Incidence Of Extracorporeal Membrane Oxygenation Research Articles

Association between regional critical care capacity and the incidence of invasive mechanical ventilation for coronavirus disease 2019: a population-based cohort study

BackgroundCoronavirus disease 2019 (COVID-19) has exposed critical care supply shortages worldwide. This study aimed to investigate the association between regional critical care capacity and the incidence of invasive mechanical ventilation following novel COVID-19 during the pandemic in Japan, a country with a limited intensive care unit (ICU) bed capacity of a median of 5.1 ICU beds per 100,000 individuals.MethodsThis population-based cohort study used data from the CRoss Icu Searchable Information System database and publicly available databases provided by the Japanese government and Japanese Society of Intensive Care Medicine. We identified patients recently diagnosed with COVID-19, those who received invasive mechanical ventilation, and those who received extracorporeal membrane oxygenation (ECMO) between February 2020 and March 2023. We analyzed the association between regional critical care capacity (ICU beds, high-dependency care unit (HDU) beds, resource-rich ICU beds, and intensivists) and the incidence of invasive mechanical ventilation, ECMO, and risk-adjusted mortality across 47 Japanese prefectures.ResultsAmong the approximately 127 million individuals residing in Japan, 33,189,809 were recently diagnosed with COVID-19, with 12,203 and 1,426 COVID-19 patients on invasive mechanical ventilation and ECMO, respectively, during the study period. Prefecture-level linear regression analysis revealed that the addition of ICU beds, resource-rich ICU beds, and intensivists per 100,000 individuals increased the incidence of IMV by 5.37 (95% confidence interval, 1.99–8.76), 7.27 (1.61–12.9), and 13.12 (3.48–22.76), respectively. However, the number of HDU beds per 100,000 individuals was not statistically significantly associated with the incidence of invasive mechanical ventilation. None of the four indicators of regional critical care capacity was statistically significantly associated with the incidence of ECMO and risk-adjusted mortality.ConclusionsThe results of prefecture-level analyses demonstrate that increased numbers of ICU beds, resource-rich ICU beds, and intensivists are associated with the incidence of invasive mechanical ventilation among patients recently diagnosed with COVID-19 during the pandemic. These findings have important implications for healthcare policymakers, aiding in efficiently allocating critical care resources during crises, particularly in regions with limited ICU bed capacities.Registry and the registration no. of the study/trial The approval date of the registry was August 20, 2020, and the registration no. of the study was lUMIN000041450.

Risk Factors for the Mortality of Patients With Coronavirus Disease 2019 Requiring Extracorporeal Membrane Oxygenation in a Non-Centralized Setting: A Nationwide Study.

Limited data are available on the mortality rates of patients receiving extracorporeal membrane oxygenation (ECMO) support for coronavirus disease 2019 (COVID-19). We aimed to analyze the relationship between COVID-19 and clinical outcomes for patients receiving ECMO. We retrospectively investigated patients with COVID-19 pneumonia requiring ECMO in 19 hospitals across Korea from January 1, 2020 to August 31, 2021. The primary outcome was the 90-day mortality after ECMO initiation. We performed multivariate analysis using a logistic regression model to estimate the odds ratio (OR) of 90-day mortality. Survival differences were analyzed using the Kaplan-Meier (KM) method. Of 127 patients with COVID-19 pneumonia who received ECMO, 70 patients (55.1%) died within 90 days of ECMO initiation. The median age was 64 years, and 63% of patients were male. The incidence of ECMO was increased with age but was decreased after 70 years of age. However, the survival rate was decreased linearly with age. In multivariate analysis, age (OR, 1.048; 95% confidence interval [CI], 1.010-1.089; P = 0.014) and receipt of continuous renal replacement therapy (CRRT) (OR, 3.069; 95% CI, 1.312-7.180; P = 0.010) were significantly associated with an increased risk of 90-day mortality. KM curves showed significant differences in survival between groups according to age (65 years) (log-rank P = 0.021) and receipt of CRRT (log-rank P = 0.004). Older age and receipt of CRRT were associated with higher mortality rates among patients with COVID-19 who received ECMO.

