Emergent Extracorporeal Membrane Oxygenation Research Articles

Extracorporeal Membrane Oxygenation-Supported Patient Outcome Undergoing Transcatheter Aortic Valve Replacement.

The efficacy and safety of extracorporeal membrane oxygenation (ECMO) support during transcatheter aortic valve replacement (TAVR) remains unknown. We conducted a meta-analysis to compare benefit and risk of ECMO in TAVR patients. Bibliographic databases were searched from inception to January 1, 2024. Included studies involved patients ≥18 years old undergoing TAVR and using ECMO emergently or prophylactically. Mortality and procedure success were primary outcomes. Peri- or postoperative complications were the secondary outcomes. We identified 11 observational studies, including 2,275 participants (415 ECMO and 1,860 non-ECMO). The unadjusted mortality risk in ECMO-supported patient was higher than non-ECMO patients (odds ratio [OR] 1.73). The mortality unadjusted risk remained high (OR 3.89) and statistically significant for prophylactic ECMO. Prophylactic ECMO had lower mortality risk compared with emergent ECMO (OR 0.17). Extracorporeal membrane oxygenation-supported patients had lower procedural success rate (OR 0.10). Extracorporeal membrane oxygenation patients undergoing TAVR had significantly increased risk of bleeding (OR 3.32), renal failure (OR 2.38), postoperative myocardial infarction (OR 1.89), and stroke (OR 2.32) compared with non-ECMO patients. Clinical results are not improved by ECMO support in patients with high-risk TAVR. Prophylactic ECMO outperforms emergent. Overall, ECMO support increases mortality and postoperative complications. Transcatheter aortic valve replacement outcomes may improve with prophylactic ECMO in high-risk situations.

The "Weekend Effect" in Extracorporeal Cardiopulmonary Resuscitation.

The phenomenon known as the "weekend effect" impacts various medical disciplines. We compared outcomes between regular hours and off hours to investigate the presence of the weekend effect in extracorporeal cardiopulmonary resuscitation (ECPR). Between January 2018 and December 2020, 159 patients at our center were treated with veno-arterial extracorporeal membrane oxygenation (ECMO) for cardiac arrest. We assessed the time required for ECMO preparation, the rate of successful weaning, and the rate of in-hospital mortality. These factors were compared among regular hours ("daytime": weekdays from 7:00 AM-7:00 PM), off hours on weekdays ("nighttime": weekdays from 7:00 PM-7:00 AM), and off hours on weekends and holidays ("weekend": Fridays at 7:00 PM to Mondays at 7:00 AM). The time from the recognition of cardiac arrest to the arrival of the ECMO team was shortest for the daytime group and longest for those treated over the weekend (daytime, 10.0 minutes; nighttime, 12.5 minutes; weekend, 15.0 minutes; p=0.064). The time from the ECMO team's arrival to ECMO initiation was shortest for the daytime and longest for the nighttime group (daytime, 13.0 minutes; nighttime, 18.5 minutes; weekend, 14.0 minutes; p=0.028). No significant difference was observed in the rate of successful ECMO weaning (daytime, 48.3%; nighttime, 39.5%; weekend, 36.1%; p=0.375). In situations involving CPR, the time to arrival of the ECMO team was longer during off hours. Furthermore, ECMO insertion required more time at night than during the other periods. These findings warrant specific training in decision-making and emergent ECMO insertion.

Neurologic Complications of Extracorporeal Cardiopulmonary Resuscitation in Neonates and Infants

