Extracorporeal Membrane Oxygenation Implantation Research Articles

Vascular Complications After Venoarterial Extracorporeal Membrane Oxygenation Support: A CT Study.

Vascular complications after venoarterial extracorporeal membrane oxygenation (ECMO) remains poorly studied, although they may highly impact patient management after ECMO removal. Our aim was to assess their frequency, predictors, and management. Retrospective, observational cohort study. Two ICUs from a tertiary referral academic hospital. Adult patients who were successfully weaned from venoarterial ECMO between January 2021 and January 2022. None. Vascular complications frequency related to ECMO cannula. A total of 288 patients were implanted with venoarterial ECMO during the inclusion period. One hundred ninety-four patients were successfully weaned, and 109 underwent a CT examination to assess for vascular complications until 4 days after the weaning procedure. The median age of the cohort was 58 years (interquartile range [IQR], 46-64 yr), with a median duration of ECMO support of 7 days (IQR, 5-12 d). Vascular complications were observed in 88 patients (81%). The most frequent complication was thrombosis, either cannula-associated deep vein thrombosis (CaDVT) (n = 63, 58%) or arterial thrombosis (n = 36, 33%). Nonthrombotic arterial complications were observed in 48 patients (44%), with 35 (31%) presenting with bleeding. The most common site of CaDVT was the inferior vena cava, occurring in 33 (50%) of cases, with 20% of patients presenting with pulmonary embolism. There was no association between thrombotic complications and ECMO duration, anticoagulation level, or ECMO rotation flow. CT scans influenced management in 83% of patients. In-hospital mortality was 17% regardless of vascular complications. Vascular complications related to venoarterial ECMO cannula are common after ECMO implantation. CT allows early detection of complications after weaning and impacts patient management. Patients should be routinely screened for vascular complications by CT after decannulation.

Lessons Learned From Extracorporeal Life Support Practice and Outcomes During the COVID-19 Pandemic.

Extracorporeal membrane oxygenation is increasingly being used to support patients with hypoxemic respiratory failure and cardiogenic shock. During the COVID-19 pandemic, consensus guidance recommended extracorporeal life support for patients with COVID-19-related cardiopulmonary disease refractory to optimal conventional therapy, prompting a substantial expansion in the use of this support modality. Extracorporeal membrane oxygenation was particularly integral to the bridging of COVID-19 patients to heart or lung transplantation. Limited human and physical resources precluded widespread utilization of mechanical support during the COVID-19 pandemic, necessitating careful patient selection and optimal management by expert healthcare teams for judicious extracorporeal membrane oxygenation use. This review outlines the evidence supporting the use of extracorporeal life support in COVID-19, describes the practice and outcomes of extracorporeal membrane oxygenation for COVID-19-related respiratory failure and cardiogenic shock, and proposes lessons learned for the implementation of extracorporeal membrane oxygenation as a bridge to transplantation in future public health emergencies.

Fit-for-Future: Lessons Learned from the COVID-19 Pandemic in Primary Extracorporeal Membrane Oxygenation (ECMO) Transports of Acute Respiratory Distress Syndrome (ARDS) Patients.

(1) Background: The COVID-19 pandemic presented significant challenges in managing acute respiratory distress syndrome (ARDS), with extracorporeal membrane oxygenation (ECMO) being a critical but resource-intensive intervention. (2) Methods: This retrospective study analyzed veno-venous (VV) ECMO therapy in ARDS patients before and during the pandemic at a high-volume ECMO center in Germany. The study used a reduced ECMO team (one medical and one nursing specialist) to optimize patient care with limited resources, aiming to offer insights for future pandemic management. Data from 181 adult patients (age ≥ 18) with severe ARDS were analyzed: 57 pre-pandemic and 124 during the pandemic. (3) Results: Despite increased isolation measures during the pandemic (25% pre-COVID-19 vs. 79% during COVID-19, p < 0.0001), there was no significant change in transportation mode (ground vs. air) or ECMO implantation times at local hospitals. Similarly, time and distance for primary ECMO transport remained unchanged between the two periods. Complication rates related to ECMO circuit placement and prolonged transport were also insignificant across groups. However, ECMO therapy duration (median 12 days pre-COVID-19 vs. 19 days during COVID-19, p < 0.0001) and hospital stays (median 3 days pre-COVID-19 vs. 7 days during COVID-19, p < 0.01) were longer during the pandemic. Mortality rates were also higher during the pandemic (49% pre-COVID-19 vs. 65% during COVID-19, p < 0.05). (4) Conclusions: In conclusion, a reduced ECMO team proved to be an effective resource-saving strategy that maintained high-quality care with low complication rates, despite the additional challenges posed by pandemic-related isolation measures.