Regional access to a centralized extracorporeal membrane oxygenation (ECMO) service in Victoria, Australia

IntroductionVictoria, Australia provides a centralised state ECMO service, supported by ambulance retrieval. Equity of access to this service has not been previously described. ObjectiveDescribe the characteristics of ECMO recipients and quantify geographical and socioeconomic influence on access. DesignRetrospective observational study with spatial mapping. Participants and settingAdult (≥18 years) ECMO recipients from July 2016–June 2022. Data from administrative Victorian Admissions Episodes Database analysed in conjunction with Australian Urban Research Infrastructure Network population data and choropleth mapping. Presumed ECMO modes were inferred from cardiopulmonary bypass and pre-hospital cardiac arrest codes. Spatial autoregressive models including Moran's test used for spatial lag testing. OutcomesDemographics and outcomes of ECMO recipients; ECMO incidence by patient residence (Statistical-Area Level 2, SA-2) and Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD); and ECMO utilisation adjusted for patient factors and linear distance from the central ECMO referral site. Results631 adults received ECMO over 6 years, after exclusion of paediatric (n = 242), duplicate (n = 135), and interstate or incomplete (n = 72) records. Mean age was 51.8 years, and 68.8 % were male. Overall ECMO incidence was 3.00 ± 3.95 per 105 population. 135 (21.4 %) were presumed VA-ECMO, 59 (9.3 %) presumed ECPR, and 437 (69.3 %) presumed VV-ECMO. Spatial lag was non-significant after adjusting for patient characteristics. Distance from the central referral site (dy/dx = 0.19, 95% CI −0.41–0.04, p = 0.105) and IRSAD score (dy/dx = 0.17, 95% CI −0.19–0.53, p = 0.359) did not predict ECMO utilisation. ConclusionVictorian ECMO incidence rates were low. We did not find evidence of inequity of access to ECMO irrespective of regional area or socioeconomic status.

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 >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 >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 < .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

Perioperative incidence of ECMO and IABP on 5901 mitral valve surgery procedures

BackgroundReport the incidence and results of peri-operative extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pump (IABP) of patients undergoing mitral valve surgery (MVS) through right mini-thoracotomy (RT) and conventional full sternotomy (FS) for a period of 6 years from eleven tertiary Cardiac Surgery Institutes of GVM Care & Research Italia.MethodsFrom January 2016 to November 2021, a total of 5901 consecutive patients underwent MVS through RT and FS. The primary outcome of the study was the mortality and incidence of low cardiac output syndrome (LCOS) treated with intra-aortic balloon pump (IABP) with or without inotropic support and the incidence of Postcardiotomy Cardiogenic Shock (PCS) treated with Veno-arterial (VA) Extracorporeal Membrane Oxygenation (ECMO) on patients undergoing mitral valve surgery (MVS) through right mini-thoracotomy (RT) versus conventional full sternotomy (FS).ResultsThe mean age was 66 ± 15 years, 3389 patients underwent in RT approach 2512 in FS, 3081 (52%) patients were male and 2.3% had previous cardiac operations. Cardiopulmonary bypass time was 93 min for RT and 81 min for FS and cross clamp time 75 min for RT and 63 min for FS for mitral valve repair. Incidence of perioperative IABP for the treatment of low cardiac output was reported on 99 patients (1.6%), 51 for RT (1.5%), 35% used inotropic support (adrenaline and milrinone) and 48 in FS (1.9), 28% use inotropic support, 21 patients died after IABP (3 RT and 18 FS). Incidence of perioperative VA-ECMO for the PCS treatment was 13 and 4 with IABP, 9 RT (0.2%) and 4 FS approach (0.15%), 12 patients died after VA-ECMO.ConclusionMinimally invasive mitral valve surgery is a safe and reproducible approach associated with low mortality and morbidity. ECMO and IABP incidence for the treatment of PCS was 0.2% and for Low cardiac output syndrome (LCOS) was 1.6% in elective mitral valve surgery is very low. The patients that use the perioperative IABP in minimally invasive mitral valve surgery (MIMVS) trough RT reported a reduced mortality compared to FS in relation to the operative risk and surgical technique. Low incidence of VA-ECMO was found in RT and FS approach, only one patient survived after VA-ECMO after minimally invasive mitral valve surgery.