Objective: Extracorporeal membrane oxygenation (ECMO) is a lifesaving measure for patients in cardiac or respiratory failure. Extracorporeal cardiopulmonary resuscitation (ECPR) is emergent ECMO cannulation during cardiac arrest. All ECMO patients are at high risk for neurologic complications, but the degree of risk of ECPR relative to ECMO without CPR in progress (non-ECPR ECMO) is not well documented in infants. The goal of the present study is to compare neurologic complication rates between infants who underwent ECPR and those who underwent non-ECPR ECMO. Methods: We performed a retrospective chart review on all patients admitted between 2009 and 2020 to the neonatal intensive care unit (NICU) in our quaternary children's hospital. We separated patients by ECPR vs. non-ECPR ECMO cannulation. We compared rates of death and used neuroimaging and video electroencephalogram (vEEG) to determine incidence of stroke, intracranial hemorrhage, and seizure. Chi-square and Fisher's exact tests were used to compare these categorical variables among groups.Results: A total of 181 infants were cannulated onto ECMO. Of these, 40 received ECPR, 56 received non-ECPR ECMO for a cardiac indication, and 85 received non-ECPR ECMO for a respiratory indication. After excluding patients currently admitted (n=1, ECPR), 180 patients were subjected to analysis. ECPR patients were less likely to survive to hospital discharge than patients who underwent non-ECPR ECMO for respiratory indications, and less likely to survive without any neurologic complication compared with infants who underwent non-ECPR ECMO for cardiac or respiratory indications. Interpretation: Significantly fewer ECPR patients survived without experiencing a neurologic complication, compared with non-ECPR ECMO patients.

Therapeutic Plasma Exchange for Treatment of Heparin Induced Thrombocytopenia in a Patient Undergoing Left Ventricular Assist Device Implantation

Introduction Heparin-induced thrombocytopenia (HIT) is an autoimmune reaction to heparin exposure that is associated with a high morbidity and mortality. HIT occurs when platelet factor 4 (PF4) antibodies are released and bind to exogenous heparin. This creates complexes that may induce a life-threatening systemic coagulopathy. Standard treatment for HIT includes discontinuation of heparin and administration an alternative thrombin inhibitor. We report a case of a man who developed HIT prior to left ventricular assist device (LVAD) implantation, a procedure which requires a large dose of intraoperative heparin. The patient was treated with therapeutic plasma exchange (TPE) and was able to safely undergo LVAD implantation. Case Report A 52-year-old Caucasian man was initially admitted for a delayed presentation ST elevation myocardial infarction. He underwent left anterior descending coronary artery (LAD) stent placement and was discharged home on appropriate medical therapy but with significant residual left ventricular dysfunction. The patient returned three weeks later in cardiogenic shock requiring emergent extracorporeal membrane oxygenation (ECMO) placement with a heparin drip per protocol. He was weaned off ECMO and transitioned to Impella support. Labs for thrombocytopenia revealed HIT which was confirmed with a positive serotonin release assay (SRA). For refractory shock and an echocardiogram which showed an ejection fraction of 10-15%, the patient was approved for durable LVAD implantation. TPE was initiated to remove the PF4 antibodies. Using optical density as a guide, the patient underwent five rounds of TPE until he was SRA negative. He then uneventfully received heparin during LVAD implantation. Post procedure, the patient was started on argatroban with warfarin until his INR was therapeutic. The patient was discharged one-month post procedure. He has completed a course of rehab and is now functionally class I with plans for a transplant evaluation. Summary To our knowledge this is the first case report of the use of optical density guided TPE for HIT in a patient undergoing LVAD implantation. The treatment required a multidisciplinary approach and led to an excellent outcome in a critically ill patient.

HandS ECMO: Preliminary Experience With "Hub and Spoke" Model in Neonates With Meconium Aspiration Syndrome.

We aim to evaluate clinical outcomes of emergent extracorporeal membrane oxygenation (ECMO) implantation in newborns with life-threatening meconium aspiration syndrome (MAS) in peripheral hospitals with Hub and Spoke (HandS) setting. We retrospectively reviewed all neonates presenting with MAS, with no other comorbidities, treated with HandS ECMO, in peripheral hospitals. Team activation time (TAT) was described as the time from first alerting call to ECMO support initiation. From May 2014 to December 2016, 4 patients met our inclusion criteria. In addition, 2 cases occurred on the same day, requiring a second simultaneous HandS ECMO team activation. All patients were younger than 8 days of life (1, 1, 4, and 7), with a mean BSA 0.21 ± 0.03m2 , and TAT of 203, 265, 320, and 340 min. One patient presented ventricular fibrillation after priming administration. Veno-arterial ECMO was established in all patients after uneventful surgical neck vessels cannulation (right carotid artery and jugular vein). Mean time from skin incision to ECMO initiation was 19 ± 1.4 min. Mean length of ECMO support was 2.75 ± 1.3 days. All patients were weaned off support without complications. At a mean follow up of 20.5 ± 7.8 months, all patients are alive, with no medications, normal somatic growth, and neuropsychological development. MAS is a life-threatening condition that can be successfully managed with ECMO support. A highly trained multidisciplinary HandS ECMO team is crucial for the successful management of these severely ill newborns in peripheral hospitals.

