Extracorporeal Membrane Oxygenation Devices Research Articles

No Sequestration of Commonly Used Anti-Infectives in the Extracorporeal Membrane Oxygenation (ECMO) Circuit-An Ex Vivo Study.

Patients undergoing extracorporeal membrane oxygenation (ECMO) often require therapy with anti-infective drugs. The pharmacokinetics of these drugs may be altered during ECMO treatment due to pathophysiological changes in the drug metabolism of the critically ill and/or the ECMO therapy itself. This study investigates the latter aspect for commonly used anti-infective drugs in an ex vivo setting. A fully functional ECMO device circulated an albumin-electrolyte solution through the ECMO tubes and oxygenator. The antibiotic agents cefazolin, cefuroxim, cefepime, cefiderocol, linezolid and daptomycin and the antifungal agent anidulafungin were added. Blood samples were taken over a period of four hours and drug concentrations were measured via high-pressure liquid chromatography (HPLC) with UV detection. Subsequently, the study analyzed the time course of anti-infective concentrations. The results showed no significant changes in the concentration of any tested anti-infectives throughout the study period. This ex vivo study demonstrates that the ECMO device itself has no impact on the concentration of commonly used anti-infectives. These findings suggest that ECMO therapy does not contribute to alterations in the concentrations of anti-infective medications in severely ill patients.

Cardiac ECMO: changing role in times of Impella and ventricular assist devices?

Mortality in infarct-related as well as heart failure-associated cardiogenic shock remains high, reaching 40-50% depending on the etiology and severity of cardiogenic shock. Percutaneous active mechanical circulatory support devices including veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and microaxial left ventricular mechanical circulatory support devices are rapidly evolving in their use. However, evidence of VA-ECMO therapy has only recently emerged and showed no benefit for mortality, with an associated higher complication rate. Evidence for microaxial left ventricular mechanical circulatory support devices such as the Impella pump (Abiomed, Danvers/MA, USA) is limited. The current article aims to give an overview of the basics of VA-ECMO therapy and microaxial left ventricular mechanical circulatory support devices, the current evidence, ongoing trials, patient selection, and potential complications. This article is freely available.

NURSING CARE OF AN ADULT PATIENT UNDERGOING VENO-VENOUS EXTRA CORPOREAL MEMBRANE OXYGENATION (VV ECMO)

In today's dynamic medical environment, evolving technologies and advanced life-saving therapies pose new challenges to nursing care. One of the pioneering achievements in this field is veno-venous ECMO (extracorporeal membrane oxygenation) therapy, which plays a key role in the treatment of adult patients with severe respiratory failure. ECMO, also known as artificial respiratory support, is a revolutionary step towards more effective care for critically ill patients. This article is devoted to a deeper understanding of the role of nurses in the care of an adult patient undergoing venovenous ECMO therapy. Venovenous ECMO therapy is a procedure in which a patient's blood is pumped outside the body, where it is oxygenated, and then reintroduced into the circulation. For adult patients with advanced respiratory failure who do not achieve effective improvement with traditional treatment methods, ECMO often becomes the last resort. However, the complex nature of this therapy requires commitment and expertise from nurses to provide effective patient care. One of the main challenges that venovenous ECMO therapy poses to nurses is monitoring the patient's precise physiological parameters. Strict control of blood pressure, oxygen levels and organ perfusion becomes crucial to the success of therapy. Nurses therefore act as guardians of physiological stability, constantly reacting to possible instabilities and adjusting the parameters of the device under control. It is also worth emphasizing that nursing care for a patient undergoing venovenous ECMO therapy is not limited only to technical aspects. The comprehensiveness of this type of treatment is also associated with concern for the patient's psychosocial aspects. Long-term connection to an ECMO device can cause emotional and mental stress in the patient, which makes the support of nurses in the field of psychological care extremely important. Nurses act as both medical professionals and empathetic companions in difficult times, which translates into the overall success of therapy. The article will also focus on nurses' protocols for dealing with a patient undergoing venovenous ECMO therapy. From an excellent understanding of device maintenance to effective communication with the entire healthcare team, nurses play a key role in ensuring safe and effective therapy. As technology advances and life therapies become more advanced, nurses' skills are continually improved to meet the demands of modern medical care.

