mild pulmonary hypertension who underwent isolated BOLT between 1/2017 and 2/2021 with planned off-pump or VA ECMO support were included. Textbook outcome was defined as freedom from intraoperative complication, 30-day reintervention, 30-day readmission, post-transplant length of stay >30 days, 90-day mortality, 30-day acute rejection, grade 3 primary graft dysfunction at 48 or 72 hours, post-transplant ECMO, tracheostomy within 7 days, inpatient dialysis, reintubation, and extubation >48 hours post-transplant. Textbook outcome achievement was compared between groups using multivariable logistic regression. Two hundred thirty-seven BOLTs were included: 68 planned VA ECMO and 169 planned off-pump. 14 (20.6%) planned VA ECMO and 27 (16.0%) planned off-pump patients achieved textbook outcome. After adjustment for prior BOLT, lung allocation score, ischemic time, and intraoperative transfusions, planned VA ECMO was associated with higher odds of textbook outcome than planned off-pump support (odds ratio 3.89, 95% confidence interval 1.58-9.90, p=0.004). At our institution, planned VA ECMO for isolated BOLT was associated with higher odds of textbook outcome than planned off-pump support among patients without pulmonary hypertension. Further investigation in a multi-institutional cohort is warranted to better elucidate the utility of this strategy.

Outcomes of Venovenous Extracorporeal Membrane Oxygenation in Viral Acute Respiratory Distress Syndrome.

Our study assessed the relationship between the duration of venovenous extracorporeal membrane oxygenation (V-V ECMO) and patient outcomes. We studied patients undergoing V-V ECMO support for acute respiratory distress syndrome (ARDS) between 2009 and 2017 who were reported to the Extracorporeal Life Support Organization registry. We evaluated survival, major bleeding, renal failure, pulmonary complications, mechanical complications, neurologic complications, infection, and duration of V-V ECMO support. Multivariable regression modeling assessed risk factors for adverse events. Of the 4,636 patients studied, the mean support duration was 12.2 ± 13.7 days. There was a progressive increase in survival after the initiation of V-VECMO, peaking at a survival rate of 73% at 10 days of support. However, a single-day increase in V-V ECMO duration was associated with increased bleeding events (odds ratio [OR] 1.038; 95% confidence interval [CI]: 1.029-1.047; p < 0.0001), renal failure (OR 1.018; 95% CI: 1.010-1.027; p < 0.0001), mechanical complications (OR 1.065; 95% CI: 1.053-1.076; p < 0.0001), pulmonary complications (OR 1.04; 95% CI: 1.03-1.05; p < 0.0001), and infection (OR 1.04; 95% CI: 1.03-1.05; p < 0.0001). V-V ECMO progressively increases survival for ARDS over the first 10 days of support. Thereafter, rising complications associated with prolonged durations of support result in a progressive decline in survival.

COVID-19 and seasonal influenza infection outcomes in the ICU: a retrospective comparison study.

To compare the characteristics and outcomes of critically ill patients admitted to the intensive care unit (ICU) due to COVID-19 or influenza- associated pneumonia. We conducted a two-center retrospective study on patients admitted to the ICU due to either COVID-19 associated pneumonia (CAP) or influenza-associated pneumonia (IAP). Baseline characteristics, therapy during hospitalization and clinical outcomes were assessed. Our study included 86 patients admitted to the ICU. Twenty-four patients (28%) had IAP and 62 patients (72%) had CAP. Those with IAP had more comorbidities of cardiac disease (p=0.005) and chronic obstructive lung disease (p=0.03) compared to those with CAP. Non-invasive ventilation was used significantly more in patients with IAP (p=0.001). The use of neuromuscular blockade was significantly higher in CAP patients (p=0.001). CAP patients had less favourable ventilation parameters. PEEP was significantly higher in those with CAP on the first day of admission (p=0.002). There was no difference in mortality (p=0.61) between the groups. Patients admission to the ICU with CAP had less comorbidity than those with IAP. Patients with CAP had poorer ventilatory parameters patterns, requiring more aggressive ventilation and ECMO support. The overall mortality did not differ significantly between the groups.

