Extracorporeal Membrane Oxygenation Weaning Research Articles

Echocardiographic and Point-of-Care Ultrasonography (POCUS) Guidance in the Management of the ECMO Patient.

Veno-arterial (V-A) and Veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) support is increasingly utilized for acute cardiogenic shock and/or respiratory failure. Echocardiography and point-of-care ultrasonography (POCUS) play a critical role in the selection and management of these critically ill patients, however, there are limited guidelines regarding their application. This comprehensive review describes current and potential application of echocardiography and POCUS for pre-ECMO assessment and patient selection, cannulation guidance with emphasis on dual-lumen configurations, diagnosis of ECMO complications and trouble-shooting of cannula malposition, diagnosis of common cardiac or pulmonary pathologies, and assessment of ECMO weaning appropriateness including identification of the aortic mixing point in V-A ECMO.

Outcomes of extracorporeal membrane oxygenation treatment post open congenital heart surgery

Objective: ECMO (Extra-Corporeal Membrane Oxygenation) is a technique that temporarily supports heart and lung function by a cardiopulmonary bypass system to treat patients who have failed to respond to the conventional treatments for cardiac or respiratory after congenital heart surgery. The objective of this study is to evaluate the outcomes of ECMO treatment post congenital heart surgery at the National Children's Hospital. Subjects and methods: Descriptive, cross-sectional research method on 64 ECMO patients post open heart surgery from January 1, 2017 until August 30, 2023 at the Department of Surgical Cardiovascular Intensive Care, Cardiovascular Center, National Children's Hospital. Results: Of 64 patients analyzed, the median age of the study group was 1.6 months, 89.1% of patients were children younger than 12 months old; median weight is 3.6 kg. The success rate of ECMO weaning was 56.3%. Overall survival of the cohort was 43.8%. The mean ECMO duration was 5,7 (IQR, 3,7-10,6) days, the mean hospital stay was 32 (IQR, 21,5-50) days, the mean ICU stay was 19,5 (IQR, 13,3-29) days. Mechanical complications during ECMO support include cannula bleeding and circuit thrombus. Acute kidney injury, hypertransaminase, and DIC (disseminated intravascular coagulation) are the most common patient-related complications during ECMO. Conclusion: ECMO is a viable rescue strategy for cardiac surgery patients with ECMO weaning rate and survival rate were 56.3% and 43.8%, respectively, nearly equivalent to other heart centers.

Predictive value of microcirculation for pediatric extracorporeal membrane oxygenation weaning test: Amonocentric prospective observational study.

Extracorporeal membrane oxygenation (ECMO) is widely used for children treated for refractory respiratory failures or refractory cardiogenic shock. Its duration depends on organ functions recovery. Weaning is decided using macro-circulatory tools, but microcirculation is not well evaluated. Sidestream dark-field video imaging is used to assess the perfusion of the sublingual microvascular vessels. The aim of this study was to assess the predictive value of microcirculatory indices in ECMO weaning. This prospective monocentric study examined pediatric patients at Trousseau Hospital between March 2017 and December 2020. The study included all patients from 35 weeks of gestational age to 18 years old who were treated with ECMO. Children were divided into two groups: one with stability after weaning and the other with instability after weaning. We collected clinical and biological data, ventilation parameters, extracorporeal membrane oxygenation parameters, and drugs used at admission and after the weaning test. Microcirculations videos were taken after weaning trials with echocardiography and blood gas monitoring. The study included 30 patients with a median age of 29 days (range: 1-770 days) at admission, including 18 patients who received venoarterial ECMO (60%). There were 19 children in the stability group and 11 in the instability group. Macrocirculatory and microcirculatory indices showed no differences between groups. The microvascular flow index was subnormal in both groups (2.3 (1.8-2.4) and 2.3 (2.3-2.6), respectively; p = 0.24). The microvascular indices were similar between cases of venovenous and venoarterial ECMO and between age groups. Microcirculation monitoring at the weaning phase did not predict the failure of ECMO weaning.