An Unusual Airway Foreign Body: A Cockroach in the Trachea

We present a case of airway obstruction by an unusual foreign body in a 10 month old male. The child was brought intubated to the emergency room after he was found unconscious and blue by his parents. His older sibling reported a choking episode after he placed a black object in his mouth. Chest x-ray on arrival demonstrated right-sided air trapping but no definite radio-opaque foreign body. Due to difficulty with ventilation and post-obstructive pulmonary edema on initial bronchoscopy, emergent extracorporeal membrane oxygenation (ECMO) was initiated to help stabilize the patient. Subsequent bronchoscopy demonstrated near total obstruction of the mid-trachea by an insect-like object. The object removed appeared to be a common American cockroach. Airway foreign body retrieval is a common part of otolaryngology practice. Most of the time, these foreign bodies are food materials or other inanimate objects. Finding a cockroach in the airway is incredibly rare and only three cases have been reported in the literature. This case also illustrates that ECMO may be considered in a patient too unstable to tolerate temporary withdrawal of ventilatory support for endoscopy. Additionally, rapid diagnosis and treatment is important when caring for a child with suspected foreign body aspiration.

Exploring the multiple disciplinary model of emergent extracorporeal membrane oxygenation for cardiac arrest patients

Objective To explore the multiple disciplinary model of emergent extracorporeal membrane oxygenation (ECMO) for cardiac arrest (CA) patients. Methods A retrospective investigation was done to analyze the general material, multiple disciplinary corporations, the complication and its treatment of patients who underwent emergent ECMO for non-surgery CA from January 2016 to August 2017. Results Three patients were all men with mean age 45.3±20.3 years. Their mean cardiopulmonary resuscitation duration was 34±10 min, and 2 patients returned to spontaneous circulation, yet hemodynamics instability. 2 patients discharged with cerebral performance category 1-2, however the third died. 3 cannulation of femoral artery and venous were all operated by cardiac surgery using surgical exposure via open cutdown. Mean duration of CA to ECMO pump-on was 132±93 min, while the mean duration of ECMO was 3 858±1 092min. The implementation and maintenance of ECMO needed collaboration of emergent physicians, cardiovascular medicine and surgeon, anesthetists, nurses and so on. At the same time, incision site oozing blood, platelet counting decreasing, coagulopathy and other complications would occur, which needed interventional vascular surgeon and blood bank to participate in. Conclusions Emergent ECMO for CA patients need corporations of prehospital emergent medical system, emergent physicians, cardiovascular physicians and surgeons, anesthetists, perfusionists, blood bank and so on. Establishing coordination and cooperation model of multiple disciplinary quick response team with emergency department as the guide is the important guarantee for emergent department developing emergent extracorporeal resuscitation. Key words: Cardiac arrest; Emergent extracorporeal membrane oxygenation; Multiple disciplinary networks; Model