ECMOve: A Mobilization Device for Extracorporeal Membrane Oxygenation Patients.

Extracorporeal membrane oxygenation (ECMO) is a temporary lifesaving treatment for critically ill patients with severe respiratory or cardiac failure. Studies demonstrated the feasibility of in-hospital mobilizing during and after ECMO treatment preventing neuromuscular weakness and impaired physical functioning. Despite more compact mobile ECMO devices, implementation of ambulatory ECMO remains labor-intensive, complex, and challenging. It requires a large multidisciplinary team to carry equipment, monitor and physically support the patient, and to provide a back-up wheelchair in case of fatigue. Moreover, there is no adequate solution to ensure the stability of the patient's cannula and circuit management during ambulation. We developed a system contributing to improvement and innovation of current ambulatory ECMO patient programs. Our modular cart-in-cart system carries necessary ECMO equipment, features an extendable walking frame, and contains a folding seat for patient transport. An adjustable shoulder brace with lockable tubing-connectors enables safe fixation of the blood tubing. ECMOve provides safety, support, and accessibility while performing ambulatory ECMO for both patient and caregiver. Prototype evaluation in a simulated intensive care unit showed feasibility of our design, but needs to be evaluated in clinical care.

A Deep Learning Framework for Predicting Patient Decannulation on Extracorporeal Membrane Oxygenation Devices: Development and Model Analysis Study

Background Venovenous extracorporeal membrane oxygenation (VV-ECMO) is a therapy for patients with refractory respiratory failure. The decision to decannulate someone from extracorporeal membrane oxygenation (ECMO) often involves weaning trials and clinical intuition. To date, there are limited prognostication metrics to guide clinical decision–making to determine which patients will be successfully weaned and decannulated. Objective This study aims to assist clinicians with the decision to decannulate a patient from ECMO, using Continuous Evaluation of VV-ECMO Outcomes (CEVVO), a deep learning–based model for predicting success of decannulation in patients supported on VV-ECMO. The running metric may be applied daily to categorize patients into high-risk and low-risk groups. Using these data, providers may consider initiating a weaning trial based on their expertise and CEVVO. Methods Data were collected from 118 patients supported with VV-ECMO at the Columbia University Irving Medical Center. Using a long short-term memory–based network, CEVVO is the first model capable of integrating discrete clinical information with continuous data collected from an ECMO device. A total of 12 sets of 5-fold cross validations were conducted to assess the performance, which was measured using the area under the receiver operating characteristic curve (AUROC) and average precision (AP). To translate the predicted values into a clinically useful metric, the model results were calibrated and stratified into risk groups, ranging from 0 (high risk) to 3 (low risk). To further investigate the performance edge of CEVVO, 2 synthetic data sets were generated using Gaussian process regression. The first data set preserved the long-term dependency of the patient data set, whereas the second did not. Results CEVVO demonstrated consistently superior classification performance compared with contemporary models (P<.001 and P=.04 compared with the next highest AUROC and AP). Although the model’s patient-by-patient predictive power may be too low to be integrated into a clinical setting (AUROC 95% CI 0.6822-0.7055; AP 95% CI 0.8515-0.8682), the patient risk classification system displayed greater potential. When measured at 72 hours, the high-risk group had a successful decannulation rate of 58% (7/12), whereas the low-risk group had a successful decannulation rate of 92% (11/12; P=.04). When measured at 96 hours, the high- and low-risk groups had a successful decannulation rate of 54% (6/11) and 100% (9/9), respectively (P=.01). We hypothesized that the improved performance of CEVVO was owing to its ability to efficiently capture transient temporal patterns. Indeed, CEVVO exhibited improved performance on synthetic data with inherent temporal dependencies (P<.001) compared with logistic regression and a dense neural network. Conclusions The ability to interpret and integrate large data sets is paramount for creating accurate models capable of assisting clinicians in risk stratifying patients supported on VV-ECMO. Our framework may guide future incorporation of CEVVO into more comprehensive intensive care monitoring systems.