Lung Transplantation in Patients With Pulmonary Hypertension With Extracorporeal Membrane Oxygenation (ECMO) Support: 5-Year Experience

Lung transplantation (LTx) is the only treatment option of patients (pts) with pulmo-nary hypertension (PH) when pharmacologic treatment is unsatisfactory. ECMO is essential during LTx in every patient with pulmonary arterial hypertension and in most patients with sec-ondary PH. This is a retrospective, single-center study comparing LTx outcomes in patients with and without PH covering a 5-year experience. In the years 2018-2023, 219 LTx were performed, of which 56 (25.6%) with ECMO support, among which PH was diagnosed in 34pts (60.7%) in WHO groups 1,3,4: 19pts, 14pts. and 1pt respectively. The veno-arterial type of ECMO was used in patients with PH as intraoperative support (n = 34; 100%). The early (30-day) and long-term survival (1 year) of patients with and without PH did not differ statistically: 91.2% (95% CI: 82.1%-100%) vs. 77.3% (95% CI: 82.1%-100%)(P = .48) and 53.0% (95% CI: 36.6%-76.7 %) vs. 41.3% (95%CI: 23.1-74.0) (P = .48) respectively and the median hospitalization time from ECMO weaning to dis-charge was also comparable: 31 days (Q1-Q3: 21-40; IQR 20) vs. 28 days (Q1-Q3: 24-42; IQR :18) (P = .99). Patients with or without PH undergoing LTx with ECMO have comparable survival and hospital stay outcomes despite being the most challenging of all lung diseases treated with lung transplantation.

Outcome after extracorporeal membrane oxygenation therapy in Norwood patients before the bidirectional Glenn operation.

Patients after the Norwood procedure are prone to postoperative instability. Extracorporeal membrane oxygenation (ECMO) can help to overcome short-term organ failure. This retrospective single-centre study examines ECMO weaning, hospital discharge and long-term survival after ECMO therapy between Norwood and bidirectional Glenn palliation as well as risk factors for mortality. In our institution, over 450 Norwood procedures have been performed. Since the introduction of ECMO therapy, 306 Norwood operations took place between 2007 and 2022, involving ECMO in 59 cases before bidirectional Glenn. In 48.3% of cases, ECMO was initiated intraoperatively post-Norwood. Patient outcomes were tracked and mortality risk factors were analysed using uni- and multivariable testing. ECMO therapy after Norwood (median duration: 5 days; range 0-17 days) saw 31.0% installed under CPR. Weaning was achieved in 46 children (78.0%), with 55.9% discharged home after a median of 45 (36-66) days. Late death occurred in 3 patients after 27, 234 and 1541 days. Currently, 30 children are in a median 4.8 year (3.4-7.7) follow-up. At the time of inquiry, 1 patient awaits bidirectional Glenn, 6 are at stage II palliation, Fontan was completed in 22 and 1 was lost to follow-up post-Norwood. Risk factor analysis revealed dialysis (P < 0.001), cerebral lesions (P = 0.026), longer ECMO duration (P = 0.002), cardiac indication and lower body weight (P = 0.038) as mortality-increasing factors. The 10-year mortality probability after ECMO therapy was 48.5% (95% CI 36.5-62.9%). ECMO therapy in critically ill patients after the Norwood operation may significantly improve survival of a patient cohort otherwise forfeited and give the opportunity for successful future-stage operations.

Analysis of Patients with Severe ARDS on VV ECMO Treated with Inhaled NO: A Retrospective Observational Study.

(1) Background: This retrospective study focused on severe acute respiratory distress syndrome (ARDS) patients treated with veno-venous (VV) extracorporeal membrane oxygenation (ECMO) and who inhaled nitric oxide (NO) for pulmonary arterial hypertension (PAH) and/or right ventricular failure (RV failure). (2) Methods: Out of 662 ECMO-supported patients, 366 received VV ECMO, including 48 who inhaled NO. We examined the NO's indications, dosing, duration, and the ability to lower PAH. We compared patients with and without inhaled NO in terms of mechanical ventilation duration, ECMO weaning, organ dysfunction, in-hospital mortality, and survival. (3) Results: Patients received 14.5 ± 5.5 ppm NO for 3 days with only one-third experiencing decreased pulmonary arterial pressure. They spent more time on VV ECMO, had a higher ECMO weaning failure frequency, and elevated severity scores (SAPS II and TIPS). A Kaplan-Meier analysis revealed reduced survival in the NO group. Multiple variable logistic regression indicated a twofold increased risk of death for ARDS patients on VV ECMO with NO. We observed no increase in continuous renal replacement therapy. (4) Conclusions: This study suggests that persistent PAH and/or RV failure is associated with poorer outcomes in severe ARDS patients on VV-ECMO, with an inhaled NO responder rate of only 30%, and it does not impact acute kidney failure rates.