A Peculiar Case of Phosphine Toxicity

SESSION TITLE: Occupational and Environmental Lung Diseases SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Phosphine gas is a colorless, flammable and highly toxic gas. Despite aggressive measures, phosphine gas toxicity has a very high mortality rate due to cardiopulmonary failure. We present an unusual case of aluminum phosphide toxicity who was the sole survivor in her family. CASE PRESENTATION: A 45-year-old woman with no medical problems presented to emergency room (ER) with acute onset of nausea, vomiting, diarrhea and dyspnea. Four children also presented with similar symptoms. Family was discharged with diagnosis of acute gastroenteritis. Because of worsening respiratory distress, family again presented to ER. Diagnosis of phosphine toxicity (PT) was made based on history. Husband sprayed Aluminum Phosphide (AP) rodenticide underneath the trailer about 2 weeks ago. Then he attempted to wash out the substance with water, which resulted in creation of phosphine gas. All four children passed away in the ER from severe cardiogenic shock and acute hypoxic respiratory failure from pulmonary edema. She was intubated due to worsening multi-organ failure. Bedside ultrasound showed significantly reduced ejection fraction. Patient was started on vasopressors and inotropes. Patient was taken to cath lab for emergent Impella ventricular support device. Arrangements were made to transfer patient to a tertiary care center for extracorporeal membrane oxygenation (ECMO). Patient was supported with ECMO until patient stabilized. She was discharged home in stable condition without any organ injury. She was the sole survivor of the family due to aggressive management of cardiorespiratory failure. DISCUSSION: Metallic phosphides (zinc and aluminum phosphide) are used worldwide as rodenticides and pesticides. They are banned in US so toxicity is rare here. Acute respiratory failure can occur due to pulmonary edema. Mortality often occurs from severe cardiac toxicity which leads to cardiac arrhythmias or refractory shock and cardiac failure. The cornerstone of treatment is supportive measures, which include oxygen and possible intubation for respiratory support; IVF, vasopressors for hypotension and shock. However, aggressive treatment by emergent Impella and ECMO support was necessary. CONCLUSIONS: PT is a fairly rare occurrence but remains to be a public health threat. Its high mortality rate and when the gas dissipates into the air can affect a large population. Supportive measures are the mainstay of treatment. More research needs to be conducted in order to expand knowledge of the treatment. It is strongly recommended to transfer these patients to ECMO supporting centers as they deteriorate rapidly and are unresponsive to ACLS protocol when the cardiovascular system collapses. Reference #1: Gupta S, Ahlawat SK. Aluminum phosphide poisoning--a review. J Toxicol Clin Toxicol 1995; 33:19. DISCLOSURE: The following authors have nothing to disclose: Totini Chatterjee, Omar Salh, Thien Vo, Manish Patel No Product/Research Disclosure Information

Outcomes of rescue cardiopulmonary support for periprocedural acute hemodynamic decompensation in patients undergoing catheter ablation of electrical storm

In patients with ventricular tachycardia or ventricular fibrillation (VT/VF) electrical storm (ES) undergoing catheter ablation (CA), hypotension due to refractory VT/VF, use of anesthesia, and cardiac stunning due to repeated implantable cardioverter-defibrillator shocks might precipitate acute hemodynamic decompensation (AHD). We evaluated the outcomes of emergent cardiopulmonary support with extracorporeal membrane oxygenation (ECMO) to rescue AHD in patients undergoing CA of ES. Between January 1, 2010 and December 31, 2016, 21 patients with ES (VT in 11 and premature ventricular complex-triggered VF in 10) were referred for CA and had periprocedural AHD requiring emergent ECMO support. In 14 patients, AHD occurred a mean of 1.5 ± 1.7 days before the procedure. In the remaining 7 patients, AHD occurred during or shortly after the procedure. ECMO was started successfully in all patients. Ablation was performed in 18 patients (9 with VF and 9 with VT). In patients with VF, premature ventricular complex suppression was achieved in 8 of 9 (89%). In those with VT, noninducibility was achieved in 7 of 9 (78%). After a median follow-up of 10 days, 16 patients died (13 during the index admission). Death was due to refractory VT/VF in 4 patients, heart failure in 11, and noncardiac cause in 1 patient. Seven patients survived beyond 6 months postablation; 5 remained free of VT/VF and 3 ultimately received a destination therapy (heart transplantation in 2 and left ventricular [LV] assist device in 1). In patients with ES undergoing CA, the outcomes of ECMO support as rescue intervention for AHD are poor. The majority of these patients die of refractory heart failure in the short-term. Strategies to prevent AHD including preemptive use of hemodynamic support may improve survival.