Extracorporeal membrane oxygenation use in Trauma Quality Improvement Program centers: Temporal trends and future directions.

Increased clinical experience and the decreased need for systemic anticoagulation have renewed interest in the use of extracorporeal membrane oxygenation (ECMO) for posttraumatic respiratory and cardiopulmonary failure. The objectives of this study were to describe the incidence and temporal trends of ECMO use at trauma centers, the outcomes of trauma patients undergoing ECMO, and the characteristics of trauma centers providing ECMO. Data were derived from the American College of Surgeons Trauma Quality Improvement Program data set. We included adults with at least one severe injury admitted to a level I or II trauma center between 2012 and 2016 who received at least 1 day of mechanical ventilation. Patients were categorized based on whether or not they received ECMO during their admission. The primary outcome was change in the incidence of ECMO across study years. We also evaluated patient outcomes and variation in ECMO volumes across centers. Of 194,314 severely injured patients undergoing mechanical ventilation across 450 centers, 269 (0.14%) received ECMO. Extracorporeal membrane oxygenation patients had significantly higher mortality than non-ECMO patients (32% vs. 19%). The standardized rate of ECMO from 2012 to 2016 increased significantly from 75.2 to 179.0 cases per 100,000 severely injured patients undergoing mechanical ventilation. The average annual growth rate was 24%. Of the 82 centers(18%) reporting at least 1 ECMO trauma case, 34 (41%) reported only a single case. The use of ECMO for trauma, although rare, is rapidly increasing. Two thirds of patients who receive ECMO following traumatic injury survive their hospitalization. These data suggest that ECMO represents a potential treatment strategy for trauma patients with respiratory or cardiopulmonary failure. However, given the rarity of the procedure, there exists an opportunity to develop practice guidelines regarding the indications for, and approach to, ECMO in the setting of trauma. Therapeutic/care management, level IV.

Characterization of Extracorporeal Membrane Oxygenation Support for Single Ventricle Patients.

Extracorporeal membrane oxygenation (ECMO) can provide crucial support for single ventricle (SV) patients at various stages of palliation. However, characterization of the utilization and outcomes of ECMO in these unique patients remains incompletely studied. We performed a single-center retrospective review of SV patients between 2010 and 2017 who underwent ECMO cannulation with primary end point of survival to discharge and secondary end point of survival to decannulation or orthotopic heart transplantation (OHT). Multivariate analysis was performed for factors predictive of survival to discharge and survival to decannulation. Forty SV patients with a median age of one month (range: 3 days to 15 years) received ECMO support. The incidence of ECMO was 14% for stage I, 3% for stage II, and 4% for stage III. Twenty-seven (68%) patients survived to decannulation, and 21 (53%) patients survived to discharge, with seven survivors to discharge undergoing OHT. Complications included infection (40%), bleeding (40%), thrombosis (33%), and radiographic stroke (45%). Factors associated with survival to decannulation included pre-ECMO lactate (hazard ratio [HR]: 0.61, 95% confidence interval [CI]: 0.41-0.90, P = .013) and post-ECMO bicarbonate (HR: 1.24, 95% CI: 1.0-1.5, P = .018). Factors associated with survival to discharge included central cannulation (HR: 40.0, 95% CI: 3.1-500.0, P = .005) and lack of thrombotic complications (HR: 28.7, 95% CI: 2.1-382.9, P = .011). Extracorporeal membrane oxygenation can be useful to rescue SV patients with approximately half surviving to discharge, although complications are frequent. Early recognition of the role of heart transplant is imperative. Further study is required to identify areas for improvement in this population.

