Extracorporeal Membrane Oxygenation Initiation Research Articles

An investigation into the contributing factors to survival of ARDS patients supported by veno-venous ECMO.

This study aimed to identify characteristics associated with survival during and post Extra Corporeal Membrane Oxygenation (ECMO) therapy, in patients with acute respiratory distress syndrome (ARDS) during the COVID-19 pandemic. A retrospective observational study on 94 consecutive patients with confirmed COVID-19 induced ARDS supported by ECMO was carried out 49/94 (52.7%) patients survived to hospital discharge. Non-survivors were found to have significantly (p < .05) higher: Pre-ECMO International normalized ratios (INR), carbon dioxide partial pressure (pCO2), Acute Kidney Injury (AKI) scores and blood urea levels. Also, lower pre-ECMO peak inspiratory pressures (PIP), mean arterial pressure, saturation of arterial oxygen (SaO2), blood bicarbonate levels (HCO3), blood Ph and fewer trials off ECMO with shorter combined trial off times. Patients that did not survive were more likely to have renal impairment and have received peri-ECMO haemofiltration. Poor prognosis was significantly associated with: receiving pre-ECMO nitric oxide (HR = 3.047, CI = 1.247-7.447, p = .015), renal impairment (HR = 3.023, CI = 1.586-5.763, p < .001), AKI of 2 (HR = 3.611, CI = 1.382-9.441, p = .009) or 3 (HR = 3.275, CI = 1.235-8.685, p = .017), peri-ECMO haemofiltration (HR = 2.412, CI = 1.310-4.442, p = .005) and the ABO blood group B (HR = 3.103, CI = 1.335-7.212, p = .008). pre-ECMO high CO2 (HR = 1.134, CI = 1.031-1.248, p = .010), blood lactate (HR = 1.350, CI = 1.156-1.576, p < .001), INR (HR = 2.571, CI = 1.438-4.598, p=<0.001) and lower blood Ph (HR = 0.023, CI = 0.002-0.210, p < .001). Commonly used mortality scores may not be of use in a COVID-19 cohort of ECMO patients. The initiation of ECMO needs to be implemented prior to metabolic derangements, renal and fulminant respiratory failure.

The Jack-in-the-Box: Pericardial Decompression Syndrome Managed by a Multidisciplinary Approach with Early Initiation of Veno-Arterial Extracorporeal Membrane Oxygenation: A Case Report

The Jack-in-the-Box: Pericardial Decompression Syndrome Managed by a Multidisciplinary Approach with Early Initiation of Veno-Arterial Extracorporeal Membrane Oxygenation: A Case Report

Hypoalbuminemia is a predictor of mortality in patients with cardiogenic shock requiring veno-arterial extracorporeal membrane oxygenation.

Hypoalbuminemia is predictive of mortality in critically ill patients, especially those with cardiac etiologies of illness. The objective of this study was to determine the association of albumin level pre-cannulation for veno-arterial (V-A) extracorporeal membrane oxygenation (ECMO) and important clinical hospital outcomes. This was a retrospective, observational cohort study of albumin levels in patients with cardiogenic shock requiring V-A ECMO between December 2015 and August 2021 in a single, high-volume ECMO center. The primary outcome was in-hospital mortality. Of 434 patients assessed, 318 were included. The overall mean pre-ECMO albumin was 3 ± 0.8g/dL and mean albumin at 72 hours post-cannulation was 2.7 ± 0.5g/dL. For patients with pre-ECMO albumin ≤3g/dL vs. >3g/dL, in-hospital mortality was 44.9% vs. 27.5%, respectively (p = .002). In multivariable logistic regression analysis, higher albumin (per 1g/dL increase) at time of V-A ECMO initiation was associated with decreased odds of in-hospital mortality (OR, 0.68; 95% CI, 0.48-0.96; p = .03). Patients with a pre-ECMO albumin ≤3g/dL required significantly more platelet transfusions and had higher incidence of gastrointestinal bleeding during V-A ECMO support (both p < .05). Hypoalbuminemia at time of cannulation is significantly associated with in-hospital mortality and ECMO-related complications including platelet transfusion and gastrointestinal bleeding. Albumin levels at the time of consideration of V-A ECMO may serve as a key prognostic indicator and may assist in effective decision-making regarding this invasive and costly resource.