The "Weekend Effect" in Extracorporeal Cardiopulmonary Resuscitation.

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

Gastrointestinal Bleeding in Extracorporeal Membrane Oxygenation Patients: A Comprehensive Analysis of Risk Factors and Clinical Outcomes.

Extracorporeal membrane oxygenation (ECMO) is an intervention for severe heart and lung failure; however, it poses the risk of complications, including gastrointestinal bleeding (GIB). Comprehensive analyses of GIB in patients undergoing ECMO are limited, and its impact on clinical outcomes remains unclear. This retrospective study included 484 patients who received venovenous and venoarterial ECMO between January 2015 and December 2022. Data collected included patient characteristics, laboratory results, GIB details, and interventions. Statistical analyses were performed to identify risk factors and assess the outcomes. GIB occurred in 44 of 484 patients (9.1%) who received ECMO. Multivariable analysis revealed that older age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.01-1.06; p=0.0130) and need to change the ECMO mode (OR, 3.74; 95% CI, 1.75-7.96; p=0.0006) were significant risk factors for GIB, whereas no association was found with antiplatelet or systemic anticoagulation therapies during ECMO management. Half of the patients with GIB (22/44, 50%) underwent intervention, with endoscopy as the primary modality (19/22, 86.4%). Patients who underwent ECMO and developed GIB had higher rates of mortality (40/44 [90.9%] vs. 262/440 [59.5%]) and ECMO weaning failure (38/44 [86.4%] vs. 208/440 [47.3%]). GIB in patients undergoing ECMO is associated with adverse outcomes, including increased risks of mortality and weaning failure. Even in seemingly uncomplicated cases, it is crucial to avoid underestimating the significance of GIB.

Abstract 13293: Predicting Successful ECMO Decannulation - A Novel Machine Learning Approach

Introduction: Extra Corporeal Membrane Oxygenation (ECMO) has emerged as a crucial life support intervention, yet the decision-making process for safe decannulation remains challenging due to a paucity of data. Methods: 199 patients who underwent venoarterial ECMO for cardiogenic shock between 2015 and 2021 were identified. Demographic, hemodynamic, laboratory, and echocardiographic data obtained within 24 hours of decannulation were collected. Successful decannulation was defined as survival without relapse to mechanical circulatory support or heart transplant within 30 days. The dataset was randomly split into 80/20 train-validation splits, and four machine learning models were employed. 5-fold cross-validation and error analysis were performed. Feature importance was derived from the best performing model. Results: 103 patients were successfully weaned off ECMO. Table 1 provides patient characteristics, which were used as features in the models. Among the models tested, Random Forest (RF) exhibited the highest performance (accuracy 85.0%, precision 90.0%, recall 85.7%, AUROC 0.94). Figure 1 depicts the performance for each model as well as the ranked feature importance and Receiver Operating Curve for the RF model. The most important features were mixed venous oxygen saturation, systolic blood pressure, ECMO flow rate and pulmonary diastolic blood pressure. Conclusion: This study demonstrates the successful application of machine learning in predicting ECMO weaning outcomes. Future research will add features and patients to enhance model performance with the goal of developing a clinical tool to assist physicians caring for ECMO patients.

Extracorporeal Membrane Oxygenation Uses in Refractory Cardiogenic Shock After Open-Heart Surgery.

Extracorporeal membrane oxygenation (ECMO) is the first-line therapy for temporary mechanical circulatory support allowing cardiac and pulmonary recovery or as a bridge to further therapeutic alternatives. The aim of this study was to report clinical outcomes in adult patients with refractory cardiac failure after open-heart surgery undergoing ECMO in a single center with an ECMO unit in Chile. We retrospectively analyzed adults with refractory cardiac failure after open-heart surgery who required a venoarterial (VA) ECMO between 2016 and 2021. Of 16 patients with VA ECMO, 60% were men (n=10), 90% had hypertension (n=14), 69% had < 30% of left ventricular ejection fraction (n=11), and the mean European System for Cardiac Operative Risk Evaluation II score was 12 ± 11%. ECMO support with central cannulation accounts for 81% (n=13), and an intra-aortic balloon pump was used in nine patients (56%). The mean time of support was 4.7 ± 2.6 days (1.5 - 12 days). ECMO weaning was achieved in 88% of patients, and in-hospital mortality was 44% (n=7) after discharge. The freedom from all-cause mortality at one year of follow-up of the entire cohort was 38% (n=6). VA ECMO is now a well-known life-saving therapeutic option, but mortality and morbidity remain high. Implementation of an ECMO program with educational training is mandatory in order to find the proper balance between patient benefits, ethical considerations, and public health financial input in South America.

