Femoral Venoarterial Extracorporeal Membrane Oxygenation Research Articles

The Effect of Acute Limb Ischemia on Mortality in Patients Undergoing Femoral Venoarterial Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) is a life-saving modality increasingly used in the management cardiopulmonary failure. However, ECMO itself is not without major complications. Mortality remains high, and morbidity such as stroke, renal failure, and acute limb threatening ischemia (ALI) are common among surviving patients. We analyzed the effect of one of these complications, ALI, on the survival of patients receiving venoarterial ECMO (VA ECMO) with femoral cannulation. Patients with cardiopulmonary failure supported by VA ECMO inserted through femoral cannulation at two institutions from December 2010 to December 2017 were enrolled in this study. Data were collected retrospectively. Our primary outcome was ALI and its effect on hospital mortality. Secondary outcomes included six-month mortality, length of hospital stay, and other complications (stroke and renal failure); multivariate logistic regression analysis was used to identify predictors of ALI and hospital mortality. There were 71 patients included in this study. The overall VA ECMO hospital mortality was 53.5%. ALI was seen in 14 (19.7%) patients. Of these, four (5.6%) patients had fasciotomy, four patients (5.6%) had thrombectomy, and one underwent arterial repair (1.4%). Five additional patients (7.0%) with ALI expired and had no vascular intervention. None of the demographic and clinical characteristics significantly correlated with ALI except for stroke and renal failure requiring new-onset hemodialysis (HD). The rate of hospital and 6-month mortality in patients with and without vascular complications were 78.6%, 92.3% and 47.4%, 57.4%, respectively (P=0.042 and P=0.023). Multivariate analysis correlated hospital and six-month mortality with ALI, stroke, and new-onset HD. ALI correlates with higher mortality in VA ECMO patients with femoral cannulation. Although some of the contributing factors to mortality in these patients are related to the consequences of cardiopulmonary failure, strong efforts should be made to avoid ALI after femoral VA ECMO cannulation.

Risk factors for critical limb ischemia in patients undergoing femoral cannulation for venoarterial extracorporeal membrane oxygenation: Is distal limb perfusion a mandatory approach?

Background:Venoarterial extracorporeal membrane oxygenation support is a well-established tool in the care of severe refractory cardiac and respiratory failure. The application of this support may serve as a bridge to transplant, recovery or to implantation of a ventricular assist device. Venoarterial extracorporeal membrane oxygenation support can be administered through an open surgical access via the common femoral or axillary artery or a percutaneous approach using Seldinger technique. Both techniques may obstruct the blood flow to the lower limb and may cause a significant ischemia with possible limb loss. Malperfusion of the distal limb can be avoided using an ipsilateral distal limb perfusion, which may be established by adding a single-lumen catheter during venoarterial extracorporeal membrane oxygenation treatment to overcome the obstruction. The aim of this study is to distinguish the presence or absence of a distal limb perfusion regarding the incidence of distal limb ischemia. Furthermore, expected risk factors of open and percutaneous femoral venoarterial extracorporeal membrane oxygenation installation were evaluated for the development of distal limb ischemia.Methods:Between January 2012 and September 2015, 489 patients received venoarterial extracorporeal membrane oxygenation support at our institution. In total, 307 patients (204 male, 103 female) with femoral cannulation were included in the analysis. The cohort was distinguished by the presence (group A; n = 237) or absence (group B; n = 70) of a distal limb perfusion during peripheral venoarterial extracorporeal membrane oxygenation treatment. Furthermore, a risk factor analysis for the development of distal limb ischemia was performed.Results:The main indications for venoarterial extracorporeal membrane oxygenation therapy were a low cardiac output syndrome (LCOS) (53%) and failed weaning of extracorporeal circulation (23%). A total of 23 patients (7.49%) under venoarterial extracorporeal membrane oxygenation support developed severe distal limb malperfusion (3.38% in group A vs 21.42% in group B). Preemptive installation of distal limb perfusion extended the intervention-free intervals to 7.8 ± 19.3 days in group A and 6.3 ± 12.5 in group B. A missing distal limb perfusion (p = 0.001) was identified as a main risk factor for critical limb ischemia. Other comorbidities such as arterial occlusion disease (p = 0.738) were not statistically significantly associated. Surgical intervention due to vascular complications after extracorporeal membrane oxygenation explantation was needed in 14 cases (4.22% in group A and 5.71% in group B).Conclusion:We were able to identify the absence of distal limb perfusion as an independent risk factor for the development of critical distal limb ischemia during femoral venoarterial extracorporeal membrane oxygenation treatment. The application of a distal limb perfusion should be considered as a mandatory approach in the context of femoral venoarterial extracorporeal membrane oxygenation treatment regardless of the implantation technique.