Epigenomic biomarkers insights in PBMCs for prognostic assessment of ECMO-treated cardiogenic shock patients

ObjectiveAs the global use of extracorporeal membrane oxygenation (ECMO) treatment increases, survival rates have not correspondingly improved, emphasizing the need for refined patient selection to optimize resource allocation. Currently, prognostic markers at the molecular level are limited.MethodsThirty-four cardiogenic shock (CS) patients were prospectively enrolled, and peripheral blood mononuclear cells (PBMCs) were collected at the initiation of ECMO (t0), two-hour post-installation (t2), and upon removal of ECMO (tr). The PBMCs were analyzed by comprehensive epigenomic assays. Using the Wilcoxon signed-rank test and least absolute shrinkage and selection operator (LASSO) regression, 485,577 DNA methylation features were analyzed and selected from the t0 and tr datasets. A random forest classifier was developed using the t0 dataset and evaluated on the t2 dataset. Two models based on DNA methylation features were constructed and assessed using receiver operating characteristic (ROC) curves and Kaplan–Meier survival analyses.ResultsThe ten-feature and four-feature models for predicting in-hospital mortality attained area under the curve (AUC) values of 0.78 and 0.72, respectively, with LASSO alpha values of 0.2 and 0.25. In contrast, clinical evaluation systems, including ICU scoring systems and the survival after venoarterial ECMO (SAVE) score, did not achieve statistical significance. Moreover, our models showed significant associations with in-hospital survival (p < 0.05, log-rank test).ConclusionsThis study identifies DNA methylation features in PBMCs as potent prognostic markers for ECMO-treated CS patients. Demonstrating significant predictive accuracy for in-hospital mortality, these markers offer a substantial advancement in patient stratification and might improve treatment outcomes.

A Randomized Embedded Multifactorial Adaptive Platform for Extra Corporeal Membrane Oxygenation (REMAP ECMO) – Design and Rationale of the Left Ventricular Unloading trial domain

BackgroundThe use of Extracorporeal Membrane Oxygenation (ECMO) remains associated with high rates of complications, weaning failure and mortality which can be partly explained by a knowledge gap on how to properly manage patients on ECMO support. To address relevant patient management issues, we designed a “Randomized Embedded Multifactorial Adaptive Platform (REMAP)” in the setting of ECMO (REMAP ECMO) and a first embedded randomized controlled trial (RCT) investigating the effects of routine early left ventricular (LV) unloading through intra-aortic balloon pumping (IABP). MethodsREMAP ECMO describes a registry-based platform allowing for the embedding of multiple response adaptive RCTs (trial domains) which can perpetually address the effect of relevant patient management issues on ECMO weaning success. A first trial domain studies the effects of LV unloading by means of an IABP as an adjunct to veno-arterial (V-A) ECMO versus V-A ECMO alone on ECMO weaning success at 30 days in adult cardiogenic shock patients admitted to the Intensive Care Unit (ICU). The primary outcome of this trial is “successful weaning from ECMO” being defined as a composite of survival without the need for mechanical circulatory support, heart transplantation, or left ventricular assist device (LVAD) at 30 days after initiation of ECMO. Secondary outcomes include the need for interventional escalation of LV unloading strategy, mechanistic endpoints, survival characteristics until one year after ECMO initiation, and quality of life. Trial data will be analysed using a Bayesian statistical framework. The adaptive design allows for a high degree of flexibility, such as response adaptive randomization and early stopping of the trial for efficacy or futility. The REMAP ECMO LV unloading study is approved by the Medical Ethical Committee of the Erasmus Medical Center and is publicly registered. ConclusionThis REMAP ECMO trial platform enables the efficient roll-out of multiple RCTs on relevant patient management issues. A first embedded trial domain will compare routine LV unloading by means of an IABP as an adjunct to V-A ECMO versus V-A ECMO alone. Trial registrationClinicalTrials.gov, NCT05913622

Model for End-Stage Liver Disease Including Na, Age, and Sex Is Powerful Predictor of Survival in COVID-19 Patients on Extracorporeal Membrane Oxygenation.