Dermabond as a Novel Solution for Needle-Hole Repair in Arterial Cannula while on Extracorporeal Membrane Oxygenation Therapy

The annual incidence of extracorporeal membrane oxygenation (ECMO) for adult patients is increasing. Indications may vary from acute lung injury, ECMO-assisted cardiopulmonary resuscitation, to cardiac failure with an inability to wean from cardiopulmonary bypass. Complications may happen to the ECMO circuit, including cannula leaks from holes, cracks, or other damage, during the support period. Here, we present a novel solution for repairing a bleeding structural leak in the side of an arterial cannula. Dermabond was used to seal a small leak in the cannula likely caused by an earlier accidental needle puncture. Dermabond was applied to the area of damage, then allowed to cure, and wrapped with Ioban for increased stability. The patient was weaned from ECMO 2 days later without any complications from the repair of the cannula. The cannula was unable to be exchanged because of the small thoracotomy used to gain access for cannulation, so a repair was attempted. Moving the cannula to the femoral vessel was ruled out because of continued hypoxia and fear of creating a mixing cloud. Although less invasive incisions are becoming more common in cardiac surgery, these incisions for ECMO may be problematic if issues related to cannulas arise.

Extracorporeal Membrane Oxygenation Characteristics and Outcomes in Adult Patients With Down Syndrome.

Patients with Down syndrome (DS) may have multiple medical issues that place them at risk for requiring extracorporeal membrane oxygenation. Use of extracorporeal membrane oxygenation in pediatric patients with Down syndrome has been described, but minimal data exist for extracorporeal membrane oxygenation use in adults with Down syndrome. The goal of this study was to describe the clinical characteristics and to determine if there were differences between adult extracorporeal membrane oxygenation patients with Down syndrome that were alive (aDS) versus those that died (dDS) prior to hospital discharge. Patients with Down syndrome that were 18 years and older registered in the Extracorporeal Life Support Organization registry from 1983 to 2016 were analyzed. Demographics and extracorporeal membrane oxygenation characteristics were recorded. A total of 21 adults with Down syndrome were identified. Incidence of extracorporeal membrane oxygenation in adults with Down syndrome was 0.88 per 1000 extracorporeal membrane oxygenation procedures. Hospital mortality was 57.1% (12/21). There were no significant differences between aDS versus dDS for age (24.9 ± 4.8 vs. 28.1 ± 10.2 years), weight (90.7 ± 13.0 vs. 79.1 ± 27.0 kg), gender (4 males vs. 8 males), initial pH (7.18 ± 0.19 vs. 7.27 ± 0.16), or initial pO2 (51.7 ± 13.9 vs. 45.4 ± 19.9), respectively. There were no significant differences between aDS versus dDS in duration of extracorporeal membrane oxygenation run (239 ± 159 h vs. 455 ± 570 h, respectively), ventilator or extracorporeal membrane oxygenation mode, and nitric oxide use. aDS had fewer incidences of mechanical and neurologic complications (41.7% vs. 0.0%, P < 0.05) versus dDS. There were no other significant differences in complication rates between the two groups. Use of extracorporeal membrane oxygenation in the adult population with Down syndrome is significantly less compared to the pediatric population with Down syndrome. Baseline characteristics are not predictive of overall survival. There were minimal differences noted between aDS versus dDS during their extracorporeal membrane oxygenation course. Mortality rates are similar to non-Down syndrome patients placed on extracorporeal membrane oxygenation. Extracorporeal membrane oxygenation may be a reasonable option for adult patients with Down syndrome requiring intensive care.

Extracorporeal Membrane Oxygenation Incidence, Characteristics, and Outcomes in Neonatal Down Syndrome Patients

Extracorporeal Membrane Oxygenation Incidence, Characteristics, and Outcomes in Neonatal Down Syndrome Patients

Interstage Survival for Patients with Hypoplastic Left Heart Syndrome After ECMO.