Acute Respiratory Distress Syndrome Associated with Intravenous Lipid Emulsion Therapy for Verapamil Toxicity, Successfully Treated with Veno-Venous ECMO

Calcium channel blocker (CCB) overdose is a potentially fatal poisoning. The use of intravenous lipid emulsion (ILE) therapy for CCB poisoning has emerged in the past few years. In 2017, the American College of Medical Toxicology published interim guidance for the use of ILE resuscitation in these cases. We report an uncommon complication of ILE, acute respiratory distress syndrome, treated with veno-venous extracorporeal membrane oxygenation (ECMO). Case report: A 40-year-old hypertensive woman presented with shock (blood pressure 62/34 mmHg, pulse 86/ min) following ingestion of 4,800 mg verapamil slow release and 1,500 mcg clonidine during a suicide attempt. She was treated with calcium gluconate, sodium bicarbonate, IV high dose insulin, IV glucagon, cardiac amines and vasopressors without response (blood pressure 69/37 mmHg, pulse 78/min). ILE was initiated, and two hours later, she developed acute respiratory failure necessitating intubation and mechanical ventilation. Due to poor oxygenation (pO2 44 mmHg; FiO2 100%) emergent veno-venous ECMO was instituted. After one hour her blood pressure increased to 104/50 mmHg (pulse 80, pO2 75 mmHg), and continued so until weaning from ECMO and ventilation. Conclusion: Acute respiratory distress syndrome can be a major life threating complication following ILE; venovenous ECMO is suggested for its treatment.

Simulation-Based Assessment of ECMO Clinical Specialists.

The aims of the study were (1) to create multiple scenarios that simulate a range of urgent and emergent extracorporeal membrane oxygenation (ECMO) events and (2) to determine whether these scenarios can provide reliable and valid measures of a specialist's advanced skill in managing ECMO emergencies. Multiscenario simulation-based performance assessment was performed. The study was conducted in the Saigh Pediatric Simulation Center at St. Louis Children's Hospital. ECMO clinical specialists participated in the study. Twenty-five ECMO specialists completed 8 scenarios presenting acute events in simulated ECMO patients. Participants were evaluated by 2 separate reviewers for completion of key actions and for global performance. The scores were highest for the hemodilution scenario, whereas the air entrainment scenario had the lowest scores. Psychometric analysis demonstrated that ECMO specialists with more than 1 year of experience outperformed the specialists with less than 1 year of experience. Participants endorsed these sessions as important and representative of events that might be encountered in practice. The scenarios could serve as a component of an ECMO education curriculum and be used to assess clinical specialists' readiness to manage ECMO emergencies.

Extracorporeal Membrane Oxygenation as a Procedural Rescue Strategy for Transcatheter Aortic Valve Replacement Cardiac Complications.

Cardiovascular complications during or after transcatheter aortic valve replacement (TAVR) are associated with extremely high mortality, but extracorporeal membrane oxygenation (ECMO) can be used as procedural rescue option to improve outcomes when patients experience respiratory or cardiac arrest. From 2012 to 2014, 230 patients underwent TAVR and 10 patients (4.3%) required emergent venous-arterial ECMO support. Mean age was 83 years, median Society of Thoracic Surgeons (STS) score was 15, and mean aortic gradient was 45 mm Hg. Median left ventricular ejection fraction was 35%. Access for most ECMOs was femoral; two patients required central arterial and femoral venous access. Extracorporeal membrane oxygenation was initiated in response to hemodynamic collapse due to perforation of left ventricle (n = 2), aortic root rupture (n = 1), moderate-to-severe aortic insufficiency (n = 1), left main impingement (n = 1), valve embolization (n = 1), severe hypotension and cardiac arrest after prolonged rapid pacing sequence (n = 1), ventricular fibrillation (n = 2), and ventricular tachycardia (n = 1). Median time of ECMO support was 87 minutes. There were three hospital deaths. Post-TAVR mean aortic gradient was 8 mm Hg and median hospital stay was 19 days. Additional procedures included valve-in-valve placement (n = 1), percutaneous coronary intervention (n = 1), surgical LV repair (n = 2), surgical valve replacement (n = 1), aortic root rupture repair, and coronary bypass grafting (n = 1). Extracorporeal membrane oxygenation is rescue therapy for hemodynamic instable patients who develop TAVR-related cardiac complications.