Extracorporeal membrane oxygenation (ECMO) is resource-intensive, is associated with significant morbidity and mortality, and requires careful patient selection. This study examined whether the model for end-stage liver disease (MELD) score is a suitable predictor of in-hospital mortality in patients with COVID-19. We retrospectively assessed patients with COVID-19 on ECMO at our institution from March 2020 to May 2021. MELD scoring was performed using laboratory values recorded prior to ECMO initiation. A multiple logistic regression model was established. A total of 66 patients with COVID-19 on ECMO were included (median age of 58.5 years; 83.3% male). The in-hospital mortality was 74.2%. In relation to mortality, patients with MELD Na scores >13.8 showed 6.5-fold higher odds, patients aged >53.5 years showed 18.4-fold higher odds, and male patients showed 15.9-fold higher odds. The predictive power of a model combining the MELD Na with age and sex was significant (AUC = 0.883, p < 0.001). The findings in the COVID-19 patients were not generalizable to a group of non-COVID-19 patients on ECMO. A model combining the MELD Na, age, and sex has high predictive power for in-hospital mortality in patients with COVID-19 on ECMO, and it may be clinically useful for guiding patient selection in critically ill COVID-19 patients both now and in the future, should the virus widely re-emerge.

Low-Frequency Ventilation May Facilitate Weaning in Acute Respiratory Distress Syndrome Treated with Extracorporeal Membrane Oxygenation: A Randomized Controlled Trial.

Although extracorporeal membrane ventilation offers the possibility for low-frequency ventilation, protocols commonly used in patients with acute respiratory distress syndrome (ARDS) and treated with extracorporeal membrane oxygenation (ECMO) vary largely. Whether strict adherence to low-frequency ventilation offers benefit on important outcome measures is poorly understood. Background/Objectives: This pilot clinical study investigated the efficacy of low-frequency ventilation on ventilator-free days (VFDs) in patients suffering from ARDS who were treated with ECMO therapy. Methods: In this single-center randomized controlled trial, 44 (70% male) successive ARDS patients treated with ECMO (aged 56 ± 12 years, SAPS III 64 (SD ± 14)) were randomly assigned 1:1 to the control group (conventional ventilation) or the treatment group (low-frequency ventilation during first 72 h on ECMO: respiratory rate 4-5/min; PEEP 14-16 cm H2O; plateau pressure 23-25 cm H2O, tidal volume: <4 mL/kg). The primary endpoint was VFDs at day 28 after starting ECMO treatment. The major secondary endpoint was ICU mortality, 28-day mortality and 90-day mortality. Results: Twenty-three (52%) patients were successfully weaned from ECMO and were discharged from the intensive care unit (ICU). Twelve patients in the treatment group and five patients in the control group showed more than one VFD at day 28 of ECMO treatment. VFDs were 3.0 (SD ± 5.5) days in the control group and 5.4 (SD ± 6) days in the treatment group (p = 0.117). Until day 28 of ECMO initiation, patients in the treatment group could be successfully weaned off of the ventilator more often (OR of 0.164 of 0 VFDs at day 28 after ECMO start; 95% CI 0.036-0.758; p = 0.021). ICU mortality did not differ significantly (36% in treatment group and 59% in control group; p = 0.227). Conclusions: Low-frequency ventilation is comparable to conventional protective ventilation in patients with ARDS who have been treated with ECMO. However, low-frequency ventilation may support weaning from invasive mechanical ventilation in patients suffering from ARDS and treated with ECMO therapy.

Extracorporeal membrane oxygenation in the therapy of cardiogenic shock: 1-year outcomes of the multicentre, randomized ECMO-CS trial.

Among patients with cardiogenic shock, immediate initiation of extracorporeal membrane oxygenation (ECMO) did not demonstrate any benefit at 30 days. The present study evaluated 1-year clinical outcomes of the Extracorporeal Membrane Oxygenation in the therapy of Cardiogenic Shock (ECMO-CS) trial. The ECMO-CS trial randomized 117 patients with severe or rapidly progressing cardiogenic shock to immediate initiation of ECMO or early conservative strategy. The primary endpoint for this analysis was 1-year all-cause mortality. Secondary endpoints included a composite of death, resuscitated cardiac arrest or implantation of another mechanical circulatory support device, duration of mechanical ventilation, and the length of intensive care unit (ICU) and hospital stays. In addition, an unplanned post-hoc subgroup analysis was performed. At 1 year, all-cause death occurred in 40 of 58 (69.0%) patients in the ECMO arm and in 40 of 59 (67.8%) in the early conservative arm (hazard ratio [HR] 1.02, 95% confidence interval [CI] 0.66-1.58; p = 0.93). The composite endpoint occurred in 43 (74.1%) patients in the ECMO group and in 47 (79.7%) patients in the early conservative group (HR 0.83, 95% CI 0.55-1.25; p = 0.29). The durations of mechanical ventilation, ICU stay and hospital stay were comparable between groups. Significant interaction with treatment strategy and 1-year mortality was observed in subgroups according to baseline mean arterial pressure (MAP) indicating lower mortality in the subgroup with low baseline MAP (<63 mmHg: HR 0.58, 95% CI 0.29-1.16; pinteraction = 0.017). Among patients with severe or rapidly progressing cardiogenic shock, immediate initiation of ECMO did not improve clinical outcomes at 1 year compared to the early conservative strategy. However, immediate ECMO initiation might be beneficial in patients with advanced haemodynamic compromise.

