Extracorporeal Life Support Organization Database Research Articles

Extracorporeal membrane oxygenation for the treatment of massive pulmonary embolism. An analysis of the ELSO database

AimExtracorporeal membrane oxygenation (ECMO) may be beneficial in treatment of massive pulmonary embolus (PE), however the current evidence to guide its use is limited. We aimed to compare the incidence, characteristics, treatments, and outcomes of patients with massive PE by mode of ECMO from a large international registry. MethodsRetrospective observational study of the Extracorporeal Life Support Organization (ELSO) database. ResultsA total of 821 patients underwent 833 ECMO episodes for PE. Mean age was 49 (±15) years, 408 (50.1%) were female, and 450 (54.7%) had a cardiac arrest prior to ECMO initiation. Venoarterial (VA) ECMO was the most common mode in 489 (58.7%), followed by extracorporeal cardiopulmonary resuscitation (ECPR) in 229 (27.4%) and venovenous (VV) ECMO in 85 (10.2%). The number of episodes per year increased over the study period, predominantly driven by an increase in ECPR. In-hospital mortality was the highest for ECPR 156/229 (68.1%), followed by VA ECMO 209/498 (42.7%) and VV ECMO 24/85 (28.2%) P < 0.001. After controlling for univariate and clinically significant variables at the time of ECMO initiation, increasing age (OR 1.02 (1.00–1.03), lower pH (OR 0.18 (0.03–0.44), lower diastolic blood pressure (OR 0.99 (0.97–1.00) and ECPR mode (OR 3.67 (1.46–9.230) were independently associated with in-hospital mortality. ConclusionECMO use for massive PE is increasing globally, and overall mortality rates compare favorably with other indications of ECMO. The use of ECPR and worsening metabolic status at initiation were associated with higher in-hospital mortality, suggesting delays in initiating ECMO should be avoided.

Venoarterial extracorporeal membrane oxygenation for cardiac support in human immunodeficiency virus-positive patients: a case report and review of a multicentre registry

BackgroundHuman immunodeficiency virus (HIV) is associated with increased risk of heart failure via multiple mechanisms both in patients with and without access to highly active antiretroviral therapy (HAART). Limited information is available on outcomes among this population supported on Venoarterial Extracorporeal Membrane Oxygenation (VA ECMO), a form of temporary mechanical circulatory support.MethodsWe aimed to assess outcomes and complications among patients with HIV supported on VA ECMO reported to a multicentre registry and present a case report of a 32 year old male requiring VA ECMO for cardiogenic shock as a consequence of his untreated HIV and acquired immune deficiency syndrome (AIDS). A retrospective analysis of the Extracorporeal Life Support Organization (ELSO) registry data from 1989 to 2019 was performed in HIV patients supported on VA ECMO.Results36 HIV positive patients were reported to the ELSO Database who received VA ECMO during the study period with known outcomes. 15 patients (41%) survived to discharge. No significant differences existed between survivors and non-survivors in demographic variables, duration of VA ECMO support or cardiac parameters. Inotrope and/or vasopressor requirement prior to or during VA ECMO support was associated with increased mortality. Survivors were more likely to develop circuit thrombosis. The patient presented was supported on VA ECMO for 14 days and was discharged from hospital day 85.ConclusionsA limited number of patients with HIV have been supported with VA ECMO and more data is required to ascertain the indications for ECMO in this population. HIV should not be considered an absolute contraindication to VA ECMO as they may have comparable outcomes to other patient groups requiring VA ECMO support.

Association Between Early Change in Arterial Carbon Dioxide Tension and Outcomes in Neonates Treated by Extracorporeal Membrane Oxygenation.