There is a reported 5-20% incidence of extracorporeal membrane oxygenation (ECMO) following stage I palliation for hypoplastic left heart syndrome (HLHS). This study compares the interstage mortality of HLHS patients supported with ECMO (HLHS-ECMO) to those who were not supported with ECMO (HLHS-nECMO) using the National Pediatric Cardiology Quality Improvement Initiative database. Patients with HLHS who survived to hospital discharge after stage I palliation were analyzed. HLHS-ECMO patients were compared to HLHS-non-ECMO patients with respect to demographics, surgical variables, and interstage survival. A total of 931 patients were identified in the database. Sixty-six (7.1%) patients were supported with ECMO during their stage I palliation admission. There were no statistically significant differences between the groups with respect to demographics or anatomic subtype. HLHS-ECMO patients were more likely to have a preoperative risk factor identified (62 vs. 48%, p=0.03) or require ECMO prior to stage I palliation (3 vs. 0.5%, p=0.03). HLHS-ECMO patients had a significantly higher incidence of death or transplant versus the HLHS-nECMO group (18 vs. 9%, p=0.03). Despite survival to discharge, patients with HLHS requiring ECMO after their palliation continue to have an increased risk of death/cardiac transplant versus patients that do not require ECMO. ECMO use is likely a marker for a high-risk patient group. These patients may benefit from closer follow-up during the interstage period.

Adverse Outcomes in Neonates and Children with Pulmonary Artery Hypertension Supported with ECMO.

Extracorporeal membrane oxygenation (ECMO) has been increasingly used to rescue neonates and children with cardiac or respiratory failure, and critical illnesses including pulmonary artery hypertension (PAH) unresponsive to conventional therapies. This study assesses mortality and outcomes in neonates and children with PAH supported with ECMO. Neonates and children from the 2012 Health Care Cost and Use Project Kids' Database were identified using ICD-9 codes. Children with congenital heart disease were excluded. Univariate logistic regression was applied to assess the relationship between ECMO and outcomes using matched cohorts for age, elective admission, and Elixhauser comorbidity score. We identified 9,355 neonates and children with PAH (0.15%). The incidence of ECMO was 1.4% (132/9,355). After propensity-matched analysis, 130 neonates and children were included in each group. The incidence of mortality was 39% in the group supported with ECMO and 8% in the control group (odds ratio [OR]: 6.98, 95% confidence interval [CI]: 3.43-14.21, p < 0.001). Neonates and children on ECMO had higher odds for acute kidney injury (OR: 2.41, 95% CI: 1.30-4.47, p = 0.005), neurologic complications (OR: 7.11, 95% CI: 1.57-32.18, p = 0.011), sepsis (OR: 2.69, 95% CI: 1.46-4.96, p = 0.002), and thrombotic complications (OR: 2.90, 95% CI: 1.10-7.67, p = 0.032). Neonates and children with PAH supported with ECMO have higher mortality rate and complications compared with matched controls with PAH.

Extracorporeal Membrane Oxygenation Incidence, Characteristics, and Outcomes in Neonatal Down Syndrome Patients.

Practice patterns for extracorporeal membrane oxygenation (ECMO) use in newborns with Trisomy 21 (T21) have not been fully reported. The goals of this study were to 1) determine the incidence of ECMO use in T21 neonates; 2) identify clinical and demographic characteristics associated with ECMO use in this population; 3) describe outcomes of neonates with T21 supported with ECMO. This was a retrospective cohort study using the Pediatric Health Information System database (January 2000 to January 2014). Given the exploratory nature, only descriptive statistics were used. p < 0.05 was considered significant. Within 43 pediatric hospitals, the incidence of ECMO use in neonates with T21 was 2.3% (131/5,737). Neonates with T21 supported with ECMO were more likely to be admitted earlier; have higher birth weight, gestational age, and longer hospitalization; and have congenital diaphragmatic hernia or select cardiac anomalies versus those who did not require ECMO. T21 neonates supported with ECMO also had higher incidence of bronchopulmonary dysplasia, necrotizing enterocolitis, and mortality (unadjusted odds ratio 12.3 [95% confidence interval: 8.6-17.6]) compared with T21 neonates not exposed to ECMO. Compared with T21 neonates not requiring ECMO, those supported with ECMO had increased morbidity and mortality. Additional investigation on timing, indications, and risk/benefit profiles, for ECMO use in T21 neonates is needed.