Outcome of extracorporeal membrane oxygenation support among children with methicillin-resistant Staphylococcus aureus infection: A single-center experience.

Introduction: The use of extracorporeal membrane oxygenation (ECMO) in children continues to increase nationally, including patients with methicillin-resistant Staphylococcus aureus (MRSA) infection. Survival of pediatric patients with MRSA sepsis has not improved over the last 20years. We sought to review our institutional experience and outcomes of ECMO support among children with MRSA infection.Methods: Children aged 0-19years who received ECMO support from October 2014 to June 2021 were reviewed retrospectively. Patients with laboratory confirmed MRSA infections were identified.Results: Out of 88 unique pediatric patients requiring ECMO support, eight patients had documented MRSA infections. The duration of mechanical ventilation prior to ECMO initiation was an average of sevendays (range 0.7 to 21.8days). The median ECMO duration was 648.1h (range 15.5 to 1580.5h). Five patients were successfully decannulated; however, only two patients survived to discharge. The two surviving patients were both cannulated via VV-ECMO. Mechanical ventilation prior to ECMO was 4.5 and 21.8days in these cases with run durations of 18.9 and 29.9days, respectively.Conclusions: Our institutional survival of patients with MRSA on ECMO is lower than what has been reported in recent database studies, but notably, 62.5% were successfully decannulated. While both surviving patients were supported with VV-ECMO, there was no other clear trend in factors that contributed to survival. MRSA continues to be a source of significant morbidity and mortality among pediatric patients. On-going investigation of outcomes and factors contributing to survival in patients with MRSA infection on ECMO is warranted.

Outcomes in Children Who Undergo Postcardiotomy Extracorporeal Membrane Oxygenation: A Report From the STS-CHSD

BackgroundChildren who undergo cardiac surgery may require postcardiotomy extracorporeal membrane oxygenation (ECMO). Although morbidities are considerable, our understanding of outcome determinants is limited. We evaluated associations between patient and perioperative factors with outcomes. MethodsThe Society of Thoracic Surgeons Congenital Heart Surgery Database was queried for patients aged <18 years old who underwent postcardiotomy ECMO from January 2016 through June 2021. The primary outcome was survival to hospital discharge. The secondary outcome was survival without neurologic injury. Logistic regression for binary outcomes and competing risk analysis for survival were used to identify the most important predictors. Variables were selected by stepwise procedure using entry level P = .35. Those with P ≤ .1 were kept in the final model. ResultsPostcardiotomy ECMO was used to support 3181 patients during the same hospitalization as cardiac surgery: (A) intraoperative initiation of ECMO, n = 1206; (B) early postoperative (≤48 hours), n = 936; and (C) late postoperative (>48 hours), n = 1039. The most common primary procedure of the index operation was the Norwood procedure. Of those with intraoperative ECMO, 57% survived to discharge vs 59% with early postoperative ECMO and 42% late postoperative ECMO (χ2(2) = 64, P < .0001, V = 0.14). In all groups, postoperative septicemia, cardiac arrest, and new neurologic injury had the strongest association with mortality, whereas postoperative reintubation and unplanned noncardiac reoperation were associated with higher survival. ConclusionsMultiple risk factors impact survival in children who undergo cardiac surgery and postcardiotomy ECMO. ECMO initiated >48 hours after surgery is associated with the poorest outcomes. This is the first step in creating a predictive tool to educate clinicians and families regarding expectations in this high-risk population.

Time to initiation of extracorporeal membrane oxygenation in conventional cardiopulmonary resuscitation affects the patient survival prognosis.