The primary objective was to investigate the association between partial pressure of carbon dioxide (PaCO 2 ) change after extracorporeal membrane oxygenation (ECMO) initiation and neurologic outcome in neonates treated for respiratory failure. A retrospective analysis of the Extracorporeal Life Support Organization (ELSO) database including newborns supported by ECMO for respiratory indication during 2015-2020. The closest Pre-ECMO (Pre-ECMO PaCO 2 ) and at 24 hours after ECMO initiation (H24 PaCO 2 ) PaCO 2 values allowed to calculate the relative change in PaCO 2 (Rel Δ PaCO 2 = [H24 PaCO 2 - Pre-ECMO PaCO 2 ]/Pre-ECMO PaCO 2 ). The primary outcome was the onset of any acute neurologic event (ANE), defined as cerebral bleeding, ischemic stroke, clinical or electrical seizure, or brain death during ECMO. We included 3,583 newborns (median age 1 day [interquartile range {IQR}, 1-3], median weight 3.2 kg [IQR, 2.8-3.6]) from 198 ELSO centers. The median Rel Δ PaCO 2 value was -29.9% [IQR, -46.2 to -8.5]. Six hundred nine (17%) of them had ANE (405 cerebral bleedings, 111 ischemic strokes, 225 seizures, and 6 brain deaths). Patients with a decrease of PaCO 2 > 50% were more likely to develop ANE than others (odds ratio [OR] 1.78, 95% confidence interval [CI], 1.31-2.42, p < 0.001). This was still observed after adjustment for all clinically relevant confounding factors (adjusted OR 1.94, 95% CI, 1.29-2.92, p = 0.001). A significant decrease in PaCO 2 after ECMO start is associated with ANE among neonates requiring ECMO for respiratory failure. Cautious PaCO 2 decrease should be considered after start of ECMO therapy.

Prevalence and Impact of Infection during Extracorporeal Membrane Oxygenation in Oncologic Patients: A Retrospective Analysis of the Extracorporeal Life Support Organization (ELSO) Registry.

Background: Extracorporeal membrane oxygenation (ECMO) is widely utilized for severe cardiopulmonary insufficiency, but its application to the oncologic population has been debated given concern for increased risk of infection. This study aims to analyze the implications of infections acquired during ECMO runs in patients with malignancy. Methods: The Extracorporeal Life Support Organization (ELSO) database was queried for patients with an International Classification of Diseases code of neoplasms over the last two decades (2000-2019). Culture-proven infections during ECMO runs were analyzed and compared to previously reported data for all ECMO runs. Results: Two thousand, seven hundred and fifty-seven patients met inclusion criteria. Infection acquired during ECMO run was found in 687 patients, a significantly greater proportion compared to all ECMO runs (24.9% vs 11.7%; P = .001). Adult patients had a significantly higher rate of infection (27.0%; P < .001) compared to neonatal (11.0%) and pediatric (21.4%) patients. Prevalence of infection was highest in pulmonary ECMO (29.0%), while the infection rate standardized with ECMO duration was highest in extracorporeal cardiopulmonary resuscitation (55.03/1000-day ECMO run). Compared with ECMO for all diagnoses, the prevalence of Candida and Klebsiella infection was significantly higher in adult and pediatric oncologic patients. Regardless of the pathogen, the presence of infection was not associated with lower survival (38.6% vs 40.0%; P = .522). Conclusions: Oncologic patients had a significantly higher infection rate while on ECMO compared with the general ECMO population. However, the prognostic impact of these infections was minimal, thus ECMO should not be withheld in oncologic patients solely with concern for infection.

Survival of Children With Pulmonary Embolism Supported by Extracorporeal Membrane Oxygenation

The purpose of this study was to describe the demographics and in-hospital mortality of children (<18 years) from 2007 to 2018 supported by Extracorporeal Membrane Oxygenation (ECMO) for a primary diagnosis of pulmonary embolism and reported to the Extracorporeal Life Support Organization database. Fifty-six patients were identified and 54 were included in this analysis. A total of 33 patients (61%) survived. No differences in demographics or ECMO details (duration, mode, and support type) were found between survivors and non-survivors. When ECMO complications were compared, pulmonary bleeding occurred more frequently in non-survivors (23.8%, n = 5) compared to survivors (n = 0) (p = 0.006).

Extracorporeal Membrane Oxygenation for Adult Patients With Neoplasms: Outcomes and Trend Over the Last 2 Decades.