Efficacy and safety of post-closure technique using Perclose ProGlide/ProStyle device for large-bore mechanical circulatory support access sites

PurposeMechanical circulatory support (MCS) using a venoarterial extracorporeal membrane oxygenation (VA-ECMO) device or a catheter-type heart pump (Impella) is critical for the rescue of patients with severe cardiogenic shock. However, these MCS devices require large-bore cannula access (14-Fr and larger) at the femoral artery or vein, which often requires surgical decannulation. MethodsIn this retrospective study, we evaluated post-closure method using a percutaneous suture-mediated vascular closure system, Perclose ProGlide/ProStyle (Abbott Vascular, Lake Bluff, IL, Perclose), as an alternative procedure for MCS decannulation. Closure of 83 Impella access sites and 68 VA-ECMO access sites performed using Perclose or surgical method between January 2018 and March 2023 were evaluated. ResultsMCS decannulation using Perclose was successfully completed in all access sites without surgical hemostasis. The procedure time of ProGlide was shorter than surgical decannulation for both Impella and VA-ECMO (13 min vs. 50 min; p < 0.001, 21 min vs. 65 min; p < 0.001, respectively). There were no significant differences in the 30-day survival rate and major adverse events by decannulation including arterial dissection requiring endovascular treatment, hemorrhage requiring a large amount of red blood cell transfusion, and access site infection. ConclusionOur results suggest that the post-closure technique using the percutaneous suture-mediated closure system appears to be a safe and effective method for large-bore MCS decannulation.

Multimodality Quantification of Thrombus Deposition in Extracorporeal Membrane Oxygenation (ECMO); Correlating Oxygenator Computed Tomography Imaging, Electron Microscopy and Histology to Clinical Outcomes

Introduction: Extracorporeal membrane oxygenation (ECMO) is essential for supporting cardiopulmonary function in critically ill patients, However, ECMO incurs thrombogenic risks due to activation of coagulation factors and blood cells by the biomaterial surfaces. This leads to complications such as frequent device replacement and systemic embolization despite the use of anticoagulation, suggesting additional mechanisms contribute to medical device-associated thrombosis. We propose that the geometry of the ECMO oxygenator significantly influences the structure and extent of clot formation and stability. To investigate this, we employed quantitative imaging and histologic techniques for a high-resolution, three-dimensional analysis of clot morphology in ECMO components, aiming to enhance our understanding of clot formation mechanisms, correlate these observations to clinical outcomes, and develop effective mitigation strategies. Methods: We developed a prospective study in which patients consented to the collection of blood samples, used ECMO components, and collection of relevant clinical variables. Computed tomography (CT) images were acquired using an Inveon microCT. H&amp;E stains, scanning electron microscopy (SEM), and CT images were processed through the Dragonfly software to accomplish a 3D visualization and analysis of clot composition. Clinical demographics and ECMO characteristics were recorded for each patient. Results: Digital photographs of used oxygenators are displayed in figure (A). Through CT scans, we quantified clot formation of distinct densities across the layers of the ECMO oxygenator (D). The results were able to quantify intraoxygenator thrombosis with high fidelity (27.65%, 14.56%, and 26.35% of the available membrane area was thrombosed across three representative oxygenators). Using a frontal CT scan to investigate clot formation identified five layers of varying structures across the intended path of blood flow (B). Clot formation was observed in layer 4 and layer 5, in which thrombosis occluded up to 12.2% of the layer on average. The overall ranking of clot formation under hemodynamic performance changes for all five layers was as follows: layer 5 &amp;gt; layer 4 &amp;gt; layer 1 = layer 2 &amp;gt;&amp;gt; layer 3. The use of anticoagulation at the time of ECMO decannulation significantly reduced the content of clot formation (P&amp;lt;0.0001). We then correlated digital biomarkers from imaging with thrombus composition. Detailed histological examination (HE) and SEM was undertaken on dismantled oxygenators (B &amp; C). We focused on thrombi at the interfaces and within the hollow fibers of the oxygenator. SEM and HE staining illustrated increased thickness, length, and density of fibrin structures in the thrombi from layer 5 to layer 4, whereas the numbers of platelets and cells decreased. Overall, layer 5 exhibited the most diverse types of thrombi, including blood cell-rich, platelet-rich, and fibrin-rich clots. We also observed aligned clots and significant clot formation in the hollow fiber area of layer 4, reflecting the geometry of the specific layer. Discussion: This pilot study examined the potential for imaging-based modalities to evaluate device associated thrombosis ex vivo, correlating these imaging findings to direct observations of thrombus composition and location. This methodology provides a platform to investigate ECMO device failure, identifying the key locations within select oxygenators where local device modification may be of most benefit. Future research will prioritize designing membrane oxygenator properties to minimize thrombus deposition, and will allow us to incorporate the use of serial imaging endpoints in future clinical trials evaluating medical device-associated thrombosis.