Advanced Perioperative Echocardiography in Venoarterial Extracorporeal Membrane Oxygenation Weaning Trial-Off.

Advanced Perioperative Echocardiography in Venoarterial Extracorporeal Membrane Oxygenation Weaning Trial-Off.

Factors associated with 30-day in-hospital mortality in critically ill adult patients receiving extracorporeal membrane oxygenation: A retrospective cohort study

ObjectiveTo identify factors associated with the 30-day in-hospital mortality rate among adult patients requiring extracorporeal membrane oxygenation (ECMO) in intensive care units. Research MethodologyRetrospective cohort study including 148 patients who underwent ECMO for at least 48 h between March 2010 and August 2021. The patients were divided into survivors and non-survivors based on their 30-day in-hospital survival. We obtained the sociodemographic information and pre- and post-ECMO data from electronic medical records. Kaplan–Meier survival curves and Multivariate Cox proportional hazards regression were used to analyse the data. SettingA tertiary-care university hospital in South Korea. Main Outcome MeasuresThe 30-day in-hospital mortality rate was the principal outcome measure. ResultsThe 30-day in-hospital mortality rate was 49.3% (n = 73). Kaplan–Meier analysis demonstrated that the duration of ECMO support in the 50th percentile of surviving patients was 13 days. Multivariable Cox regression analysis showed that new-onset renal failure, lower mean arterial pressure, and ECMO weaning failure were associated with an increased 30-day in-hospital mortality risk among patients who received ECMO. Subgroup analysis also revealed a significant association between weaning failure and 30-day in-hospital mortality after adjusting for covariates in patients undergoing veno-arterial ECMO. ConclusionClose monitoring of post-ECMO renal function and mean arterial pressure is required to minimize the risk of 30-day in-hospital mortality, especially in adults within the first two weeks of ECMO initiation. Moreover, the success of ECMO weaning should be optimized by collaboration within the ECMO team. Implications for Clinical PracticeCritical care nurses should pay close attention to patients’ response to weaning trials as well as alternations in renal function and mean arterial pressure during ECMO support. Furthermore, developing nursing care guidelines for adult patients receiving ECMO and standardized training programs for nurses in intensive care, are required in Korea.

Effects of levosimendan on the outcome of veno-arterial extracorporeal membrane oxygenation: a systematic review and meta-analysis.

For patients with severe cardiopulmonary failure, such as cardiogenic shock, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is primarily utilized to preserve their life by providing continuous extracorporeal respiration and circulation. However, because of the complexity of patients' underlying diseases and serious complications, successful weaning from ECMO is often difficult. At present, there have been limited studies on ECMO weaning strategies, so the principal purpose of this meta-analysis is to examine how levosimendan contributes to the weaning of extracorporeal membrane oxygenation. The Cochrane Library, Embase, Web of Science, and PubMed were browsed for all potentially related research about clinical benefits of levosimendan in weaning patients receiving VA-ECMO and included 15 of them. The main outcome is success of weaning from extracorporeal membrane oxygenation, with the secondary outcomes of 1-month mortality (28 or 30days), ECMO duration, hospital or intensive care unit (ICU) length of stay, and use of vasoactive drugs. 1772 patients altogether from 15 publications were incorporated in our meta-analysis. We used fixed and random-effect models to combine odds ratio (OR) and 95% confidence interval (CI) for dichotomous outcomes and standardized mean difference (SMD) for continuous outcomes. The weaning success rate in the levosimendan group was considerably higher in contrast to the comparison (OR = 2.78, 95% CI 1.80-4.30; P < 0.00001; I2 = 65%), and subgroup analysis showed that there was less heterogeneity in patients after cardiac surgery (OR = 2.06, 95% CI, 1.35-3.12; P = 0.0007; I2 = 17%). In addition, the effect of levosimendan on improving weaning success rate was statistically significant only at 0.2 mcg/kg/min (OR = 2.45, 95% CI, 1.11-5.40; P = 0.03; I2 = 38%). At the same time, the 28-day or 30-day proportion of deaths in the sample receiving levosimendan also decreased (OR = 0.47, 95% CI, 0.28-0.79; P = 0.004; I2 = 73%), and the difference was statistically significant. In terms of secondary outcomes, we found that individuals undergoing levosimendan treatment had a longer duration of VA-ECMO support. In patients receiving VA-ECMO, levosimendan treatment considerably raised the weaning success rate and helped lower mortality. Since most of the evidence comes from retrospective studies, more randomized multicenter trials are required to verify the conclusion.