Cardiopulmonary resuscitation (CPR) is the cornerstone intervention for cardiac arrest, with extracorporeal CPR (ECPR) demonstrating enhanced survival and neurologic outcomes in in-hospital cardiac arrest. This study explores the time interval between CPR initiation and the onset of extracorporeal membrane oxygenation (ECMO) in ECPR recipients, investigating its impact on survival outcomes. This retrospective analysis included 1950 adults who received CPR at a single medical center between March 2019 and April 2023. Data from 198 adult patients who had ECMO inserted during CPR were analyzed. The interval from CPR initiation to ECMO initiation was quantified and categorized as ≤20, 20-40, and >40min. Cox regression analysis assessed associations between CPR-to-ECMO time and short- and long-term mortalities. Among the 198 patients who underwent ECPR, 116 (58.6%) experienced 30-day mortality. Initiation of ECMO within 20min occurred in 46 (23.2%), whereas 74 (37.4%) had ECMO initiated after 40min. Cox regression revealed a significant association between time from CPR to ECMO initiation and 30-day mortality (adjusted hazard ratio [HR]: 2.20 in >40min, HR: 2.63 in 20-40min, p=0.006) and 6-month mortality (HR: 1.81, in >40min, HR: 1.99 in 20-40min, p=0.021). This study revealed that, in ECPR recipients, a shorter duration between CPR initiation and ECMO flow commencement is associated with improved short- and long-term patient prognoses. These findings emphasize the critical role of timely ECMO application in optimizing outcomes for patients undergoing ECPR.

Extubated, Rehabilitation-Focused Extracorporeal Membrane Oxygenation for Pediatric Coronavirus Disease 2019: A Case Series.

During the coronavirus 2019 (COVID-19) pandemic, children suffered severe lung injury resulting in acute respiratory distress syndrome requiring support with extracorporeal membrane oxygenation (ECMO). In this case series, we described our center's experience employing a rehabilitation-focused ECMO strategy including extubation during ECMO support in four pediatric patients with acute COVID-19 pneumonia hospitalized from September 2021 to January 2022. All four patients tolerated extubation within 30 days of ECMO initiation and achieved mobility while on ECMO support. Duration of ECMO support was 35-152 days and hospital lengths of stay were 52-167 days. Three of four patients survived. Two of three survivors had normal functional status at discharge except for ongoing respiratory support. The third survivor had significant motor deficits due to critical illness polyneuropathy and was supported with daytime oxygen and nocturnal noninvasive support. Overall, these patients demonstrated good outcomes and tolerance of a rehabilitation-focused ECMO strategy.

Recovery from severe cardio-respiratory failure: the trajectory of muscle mass, strength, function and health related quality of life

Abstract Background The impact of intensive care unit acquired weakness (ICUAW) is associated with reduced muscle mass, strength, function and health related quality of life (HRQoL). Patients suffering from severe cardio-respiratory failure are known to lose considerable muscle mass and strength in the first 7 days of admission to the intensive care unit (ICU). Furthermore, patients surviving critical illness have a considerable less HRQoL and physical function with long term outcomes such as inability to return to work being reported. However, more information regarding muscle loss and recovery is required when patients leave hospital. Currently there are no treatments for ICUAW as once the process is established management is supportive, such as physical therapy. Purpose We Sought to investigate the effects of severe cardio-respiratory failure, in patients receiving extra corporeal membrane oxygenation (ECMO), on ICUAW (including muscle mass, strength, function and HRQoL). Researching a real life model of ICUAW allows the observation of the loss of muscle mass and strength in the first stages of critical illness and severe cardio-respiratory failure. Methods Adults receiving ECMO for severe cardiorespiratory failure were included. Muscle mass was measured using ultrasound of the rectus femoris cross sectional area (RFcsa). Muscle strength was measured using hand held dynamometry for both hand held grip strength and isometric leg extension. HRQoL was measured using the EQ-5D-5L. Function was measured using the short physical performance battery (SPPB). Measurements were taken on day 0, day 7, ICU discharge, hospital discharge and at out-patient follow up. Results 17 patients were recruited with 10 patients completing follow up. Patients lost 24% muscle mass in the first 7 days of ICU admission and ECMO initiation, with muscle loss continuing up until ICU discharge. Contrary to the hypothesis only 50% of the patients were seen to recover muscle mass at follow up. Strength and function all considerably improved between ICU discharge and out patient follow up. The EQ5D crosswalk index supported this suggesting considerable functional improvement. Conclusion Patients in severe cardio-respiratory failure lose considerable muscle mass in the first 7 days of admission, with only 50% of these patients recovering the initial muscle loss at follow up. However, strength, function and HRQoL all improve following ICU discharge suggesting an element of functional recovery. Strength and function have shown to improve regardless of the status of the muscle mass. Therefore, given the advantages of the real-life model and novel findings, this could serve as a platform to assess muscle loss and recovery over a longer time frame continuing to build the understanding of the patients recovery trajectory from critical illness.Rectus Femoris Muscle MassHand-Held Grip Strength