Outcome of COVID-19 patients treated with VV-ECMO in Tyrol during the pandemic

Summary Introduction A small percentage of patients infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV‑2) showed severe respiratory deterioration requiring treatment with extracorporeal membrane oxygenation (ECMO). During the pandemic surges availability of ECMO devices was limited and resources had to be used wisely. The aim of this analysis was to determine the incidence and outcome of venovenous (VV) ECMO patients in Tyrol, when criteria based on the Extracorporeal Life Support Organization (ELSO) guidelines for VV-ECMO initiation were established. Methods This is a secondary analysis of the Tyrol-CoV-ICU-Reg, which includes all patients admitted to an intensive care unit (ICU) during the coronavirus disease 2019 (COVID-19) pandemic in Tyrol. Of the 13 participating departments, VV-ECMO was performed at 4 units at the University Hospital Innsbruck. Results Overall, 37 (3.4%) of 1101 patients were treated with VV-ECMO during their ICU stay. The hospital mortality rate was approximately 40% (n = 15). Multiorgan failure due to sepsis was the most common cause of death. No significant difference in survival rates between newly initiated and experienced centers was observed. The median survival time of nonsurvivors was 27 days (interquartile range, IQR: 22–36 days) after initiation of VV-ECMO. Acute kidney injury meeting the Kidney Disease: Improving Global Outcomes (KDIGO) criteria occurred in 48.6%. Renal replacement therapy (RRT) was initiated in 12 (32.4%) patients after a median of 18 days (IQR: 1–26 days) after VV-ECMO start. The median length of ICU and hospital stays were 38 days (IQR: 30–55 days) and 50 days (IQR: 37–83 days), respectively. Discussion Despite a rapidly increased demand and the resulting requirement to initiate an additional ECMO center, we could demonstrate that a structured approach with interdisciplinary collaboration resulted in favorable survival rates similar to multinational reports.

40: Preliminary Data on the Safety and Performance of a Novel Extracorporeal Membrane Oxygenation Device in a Long-term Ovine Model

40: Preliminary Data on the Safety and Performance of a Novel Extracorporeal Membrane Oxygenation Device in a Long-term Ovine Model

Pneumatic driven pulsatile ECMO in vitro evaluation with oxygen tanks.