Two Birds, One Stone: Awake Extracorporeal Life Support.

Case A 55 year old female, no previous medical history, underwent out-of-hospital cardiac arrest. Advanced cardiac life support (ACLS) was initiated, with return of spontaneous circulation after 30’ of conventional resuscitation efforts. At first hospital arrival coronary angiography and successful percutaneous transluminal angioplasty were performed to treat right coronary artery stenosis. Incidentally, lung computed tomography (CT) revealed signs of aspiration pneumonia (Figure 1). Moreover, as a result of improper out-of-hospital endotracheal tube (ETT) positioning (ID 7.5/OD 10.7 mm) during ACLS, the patient suffered iatrogenic airway injury, as confirmed by bronchoscopy (12 x 19 mm respectively sagittal and longitudinal axis, Figures 1 and 2).Figure 1.: Tracheal injury (white arrow) and aspiration pneumonia at CT scan performed at hospital admission: distal end of the endotracheal tube in the main right bronchus (white arrow); retrocarinal pneumomediastinum (black arrow); evidence of basal consolidation in the left lung. CT, computed tomography.Figure 2.: Evolution of tracheal injury (white arrows) at fiberoptic bronchoscopy. A: day 1 large tear in the pars membranacea (posterior wall) of the trachea, extended to the emergence of the main right bronchus (white arrow), with hyperemic peripheral area; (B) day 7: partial re-epithelialization of the posterior wall, and decreased mucosal hyperemia; (C) day 24 evidence of resolution of the injury, with a residual linear scar. ECMO, extracorporeal membrane oxygenation; LMB, left main bronchus; RMB, right main bronchus.Pneumonia worsened rapidly to acute respiratory distress syndrome (ARDS) over subsequent days, and the presence of tracheal injury complicated mechanical ventilation management, so femoro-femoral veno-venous extracorporeal membrane oxygenation (V-V ECMO) was initiated in referring hospital (details in online supplement, Supplemental Digital Content 1, https://links.lww.com/ASAIO/A876). After cannulation the patient was transferred to referral center. For the first 2 days deep sedation and neuromuscular blockade were deemed necessary to provide lung protective ventilation (settings detailed in online supplement, Supplemental Digital Content 1, https://links.lww.com/ASAIO/A876). Due to the location of the distal end of the ETT cuff tube, the intracuff pressure was strictly monitored and maintained at 20 mm Hg. On minimal ECMO support gas exchange rapidly improved. To improve tracheal tear healing the patient was extubated on third day of ECMO, and high flow nasal oxygen (HFNO) initiated. After 8 days successful weaning trial was attempted, and decannulation performed. Follow up CTs demonstrated progressive resolution of lung disease and airway injury, with reabsorption of pneumodediastinum. Since ECMO weaning the patient remained eupneic; she was discharged home with almost complete lung recovery and intact tracheal wall (evolution of injury and clinical course are depicted in supplementary figures 1 and 2, Supplemental Digital Content 1, https://links.lww.com/ASAIO/A876). Full neurologic recovery was achieved, with no signs of physical impairment.

Effect of preoperative extracorporeal membrane oxygenation therapy on postventricular assist device outcomes: an analysis of the STS Pedimacs database.