Factors affecting death and progression towards next stage following modified Blalock-Taussig shunt in neonates.

The modified Blalock-Taussig shunt (BTS) is utilized to palliate neonates born with restrictive pulmonary blood flow including those with single ventricle (SV) or biventricular (BV) cardiac anomalies. We aim in the current study to report palliation outcomes of neonates with BTS and to examine factors affecting death and progression to the subsequent stage of palliation or repair. Between 2002 and 2012, 341 patients underwent BTS including 175 with SV and 166 with BV anomalies. Competing risk analysis modelled events after BTS (death or transplantation, transition to Glenn shunt or biventricular repair) and examined risk factors affecting outcomes. SV patients had a higher incidence of extracorporeal membrane oxygenation (ECMO) support requirement (12 vs 4%, P = 0.004) and unplanned cardiac reoperation (14 vs 7%, P = 0.051) than their BV counterparts. Additionally, hospital mortality was higher in SV than in BV patients (15 vs 3%, P < 0.001). In SV patients, competing risk analysis showed that, 2 years following BTS, 27% of patients had died or received transplantation and 73% had undergone the Glenn shunt. On multivariable analysis, factors associated with time until death or transplantation prior to Glenn were cardiopulmonary bypass [hazard ratio (HR) 3.6 (2.0-6.4), P < 0.001], unplanned cardiac reoperation [HR 2.4 (1.3-4.6), P = 0.007], pulmonary atresia [HR 2.0 (1.1-3.7), P = 0.026] and the shunt size/weight ratio [HR 1.3 (1.1-1.4) per 0.1 increase, P = 0.001]. In BV patients, competing risk analysis showed that, 2 years following BTS, 13% of patients had died or received transplantation, 85% had undergone biventricular repair and 2% were alive without biventricular repair. On multivariable analysis, factors associated with time until death or transplantation prior to biventricular repair were genetic syndromes and extracardiac malformations [HR 6.1 (2.0-18.2), P = 0.001], weight ≤2.5 kg [HR 5.6 (2.0-16.0), P = 0.001] and male gender [HR 3.4 (1.1-11.0), P = 0.041]. Palliation with BTS continues to be associated with significant operative morbidity and mortality. In addition to hospital death, there is an important interstage attrition risk prior to subsequent palliation or biventricular repair. Inherent patient characteristics (i.e. genetic syndromes and low weight) and anatomical details (i.e. SV, pulmonary atresia and concomitant cardiac anomalies) are associated with worse survival.

Extracorporeal Membrane Oxygenation Incidence, Characteristics, and Outcomes in Neonatal Down Syndrome Patients

Extracorporeal Membrane Oxygenation Incidence, Characteristics, and Outcomes in Neonatal Down Syndrome Patients

Comparison of 30-Day Mortality between Anterior-Wall versus Inferior-Wall ST-Segment Elevation Myocardial Infarction Complicated by Cardiogenic Shock in Patients Undergoing Primary Coronary Angioplasty

Objectives: In this study, 30-day mortality from cardiogenic shock caused by left anterior descending artery (LAD) occlusion was compared with that caused by left circumflex (LCX) or right coronary artery (RCA) occlusion after primary percutaneous coronary intervention (PCI). Methods: Between May 2001 and December 2009, 212 consecutive patients with anterior-wall ST-elevation myocardial infarction complicated by cardiogenic shock due to LAD (n = 97) occlusion (group 1) and LCX or RCA (n = 115) occlusion (group 2) undergoing primary PCI were enrolled. Results: The results showed a higher mean peak level of creatine phosphokinase and incidence of extracorporeal membrane oxygenation in group 1 than group 2 (all p < 0.01). However, no significant difference was noted in the achievement of normal blood flow in the infarct-related artery (p = 0.461) and 30-day morality (p = 0.338). Univariate analysis demonstrated a significant association of 30-day morality with age, lower left-ventricular ejection fraction, advanced congestive heart failure and unsuccessful reperfusion (all p < 0.02). Multivariate analysis revealed unsuccessful reperfusion as the most independent predictor of 30-day mortality (p = 0.002). Conclusion: No significant difference was noted in 30-day mortality between patients with acute myocardial infarction and cardiogenic shock caused by LAD occlusion and by either RCA or LCX occlusion undergoing primary PCI.