Extracorporeal membrane oxygenation (ECMO) is utilized in the management of severe respiratory and circulatory failure. Advanced malignancy is a relative contraindication, but the indication for ECMO in the oncologic population has not been clearly established because of the wide spectrum of malignant disease and prognoses. The Extracorporeal Life Support Organization database was queried for patients older than 18 years with an International Classification of Diseases code of neoplasm over the past 2 decades (2000-2019). The data were divided into 2 decades to analyze and compare the trends with background and outcomes. One thousand six-hundred ninety-seven patients met inclusion criteria from the latest decade which is over 15 times the previous decade (n = 110). Compared with the previous decade, ECMO was used more in patients with older age (56 vs . 50.5 years old; p < 0.001), cardiac and extracorporeal cardiopulmonary resuscitation (ECPR) support type ( p = 0.011), and lower oxygenation index (23.0 vs . 35.6; p < 0.001) in the latest decade. Although overall survival did not show significant improvement overall (38.9% vs . 33.6%; p = 0.312), survival in pulmonary ECMO has significantly improved in the latest decade (41.6% vs . 29.1%; p = 0.032). Compared with the previously reported data for all adult ECMO, our patients had a significantly lower survival with pulmonary (41.6% vs . 61.1%; p < 0.001) and cardiac (38.4% vs . 44.3%; p = 0.008) support while not with ECPR.

Patients Listed for Heart Transplant and Bridged on EMO in the New Allocation System Are Less Ill Than Those in the Old Allocation System: An ELSO Data Base Analysis

<h3>Purpose</h3> We previously reported using UNOS data that patients bridged with ECMO to heart transplantation (HT) in the new allocation system have improved survival in the waitlist and after transplantation. Whether this improvement was due to the improved access to HT in this population or due to differences in patient characteristics was unclear. The purpose of our study was to compare the clinical characteristics of patients who received ECMO as a bridge to transplant before and after the allocation system using the Extracorporeal Life Support Organization (ELSO) database. <h3>Methods</h3> Adult patients listed for HT who received ECMO as a bridge to HT in the United States and were registered in the ELSO database were included in this study. Patients were classified in old allocation system (2016-2017) and new allocation system (2019-2021). Clinical characteristics were compared between groups. <h3>Results</h3> A total of 623 patients were listed for HT and received VA-ECMO as a bridge to transplant during the study period. Of these, 214 and 409 were classified in the old and new systems respectively. The proportion of patients who received HT was higher (34% vs. 3.74%, p<0.001) and mortality was lower (23.47% vs. 36.45%, p<0.001) in the new system. At the time of ECMO cannulation, patients in the new system had a better tissue perfusion profile as demonstrated by higher pH and bicarbonate, improved oxygenation as demonstrated by decreased frequency of mechanical ventilation and higher PaO2 at similar FIO₂, and less hemodynamic instability as demonstrated by higher pre-cannulation systolic blood pressure and lower pump flow (Table 1). <h3>Conclusion</h3> Patients bridged on ECMO to HT in the United States after 2018 (new allocation system) are less sick than those in the old allocation system and are more likely to get transplanted on ECMO. This difference could, in part, explain the previously described improved outcomes in the waitlist and post-transplantation in this population.

Multicenter Study on Sex-Based Differences in Patients Placed on Extracorporeal Life Support for Cardiogenic Shock

<h3>Purpose</h3> The use of extracorporeal life support (ECLS) for patients in cardiogenic shock has significantly increased over the past decade. However, there are insufficient data for the presence of gender-associated differences in outcomes. Our study assesses differences between male and female patients placed on venoarterial ECLS (VA-ECLS) for cardiogenic shock at numerous centers worldwide. <h3>Methods</h3> This is a multicenter retrospective study conducted on 9888 patients from the Extracorporeal Life Support Organization database. We looked at adult patients (>18 years old) who were placed on VA-ECLS between January 1^st, 2011 and December 31^st, 2019 for cardiogenic shock. We only looked at patients' first ECLS runs, excluding subsequent ECLS runs for patients who received ECLS multiple times. The primary endpoint was in-hospital mortality. Patients who were transferred to outside hospitals after ECLS placement were excluded. Secondary endpoints include postoperative bleeding, infection, cardiac arrhythmia, cardiac arrest, limb ischemia, compartment syndrome, fasciotomy requirement, stroke, renal replacement therapy, and metabolic acidosis. <h3>Results</h3> There were 6747 male patients and 3141 female patients. In an unadjusted comparison, male patients were more likely to have prior myocardial infarction (29.5% vs 20.9%, p<0.001), coronary artery disease (23.1% vs 15.6%, p<0.001), diabetes (10.6% vs 9.2%, p=0.038), chronic kidney disease (7.7% vs 5.2%, p<0.001), and CHF (23.9% vs 21.4%, p=0.006). Female patients were more likely to be centrally cannulated (23% vs 18.5%, p<0.001). There was no difference in in-hospital mortality between male and female patients (57.2% vs 55.7%, p=0.169). Female patients were more likely to have limb ischemia as a complication (7.0% vs 4.6%, p<0.001), whereas male patients were more likely to require renal replacement therapy (43.5% vs 38.6%, p<0.001) and have arrhythmias (15.2 vs 13.1, p=0.008) after ECLS. There were no other differences in the secondary outcomes between male and female patients. <h3>Conclusion</h3> Compared with male patients, female patients were more likely to centrally cannulated and experience limb ischemia as a complication of ECLS, potentially due to their smaller vessel size. Varying cannulation approach based on biologic sex may be warranted to reduce ECLS complication rates in female patients.