Actual Cost of Extracorporeal Cardiopulmonary Resuscitation: A Time-Driven Activity-Based Costing Study.

To determine the actual cost and drivers of the cost of an extracorporeal cardiopulmonary resuscitation (E-CPR) care cycle. A time-driven activity-based costing study conducted from a healthcare provider perspective. A quaternary care ICU providing around-the-clock E-CPR service for out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) in Australia. The E-CPR care cycle was defined as the time from initiating E-CPR to hospital discharge or death of the patient. Detailed process maps with discrete steps and probabilistic decision nodes accounting for the complex trajectories of E-CPR patients were developed. Data about clinical and nonclinical resources and timing of activities was collected multiple times for each process . Total direct costs were calculated using the time estimates and unit costs per resource for all clinical and nonclinical resources. The total direct costs were combined with indirect costs to obtain the total cost of E-CPR. From 10 E-CPR care cycles observed during the study period, a minimum of 3 observations were obtained per process. The E-CPR care cycle's mean (95% CI) cost was $75,014 ($66,209-83,222). Initiation of extracorporeal membrane oxygenation (ECMO) and ECMO management constituted 18% of costs. The ICU management (35%) and surgical costs (20%) were the primary cost determinants. IHCA had a higher mean (95% CI) cost than OHCA ($87,940 [75,372-100,570] vs. 62,595 [53,994-71,890], p < 0.01), mainly because of the increased survival and ICU length of stay of patients with IHCA. The mean cost for each E-CPR survivor was $129,503 ($112,422-147,224). Significant costs are associated with E-CPR for refractory cardiac arrest. The cost of E-CPR for IHCA was higher compared with the cost of E-CPR for OHCA. The major determinants of the E-CPR costs were ICU and surgical costs. These data can inform the cost-effectiveness analysis of E-CPR in the future.

Clinician Prediction of Survival vs Calculated Prediction Scores in Patients Requiring Extracorporeal Membrane Oxygenation.

Determining appropriate extracorporeal membrane oxygenation (ECMO) candidacy ensures appropriate utilization of this costly resource. The current ECMO survival prediction scores do not consider clinician assessment of patient viability. This study compared clinician prediction of survival to hospital discharge versus prediction scores. The aim of this study was to compare clinician prediction of patients' survival to hospital discharge versus prognostic prediction scores (Respiratory ECMO Survival Prediction [RESP] or Survival After Veno-Arterial ECMO [SAVE] score) to actual survival. This was an observational descriptive study from January 2020 to November 2021 conducted with interviews of nurses, perfusionists, and physicians who were involved during the initiation of ECMO within the first 24 hours of cannulation. Data were retrieved from the medical record to determine prediction scores and survival outcomes at hospital discharge. Accuracy of clinician prediction of survival was compared to the RESP or SAVE prediction scores and actual survival to hospital discharge. Accurate prediction of survival to hospital discharge for veno-venous ECMO by nurses was 47%, 64% by perfusionists, 45% by physicians, and 45% by the RESP score. Accurate predictions of patients on veno-arterial ECMO were correct in 54% of nurses, 77% of physicians, and 14% by the SAVE score. Physicians were more accurate than the SAVE score, P = .021, and perfusionists were significantly more accurate than the RESP score, P = .044. There was no relationship between ECMO specialists' years of experience and accuracy of predications. Extracorporeal membrane oxygenation clinicians may have better predictions of survival to hospital discharge than the prediction scores. Further research is needed to develop accurate prediction tools to help determine ECMO eligibility.