Extracorporeal membrane oxygenation (ECMO) support prior to ventricular assist device (VAD) therapy is frequently used for stabilizing INTERMACS 1 and 2 paediatric patients. Data regarding outcomes with this strategy is limited. Patient characteristics and outcomes post-VAD therapy with and without preop ECMO support were compared. Survival and risk factor analysis was performed for all patients and INTERMACS profile 1 subgroup. Of 541 INTERMACS 1 and 2 patients enrolled in Paediatric Interagency Registry for Mechanical Circulatory Support registry, 391 received primary VAD implantation and ECMO prior to VAD therapy was utilized in 150 patients. Younger age (P < 0.0001) and shock (P < 0.0001) were more common in group 2, with lower survival at 1, 6 and 12 months compared to group 1 (P < 0.0001). Freedom from infection (P = 0.03) was higher in group 1. Freedom from stroke (P = 0.7) was similar. Paracorporeal continuous flow devices led to poor survival in both groups 1 and 2 (P = 0.4). Implantable continuous flow (P < 0.0001) and paracorporeal pulsatile devices (P = 0.007) had better survival in primary VAD group. INTERMACS profile 1, lower weight, hepatic dysfunction, renal failure, paracorporeal continuous and percutaneous devices were associated with higher mortality. Preop ECMO therapy was not associated with higher mortality (P = 0.12). Survival of INTERMACS profile 1 patient was similar at 1, 6 and 12 months in both groups (P = 0.1). INTERMACS profile 1, lower weight, hepatic dysfunction, renal failure and use of paracorporeal continuous flow or percutaneous assist devices are associated with a higher postoperative mortality. Preop ECMO therapy however is not independently associated with higher postop mortality.

Prolonged Noninvasive Respiratory Support Before Intubation Is Associated With Increased Duration of Extracorporeal Membrane Oxygenation.

Prolonged Noninvasive Respiratory Support Before Intubation Is Associated With Increased Duration of Extracorporeal Membrane Oxygenation.

Use of CytoSorb© Hemoadsorption in Patients on Veno-Venous ECMO Support for Severe Acute Respiratory Distress Syndrome: A Systematic Review.

Acute respiratory distress syndrome (ARDS) is associated with high morbidity and mortality. Adjunct hemoadsorption is increasingly utilized to target underlying hyperinflammation derived from ARDS. This article aims to review available data on the use of CytoSorb© therapy in combination with V-V ECMO in severe ARDS, and to assess the effects on inflammatory, laboratory and clinical parameters, as well as on patient outcomes. A systematic literature review was conducted and reported in compliance with principles derived from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. When applicable, a before-and-after analysis for relevant biomarkers and clinical parameters was carried out. CytoSorb© use was associated with significant reductions in circulating levels of C-reactive protein and interleukin-6 (p = 0.039 and p = 0.049, respectively). Increases in PaO2/FiO2 reached significance as well (p = 0.028), while norepinephrine dosage reductions showed a non-significant trend (p = 0.067). Mortality rates in CytoSorb© patients tended to be lower than those of control groups of most included studies, which, however, were characterized by high heterogeneity and low power. In an exploratory analysis on 90-day mortality in COVID-19 patients supported with V-V ECMO, the therapy was associated with a significantly reduced risk of death. Based on the reviewed data, CytoSorb© therapy is able to reduce inflammation and potentially improves survival in ARDS patients treated with V-V ECMO. Early initiation of CytoSorb© in conjunction with ECMO might offer a new approach to enhance lung rest and promote recovery in patients with severe ARDS.

Left Atrial Veno-Arterial Extracorporeal Membrane Oxygenation Case Series: A Single-Center Experience

IntroductionWe aimed to review the characteristics and outcomes of left atrial veno-arterial extra corporeal membrane oxygenation (LAVA ECMO) at our institution over a 4-y period from 2017 to 2020. MethodsAmong 227 adult patients who received VA ECMO support from January 2017 to December 2020, we reviewed 33 of these who underwent transseptal cannulation and were converted to LAVA ECMO. The timing of transseptal cannulation, either at initiation of VA ECMO (n = 25) or with a later transseptal cannulation to treat complications of left ventricular (LV) distention while on VA ECMO (n = 8), was reviewed. The clinical characteristics, indications, echocardiography data, and outcomes were assessed. ResultsDuration of LAVA ECMO support ranged from 1 to 13 d, with a median of 5 d. Successful weaning from the LAVA ECMO circuit was achieved for 15 patients (45%). The in-hospital mortality rate was 66%. There were 11 patients (33%) who survived to be discharged from the hospital. ConclusionsLV distention is a known complication of VA ECMO and impedes the recovery of the heart. LAVA ECMO provides a novel approach to treating LV distention. Additionally, our review shows that this modality may be used as a bridge to durable mechanical circulatory support, cardiac transplantation, or recovery.