Respiratory ECMO Survival Prediction (RESP) Score for COVID-19 Patients Treated with ECMO.

Veno-venous extracorporeal membrane oxygenation (VV ECMO) has been used as a life-supporting modality for patients with severe respiratory failure because of coronavirus disease 2019 (COVID-19). We aim to evaluate the performance of the RESP score in predicting the hospital survival of COVID-19 patients undergoing VV ECMO. We performed retrospective analysis of the extracorporeal life support organization (ELSO) dataset for COVID-19 patients requiring ECMO support to evaluate the performance of RESP score in predicting in hospital survival. All adult (age ≥18) COVID-19 patients receiving VV ECMO for acute respiratory failure enrolled in the ELSO database from March to August 2020 were included in the analysis. A total of 1985 patients from the ELSO registry were identified and analyzed based on pre-ECMO variables. Median RESP score of survivors was 3 (IQR 1-5) compared to 2 (IQR 0-4) in deceased. A logistic model including RESP score variables poorly discriminated survival and death with AUC (area under curve) 0.61 (95% confidence interval: 0.59-0.64). In-hospital survival for COVID-19 patients based on RESP score class from I to V was 69.7%, 59.3%, 45.7%, 42.5%, and 32.3%, respectively. Patients with immunosuppression (relative risk = 0.43) and pre-ECMO cardiac arrest (relative risk = 0.48) had lower survival. RESP score is a poor predictor of survival in COVID-19 patients undergoing ECMO. Compared to the original cohort used for RESP score creation, COVID-19 patients in RESP class I-III had worse survival whereas the patients in RESP class IV-V had better survival.

Abstract 11514: Extracorporeal Membrane Oxygenation is a Feasible Life Saving Modality for Adult Patients With Neoplasms- Outcomes and Trends in the Last Two Decades

Introduction: Extracorporeal Membrane Oxygenation (ECMO) is utilized in the management of severe respiratory and circulatory failure. Advanced malignancy is a relative contraindication but the indication for ECMO in the oncologic population has not been clearly established due to the wide spectrum of malignant disease and prognoses. Hypothesis: ECMO is a feasible treatment modality in selected adult oncologic population. Method: The Extracorporeal Life Support Organization (ELSO) database was queried for patients older than 18 years with an International Classification of Diseases (ICD) code of neoplasm over the past two decades (2000-2019). The data were divided into two decades to analyze and compare the trends with background and outcomes. Results: One thousand, six hundred, and ninety-seven patients met inclusion criteria from the last decade which is more than 15 times the number from the previous decade (n=110). Compared with the previous decade, ECMO was used more in patients with older age (56 vs 50.5 years old; p&lt;0.001), cardiac and extracorporeal cardiopulmonary resuscitation (ECPR) support type (p = 0.001), higher P/F ratio (79.0 vs 61.8; p=0.001), and lower oxygenation index (23.0 vs 35.6; p&lt; 0.001) in the last decade. Although survival did not show significant improvement overall (38.9% [660 of 1697] vs 33.6% [37 of 110]; p=0.272), survival in pulmonary ECMO has significantly improved in the last decade (41.6% [409 of 983] vs 29.1% [23 of 79]; p=0.030). Diagnosis of hematologic malignancy, ECPR, and hematopoietic stem cell transplant were identified as predictors of poor prognosis (p = 0.025, &lt;0.001, and 0.021 respectively). Conclusion: Utilization of ECMO for patients with neoplasms has increased over time mirroring the overall increase of adult ECMO. With careful patient selection, ECMO can be successful in oncologic population.