A screw-type pacemaker lead implanted in the right atrium perforated the ascending aorta

BackgroundPerforation by pacemaker leads, although rare, is a complication reported since the introduction of pacemaker therapy. Although historically reported frequencies were as high as 5%, recent reports have cited frequencies ranging from 1 to 2%. We report a case where a screw-type atrial lead slightly penetrated the right atrial wall, causing chronic abrasion of the ascending aorta, resulting in shock.Case presentationA 54-year-old male presented with dilated cardiomyopathy diagnosed at 40 years of age when he developed decompensated heart failure. Despite ongoing treatment, his heart failure worsened, leading to hospitalization at the age of 54. During his hospital stay, he experienced cardiac arrest that required cardiopulmonary resuscitation, followed by a return of spontaneous circulation. He was subsequently transferred to our institution after initiation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) and an intra-aortic balloon pump (IABP). Echocardiography revealed an ejection fraction of 25%, left ventricular end-diastolic diameter of 60 mm, and severe mitral regurgitation (MR). Transcatheter mitral valve repair was performed to treat severe MR, followed by implantation of a cardiac resynchronization therapy defibrillator (CRT-D). Three months later, the patient was brought to our emergency department by ambulance because of hypotension. Contrast-enhanced computed tomography revealed pericardial effusion causing cardiac tamponade, necessitating emergency pericardial decompression via left fourth intercostal mini-thoracotomy and drain placement. Upon transfer to the intensive care unit, 1200 mL of blood was drained from the chest tube, prompting a return to the operating room for a median sternotomy. It was discovered that the pacemaker lead on the left side of the right atrium had slowly eroded into the aorta, leading to perforation. The ascending aorta was repaired and hemostasis was achieved; the patient recovered uneventfully and was discharged on postoperative day 18.ConclusionsThe pacemaker lead perforated the right atrium; chronic abrasion of the lead against the ascending aorta resulted in bleeding from the ascending aorta 3 months later.

#75 Extracorporeal membrane oxygenation (ECMO) in patients with acute kidney injury (AKI): a prospective, observational, multi-center study

Abstract Background and Aims Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy for patients with severe respiratory and/or cardiovascular failure. Acute kidney injury (AKI) is a frequent complication in ECMO, resulting in increased morbidity and mortality. We aim to evaluate impact of ECMO on AKI outcome in Kuwait. Method Demographics, comorbidities, management, and 30-day kidney and patient outcome data for adult inpatients with native kidneys with AKI who received ECMO in seven public hospitals in Kuwait from 1/January to 31/December 2021, were prospectively collected and analyzed. Results Total number of AKI cases during study period was 3744, but only 121 patients received ECMO, or only 3.2%, with mean age of 56.3 years; and mean baseline eGFR of 81.6 ml/min. Males were 62.8% of the cohort, and 91.7% of cases were hospital-acquired AKI. Only 21.5% had pre-existing CKD (mainly diabetic kidney disease), and only 26.5% were older than 65, however, 58.7% were diabetics, and 48% were hypertensive. COVID-19 infection was a cause for AKI in 69% of patients. ECMO was veno-venous in 90% of cases, and AKI developed before ECMO initiation in 62.8% of cases. Dialysis was provided for 92% with continuous kidney replacement therapy (CKRT) accounting for 97%, and 93% of patients were in ICU (all on inotropic support). At 30 days, 86.8% of the whole group died (91% of those died on dialysis), six patients remained alive on dialysis, and only four patients recovered kidney function completely. Conclusion Although ECMO utilization in patients with AKI is limited in our AKI cohort, and despite relatively young age and reasonable baseline eGFR for the cohort, ECMO is associated with high need for ICU admission, high incidence of AKI, high need for dialysis, and high mortality rates.

Extracorporeal Membrane Oxygenation: Rescue Therapy in Pediatric Bupropion Cardiotoxicity