Factors Associated with Ipsilateral Limb Ischemia in Patients Undergoing Femoral Cannulation Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) is an important life-saving modality for patients with cardiopulmonary failure. Vascular complications, including clinically significant limb ischemia, may occur as a result of femoral artery cannulation for venoarterial (VA) ECMO. This study examines our institutional experience with femoral VA ECMO and the development of ipsilateral limb ischemia. We performed a retrospective review of all consecutive patients undergoing femoral VA ECMO between 2011 and 2016. The primary endpoint was clinical evidence of limb-threatening ischemia. Multivariate logistic regression analysis was used to identify predictors for limb ischemia after cannulation. Between March 2011 and September 2016, 154 patients underwent femoral cannulation for VA ECMO. Overall in-hospital mortality was 59.7%. Clinically significant ipsilateral limb ischemia occurred in 34 (22%) patients; 7 required four-compartment fasciotomy, and 3 of these patients required amputation. On univariate analysis, a history of pulmonary disease, peripheral arterial disease, and stroke or transient ischemic attack was significantly associated with clinical limb ischemia. On multivariate analysis, younger age (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.93-0.99), diabetes (OR, 2.77; 95% CI, 1.08-7.12), pulmonary disease (OR, 3.86; 95% CI, 1.38-10.78), and peripheral arterial disease (OR, 13.68; CI, 2.75-68.01) were associated with limb ischemia. Lack of prophylactic distal perfusion catheter and arterial cannula size were not independently associated with limb ischemia. Femoral ECMO cannulation can be associated with significant limb ischemia necessitating surgical intervention. Younger patients, as well as those with a history of diabetes, pulmonary disease, and peripheral arterial disease, may be at increased risk for this complication.

Malposition of the Extracorporeal Membrane Oxygenation Venous Cannula in an Accessory Hepatic Vein

We report a case of a refractory cardiogenic shock secondary to myocardial infarction in a 70-year-old patient requiring femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO). At initial transesophageal echocardiography, the venous cannula tip was seen in the inferior vena cava (IVC), but not in right atrium. On day 8, ultrasonic examination identified that the end of the venous cannula was in the hepatic vein (HV). Despite such malposition, no disturbance in extracorporeal membrane oxygenation (ECMO) venous return was observed. Moving or replacing the cannula was considered a high-risk maneuver potentially resulting in hepatic laceration with hemoperitoneum. Because of adequate venous drainage, allowing sufficient blood flow, venous cannula repositioning was delayed until day 10, when a ventricular defect was repaired and ECMO was weaned off. At the time of VA-ECMO implantation, the venous cannula has to be positioned in the right atrium using real time echo monitoring. Visualization of the guide wire in the IVC but not in the right atrium is insufficient to ensure appropriate venous cannula positioning. Indeed, either accidental catheterization or cannula migration into the HV is possible during ECMO. Health care professionals dealing with ECMO have to be aware of this possible malposition, to correct it and prevent insufficient venous drainage or traumatic complications.

Distal Perfusion Cannulation and Limb Complications in Venoarterial Extracorporeal Membrane Oxygenation

The utility of distal perfusion cannula (DPC) placement for the prevention of limb complications in patients undergoing femoral venoarterial (VA) extracorporeal membrane oxygenation (ECMO) is poorly characterized. Patients undergoing femoral VA ECMO cannulation at two institutions were retrospectively assessed. Patients were grouped into those who did and those who did not receive a DPC at the time of primary cannulation. The primary outcome was any limb complication. Secondary outcomes included successfully weaning ECMO and in-hospital mortality. A total of 75 patients underwent femoral cannulation between December 2010 and December 2017. Of those, 65 patients (86.7%) had a DPC placed during primary cannulation and 10 patients (13.3%) did not. Baseline demographics, indications for ECMO, and hemodynamic perturbations were well matched between groups. The rate of limb complications was 14.7% (11/75) for the overall cohort and did not differ between groups (p = .6). Three patients (4%) required a four-compartment fasciotomy for compartment syndrome in the DPC group; no patients without a DPC required fasciotomy. Of the three patients who required a thrombectomy for distal ischemia, two were in the DPC group and one was in the no-DPC group (p = .3). Two patients (2.7%) underwent delayed DPC placement for limb ischemia with resolution of symptoms. The in-hospital morality rate was 59.5% and did not differ between groups (p = .5). Patients in the present study, undergoing femoral VA ECMO without preemptive DPC placement did not experience a higher rate of limb complications. However, the two patients who underwent delayed DPC placement for post-cannulation ischemia experienced resolution of symptoms, suggesting that a DPC may be used as an effective limb salvage intervention.