Extracorporeal Membrane Oxygenation for Pediatric Burn Patients: Is Management Improving Over Time?

Over the last few decades, extracorporeal membrane oxygenation (ECMO) has become a lifesaving modality for patients with severe respiratory failure following burn injury. With the advancement in critical care and ECMO management, this study aims to analyze the outcomes of ECMO in pediatric burn patients. The Extracorporeal Life Support Organization database was queried from 1999 to 2018 for patients 18 years old and under with a burn injury. The data were divided into two decades, the first (1999-2008) and the second (2009-2018), for analysis of background characteristics and clinical outcomes. Ninety-five patients met inclusion criteria. The overall use of ECMO increased in the second decade (60 cases) when compared to the first decade (35 cases), and use of venovenous ECMO increased in the second decade from 16 cases to 38 cases. Although more patients survived because of the increased application of venovenous ECMO, the survival rate was unchanged between decades (53.4% vs. 54.3%; P = 0.937). Patients with pre-ECMO cardiac arrest had a significant improvement in mortality during the second decade (54.5% vs. 0%; P = 0.043). Metabolic (P = 0.022) and renal (P = 0.043) complications were most common in nonsurvivors during the first decade whereas cardiovascular (P = 0.031) and neurologic (P = 0.003) complication were higher in the second decade (P = 0.031, 0.003). Use of ECMO after burn injury has become more common; however, overall mortality remains unchanged. The data suggests pre-ECMO cardiac arrest is no longer a contraindication to start ECMO.

Longitudinal Trends in Bleeding Complications on Extracorporeal Life Support (ECLS) Over the Past Two Decades – ELSO Registry Analysis

Background: The use of extracorporeal life support (ECLS) has increased worldwide over the last decade including for new emerging indications like extracorporeal cardiopulmonary resuscitation, trauma, and COVID-19. Bleeding complications remain feared and frequent, with high morbidity and increased mortality. Yet, data about trends, and in-hospital outcomes, have been poorly investigated.Methods: The Extracorporeal Life Support Organization (ELSO) Registry database was explored for patients who received veno-venous (V-V) and veno-arterial (V-A) ECLS between the years 2000 and 2020. Trends in bleeding complications and mortality were analyzed. Bleeding complications were classified according to site (gastro-intestinal, cannulation site, surgical site, pulmonary, tamponade and central nervous system) and analyzed separately. Multivariable analysis was performed to identify risk factors for bleeding complications.Results: ELSO database analysis included 53.644 patients with single ECLS runs, mean age 51.4± 15.9 years, 33.859 (64.5%) male. Study cohort included 19.748 patients cannulated for V-V ECLS and 30.696 patients for V-A ECLS. Bleeding complications were reported in 14.786 patients (27.6%) and occurred more often in V-A-modalities compared to V-V modalities (30.0% versus 21.9%, pConclusions: The steady decrease in particular cannulation and surgical site related bleeding complications over the past 20 years suggests advances in equipment development (membrane and tubes surfaces) as well as better understanding of anticoagulation management. However, the high incidence of bleeding and association with hospital mortality reinforces the need for studies to understand bleeding complications more thoroughly during ECLS.Funding Information: No funding.Declaration of Interests: Prof. Dr. Lorusso is a consultant for Medtronic, Getinge and LivaNova and medical advisory board member for EUROSETS, all unrelated to this work; all honoraria to the university for research funding. Dr. Tonna is supported by a Career Development Award from the National Institutes of Health/National Heart, Lung, And Blood Institute (K23 HL141596). Dr. Tonna received speaker fees and travel compensation from LivaNova and Philips Healthcare, unrelated to this work. Prof. Ten Cate received research support from Bayer and Pfizer, is a consultant for Alveron and stockholder with Coagulation Profile; all unrelated to this work. Prof Zoe McQuilten is supported by an Australian National Health and Medical Council (NHMRC) Investigator Grant.Other authors have no conflict of interest to declare.Ethics Approval Statement: Each institution participating in ELSO Registry approves data reported to the registry through their local institutional review board. This study involved only analysis of pre-existing de-identified data from an international registry, and as such no ethics approval was required. Similarly, no patient consent was required.