Extracorporeal membrane oxygenation device is a procedure in which mechanical systems circulate blood and supply oxygen to patients with impaired cardiopulmonary function. Current venoarterial systems are associated with low patient survival rates and new treatments are needed to avoid left ventricular dilation, which is a major cause of death. In this study, a new mobile pulsatile ECMO with a pump structure that supplies pulsatile flow by using an oxygen tank as a power source is proposed. In vitro experiments conducted under mock circulation system as like patient conditions demonstrated that 2.8L oxygen can sustain the outflow of 1L/min of pulsatile blood flow for 53min, while a 4.6L tank was able to sustain the same flow for 85min. The energy equivalent pressure evaluation index of the pulsatile blood pump shows that the mobile pulsatile ECMO could supply sufficient pulsatile blood flow compared to the existing pulsatile ECMO. Through in vitro experiments performed under mock circulation conditions, this new system was proven to supply sufficient oxygen and pulsatile blood flow using the pressure of an oxygen tank even while transporting a patient.

Relative risk of primary bloodstream infection in patients with mechanical circulatory support devices

Background: Patients requiring mechanical circulatory support (MCS) during episodes of cardiogenic shock are at risk for hospital-acquired bloodstream infection (HABSI). Clinically MCS devices include extracorporeal membrane oxygenation (ECMO) devices, durable and temporary left ventricular-assist devices (VADs), and intra-aortic balloon pumps (IABPs). However, the MCS exclusion to the NHSN central-line–associated bloodstream infection (CLABSI) surveillance rules in 2018 did not include IABP as a qualifying device. We have described utilization and incidence of primary HABSI (pHABSI) in our patients requiring MCS. Methods: The setting for this study was 9 cardiothoracic and heart failure intensive care units with 131 total beds at the Cleveland Clinic Main Campus. Surveillance for HABSI to include determination of CLABSI was performed prospectively. MCS-associated pHABSI were patients who had ECMO, LVAD, or IABP present for &gt;2 calendar days with device in place on the date of infection or removed the day before. A patient with 2 device types at time of infection was counted as a pHABSI for both groups. Patient, device, and MCS days were extracted from an electronic database. Non-MCS patient days were calculated as the difference between total patient days and total MCS days. The incidence of ECMO-, VAD-, and IABP-associated pHABSI were compared to each other and to non–MCS-associated pHABSI using OpenEpi version 3.01 software. Results: Surveillance results are shown in Table 1. During the observation period, there were 221 pHABSIs and 139,013 patient days. Moreover, 67 pHABSIs were associated with an MCS device over 17,044 total MCS days: 43 ECMO days, 18 VAD days, and 13 IABP days. Also, 9 patients had &gt;1 type of eligible device and 7 (39%) of the IABP-associated pHABSIs were CLABSIs.The cumulative incidences of pHABSI associated with ECMO, VAD, and IABP were 5.68, 4.59, and 2.34 per 1,000 MCS days, respectively. The incidence of IABP pHABSI was not significantly different from VAD pHABSI (P = .06), but it was different from ECMO pHABSI (P &lt; .01). The pHABSI rate for non-MCS days was 1.26 per 1,000 patient days. Conclusions: In our patients requiring MCS, the risk of pHABSI associated with IABP was significantly greater than in patients without MCS and was similar to patients with VAD. MCS of all types should be considered a risk for HABSI in patients with cardiogenic shock beyond the presence of a central line. Protocols to further prevent HABSI morbidity in IABP patients are needed.Disclosure: None