Pharmacological strategies in extracorporeal membrane oxygenation weaning failure: a call to action

Abstract Extracorporeal membrane oxygenation has emerged as a viable alternative for stabilizing and improving critically ill patients in acute cardiovascular diseases. However, the weaning stage has been associated with a high morbidity and mortality rate. This makes searching for strategies that reduce failure in this final process necessary. Implementing a new approach must be tried and included in our protocols, seeking the patient’s well-being at all times. In this article, the authors discuss their point of view regarding potential pharmacological alternatives and the mechanism of action involved, which could decrease the mortality associated with this therapeutic.

Pulse pressure loss after extracorporeal cardiopulmonary resuscitation is an independent predictor of ECMO weaning failure

To analyze the predictors of successful weaning off extracorporeal membrane oxygenation (ECMO) after extracorporeal cardiopulmonary resuscitation (ECPR). The clinical data of 56 patients with cardiac arrest who underwent ECPR in Hunan Provincial People's Hospital (the First Affiliated Hospital of Hunan Normal University) from July 2018 to September 2022 were retrospectively analyzed. According to whether ECMO was successfully weaning off, patients were divided into the successful weaning off group and the failed weaning off group. The basic data, duration of conventional cardiopulmonary resuscitation (CCPR, the time from cardiopulmonary resuscitation to ECMO), duration of ECMO, pulse pressure loss, complications, and the use of distal perfusion tube and intra-aortic balloon pump (IABP) were compared between the two groups. Univariate and multivariate Logistic regression analyses were performed to identify the risk factors for weaning failure of ECMO. Twenty-three patients (41.07%) were successfully weaned from ECMO. Compared with the successful weaning off group, patients in the failed weaning off group were older (years old: 46.7±15.6 vs. 37.8±16.8, P < 0.05), higher incidence of pulse pressure loss and ECMO complications [81.8% (27/33) vs. 21.7% (5/23), 84.8% (28/33) vs. 39.1% (9/23), both P < 0.01], and longer CCPR time (minutes: 72.3±19.5 vs. 54.4±24.6, P < 0.01), shorter duration of ECMO support (hours: 87.3±81.1 vs. 147.7±50.8, P < 0.01), and worse improvement in arterial blood pH and lactic acid (Lac) levels after ECPR support [pH: 7.1±0.1 vs. 7.3±0.1, Lac (mmol/L): 12.6±2.4 vs. 8.9±2.1, both P < 0.01]. There were no significant differences in the utilization rate of distal perfusion tube and IABP between the two groups. Univariate Logistic regression analysis showed that the factors affecting the weaning off ECMO of ECPR patients were pulse pressure loss, ECMO complications, arterial blood pH and Lac after installation [pulse pressure loss: odds ratio (OR) = 3.37, 95% confidence interval (95%CI) was 1.39-8.17, P = 0.007; ECMO complications: OR = 2.88, 95%CI was 1.11-7.45, P = 0.030; pH after installation: OR = 0.01, 95%CI was 0.00-0.16, P = 0.002; Lac after installation: OR = 1.21, 95%CI was 1.06-1.37, P = 0.003]. After adjusting for the effects of age, gender, ECMO complications, arterial blood pH and Lac after installation, and CCPR time, showed that pulse pressure loss was an independent predictor of weaning failure in ECPR patients (OR = 1.27, 95%CI was 1.01-1.61, P = 0.049). Early loss of pulse pressure after ECPR is an independent predictor of failed weaning off ECMO in ECPR patients. Strengthening hemodynamic monitoring and management after ECPR is very important for the successful weaning off ECMO in ECPR.