Neurological complications during veno-venous extracorporeal membrane oxygenation: Does the configuration matter? A retrospective analysis of the ELSO database

BackgroundSingle- (SL) and double-lumen (DL) catheters are used in clinical practice for veno-venous extracorporeal membrane oxygenation (V-V ECMO) therapy. However, information is lacking regarding the effects of the cannulation on neurological complications.MethodsA retrospective observational study based on data from the Extracorporeal Life Support Organization (ELSO) registry. All adult patients included in the ELSO registry from 2011 to 2018 submitted to a single run of V-V ECMO were analyzed. Propensity score (PS) inverse probability of treatment weighting estimation for multiple treatments was used. The average treatment effect (ATE) was chosen as the causal effect estimate of outcome. The aim of the study was to evaluate differences in the occurrence and the type of neurological complications in adult patients undergoing V-V ECMO when treated with SL or DL cannulas.ResultsFrom a population of 6834 patients, the weighted propensity score matching included 6245 patients (i.e., 91% of the total cohort; 4175 with SL and 20,270 with DL cannulation). The proportion of patients with at least one neurological complication was similar in the SL (306, 7.2%) and DL (189, 7.7%; odds ratio 1.10 [95% confidence intervals 0.91–1.32]; p = 0.33). After weighted propensity score, the ATE for the occurrence of least one neurological complication was 0.005 (95% CI − 0.009 to 0.018; p = 0.50). Also, the occurrence of specific neurological complications, including intracerebral hemorrhage, acute ischemic stroke, seizures or brain death, was similar between groups. Overall mortality was similar between patients with neurological complications in the two groups.ConclusionsIn this large registry, the occurrence of neurological complications was not related to the type of cannulation in patients undergoing V-V ECMO.

Risk Factors for Hemolysis During Extracorporeal Life Support for Congenital Diaphragmatic Hernia

Neonates receiving extracorporeal life support (ECLS) for congenital diaphragmatic hernia (CDH) require prolonged support compared with neonates with other forms of respiratory failure. Hemolysis is a complication that can be seen during ECLS and can lead to renal failure and potentially to worse outcomes. The purpose of this study was to identify risk factors for the development of hemolysis in CDH patients treated with ECLS. The Extracorporeal Life Support Organization database was used to identify infants with CDH (2000-2015). The primary outcome was hemolysis (plasma-free hemoglobin >50mg/dL). Potentially associated variables were identified in the data set. Descriptive statistics and a series of nested multivariable logistic regression models were used to identify associations between hemolysis and demographic, pre-ECLS, and on-ECLS factors. There were 4576 infants with a mortality of 52.5%. The overall mean rate of hemolysis was 10.5% during the study period. In earlier years (2000-2005), the hemolysis rates were 6.3% and 52.7% for roller versus centrifugal pumps, whereas in later years (2010-2015), they were 2.9% and 26.5%, respectively. The fully adjusted model demonstrated that the use of centrifugal pumps was a strong predictor of hemolysis (odds ratio: 6.67, 95% confidence interval: 5.14-8.67). In addition, other risk factors for hemolysis included low 5-min Apgar score, on-ECLS complications (renal, metabolic, and cardiovascular), and duration of ECLS. In our cohort of CDH patients receiving ECLS over 15 y, the use of centrifugal pumps increased over time, along with the rate of hemolysis. Patient- and treatment-level risk factors were identified contributing to the development of hemolysis.

Hemocompatibility-Related Adverse Events and Survival on Venoarterial Extracorporeal Life Support: An ELSO Registry Analysis

ObjectivesThis study sought to determine the frequency, incidence rates over time, association with mortality, and potential risk factors for hemocompatibility-related adverse events (HRAEs) occurring during venoarterial-extracorporeal life support (VA-ECLS). BackgroundHRAEs are common complications of VA-ECLS. Studies examining relevant clinical predictors and the association of HRAEs with survival are limited by small sample size and single-center setting. MethodsWe queried adult patients supported with VA-ECLS from 2010 to 2017 in the Extracorporeal Life Support Organization database to assess the impact of HRAEs on in-hospital mortality. ResultsAmong 11,984 adults meeting study inclusion, 8,457 HRAEs occurred; 62.1% were bleeding events. The HRAE rate decreased significantly over the study period (p trend <0.001), but rates of medical bleeding and ischemic stroke remained stable. HRAEs had a cumulative association with mortality in adjusted analysis: 1 event, odds ratio (OR) of 1.43; 2 events, OR of 1.86; ≥3 events, OR of 3.27 (p < 0.001 for all). HRAEs most strongly associated with mortality were medical bleeding, including intracranial (OR: 7.71), pulmonary (OR: 3.08), and gastrointestinal (OR: 1.95) hemorrhage and ischemic stroke (OR: 2.31); p < 0.001 for all. Risk factors included the following: for bleeding: older age, lower pH, and female sex; for thrombosis: younger age, male sex, Asian race, and non-polymethylpentene oxygenator; and for both: time on ECLS, central cannulation, and renal failure. ConclusionsAlthough decreasing, HRAEs remain common during VA-ECLS and have a cumulative association with survival. Bleeding events are twice as common as thrombotic events, with a hierarchy of HRAEs influencing survival. Differential risk factors for bleeding and thrombotic complications exist and raise the possibility of a tailored approach to ECLS management.