Usefulness of Near-infrared Reflectance Spectroscopy to Assess Lower-limb Perfusion on Femoral Veno-arterial Extracorporeal Membrane Oxygenation

Usefulness of Near-infrared Reflectance Spectroscopy to Assess Lower-limb Perfusion on Femoral Veno-arterial Extracorporeal Membrane Oxygenation

Factors Associated With Ipsilateral Limb Ischemia in Patients Undergoing Femoral Cannulation ECMO

Extracorporeal membrane oxygenation (ECMO) is an important life-saving modality for patients with cardiopulmonary failure. Vascular complications, including clinically significant limb ischemia, may occur as a result of femoral artery cannulation for venoarterial (VA) ECMO. This study examines our institutional experience with femoral VA ECMO and the development of limb ischemia.

Left ventricular thrombus formation in patients undergoing femoral veno-arterial extracorporeal membrane oxygenation.

Profoundly impaired left ventricular (LV) function in patients undergoing femoral veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) can result in intra-cardiac stasis and thrombus formation. There have been several attempts to improve LV unloading in patients with peripheral VA-ECMO, either by improving contractility or by venting the LV. Data from all patients who underwent femoral VA-ECMO between 2007 and 2015 due to cardiogenic decompensation were retrospectively analysed regarding intra-cardiac thrombus formation. In total, 11 of 281 patients (3.91%) with femoral VA-ECMO developed an intra- or extra-cardiac thrombus despite adequate anticoagulation therapy. None of the patients survived this serious complication. Management strategies for patients with femoral VA-ECMO support and severely impaired LV function must be reassessed to avoid insufficient LV unloading at an early stage of ECMO therapy. Early LV decompression should be considered in patients with insufficient unloading of the LV to prevent intra-cardiac thrombus formation.

Novel Rotational Speed Modulation System Used With Venoarterial Extracorporeal Membrane Oxygenation

Femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO) is widely used to maintain blood flow in patients with cardiogenic shock. However, retrograde blood flow increases left ventricular (LV) afterload during femoral VA-ECMO. Additional support by means of an intraaortic balloon pump (IABP) alleviates LV afterload but is associated with significant adverse events. We previously developed a system for rotational speed modulation in synchrony with the native cardiac cycle, for use with implantable continuous-flow LV assist devices. Here, we aimed to evaluate whether our novel rotation speed modulation system can improve coronary artery flow and reduce LV during femoral VA-ECMO. VA-ECMO was installed by means of right atrial drainage and distal abdominal aortic perfusion in six adult goats. Cardiogenic shock was induced with β-adrenergic antagonist infusion. An IABP was placed in the descending aorta. LV stroke work, LV end-systolic pressure, and coronary arterial flow were evaluated. Data were collected under five conditions (modes): baseline, circuit-clamp (cardiogenic shock), continuous mode (constant rotational speed), counterpulse mode (increasing rotational speed during diastole), and continuous mode with IABP support. LV stroke work and LV end-systolic pressure tended to be lower in the counterpulse mode, indicating decreased LV work load and afterload in this mode. Furthermore, coronary arterial flow tended to be higher in the counterpulse mode. Our system enabled an increase in coronary arterial flow and a decrease in LV work load and afterload during VA-ECMO. The system offers the effects of VA-ECMO and an IABP in a single device.

Use of distal perfusion in peripheral extracorporeal membrane oxygenation.

Extra corporeal membrane oxygenation (ECMO) is a life-saving technique to manage refractory cardiopulmonary failure. Its usage and indication continue to increase. Femoral venoarterial ECMO (VA ECMO) is relatively less invasive and the cardiac support may be more rapidly instituted in in these extremely tenuous patients. Vascular injuries and limb ischemia unfortunately occur in these emergent access settings. Here we will discuss the optimal techniques of preventing this complication which might affect patient survival and impact the patient quality of life.