Extracorporeal membrane oxygenation states basilar artery thrombectomy and left posterior cerebral artery stent thrombectomy: A case report

BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a new type of extracorporeal respiratory and circulatory assistance device. It can drain venous blood out of the body and inject it into veins or arteries after being oxygenated by an oxygenator (membrane lung) to replace lung and heart functions in a short time. ECMO can provide tissue blood perfusion and gas exchange almost equivalent to cardiac output and extend the effective treatment time window for patients with acute circulatory failure to restore cardiopulmonary function. CASE SUMMARY We report a case of an 81-year-old woman who underwent whole cerebral angiography, basilar artery thrombectomy and stent thrombectomy in the posterior artery of the left brain after implantation of ECMO. The patient was admitted to the hospital due to myocardial infarction. Considering that the cause of the patient’s disturbance of consciousness was unknown and cerebrovascular accident could not be ruled out after the implantation of ECMO, the department of Radioactive Intervention performed cerebral angiography. And the result of the angiography indicated vascular occlusion. After the basilar artery thrombectomy and stent thrombectomy in the posterior artery of the left brain, the patency of the occlusive vessel was achieved. CONCLUSION Although the patient eventually died of circulatory failure, the result of this case verifies the feasibility of cerebral angiography and thrombectomy in patients with implanted ECMO in the intubated state.

Left ventricular unloading during venoarterial extracorporeal membrane oxygenation implantation: benefits or complications?

Abstract Funding Acknowledgements None. Introduction Peripheral venoarterial extracorporeal membrane oxygenation (VA ECMO) is a therapeutic option for refractory cardiogenic shock (CS). However, the retrograde flow increases afterload, leading to pulmonary edema, blood stasis in the left ventricle (LV) and formation of thrombi. Several strategies try to reduce LV pressure, including the percutaneous transvalvular microaxial pump (p-MCS) and intra-aortic balloon pump (IABP). However, these interventions are associated to complications, such as limb ischemia, embolism, bleeding and hemolysis. Purpose This study aims to investigate whether simultaneous LV unloading at ECMO implant yields clinical benefits or complications compared to ECMO implantat alone. Methods Consecutive patients (pts) with CS requiring peripheral VA ECMO from January 2020 to August 2023 were prospectively included, comparing the group that received LV unloading through IABP or p-MCS to the group that received ECMO only. Standard statistical methods were used. Results A total of 38 pts required VA ECMO. 18 of them received LV unloading since cannulation (8 with IABP and 10 with p-MCS). In the group without initial LV-unloading (20), 3 pts required IABP and 1 p-MCS during support and 1 was changed to VAV ECMO. Change to axillar configuration was perfomed in 1 pts in the unloaded group and in 2 in the only-ECMO group. A higher prevalence of SCAI E (72.2%) was observed in the unloaded-ECMO, compared to the only-ECMO, where SCAI D was more prevalent (60%) (p=0.024). In the LV unloaded group, acute myocardial infarction (AMI) was the leading cause of CS, while myocarditis was the predominant one in the other group (p=0.01). The simultaneous support had a higher rate of intubation (94.4% vs 50% p=0.004) and more acute pulmonary edema (44.4% vs 10% p=0.027). In the ECMO-only 2 pts required intubation during support and LV stasis was observed in 1, whereas no cases were reported in the LV-unloaded group (p=0.036). The mean PaO2/FiO2 during support were higher in the not unloaded group (284.54 vs 200.50 mmHg p=0.036), necessitating lower FiO2 levels (40.89 vs 61.47% p=0.003). In terms of complications, we included the 4 patients from the ECMO-only group who eventually required LV unloading in the unloaded-ECMO. There were no significant differences in the duration of support, in-hospital mortality, stroke, embolism, systemic and local bleeding, or hemolysis. Conclusions Pts with ECMO and LV unloading since cannulation debuted with more severe CS, more AMI as the underlying cause, higher rates of acute pulmonary edema, and intubation. Despite these challenges, they did not experience worse outcomes in terms of in-hospital mortality or ischemic and hemorrhagic events. Notably, 4 patients initially managed with ECMO eventually required subsequent LV unloading. Consequently, the simultaneous implantation of ECMO and a LV unloading device appears to be a reasonable alternative for select patients with a higher risk profile.