Mortality trends in neonatal ECMO for pulmonary hypoplasia: A review of the Extracorporeal Life Support Organization database from 1981 to 2016

BackgroundThe purpose of this review is to provide ECMO outcome data for medical personnel who counsel families of patients with pulmonary hypoplasia (PH), often secondary to renal abnormalities. We report diagnoses and outcomes associated with PH in neonates that were treated with ECMO over the past 35 years. MethodsRetrospective cohort study using the ELSO database for neonates born between 1981 and 2016 with a primary or secondary diagnosis of PH. Five patient groups were created based on ICD-9 codes. Mortality rates were compared and trends over time were investigated. ResultsThirty-three percent of the 1385 patients survived to discharge. Congenital diaphragmatic hernia (CDH) patients had significantly higher mortality than PH patients secondary to renal dysplasia (p < 0.001). Mortality decreased significantly over time for all groups (p < 0.001). The proportion of patients alive at discharge increased over time for CDH patients (p < 0.001), whereas survival decreased for patients with PH secondary to renal dysplasia (p = 0.012). ConclusionsNeonates with PH that require ECMO have high mortality rates, which have generally decreased over the past 35 years; however, mortality for neonates with PH secondary to renal dysplasia continues to increase. We speculate that the apparent rise in mortality for these patients is because of changes in patient selection subsequent to improvements in non-ECMO ventilatory support. Level of evidenceII

The Known Unknowns of Obesity and Extracorporeal Membrane Oxygenation.

The Known Unknowns of Obesity and Extracorporeal Membrane Oxygenation.

Outcomes of Adults with Congenital Heart Disease Supported with Extracorporeal Life Support After Cardiac Surgery.

Patients with adult congenital heart disease (ACHD) who undergo cardiac surgery may require extracorporeal life support (ECLS) for cardiopulmonary support, but outcomes after ECLS support have not been well described. This study aimed to identify risk factors for ECLS mortality in this population. We identified 368 ACHD patients who received ECLS after cardiac surgery between 1994 and 2016 in the Extracorporeal Life Support Organization (ELSO) database, a multicenter international registry of ECLS centers. Risk factors for mortality were assessed using multivariate logistic regression. Overall mortality was 61%. In a multivariate model using precannulation characteristics, Fontan physiology (odds ratio [OR]: 5.7; 95% CI: 1.6-20.0), weight over 100 kg (OR: 2.6; 95% CI: 1.3-5.4), female gender (OR: 1.6; 95% CI: 1.001-2.6), delayed ECLS cannulation (OR: 2.0; 95% CI: 1.2-3.2), and neuromuscular blockade (OR: 1.9; 95% CI: 1.1-3.3) were associated with increased mortality. Adding postcannulation characteristics to the model, renal complications (OR: 3.0; 95% CI: 1.7-5.2), neurologic complications (OR, 4.7; 95% CI: 1.5-15.2), and pulmonary hemorrhage (OR: 6.4; 95% CI: 1.3-33.2) were associated with increased mortality, whereas Fontan physiology was no longer associated, suggesting the association of Fontan physiology with mortality may be mediated by complications. Fontan physiology was also a risk factor for neurologic complications (OR: 8.2; 95% CI: 3.3-20.9). Given the rapid increase in ECLS use, understanding risk factors for ACHD patients receiving ECLS after cardiac surgery will aid clinicians in decision-making and preoperative planning.

Extracorporeal Membrane Oxygenation in Pediatric Pulmonary Hypertension.