Extracorporeal membrane oxygenation for very high-risk transcatheter aortic valve implantation

Introduction: Transcatheter aortic valve implantation (TAVI) can cause profound haemodynamic perturbation in the peri-operative period. Veno-arterial extracorporeal membrane oxygenation (ECMO) can be used to provide cardiorespiratory support during this time, either prophylactically or emergently. Methods: 100 TAVI procedures were performed between 2009 and 2013 in our institution. ECMO was used in 11 patients, including 8 prophylactic and 3 rescue cases. Rescue ECMO was required for ventricular fibrillation after valvuloplasty, and aortic annulus rupture. The criteria for prophylactic ECMO included heart failure requiring stabilisation pre-TAVI, haemodynamic instability with balloon aortic valvuloplasty performed to improve heart function pre-TAVI, moderate or severe left and/or right ventricular failure, or borderline haemodynamics at procedure. Differences in preoperative characteristics and postoperative outcomes between ECMO and non-ECMO TAVI patients were compared, and significant results were further assessed controlling for EuroSCORE. Results: Compared to TAVI patients who did not require ECMO, ECMO patients had significantly higher mean EuroSCORE (51 vs. 30%, p<.05). All-cause mortality occurred in nil prophylactic ECMO patients, one rescue ECMO patient, and two non-ECMO patients. The difference in mortality between ECMO and non-ECMO patients was not significantly different (9 vs. 2%; p>.05). Other non-significant outcomes (p<.05) included peri-procedural and spontaneous myocardial infarction (0 vs. 2% and 0 vs. 0%, respectively); disabling and non-disabling stroke (0 vs. 0% and 0 vs. 2%, respectively); transient ischaemic attack (0 vs. 0%); life-threatening, major and minor bleeding (12 vs. 3%, 0 vs. 12% and 38 vs. 13%, respectively); and major and minor vascular complications (12 vs. 5% and 0 vs. 13%, respectively). ECMO patients were more likely to develop acute renal failure than non-ECMO patients (36 vs. 8%, p<.05), which was most likely due to haemodynamic collapse and end-organ dysfunction in patients that required emergent ECMO rescue. Discussion: ECMO, in both prophylactic and rescue settings, is effective at providing cardiorespiratory support in very-high risk TAVI patients, and may have contributed to the low mortality in this series. Instituting prophylactic ECMO in an elective, controlled setting may help avoid consequences of intraoperative complications such as systemic hypoperfusion and acute renal failure, compared to emergent ECMO with rapid setup and cannulation. Limitations of this study include small patient sample size and observational nature. Future studies performed in a prospective, randomised fashion are required to evaluate the use of prophylactic ECMO, and to determine the ideal selection criteria.

Extracorporeal Membrane Oxygenation for Very High-risk Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) can cause profound haemodynamic perturbation in the peri-operative period. Veno-arterial extracorporeal membrane oxygenation (ECMO) can be used to provide cardiorespiratory support during this time, either prophylactically or emergently. 100 TAVI procedures were performed between 2009 and 2013 in our institution. ECMO was used in 11 patients, including eight prophylactic and three rescue cases. Rescue ECMO was required for ventricular fibrillation after valvuloplasty, and aortic annulus rupture. The criteria for prophylactic ECMO included heart failure requiring stabilisation pre-TAVI, haemodynamic instability with balloon aortic valvuloplasty performed to improve heart function pre-TAVI, moderate or severe left and/or right ventricular failure, or borderline haemodynamics at procedure. Differences in preoperative characteristics and postoperative outcomes between ECMO and non-ECMO TAVI patients were compared, and significant results were further assessed controlling for EuroSCORE. Compared to TAVI patients who did not require ECMO, ECMO patients had significantly higher mean EuroSCORE (51 vs. 30%, p<.05). Postoperative outcomes, however, were largely comparable between the two groups. All-cause mortality occurred in nil prophylactic ECMO patients, one rescue ECMO patient, and two non-ECMO patients. The difference in mortality between ECMO and non-ECMO patients was not significantly different (9 vs. 2%; p>.05). ECMO patients were more likely to develop acute renal failure than non-ECMO patients (36 vs. 8%, p<.05), which was most likely due to haemodynamic collapse and end-organ dysfunction in patients that required ECMO rescue. Instituting prophylactic ECMO in selected very high-risk patients may help avoid consequences of intra-operative complications and the need for emergent rescue ECMO.