Nosocomial infections in adult patients receiving extracorporeal membrane oxygenation in China: A retrospective cohort study

Extracorporeal membrane oxygenation (ECMO) has been increasingly used in China, but nosocomial infections (NI) in patients receiving ECMO remain poorly characterized. Thus, this study aimed to investigate the incidence rate, causative was pathogens, and risk factors of NIs in ECMO patients. A retrospective cohort study of patients receiving ECMO between January 2015 and October 2021 was conducted in a tertiary hospital. General demographics and clinical data of the included patients were collected from the electronic medical record system and the real-time NI surveillance system. A total of 86 infected patients with 110 episodes of NIs were identified in 196 patients receiving ECMO. The incidence of NI was 59.2/1000 ECMO days. The median time for the first NI in ECMO patients was 5days (interquartile range: 2-8days). Hospital-acquired pneumonia and bloodstream infections were common types of NIs in ECMO patients, and the main pathogens were gram-negative bacteria. Pre-ECMO invasive mechanical ventilation (OR=2.40, 95%CI:1.12-5.15) and prolonged duration of ECMO (OR=1.26, 95%CI:1.15-1.39) were risk factors for NIs during ECMO support. This study identified the main infection sites and pathogens of NIs in ECMO patients. Although NIs may not affect successful ECMO weaning, additional measures should be implemented to reduce the incidence of NI during ECMO support.

Same but Different-ECMO in COVID-19 and ARDS of Other Etiologies. Comparison of Survival Outcomes and Management in Different ARDS Groups.

Background: COVID-19 has led to increased numbers of patients in need of venovenous extracorporeal membrane oxygenation (ECMO) support, but knowledge on management in comparison to acute respiratory distress syndrome (ARDS) of other etiologies is still lacking. We analyzed venovenous ECMO management and survival outcomes in patients with COVID-19 in comparison to influenza ARDS and pulmonary ARDS of other origin. Results: Retrospective analysis of prospective venovenous ECMO registry-based data collection was performed. One hundred consecutive venovenous ECMO patients with severe ARDS were included (41 COVID-19, 24 influenza A, 35 ARDS of other etiologies). Patients with COVID-19 had higher BMI (body mass index), lower SOFA (Sequential Organ Failure Assessment) and APACHE II (Acute Physiology and Chronic Health Evaluation II) scores, lower C-reactive protein and procalcitonin levels and less vasoactive support at ECMO initiation. Significantly more patients were mechanically ventilated for more than 7 days prior to ECMO initiation in the COVID-19 group, however they were ventilated with lower tidal volumes and more often received additional rescue therapies prior to and on ECMO. COVID-19 patients had significantly more barotrauma and thrombotic events on ECMO. There were no differences in weaning of ECMO, however duration of ECMO runs and ICU length of stay was significantly longer in the COVID-19 group. The leading cause of death in the COVID-19 group was irreversible respiratory failure, while uncontrolled sepsis and multiorgan failure were leading causes in the other 2 groups. All patients who survived ICU treatment were discharged out of hospital, and there were no differences in survival among groups at 180 days. Conclusions: Survival outcomes of venovenous ECMO patients do not differ between COVID-19 and ARDS of other pulmonary etiologies. ARDS guidelines were in greater proportion adhered to in COVID-19 patients, with, however, longer time to ECMO initiation. COVID-19 ARDS seems specific as a more single-organ disease with longer ECMO duration and irreversible respiratory failure as a main cause of ICU mortality.

Cardiac tamponade during venoarterial extracorporeal membrane oxygenation: a case report

BackgroundCardiac tamponade may present with very different signs and clinical consequences in patients who are supported with venoarterial extracorporeal membrane oxygenation. Failure to recognize cardiac tamponade in this setting can cause failure to wean from venoarterial extracorporeal membrane oxygenation, and even lead to death.Case presentationWe present a 44-year-old Caucasian female in whom cardiac tamponade manifested as venoarterial extracorporeal membrane oxygenation weaning failure. After discovering the contribution of cardiac tamponade, it was possible to wean the patient from venoarterial extracorporeal membrane oxygenation support. No clear signs of cardiac tamponade had existed beforehand.ConclusionsThe diagnosis of cardiac tamponade can be very challenging in venoarterial extracorporeal membrane oxygenation supported patients due to (patho)physiological particularities related to the parallel blood flow.