ECMOve: A Mobilization Device for Extracorporeal Membrane Oxygenation Patients.

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

Vasoactive-Inotropic Score as a Promising Predictor of Acute Kidney Injury in Adult Patients Requiring Extracorporeal Membrane Oxygenation.

Acute kidney injury (AKI) is a common complication in patients supported by extracorporeal membrane oxygenation (ECMO). Vasoactive-Inotropic Score (VIS) serves as an indicator of the extent of cardiovascular drug support provided. Our objective is to assess the relationship between the VIS and ECMO-associated AKI (EAKI). This single-center retrospective study extracted adult patients treated with ECMO between August 2016 and September 2022 from an intensive care unit (ICU) in a university hospital. A total of 126 patients requiring ECMO support were included in the study, of which 76% developed AKI. Multivariate logistic regression analysis identified VIS-max Day1 (odds ratio [OR]: 1.025, 95% confidence interval [CI]: 1.007-1.044, p = 0.006), VIS-max Day2 (OR: 1.038, 95% CI: 1.007-1.069, p = 0.015), VIS-mean Day1 (OR: 1.048, 95% CI: 1.013-1.084, p = 0.007), and VIS-mean Day2 (OR: 1.059, 95% CI: 1.014-1.107, p = 0.010) as independent risk factors for EAKI. VIS-max Day1 showing the best predictive effect (Area under the receiver operating characteristic curve (AUROC): 0.80, sensitivity: 71.87%, specificity: 80.00%) for EAKI with a cutoff value of 33.33. Surprisingly, VIS-mean Day2 was also excellent at predicting 7 day mortality (AUROC: 0.77, sensitivity: 87.50%, specificity: 56.38%) with a cutoff value of 8.67. In conclusion, VIS could independently predict EAKI and 7 day mortality in patients with ECMO implantation, which may help clinicians to recognize the poor prognosis in time for early intervention.

Comparison of PCO2gap, SvO2 and plasmatic lactate in patients on venoarterial extracorporeal circulation support.

Clinical assessment and laboratory markers provide valuable information on tissue perfusion and enhance the optimalisation of management in the treatment of patients on extracorporeal membrane oxygenation (ECMO). The PCO2 gap is areliable marker of cardiac output (CO) and perfusion. The aim of this study was to evaluate the PCO2 gap as amarker of tissue hypoperfusion and to compare it to lactate and SvO2. Asingle-center retrospective study on 131 adult cardiac patients who underwent ECMO implantation in the period between 2010 and 2021. Baseline characteristics, laboratory markers and mortality were analyzed. There was astatistically significant difference in the plasmatic levels of lactate, SvO2 and PCO2 gap between patients that survived and those who died post ECMO implantation (3.6±3.29 vs 7.15±7.38 mmol/l, p<0.001; 69.13±9 vs 67.38±10%, p<0.001; 7.65±2.93 vs 8.34±3.71, p<0.001 respectively). There was astatistically significant difference in PCO2 gap in the first 5 arterial blood gas (ABG) samples post ECMO implantation between patients that survived and those who died (9.08±4.79 vs 10.37±5.35, p<0.003). For SvO2, this difference was not statistically significant (69.82±11.91 vs 68.51±11.72, p<0.104). There was astatistically significant but low negative correlation between SvO2 and PCO2 gap post ECMO implantation (r = ‒0.354, p<0.001). The PCO2 gap is avaluable biomarker for monitoring tissue perfusion in patients on ECMO. It is associated with increased mortality and should be an integral part of clinical evaluation. (Tab. 1, Fig. 5, Ref. 26). Text in PDF www.elis.sk Keywords: PCO2 gap, VA-ECMO, lactate.