P69: ECMO mobilizing device

Extracorporeal Membrane Oxygenation (ECMO) is a temporary lifesaving treatment for critically ill patients suffering from severe respiratory and/or cardiac failure. Studies have demonstrated the feasibility of mobilization in ECMO patients within the hospital during their bridge to recovery or transplantation. Ambulatory ECMO is a comprehensive form of mobilization aimed at preventing neuromuscular weakness and impaired physical functioning during and after treatment. Despite more compact and mobile ECMO devices, the implementation of ambulatory ECMO remains a labour-intensive, complex, and challenging operation. Ambulatory ECMO requires a large multidisciplinary team to carry all the equipment, to monitor and physically support the patient, and to provide a back-up wheelchair in case of patient fatigue. Additionally, current device configuration contributes to unnecessary device transport. Moreover, there is no adequate solution for ensuring the stability of the patient’s cannula and circuit management during ambulation. We developed a system that contributes to the improvement and innovation of current ambulatory ECMO patient programs and combines: (1) A modular cart-in-cart system (A) consisting of two distinct carts - the stationary cart (B) and the ambulatory cart (C). The stationary cart carries the devices (e.g. heater-cooler) not required during ambulation and remains in the ICU next to the patient’s bed. The ambulatory cart carries all the necessary devices during ambulation and features an extendable walking frame (D) that ensures safe walking support for the patient. A foldable seat (E) allows the patient to sit and facilitates transport back to the ICU in case of patient fatigue. Additionally, a safety brake system prevents unintentional movement of the ambulatory cart. Devices on both carts can be (dis)connected through a multi-connector hub, enabling easy configuration of necessary fluids, gases, and electricity. The connection between the stationary and ambulatory cart is maintained by a foot pedal-controlled lift mechanism that prevents accidental disconnection of the multi-connector and enables transport of both carts simultaneously. The system also features a gas switching device that allows for convenient switching between wall-mounted gas and bottled gas. (2) A universal-sized shoulder brace (F) with integrated blood tubing connector that can be adjusted to the patient via Velcro closure, facilitates secure fixation of the blood tubing, and minimizes strain on the cannula. At the time of writing, the project is undergoing design optimization. Subsequently, a physical prototype will be constructed and subjected to verification and validation processes. Internal testing will be performed to assess compliance with the user requirements. The prototype will then be evaluated in a simulated ICU environment to determine its suitability for use in a clinical setting. The patent for this invention has been filed and is currently pending.

Intravenous enoxaparin as alternative ECMO anticoagulation over a period of 94 days: a case report

BackgroundUnfractionated heparin is used worldwide as a standard anticoagulation therapy for extracorporeal membrane oxygenation (ECMO) machines. However, its use brings about significant bleeding and thrombotic complications for critically ill patients. This case report shows that low molecular weight heparin together with ECMO-produced primary haemostasis pathology can be used as an alternative way of ECMO anticoagulation.Case presentationThis paper presents the case of a patient with respiratory failure who subsequently suffered from cardiac failure and spent 94 days on combined V-V and V-A ECMO devices (two ECMO devices running simultaneously on one patient) with intravenous enoxaparin used instead of unfractionated heparin anticoagulation. No life-threatening bleeding/thrombotic events happened during this period, nor did any technical problems with ECMO occur.ConclusionsIn this case report, continuous intravenous low molecular weight heparin anticoagulation was used as a safe alternative to ECMO anticoagulation.

Clinical practice of emergency department-initiated extracorporeal cardiopulmonary resuscitation for cardiac arrest in adults.

Clinical practice of emergency department-initiated extracorporeal cardiopulmonary resuscitation for cardiac arrest in adults.

Addressing inadequate blood flow during normothermic regional perfusion for in-situ donation after circulatory death grafts preservation.

Donation after circulatory death (DCD) has emerged as attainable strategy to tackle the issue of organ shortage, expanding the donor pool. The DCD concept has been applied to the multiple declinations of circulatory arrest, as per the Modified Maastricht Classification. Notwithstanding, whichever the scenario, DCD donors experience a variable warm ischemia time whose correlation with graft dysfunction is ascertained. This applies to both "controlled" (cDCD) donors (i.e., the timespan from the withdrawal of life-sustaining therapies to the onset of in-situ perfusion), and "uncontrolled" DCD (uDCD) (i.e., the low-flow period during cardiopulmonary resuscitation - CPR). This sums up to the no-flow time from cardiac arrest to the start of CPR for uDCD donors, and to the no-touch period for both uDCDs and cDCDs. Static and hypothermic storage may not be appropriate for DCD grafts. In order to overcome this ischemic insult, extracorporeal membrane oxygenation devices are adopted to guarantee the in-situ grafts preservation by means of techniques such as the normothermic regional perfusion (NRP) which consists in a selective abdominal perfusion obtained via the endovascular or surgical occlusion of the thoracic aorta. The maintenance of an adequate pump flood throughout NRP is therefore a sine qua non to accomplish the DCD donation. The issue of insufficient pump flow during NRP is prevalent and clinically significant but its management remains technically challenging and not standardized. Hereby we propose a systematic algorithmic approach to address this relevant occurrence.