Transition from ECMO to left ventricular support via trans-septal cannula using a single CentriMag device

A 67-year-old male presented in cardiogenic shock and multi-system organ failure requiring emergent venous-arterial extracorporeal membrane oxygenation (ECMO). He was deemed ineligible for heart transplantation and a left ventricular assist device (LVAD) was thought to be high risk due to persistent right heart failure. To determine if he could tolerate left ventricular support alone, a trans-septal cannula was placed via the left femoral vein. Transition from veno-arterial ECMO to isolated left-sided support allowed for risk assessment for LVAD implantation and extubation, providing the patient an opportunity to participate in further clinical decision making.

Extracorporeal membrane oxygenation as a bridge to lung transplantation in a patient with persistent severe porto-pulmonary arterial hypertension following liver transplantation

Idiopathic pulmonary artery hypertension (IPAH) is a progressive disease with a dismal prognosis and lung transplantation is often the only option for patients, who do not respond to pharmacological therapy. We report the use of an extracorporeal membrane oxygenation (ECMO) system in a 49-year-old woman with primary pulmonary hypertension, previously liver transplanted. The patient, listed for lung transplantation, developed respiratory and circulatory failure despite maximal pharmacological therapy and was successfully bridged to emergent bilateral lung transplantation with veno-arterial ECMO. Emergent veno-arterial ECMO was able to rescue the patient and bridge her to bilateral lung transplantation and should therefore be an option for patients with PAH and circulatory collapse.

Long-term Extracorporeal Circulation Management: The Role of Low- and High-range Heparin ACT Tests

Modern management of extracorporeal circulation, especially during long-term support of post-cardiac surgical patients, remains challenging and requires optimal care of the patient’s fluid balance and coagulation hemostasis for its successful outcome. The activated clotting time assay is one of the tests used to manage extracorporeal circulation and is available in a low- and high-range level. The question of which assay is more appropriate for procedures that require low to moderate heparin dosing is still unclear. We report our experience with a neonate diagnosed with hypoplastic left heart syndrome who needed emergent extracorporeal membrane oxygenation support for 13 days after Norwood stage I palliation using a Sano shunt. Although successful, bleeding complications prompted us to review our strategy for management of coagulation hemostasis.

Right Ventricular Pseudoaneurysm After Modified Norwood Procedure

A newborn with hypoplastic left heart syndrome underwent a modified Norwood Stage I palliation, including placement of a 5-mm Goretex conduit (W.L. Gore & Associates, Newark, DE) between the right ventricle and pulmonary artery. The immediate postoperative course was complicated by conduit obstruction requiring emergent extracorporeal membrane oxygenation and conduit revision. At 3 months of age, the patient underwent an elective bidirectional Glenn procedure. The right ventricle-to-pulmonary artery conduit was found unexpectedly to be invested in an abscess cavity from which purulent material was drained.

Application of “double bridge mechanical” resuscitation for profound cardiogenic shock leading to cardiac transplantation

Background. In patients with acute profound cardiogenic circulatory failure unresponsive to conventional resuscitation, we instituted immediate aggressive application of extracorporeal membrane oxygenation (ECMO) to restore circulatory stability. Long-term hemodynamic support was accomplished with an early “bridge” to ventricular assist device (VAD) before definitive treatment with cardiac transplantation. Methods. A respective review of ECMO and VAD data registries was instituted. Results. From May 1996 to July 2000, 23 patients were placed on ECMO support for profound cardiogenic circulatory failure. Eleven patients (47%) were withdrawn from support due to severe neurologic injury or multisystem organ failure. Three patients (13%) were weaned off ECMO with good outcome. Nine patients (39%) were transferred to a VAD. Two patients expired while on VAD support, and 7 of the VAD-supported patients (78%) survived to transplantation. Overall survival was 43%. Conclusions. Emergent ECMO support is a salvage approach for cardiac resuscitation once conventional measures have failed. In neurologically intact patients, the early transfer to a VAD quickly stabilizes hemodynamics, avoids complications, and is essential for long-term circulatory support before definitive treatment with cardiac transplantation.