Clinical indications and outcomes of Impella devices for severe cardiogenic shock in COVID-19 patients: a systematic review

Background: Coronavirus disease 2019 (COVID-19) can present with significant cardiac dysfunction, including cardiogenic shock. Mechanical circulatory support with an Impella device may be utilized in these patients to support and offload native right ventricle (RV) and left ventricle (LV) functions. This systematic review aims to describe clinical indications, management, laboratory data, and outcomes in patients with severe cardiogenic shock from COVID-19 treated with an Impella device. Methods: A PRISMA-directed systematic review was performed and prospectively registered in PROSPERO. The databases accessed included PubMed/MEDLINE, Scopus, and ScienceDirect. Quality and risk of bias assessments were completed using the Joanna Briggs Institute (JBI) checklist for case reports. Results: A total of 16 records were included in the qualitative synthesis; 8/16 (50%) of the patients were men. The average age was 39 years (SD: 14.7). The biventricular Impella (BiPella) approach was recorded in 3/16 (18.75%) patients. A total of 4/16 (25%) individuals required renal replacement therapy (RRT). Single-device usage was observed in three cases: 2/16 Impella CP (12.5%) and 1/16 Impella RP (6.25%). Treatment of COVID-19 myocarditis included a wide range of antivirals and immunomodulators; 8/16 (50%) cases needed ECMO (extracorporeal membrane oxygenation) support. Overall, only 2/16 (11.7%) individuals died. Conclusions: Sixteen reported individuals have received an Impella implanted with a mortality rate of 11.7%. Concurrent use of RRT and ECMO implantation was often observed. Overall, the Impella device is an effective and safe strategy in the management of COVID-19-related cardiogenic shock. Future studies should include long-term results.

Should the Vasoactive Inotropic Score be a Determinant for Early Initiation of VA ECMO in Postcardiotomy Cardiogenic Shock?

The authors investigated the role of early venoarterial extracorporeal membrane oxygenation (VA ECMO) implantation in patients with postcardiotomy cardiogenic shock (PCS) on mortality and morbidity when integrating vasoactive-inotropic score (VIS) and type of catecholamine support. A retrospective, multicenter, observational study with propensity-weight matching. Four university-affiliated intensive care units. Patients with PCS in the operating room. Early VA ECMO support. Of 2,742 patients screened during the study period, 424 (16%) patients were treated with inotropic drugs, and 75 (3%) patients were supported by VA ECMO in the operating room. Patients supported by VA ECMO had a higher use of vasopressor and inotropic drugs, with a higher VIS score. After propensity matching (integrating VIS and catecholamines type), mortality (56% v 20%, p < 0.001) and morbidity (cardiac, renal, transfusion) were higher in patients supported by VA ECMO than in a matched control group. When matching integrated the pre-ECMO VIS and the type of catecholamines, VA ECMO remained associated with high mortality and morbidity, suggesting that VIS alone should not be used as a main determinant of VA ECMO implantation.

Outcomes comparison between the first and the subsequent SARS-CoV-2 waves - a systematic review and meta-analysis.