Outcomes of Extracorporeal Membrane Oxygenation (ECMO) for COVID-19 Patients: A Multi-Institutional Analysis

In March 2020, COVID-19 was announced as a global pandemic. The first COVID-19 patient was connected to an ECMO device in Israel during that time. Since then, over 200 patients have required ECMO support due to COVID-19 infection. The present study is a multi-institutional analysis of all COVID-19 patients requiring veno-venous (VV) ECMO in Israel. The aim was to characterize and compare the survivors and deceased patients as well as establish risk factors for mortality. This retrospective multi-institutional study was conducted from March 2020 to March 2021 in eleven of twelve ECMO centers operating in Israel. All COVID-19 patients on VV ECMO support were included in the cohort. The patients were analyzed based on their comorbidities, procedural data, adverse event on ECMO, and outcomes. Univariate and multivariate analyses were used to compare the deceased and the surviving patients. The study included 197 patients, of which 150 (76%) were males, and the mean age was 50.7 ± 12 years. Overall mortality was 106 (54%). Compared with the deceased subjects, survivors were significantly younger (48 ± 11 vs. 53 ± 12 years), suffered less from ischemic heart disease (IHD) (3% vs. 12%), and were ventilated for a significantly shorter period (≤4 days) prior to cannulation (77% vs. 63%). Patients in the deceased group experienced more kidney failure and sepsis. Rates of other complications were comparable between groups. Based on this study, we conclude that early cannulation (≤4 days) of younger patients (≤55 years) may improve overall survival and that a history of IHD might indicate a reduced prognosis.

Tips and Tricks of Peripheral ECMO Cannulation and Management for Postcardiotomy Shock

Postcardiotomy cardiogenic shock is a severe and feared complication of open-heart surgery. Even if the frequency seems low, the mortality is very high. The use of an extracorporeal membrane oxygenation device in this context can save up to a third of patients, but its implantation and management must be carried out by specialized teams; proper cannulation technique will help prevent many complications and facilitate weaning from the device. For this, all steps and preventive measures must be known and respected, which may include the coexistence of other circulatory assistance devices.

Outcomes among ST-Elevation Myocardial Infarction (STEMI) patients with cardiogenic shock and COVID-19: A nationwide analysis

BackgroundThere is paucity of data regarding the characteristics and outcomes of patients admitted for ST Elevation Myocardial Infarction (STEMI) complicated by cardiogenic shock (CS) with concomitant Coronavirus Disease 2019 (COVID-19) infection. MethodsUsing the National Inpatient Sample (NIS) Database for the year 2020, we conducted a retrospective cohort study to investigate the outcomes of patients who sustained STEMI-associated cardiogenic shock (STEMI-CS) with concomitant COVID-19 infection looking at its impact on in-hospital mortality and secondarily at the in-hospital procedure and intervention utilization rates as well as hospital length of stay. ResultsWe identified a total of 22,775 patients with STEMI-CS, of which 1.71 % (n = 390/22,775) had COVID-19 infection. Using a stepwise survey multivariable logistic regression model that adjusted for patient and hospital level confounders, concomitant COVID-19 infection among STEMI-CS patients was found to be an independent predictor of overall in-hospital mortality compared to those without COVID-19 (adjusted OR 2.10; 95 % confidence interval [CI], 1.30–3.40). STEMI-CS patients with concomitant COVID-19 infection had similar in-hospital utilization rates for percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), extracorporeal membrane oxygenation (ECMO), percutaneous and durable left ventricular device, intra-arterial aortic balloon pump (IABP), renal replacement therapy (RRT), mechanical ventilation, as well as similar hospital lengths of stay. ConclusionConcomitant COVID-19 infection was associated with higher in-hospital mortality rates among patients with cardiogenic shock related to STEMI but had similar in-hospital procedure and intervention utilization rates as well as hospital length of stay.