Persistent hypoxemia on ECMO

Extracorporeal membrane oxygenation (ECMO) is used to support patients with hypoxemia due to severe respiratory failure. Hypoxemia can persist during ECMO as a result of reduction in mechanical ventilatory support as part of a lung protective strategy, following which gas exchange provided by the native lungs is reduced or absent. If tissue oxygen delivery is maintained, mild to moderate hypoxemia will be well tolerated, but if tissue hypoxia develops, then the cause of hypoxemia must be addressed and corrected. Patterns of hypoxemia are dependent on the mode of ECMO support. During veno-venous support for respiratory failure, hypoxemia is global, with all tissues receiving hypoxemic blood. When femoral veno-arterial support is used in the presence of respiratory failure, then differential hypoxemia can result, with hypoxemia limited to the upper part of the body. The approach to hypoxemia is dependent on whether veno-venous (VV) or veno-arterial (VA) ECMO is used. Adequate oxygen saturation on VV ECMO requires adequate hemoglobin, a membrane lung operating below its rated flow, low recirculation, and extracorporeal circuit flow that captures most of the cardiac output. The approach to hypoxemia during VV ECMO includes addressing each of these. Identifying and limiting recirculation will improve effective extracorporeal flow. Anemia has two detrimental effects. First, it limits oxygen transfer through the membrane lung. Second, it increases oxygen extraction resulting in low mixed venous oxygen saturation that increases the effective venous admixture with circuit blood. Transfusion to near normal levels will help improve oxygen saturation. Increasing effective extracorporeal flow to capture at least 60% of the cardiac output is necessary.1 If the extracorporeal flow fraction is less than 60% due to an increased cardiac output, then reducing cardiac output through reducing exogenous catecholamines, use of beta blockade,2 or hypothermia3 will help improve the extracorporeal flow fraction. Hypothermia has the added benefit of reducing oxygen consumption and therefore improving mixed venous saturation. A final option is to leverage the native lungs, such as through prone positioning, as long as lung protective strategies can be maintained.4 Oxygen saturation on femoral VA ECMO is typically normal (>90%). The upper part of the body is provided with blood from the left ventricle that has been saturated by normally functioning lungs. The lower part of the body is provided with fully saturated blood from the extracorporeal circuit. The two circulations meet at some point in the aorta that depends on the relative magnitude of flow rate in these two circulations. If there is pulmonary dysfunction, then the blood ejected by the left ventricle will be hypoxemic, and tissues perfused proximal to the mixing point will be perfused with hypoxemic blood, while the lower body will have a normal saturation. Management of this differential hypoxemia is through improvement of pulmonary gas exchange if possible, increasing extracorporeal flow to decrease pulmonary blood flow, or conversion of VA ECMO to VVA (hybrid veno-arterial and veno-venous).

Routine Use of Distal Arterial Perfusion in Pediatric Femoral Venoarterial Extracorporeal Membrane Oxygenation.

Lower-extremity ischemia is a significant complication in children on femoral venoarterial extracorporeal membrane oxygenation (VA ECMO). Our institution currently routinely uses distal perfusion catheters (DPCs) in all femoral arterial cannulations in attempts to reduce ischemia. We performed a single-center, retrospective review of pediatric patients supported with femoral VA ECMO from January 2005 to November 2015. The outcomes of patients with prophylactic DPC placement at cannulation (prophylactic DPC) were compared to a historical group with DPCs placed in response only to clinically evident ischemic changes (reactive DPC). Ischemic complication requiring invasive intervention (fasciotomy or amputation) was the primary outcome. Twenty-nine patients underwent a total of 31 femoral arterial cannulations, 17 with prophylactic DPC and 14 with reactive DPC. Ischemic complications requiring invasive intervention developed in 2 of 17 (12%) prophylactic DPC patients versus 4 of 14 (29%) reactive DPC. In the reactive DPC group, 7 of 14 (50%) had ischemic changes postcannulation, six underwent DPC placement, and three out of six of these patients still required invasive intervention. One of the seven patients had ischemic changes, did not undergo DPC, and required amputation. While a greater percentage of patients in the prophylactic group was cannulated during extracorporeal cardiopulmonary resuscitation (ECPR), statistical significance was not otherwise demonstrated. We demonstrate feasibility of superficial femoral artery (SFA) access in pediatric patients. We note fewer ischemic complications with prophylactic DPC placement, and observe that salvaging a limb with a reactive DPC was only successful 50% of the time. Although there was no statistical difference in the primary outcome between the two groups, limitations and confounding factors include small sample size and a greater percentage of patients in the prophylactic DPC group cannulated with ECPR in progress.