In the beginning of the SARS-CoV-2 pandemic, health care professionals dealing with COVID-19 had to rely exclusively on general supportive measures since specific treatments were unknown. The subsequent waves could be faced with new diagnostic and therapeutic tools (e.g., anti-viral medications and vaccines). We performed a meta-analysis and systematic review to compare clinical endpoints between the first and subsequent waves. Three databases were assessed. The primary outcome was in-hospital mortality. The secondary outcomes were intensive care unit (ICU) mortality, ICU length of stay (LOS), acute renal failure, extracorporeal membrane oxygenation (ECMO) implantation, mechanical ventilation time, hospital LOS, systemic thromboembolism, myocarditis and ventilator associated pneumonia. A total of 25 studies with 126,153 patients were included. There was no significant difference for the primary endpoint (OR=0.94, 95% CI 0.83-1.07, p=0.35). The first wave group presented higher rates of ICU LOS (SMD= 0.23, 95% CI 0.11-0.35, p<0.01), acute renal failure (OR=1.71, 95% CI 1.36-2.15, p<0.01) and ECMO implantation (OR=1.64, 95% CI 1.06-2.52, p=0.03). The other endpoints did not show significant differences. The analysis suggests that the first wave group, when compared with the subsequent waves group, presented higher rates of ICU LOS, acute renal failure and ECMO implantation, without significant difference in in-hospital or ICU mortality, mechanical ventilation time, hospital LOS, systemic thromboembolism, myocarditis or ventilator- associated pneumonia.

Purified VWF Corrects Dysfunctional Primary Hemostasis in Patients with Extracorporeal Life Support. in Vitro Studies Against Cryoprecipitate

INTRODUCTION. Extracorporeal membrane oxygenation (ECMO) is a mechanical assistance system used to temporarily support patients with life-threatening cardiac and/or respiratory dysfunction when traditional treatment fails. Bleeding is one of the main complications causing significant morbidity and mortality. Development of acquired von Willebrand disease (AVWD) within 1-6 hours after ECMO implantation has been described, with recovery 3-24 hours after device explant. There is no consensus on the most suitable treatment for these patients. OBJECTIVE. To investigate the improvement in primary hemostasis after the in vitro addition of VWF-containing concentrates in samples from patients with ECMO. MATERIAL AND METHODS: During 2023, 7 adults with ECMO (n=2 venous-venous, and n=5 veno-arterial) due to pulmonary or cardiovascular diseases were included in the study. Samples were collected within the first 72 hours after implantation and 5 days after removal (n=16 samples).Hematocrit, platelet counts, and ADAMTS13 activity, by FRETS assay, were determined.Platelet function was evaluated by PFA-200 ( Siemens Healthineers®) with collagen-epinephrine and collagen-ADP cartridges, and platelet aggregation with ristocetin 1 mg/mL ( Helena BioSciences APACT4 ®). VWF function was assessed by antigen (VWF:Ag), activity (VWF:GPIbM), and VIII factor (VIIIF) quantification ( Siemens Atellica COAG360®), collagen (VWF:CB) and VIIIF binding (VWF:VIIIF) to VWF ( Asserachrom ®and Thermo Scientific MultiSkan FC ®) and VWF multimeric analysis (agarose gels and immunoblotting). Total-TAS ®( Zacros) was used to analyze hemostasis before and after in vitro addition of VWF concentrate ( Haemate-P ® ) or cryoprecipitate (Cp) in each sample. The cohort was divided into two groups according to the time when the samples were collected. Only the subjects showing a correction of the occlusion times at Total-TAS® were included in the comparative analysis. RESULTS. Mucocutaneous bleeding and pulmonary embolism were reported in n=3.One patient died before device removal. Within the first 72 hours after implantation PFA-200 was prolonged (&amp;gt;300s), VWF:Ag, VWF:GPIbM, and VWF:CB values increased, and hematocrit, platelet counts, ristocetin aggregation and VWF:VIIIFdecreased, as reported in Table 1.VIIIF was within normal range. Loss of high molecular weight VWF multimers was observed in all samples, and VWF:GPIbM/VWF:Ag ratio was &amp;lt;0.70 in 29% patients. These findings persisted within 5 days after removal, except for PFA-200 and platelet counts that normalized in 29% and 50%, respectively, while VIIIF values increased. In the samples collected after ECMO removal, the addition of Haemate-P® significantly reduced Total-TAS ® occlusion times (573.00±280.91 vs 821.20±586.54 p=0.043, post- vs pre-). Correction of the occlusion time with Cp was not statistically significant. The hemostatic effect of Haemate-P® was superior to Cp (790.80 ± 582.02, p=0.043). No differences were observed between basal values and the addition of neither Haemate-P ® nor Cp in samples collected during ECMO, Figure 1. CONCLUSIONS. Treatment with ECMO alters primary hemostasis in association with AVWD. In our cohort, these effects were seen early after implantation and, at least, up to 5 days after device removal. Most patients requiring ECMO treatment exhibit a complex medical history and are exposed to multiple drugs affecting numerous analytical values, making the interpretation of primary hemostasis complicated. The addition of Haemate-P ® in vitro significantly improved the hemostatic efficiency compared to Cp only when ECMO was discontinued. More studies are needed to evaluate the role of VWF-containing concentrates in the treatment of these patients, being Total-TAS ® a potentially useful mechanism to investigate it. GRANTS: López-Borrasca Scholarship funded by FETH/SETH, with the collaboration of CSL Behring (Spain) and Zacros (Fujimori Kogyo Co, Ltd, Japan), and 2021-SGR-01118, Agencia de Gestió de Ajuts Universitaris i de Recerca (AGAUR), Generalitat de Catalunya.