Liver position and lung-to-head ratio for prediction of extracorporeal membrane oxygenation and survival in isolated left congenital diaphragmatic hernia

The purpose of this study was to determine the ability of liver position and lung-to-head ratio to predict outcome in isolated left congenital diaphragmatic hernia. We reviewed prenatal studies and postnatal outcomes of congenital diaphragmatic hernia between January 1996 and January 2006. Eighty-nine patients received prenatal and postnatal care at 1 institution. In fetuses with liver up, extracorporeal membrane oxygenation was required in 39 of 49 fetuses (80%), compared with 10 of 40 fetuses (25%) for those with liver down (P < .0001). Overall survival rate was 45%, compared with 93% for those with liver down (P < .00005). Low lung-to-head ratio (<1.0) predicted increased incidence of extracorporeal membrane oxygenation (75%; P = .036) and lower survival (35%; P = .0003). However, when measured at <24 weeks of gestation, lung-to-head ratio was not predictive of outcome (extracorporeal membrane oxygenation, P = .108; survival, P = .150); liver position remained highly predictive (extracorporeal membrane oxygenation, P = .006; survival, P = .001). Liver position is the best prenatal predictor of outcome in isolated left congenital diaphragmatic hernia. Lung-to-head ratio alone should not be used to counsel families regarding mid gestational management choices.

Liver position is best prenatal predictor of need for ECMO and survival in left congenital diaphragmatic hernia

SURVIVAL IN LEFT CONGENITAL DIAPHRAGMATIC HERNIA HOLLY HEDRICK, ENRICO DANZER, HUAQING ZHAO, AZIZ MERCHANT, ALAN FLAKE, KENNETH LIECHTY, LORI HOWELL, MARK JOHNSON, DOUGLAS WILSON, MICHAEL BEBBINGTON, SCOTT ADZICK, Children’s Hospital of Philadelphia, Center for Fetal Diagnosis and Treatment, Philadelphia, Pennsylvania, Children’s Hospital of Philadelphia, Biostatistics, Philadelphia, Pennsylvania OBJECTIVE: To compare the ability of liver position (LP) and lung-to-head circumference ratio (LHR) to predict the need for extracorporeal membrane oxygenation (ECMO) and survival in fetuses with isolated left congenital diaphragmatic hernia (LCDH). STUDY DESIGN: We reviewed prenatal studies, hospital course, and postnatal outcomes of LCDH presenting to a single institution between January 1996 and January 2006. Logistic regression models were used to explain the need for ECMO using LP, LHR and gestational age (GA). Survival was determined by Kaplan-Meier analysis. Cox regression models were used to explore associations between LHR, LP, GA and survival. RESULTS: Eighty-nine cases with LCDH received prenatal and postnatal care at our institution. Overall 10-year survival was 66.3% at median follow up of survivors 57.8 months (range, 8-120 months). LP was intrathoracic in 49/89 (55%). In fetuses with liver-up, 39/49 (80%) required ECMO compared to 10/ 40 (25%) for those with liver-down (p!0.0001). Ten-year survival rate was 45% compared to 93% for those with liver-down (p!0.0001). Severe LHR (!1.0) predicted increased incidence of ECMO (75%, p=0.036) and lower 10year survival rate (34%, p=0.0003). Median GA at LHR measurement was 24.3 weeks. A lower LHR correlated with an increased need for ECMO and shorter time to survival independent of GA at time of measurement (ECMO, p=0.008; survival, p=0.007). When GA and LP were jointly fit into models, LHR (ECMO p=0.19, survival p=0.067) was no longer predictive of outcome at less than 24 weeks while LP (ECMO p!0.0005, survival p=0.001) remained highly predictive. CONCLUSION: LP is the best prenatal predictor of need for ECMO and survival in LCDH. LHR alone should not be used to counsel families regarding midgestational management choices.