Emergency percutaneous implantation of veno-arterial extracorporeal membrane oxygenation in the catheterisation laboratory.

Our aim was to describe our protocol for emergency percutaneous implantation of femoral veno-arterial extracorporeal membrane oxygenation (VA ECMO) in the catheterisation laboratory and to compare its effectiveness and safety with implantation in the intensive care unit and the operating room. Our retrospective observational study enrolled 56 consecutive patients undergoing VA ECMO implantation in the catheterisation laboratory (n=23), the intensive care unit (n=8) and the operating room (n=25). Among patients undergoing catheterisation laboratory implantation, 11 patients had profound cardiogenic shock but preserved arterial pulsations, and 12 patients had refractory cardiac arrest undergoing automated mechanical chest compression. Using our fluoroscopy-guided protocol, arterial and venous cannulas were successfully implanted and the desired ECMO flow obtained in each patient. There was no vessel perforation/dissection. Moderate/severe GUSTO or BARC 3 and 5 bleeding occurred in 13%. Ipsilateral limb ischaemia occurred in one of eight patients (13%) with upfront perfusion sheath implantation, and in two of three patients (75%) in whom this strategy was not used (p=0.15). There was no infection at the site of cannula implantation. Complications related to implantation in the catheterisation laboratory were comparable to surgical implantation in the operating room and percutaneous implantation in the intensive care unit using ultrasound guidance. Fluoroscopy-guided emergency implantation of femoral VA ECMO by an interventional cardiologist in the catheterisation laboratory is effective and safe for both patients in cardiogenic shock and those in refractory cardiac arrest.

Superior vena cava drainage improves upper body oxygenation during veno-arterial extracorporeal membrane oxygenation in sheep.

IntroductionDifferential hypoxia is a pivotal problem in patients with femoral veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) support. Despite recognition of differential hypoxia and attempts to deliver more oxygenated blood to the upper body, the mechanism of differential hypoxia as well as prevention strategies have not been well investigated.MethodsWe used a sheep model of acute respiratory failure that was supported with femoral VA ECMO from the inferior vena cava to the femoral artery (IVC-FA), ECMO from the superior vena cava to the FA (SVC-FA), ECMO from the IVC to the carotid artery (IVC-CA) and ECMO with an additional return cannula to the internal jugular vein based on the femoral VA ECMO (FA-IJV). Angiography and blood gas analyses were performed.ResultsWith IVC-FA, blood oxygen saturation (SO2) of the IVC (83.6 ± 0.8%) was higher than that of the SVC (40.3 ± 1.0%). Oxygen-rich blood was drained back to the ECMO circuit and poorly oxygenated blood in the SVC entered the right atrium (RA). SVC-FA achieved oxygen-rich blood return from the IVC to the RA without shifting the arterial cannulation. Subsequently, SO2 of the SVC and the pulmonary artery increased (70.4 ± 1.0% and 73.4 ± 1.1%, respectively). Compared with IVC-FA, a lesser difference in venous oxygen return and attenuated differential hypoxia were observed with IVC-CA and FA-IJV.ConclusionsDifferential venous oxygen return is a key factor in the etiology of differential hypoxia in VA ECMO. With knowledge of this mechanism, we can apply better cannula configurations in clinical practice.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-015-0791-2) contains supplementary material, which is available to authorized users.

Heart beats: not to be beaten.

Heart beats: not to be beaten.

Non-intubated recovery from refractory cardiogenic shock on percutaneous VA-extracorporeal membrane oxygenation.

We report on the use of percutaneous femoral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in a fully awake, non-intubated and spontaneously breathing patient suffering from acute, severe and refractory cardiogenic shock due to a (sub)acute anterior myocardial infarction. Intensified heart failure therapy was closely monitored with a pulmonary artery catheter and allowed gradual weaning off the ECMO support without additional invasive measures, notably without mechanical ventilation. Neurological assessment was possible at all times and complete physical mobilisation was straightforward directly after weaning from ECMO. This limited invasive approach may encourage a more widespread use of percutaneous VA-ECMO.