Extracorporeal membrane oxygenation for cardiogenic shock: a meta-analysis of mortality and complications

BackgroundVenoarterial extracorporeal membrane oxygenation (va-ECMO) is an advanced life support for critically ill patients with refractory cardiogenic shock. This temporary support bridges time for recovery, permanent assist, or transplantation in patients with high risk of mortality. However, the benefit of this modality is still subject of discussion and despite the continuous development of critical care medicine, severe cardiogenic shock remains associated with high mortality. Therefore, this work aims to analyze the current literature regarding in-hospital mortality and complication rates of va-ECMO in patients with cardiogenic shock.MethodsWe conducted a systematic review and meta-analysis of the most recent literature to analyze the outcomes of va-ECMO support. Using the PRISMA guidelines, Medline (PubMed) and Scopus (Elsevier) databases were systematically searched up to May 2022. Meta-analytic pooled estimation of publications variables was performed using a weighted random effects model for study size.ResultsThirty-two studies comprising 12756 patients were included in the final analysis. Between 1994 and 2019, 62% (pooled estimate, 8493/12756) of patients died in the hospital. More than one-third of patients died during ECMO support. The most frequent complications were renal failure (51%, 693/1351) with the need for renal replacement therapy (44%, 4879/11186) and bleeding (49%, 1971/4523), bearing the potential for permanent injury or death. Univariate meta-regression analyses identified age over 60 years, shorter ECMO duration and presence of infection as variables associated with in-hospital mortality, while the studies reporting a higher incidence of cannulation site bleeding were unexpectedly associated with a reduced in-hospital mortality.ConclusionsExtracorporeal membrane oxygenation is an invasive life support with a high risk of complications. We identified a pooled in-hospital mortality of 62% with patient age, infection and ECMO support duration being associated with a higher mortality. Protocols and techniques must be developed to reduce the rate of adverse events. Finally, randomized trials are necessary to demonstrate the effectiveness of va-ECMO in cardiogenic shock.

Predictors of early renal dysfunction after heart transplantation: a report from the International Consortium on Primary Graft Dysfunction

Abstract Background Renal dysfunction is a common complication after heart transplantation (HT). Renal replacement therapy (RRT) after HT has been associated with increased risk of death. Long-term renal dysfunction is associated mainly to immunosuppressive therapy but is also strongly related to post-transplant renal failure. Predictors of early renal dysfunction after HT have not been clearly identified. Purpose We aimed to define predictors of early renal dysfunction after HT. Methods Our consortium includes 10 centers in the US, Canada and Europe. We collected data on all consecutive single-organ HT recipients from 2010 to 2020. The primary outcome was early renal dysfunction (ERD), defined as a composite of need for RRT or creatinine ≥2.5 mg/dL 24 hours after HT. We assessed the incidence of early renal dysfunction and performed univariate and multivariate analyses to identify the recipient and transplant characteristics associated with its development. Results We included 2,764 HT recipients: 282 (10.2%) presented early renal dysfunction and 2482 (89.8%) did not. Recipients who presented postoperative renal dysfunction were more frequently male, Caucasian, with previous sternotomy, higher baseline creatinine, longer ischemic time and worse donor LVEF. They were also more likely to be under RRT, intravenous inotropes or ECMO support and there was more incidence of severe primary graft dysfunction (PGD) (Table 1). Multi-variable logistic regression demonstrated that the strongest predictors for post-transplant renal dysfunction were development of severe PGD (OR 5.26, 2.88–9.62, p&amp;lt;0,001) and RRT prior to HT (OR 5.80, 2.93–11.5, p&amp;lt;0.001). Other predictors were male sex, previous sternotomy, long ischemic time and need for inotropes prior to HT. Conclusions Early renal dysfunction is a common complication after HT with an incidence around 10% in a large and contemporary cohort. The presence of PGD and need for RRT pre-transplant were the strongest predictors for its development. Interestingly, emergent transplantation or need for MCS were not independently associated with ERD. Further studies are needed to identify patients at high risk of early and late kidney dysfunction that may benefit from combined transplantation. Funding Acknowledgement Type of funding sources: None.