Cost-Effectiveness of Inhaled Nitric Oxide in the Treatment of Neonatal Respiratory Failure in the United States

Two recent randomized controlled trials (RCTs) reported that inhaled nitric oxide (iNO) decreased the incidence of extracorporeal membrane oxygenation (ECMO) or death in term and near-term newborns with hypoxic respiratory failure. Our objective was to estimate the cost-effectiveness ratio of iNO in this population. We studied 1000 simulation cohorts (n = 483 for each cohort) of term/near-term newborns with hypoxemic respiratory failure. We conducted our study following US Public Health Service Panel on Cost-Effectiveness in Health and Medicine guidelines, adopting the US societal perspective. We constructed a decision tree reflecting iNO use, subsequent ECMO use, death, and long-term neurologic and respiratory morbidity in survivors, as determined from the combined outcomes of the 2 RCTs (n = 483). We estimated costs on the basis of length-of-stay data for the initial episode of care from 1 of the RCTs, unit costs from administrative data sets, and current pricing for iNO. We ran a Monte Carlo simulation to generate estimates of differences in costs and effects at 1 year, along with the stochastic uncertainty around these estimates. We expressed effects as quality-adjusted survival, assuming quality of life = 1 with no comorbidity, 0.7 with 1 comorbidity, and 0.49 (0.7 x 0.7) with 2 comorbidities. We constructed a base case, in which iNO was initiated at tertiary care ECMO centers (mimicking the RCTs) and a Public Health Service Panel on Cost-effectiveness in Health and Medicine reference case, in which iNO was initiated at the local hospital before transfer (mimicking real-world practice). We exposed our assumptions to a sensitivity analysis. Direct application of the trial results (base case) suggested that iNO was both more effective and cheaper (cost savings of 1880 dollars per case despite acquisition costs of 5150 dollars, predominantly as a result of decreased need for ECMO), with 84.6% probability that the cost-effectiveness ratio was better than 100,000 dollars per quality-adjusted life-year. Under the reference case, iNO was also more effective (though slightly less so) and was even cheaper (cost savings of 4400 dollars per case), with 71.6% probability that iNO was cheaper and more effective and 91.6% probability that the cost effectiveness ratio was better than 100,000 dollars per quality-adjusted life-year. Sensitivity analyses showed these estimates to be sensitive to patient selection and the price of iNO but insensitive to assumptions regarding quality of life. From a US societal perspective, iNO has a favorable cost-effectiveness profile when initiated either at ECMO centers or at local hospitals in term/near-term neonates with hypoxemic respiratory failure.

A prospective randomized trial of delayed versus immediate repair of congenital diaphragmatic hernia

From March 1990 to January 1993, a randomized prospective study was performed to determine the optimal timing of surgery for infants with high-risk congenital diaphragmatic hernia (CDH). Thirty-two CDH patients who presented with respiratory distress within 12 hours after birth were randomly divided into two groups: Group A had early repair (within 6 hours), and group B had delayed repair (at 96 + hours). Extracorporeal membrane oxygenation (ECMO) was initiated in both groups as necessary. Fourteen patients were assigned to group A, and 18 were assigned to group B. Two patients inially assigned to group A had acute deterioration, and their operations had to be postponed. Data were collected, but these patients were eliminated from the study. The two groups were comparable based on gestational age, birth weight, Bohn's criteria, and oxygenation and ventilatory index. Nine of 12 group A patients (75%) survived, and 13 of 18 group B patients (72%) survived ( P > .05, not significant). The ECMO requirements for the two groups were not significantly different (8 of 12 (67%) v 16 of 18 (89%); P > .05). Surgical intervention for bleeding complications related to ECMO was required in three of eight (38%) with immediate repair and seven of 16 (44%) with delayed repair ( P > .05). There was no difference in survival nor incidence of ECMO between the two groups. This is the first prospective study of timing of hernia repair that supports the conclusions of earlier reports of retrospective studies.