RR8. Outcome of Rectus Femoris Muscle Flaps for Femoral Arterial Graft Complications

Objectives: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a salvage therapy in patients with severe cardiopulmonary failure. Because large cannulas (16-24F) are necessary to achieve adequate oxygenation, the femoral artery is the most common access site. Unfortunately, femoral cannulation has been associated with limb complications (10%-70%), including ischemia, limb loss, and compartment syndrome. This study aimed to evaluate these complications and management related to limb salvage. Methods: A retrospective review was conducted of 91 consecutive patients requiring VAECMO via femoral cannulation from July 2010 until January 2015. At the time of cannulation, most patients had percutaneous placement of distal arterial perfusion catheters (DPC). After cannulation, all patients were monitored by a near-infrared spectroscopy (NIRS) algorithm and hourly lower extremity examination by trained cardiac intensive care nursing staff, with immediate notification of any change from baseline. ECMO decannulation involved a femoral cutdown with arteriotomy closure by either primary repair or patch angioplasty with bovine pericardium. Study end points included limb ischemia, compartment syndrome requiring fasciotomies, and limb loss. Results: Ninety-one patients were supported with VA-ECMO with femoral arterial cannula sizes from 1624F. Mean length of time on ECMO was 9.1 days (range, 1-40 days). Percutaneous DPC was placed immediately in 62 of 91 patients, with no subsequent ischemia. Of the 29 patients without initial DPC placement, 12 (41.4%; 13.2% of all VA ECMO) developed acute ischemia. Two patients subsequently had DPC placement only, 5 had DPC placement and fasciotomies, 4 had fasciotomies only, and 1 patient required amputation after presenting with acute ischemia after cannulation at another hospital. After DPC placement, all patients had resolution of limb ischemia. The remaining 17 patients without DPC placement experienced no vascular compromise. Overall survival in our VAECMO population was 64%; in patients with limb complications, mortality was 75%. Conclusions: Historically, femoral VA-ECMO has been associated with significant limb ischemic complications. A systematic protocol including NIRS monitoring, trained intensive care nursing staff, DPC placement, decannulation with primary repair of arteriotomies or patch angioplasty can decrease rates of limb ischemia leading to limb loss.

Extracorporeal membrane oxygenation support in acute coronary syndromes complicated by cardiogenic shock.

Acute coronary syndrome (ACS) complicated by shock is associated with high mortality despite the use of percutaneous support devices. Extracorporeal membrane oxygenation (ECMO) offers cardiopulmonary support but its safety and efficacy in the ACS setting is still under investigation. We reviewed the clinical characteristics and course of 18 consecutive patients who received femoral veno-arterial ECMO in the cardiac catheterization lab for severe shock due to ACS at our center between 2007 and 2013. The average age was 59.9 years, 72.2% male. Of the 18 patients, 83% had a ST-segment elevation myocardial infarction, of which 55% had a left main or left anterior descending artery occlusion. Thirteen patients received stents, three were referred for coronary artery bypass grafting alone, and two received balloon angioplasty. All patients received aspirin, a thienopyridine (either clopidogrel or ticagrelor), and heparin. Five patients received a glycoprotein IIb/IIIa inhibitor during the catheterization. The average length of ECMO was 3.2 ± 2.5 days, length of stay was 23.4 days, and 67% survived to discharge. Seventeen of eighteen patients (94%) required at least one blood transfusion and use of blood products was significantly higher in the group receiving glycoprotein IIb/IIIa inhibitors [19 U of packed red blood cells (PRBC) vs. 8.2 U (P = 0.003)]. In patients with severe shock or refractory ventricular arrhythmias due to ACS, VA-ECMO likely offers an alternative form of biventricular support albeit with significant resource utilization and morbidity. A better understanding of how to manage patients with ACS requiring VA-ECMO support including the associated morbidities such as bleeding is necessary.

Differential venous oxygen return: a key factor of differential hypoxia in venoarterial extracorporeal membrane oxygenation

Differential hypoxia is a pivotal problem in cardiopulmonary failure patients with femoral venoarterial extracorporeal membrane oxygenation (VA ECMO) support. Although there was some attempt to deliver more oxygenated blood to the upper body, the mechanism of differential hypoxia has not been well investigated.

The role of the total artificial heart in the treatment of post–myocardial infarction ventricular septal defect

improved durability and performance relative to previous VADs. Our major rationale for choosing the HeartWare HVAD was its relatively small size and ability to be contained within the pericardium, thus eliminating the potential need to create a pocket or rotate the pump configuration. In addition, the device’s integrated inflow cannula could decrease the chance of inflow obstruction related to the abnormal position of the ventricles in CC-TGA. TEE guidance ensured successful selection of the optimal insertion site for the VAD inflow cannula. In summary, we report a case of successful HeartWare HVAD implantation in a patient with CC-TGA to support the function of the RV (systemic ventricle).