To describe the epidemiology, critical care interventions, and mortality of children with pulmonary hypertension receiving extracorporeal membrane oxygenation. Retrospective analysis of prospectively collected multicenter data. Data entered into the Extracorporeal Life Support Organization database between January 2007 and November 2018. Pediatric patients between 28 days and 18 years old with a diagnosis of pulmonary hypertension. Six hundred thirty-four extracorporeal membrane oxygenation runs were identified (605 patients). Extracorporeal membrane oxygenation support type was pulmonary (43.1%), cardiac (40.2%), and extracorporeal cardiopulmonary resuscitation (16.7%). The majority of cannulations were venoarterial (80.4%), and 30% had a pre-extracorporeal membrane oxygenation cardiac arrest. Mortality in patients with pulmonary hypertension was 51.3% compared with 44.8% (p = 0.001) in those without pulmonary hypertension. In univariate analyses, significant predictors of mortality included age less than 6 months and greater than 5 years; pre-extracorporeal membrane oxygenation cardiac arrest; pre-extracorporeal membrane oxygenation blood gas with pH less than 7.12, PaCO2 greater than 75, PaO2 less than 35, and arterial oxygen saturation less than 60%; extracorporeal membrane oxygenation duration greater than 280 hours; extracorporeal cardiopulmonary resuscitation; and extracorporeal membrane oxygenation complications including cardiopulmonary resuscitation, inotropic support, myocardial stun, tamponade, pulmonary hemorrhage, intracranial hemorrhage, seizures, other hemorrhage, disseminated intravascular coagulation, renal replacement therapy, mechanical/circuit problem, and metabolic acidosis. A co-diagnosis of pneumonia was associated with significantly lower odds of mortality (odds ratio, 0.5; 95% CI, 0.3-0.8). Prediction models were developed using three sets of variables: 1) pre-extracorporeal membrane oxygenation (age, absence of pneumonia, and pH < 7.12; area under the curve, 0.62); 2) extracorporeal membrane oxygenation related (extracorporeal cardiopulmonary resuscitation, any neurologic complication, pulmonary hemorrhage, renal replacement therapy, and metabolic acidosis; area under the curve, 0.72); and 3) all variables combined (area under the curve, 0.75) (p < 0.001). Children with pulmonary hypertension who require extracorporeal membrane oxygenation support have a significantly greater odds of mortality compared with those without pulmonary hypertension. Risk factors for mortality include age, absence of pneumonia, pre-extracorporeal membrane oxygenation acidosis, extracorporeal cardiopulmonary resuscitation, pulmonary hemorrhage, neurologic complications, renal replacement therapy, and acidosis while on extracorporeal membrane oxygenation. Identification of those pulmonary hypertension patients requiring extracorporeal membrane oxygenation who are at even higher risk for mortality may inform clinical decision-making and improve prognostic awareness.

The development of multiorgan dysfunction in CDH-ECMO neonates is associated with the level of pre-ECMO support

PurposeCongenital diaphragmatic hernia (CDH) is the most common indication for neonatal extracorporeal membrane oxygenation (ECMO), but mortality remains at 50%. Multiorgan failure can occur in 25% and has been linked to worse outcomes. We sought to examine the factors that would increase the risk of multiorgan dysfunction (MOD). MethodsThe Extracorporeal Life Support Organization (ELSO) database was used to identify infants with CDH (2000–2015). The primary outcome was MOD, which was defined as the presence of organ failure in ≥2 organ systems. We used a multivariable logistic regression to examine the effect of demographics, pre-ECMO respiratory status, comorbidities, and therapies on MOD. ResultsThere were a total of 4374 CDH infants who were treated with ECMO. Overall mortality was 52.4%. The risk models demonstrated that pre-ECMO cardiac arrest (OR 1.458, CI: 1.146–1.861, p = 0.002) and hand-bagging (OR 1.461, CI: 1.094–1.963, p = 0.032) had the strongest association with MOD. In addition, other pre-ECMO indicators of disease severity (pH, HFOV, MAP, 5-min APGAR) and pre-ECMO therapies (bicarb, neuromuscular [NM] blockers) were also associated with MOD. ConclusionsThe level of pre-ECMO support has a significant association with the development of MOD, and initiation of ECMO prior to arrest seems to be critical to avoid complications. Type of studyTreatment study. Level of evidenceLevel III.