Risk of COVID-19 infection among mobile extracorporeal membrane oxygenation team.

The transport of coronavirus-2019 (COVID-19) patients on extracorporeal membrane oxygenation (ECMO) is a challenging situation, especially for healthcare workers (HCWs), due to the risk of cross-infection. Hence, certain precautions are needed for their safety. The study aims to evaluate the risk of COVID-19 transmission to HCWs who transport COVID-19 patients on ECMO device. A retrospective review of adult patients with COVID-19 infection supported with ECMO and transported by ground route to the Medical Intensive Care Unit (MICU) at Hamad General Hospital (HGH) and a survey of HCWs involved in those cases. A total of 63 HCWs of the mobile ECMO team were exposed to COVID-19-positive patients on 199 occasions. HCWs exposure time was nearly 110 h, and the total transport distance was 1018 km. During the study period, only two of the mobile ECMO HCWs tested positive for COVID-19. There was zero incidence of transfer-associated injuries or accidents to HCWs. The risk of COVID-19 cross-infection to the mobile ECMO team seems to be very low, provided that strict infection prevention and control measures are applied.

Abstract 15122: Escalation Strategies, Management, and Outcomes of Acute Myocardial Infarction-Cardiogenic Shock Patients Receiving Percutaneous Left Ventricular Support

Introduction: Despite well-established device selection algorithms, there remain wide variations in mechanical circulatory support (MCS) device utilization in patients with cardiogenic shock complicating acute myocardial infarction (AMI-CS). Further, there are limited national-level data on the contemporary practices of MCS device use. Methods: To evaluate national utilization patterns of MCS devices, we identified adult admissions (&gt;18 years) with AMI-CS from the HCUP-NIS data (2005-2017). Use of MCS devices including intraaortic balloon pump (IABP), percutaneous left ventricular assist devices (pLVAD) (Impella/Tandem Heart), and extracorporeal membrane oxygenation (ECMO) during hospitalization was identified. We evaluated trends in the initial MCS device used (IABP alone, pLVAD alone, or ≥2 MCS devices), device escalation, bridging to durable LVAD/heart transplantation, and predictors of in-hospital mortality and device escalation. Results: Among a total of 327,283 AMI-CS admissions in this 13-year period, 132,146 (40.2%) had an MCS device with information on timing of placement. IABP, pLVAD, ≥2 MCS, and ECMO devices were used as initial device in 120,928 (92.0%), 8,202 (6.2%), 2,305 (1.7%), and 711 (0.1%) admissions, respectively. Most admissions were maintained on initiated MCS device with 1-1.5% being escalated (IABP to pLVAD/ECMO, pLVAD to ECMO). The median time to escalation across all devices categories was 2 (IQR 1-4) days. Urban, medium, and large-sized hospitals, and acute multiorgan failure were significant independent predictors of MCS escalation. In admissions receiving MCS, escalation of MCS device was associated with higher in-hospital mortality (adjusted OR 1.56, 95% CI 1.38-1.75; p &lt;0.001). Admissions receiving durable LVAD/heart transplantation increased over time in those initiated on pLVAD and ≥2 MCS devices resulting in lower in-hospital mortality. Conclusions: In this 13-year study, escalation from initial MCS device was associated with higher in-hospital mortality suggestive of higher acuity of illness. However, the observed increase in number of durable LVADs or heart transplantations may be an indication of the utility of these MCS devices as successful bridge therapies.