Bronchoscopic Endobronchial Valve Therapy for Persistent Air Leaks in COVID-19 Patients Requiring Veno-Venous Extracorporeal Membrane Oxygenation.

COVID-19 acute respiratory distress syndrome (ARDS) can be associated with extensive lung damage, pneumothorax, pneumomediastinum and, in severe cases, persistent air leaks (PALs) via bronchopleural fistulae (BPF). PALs can impede weaning from invasive ventilation or extracorporeal membrane oxygenation (ECMO). We present a series of patients requiring veno-venous ECMO for COVID-19 ARDS who underwent endobronchial valve (EBV) management of PAL. This is a single-centre retrospective observational study. Data were collated from electronic health records. Patients treated with EBV met the following criteria: ECMO for COVID-19 ARDS; the presence of BPF causing PAL; air leak refractory to conventional management preventing ECMO and ventilator weaning. Between March 2020 and March 2022, 10 out of 152 patients requiring ECMO for COVID-19 developed refractory PALs, which were successfully treated with bronchoscopic EBV placement. The mean age was 38.3 years, 60% were male, and half had no prior co-morbidities. The average duration of air leaks prior to EBV deployment was 18 days. EBV placement resulted in the immediate cessation of air leaks in all patients with no peri-procedural complications. Weaning of ECMO, successful ventilator recruitment and removal of pleural drains were subsequently possible. A total of 80% of patients survived to hospital discharge and follow-up. Two patients died from multi-organ failure unrelated to EBV use. This case series presents the feasibility of EBV placement in severe parenchymal lung disease with PAL in patients requiring ECMO for COVID-19 ARDS and its potential to expedite weaning from both ECMO and mechanical ventilation, recovery from respiratory failure and ICU/hospital discharge.

Quantitative evaluation of hemodynamic parameters by echocardiography in patients with post-cardiotomy cardiac shock supported by extracorporeal membrane oxygenation

BackgroundWhen drugs fail to reverse post-cardiotomy cardiac shock (PCS), extracorporeal membrane oxygenation (ECMO) is considered the most effective adjuvant strategy. Transthoracic echocardiography is a useful imaging modality for monitoring of cardiac hemodynamics. The aim of this study was to investigate the value of echocardiography for monitoring the left and right heart hemodynamics in PCS patients before, during, and after weaning from ECMO.MethodsFifty-two patients were divided into successful weaning group (group A, n = 23) and non-successful weaning group (group B, n = 29). Hemodynamic parameters measured by echocardiography were collected before, during, and after ECMO. The intra-group changes and inter-group differences were retrospectively analyzed.ResultsIn group A, the central venous pressure (CVP), proximal right ventricular outflow tract (RVOT), tricuspid annular plane systolic excursion (TAPSE), velocity of tricuspid valve (TVDV), and systolic velocity of tricuspid annulus ({text{s}}_{{{text{TV}}}}^{{prime }}) during ECMO were significantly lower than those before ECMO. After ECMO, left ventricular ejection fraction (LVEF), systolic velocity of mitral annulus ({text{s}}_{{{text{MV}}}}^{{prime }}), and velocity–time integral of LV outflow tract (LVOT-VTI) were higher than pre-ECMO levels, and CVP, LVEF, {text{s}}_{{{text{MV}}}}^{{prime }}, LVOT-VTI, RVOT, TAPSE, TVDV and {text{s}}_{{{text{TV}}}}^{{prime }} were higher than those during ECMO (all P < 0.05).In group B, compared to pre-ECMO, subjects exhibited decreased CVP, RVOT, TAPSE, TVDV and {text{s}}_{{{text{TV}}}}^{{prime }} during ECMO. TAPSE, TVDV, and {text{s}}_{{{text{TV}}}}^{{prime }} were continuously lower after ECMO, while CVP and RVOT increased after ECMO (all P < 0.05). After ECMO, LVEF, {text{s}}_{{{text{MV}}}}^{{prime }}, LVOT-VTI, TAPSE, TVDV and {text{s}}_{{{text{TV}}}}^{{prime }} in group A were higher than those in group B (all P < 0.05). Inter-group comparison showed the LVEF and RV Tei indices of group A were significantly different than those of group B before, during, and after ECMO.ConclusionQuantitative assessment of both LV and RV by echocardiography is important for ECMO weaning. Patients with better LVEF and lower RV Tei index may have a better chance of successful weaning from ECMO.