Abstract Objective Our objective was to describe clinical characteristics and course of pediatric bupropion ingestions requiring extracorporeal membrane oxygenation (ECMO) life support. Desgin The study included a retrospective cohort of patients ≤18 years of age reported to a regional poison control (PC) system covering three states in the upper Midwest United States. All bupropion exposures ≤18 years of age, coded as receiving ECMO to treat toxicity, were included. Clinical presentation and management including ECMO are presented as descriptive statistics. Results During the study period, 4,951 bupropion exposures were reported; 1,145 (23.1%) were children. Nine patients were coded as undergoing ECMO; four (44.4%) were ≤18 years of age (median 16, range 14–17). All were treated with venoarterial ECMO. The median time from ingestion to presentation was 2.25 hours (range: 1–3.5). Median first systolic blood pressure and pulse were 100 mm Hg (range: 70–124) and 119.5 (range: 70–175). The median time from ingestion to ECMO was 17.63 hours (range: 7.25–33.75); median number of vasopressors was 2.5 (range: 2–3). All experienced multiple seizures, ventricular dysrhythmias, and hypotension. Three of four sustained cardiac arrest. All but one required transfer to an ECMO-capable facility for definitive care. Three patients survived with full neurologic recovery; one died. Conclusion Pediatric bupropion cases requiring ECMO were rare in this study. Time to initiation and duration of EMCO suggest that the variable onset of hemodynamic instability may delay ECMO initiation. It is incumbent on PCs and medical toxicologists to educate prescribers and pediatricians about bupropion's potential lethality and to consider early transfer to an ECMO center.

Long-Term Clinical Outcomes of Acute Kidney Disease in Patients Receiving Extracorporeal Membrane Oxygenation.

Extracorporeal membrane oxygenation (ECMO) is widely used; however, studies on the long-term outcomes of ECMO are scarce. We investigated the long-term clinical outcomes of acute kidney disease (AKD) in patients receiving ECMO. Electronic data (2009-2018) were retrospectively collected from a multicenter database. Patients were divided into two groups (AKD and non-AKD) according to their AKD status 8-90 days after the initiation of ECMO. Inverse probability of treatment weighting was used to balance baseline covariates between the two groups. The primary outcomes were major adverse kidney events (MAKEs) and major adverse cardiovascular events (MACEs), and the secondary outcomes were all-cause readmission, sepsis-related readmission, infection-related readmission, and dementia. Totally, 395 patients were eligible for analysis; of them, 160 patients (40.5%) developed AKD. The AKD group had a higher risk of MAKEs (hazard ratio [HR]: 2.06; 95% confidence interval [CI]: 1.68-2.53) than did the non-AKD group. Subgroup analysis revealed that the observed unfavorable effect of AKD on the risk of MAKEs was more pronounced in patients receiving venovenous ECMO than in those receiving venoarterial ECMO (HR: 5.69 vs. 1.85, respectively; p for interaction = 0.004). AKD group had a higher risk of MACE during the initial 3-year post-ECMO in comparison to those without (HR: 1.68; 95% CI: 1.22-2.30). Moreover, the risks of all-cause, sepsis-related, and infection-related readmissions were high in AKD survivors. AKD is associated with an increased risk of long-term MAKEs and initial 3-year MACE in ECMO recipients. In addition, AKD is associated with increased risks of all-cause, infection-related, and sepsis-related readmissions.

Refractory cor pulmonale under extracorporeal membrane oxygenation for acute respiratory distress syndrome: the role of conversion to veno-pulmonary arterial assist-a case series.

Pulmonary vascular dysfunction during severe acute respiratory distress syndrome (ARDS) may lead to right ventricle (RV) dysfunction and acute cor pulmonale (ACP). The occurrence/persistence of ACP despite conventional extracorporeal membrane oxygenation (ECMO) is a challenging situation. We explored the usefulness of a specific dual-lumen cannula that bypasses the RV, and on which a veno-pulmonary arterial assist (V-P ECMO) was mounted, in ARDS patients. We report a case-series of ARDS patients put on conventional veno-arterial or veno-venous ECMO and presented refractory ACP as an indication for a reconfiguration to V-P ECMO using the ProtekDuo cannula. The primary endpoint was the mitigation of RV and pulmonary vascular dysfunction as assessed by the change in end-diastolic RV/left ventricle (LV) surface ratio. Six patients had their conventional ECMO reconfigured to V-P ECMO to treat refractory ACP. There was a decrease in end-diastolic RV/LV surface ratio, as well as end-systolic LV eccentricity index, and lactatemia immediately after V-P ECMO initiation. The resolution of refractory ACP was immediately achieved in four of our six (66%) patients. The V-P ECMO was weaned after a median of 26 [8-93] days after implantation. All but one patient were discharged home. We detected one case of severe hemolysis with V-P ECMO and two suspected cases of right-sided infective endocarditis. V-P ECMO is useful to mitigate RV overload and to improve hemodynamics in case of refractory ACP despite conventional ECMO.