Experience in applied veno-arterial extracorporeal membrane oxygenation to support catheter ablation of malignant ventricular tachycardia

BackgroundAn electrical storm due to malignant ventricular tachycardia (VT) is a life-threatening condition that requires catheter ablation (CA). Most VT arrhythmias evolve over time after acute myocardial infarction, coronary artery bypass grafting, or chronic heart failure. Clinically, only radiofrequency ablation can identify and block all arrhythmia origin points. The procedure necessitates continuous VT induction in patients, resulting in hemodynamic instability; therefore, extracorporeal membrane oxygenation (ECMO) support is required. Earlier studies have reported substantial mortality rates; however, our results are significantly more favorable. In this study, we combined the minimally invasive extracorporeal circulation (MiECC) approach with ECMO to preserve an appropriate ECMO flow rate, thus reducing intraoperative left heart afterload. We report 21 cases illustrating the usefulness of modified veno-arterial (VA)-ECMO in this scenario. MethodsData of 21 patients supported by the modified VA-ECMO system (MiECC approach combined with the ECMO system) during VT CA in the Wuhan Asia Heart Hospital between June 2020 and July 2021 were reviewed retrospectively. ResultsSuccessful ablation was achieved in 20 out of 21 patients (95%). The median time for ECMO implantation was 206 min. Only two patients experienced complications post-treatment. All patients made complete recovery and were discharged. All patients were alive at the 1-year-follow-up. ConclusionsOur modified VA-ECMO system helped restore systemic circulation in patients experiencing an electrical storm, thus achieving greater electrical stability during VT CA. Pre-insertion of VA-ECMO can achieve even better results.

Effect of hemoglobin and oxygen saturation on adverse outcomes in children with tetralogy of fallot: a retrospective observational study

BackgroundTetralogy of Fallot (TOF) is a common cyanotic congenital heart malformation that carries a high risk of right-to-left shunting. Anemia is characterized by decreased hemoglobin (Hb) levels that can affect tissue oxygen delivery and impact postoperative recovery in patients. Chronic hypoxia caused by right-to-left shunting of TOF could lead to compensatory increases in Hb to maintain systemic oxygen balance. This study aims to investigate whether preoperative Hb and blood oxygen saturation (SpO2) can predict adverse outcomes in children undergoing corrective surgery for TOF.MethodsThis retrospective study included patients under 18 years of age who underwent corrective surgery for TOF at Fuwai Hospital between January 2016 and December 2018. Adverse outcomes, including in-hospital death, extracorporeal membrane oxygenation implantation, ICU stay > 30 days, and severe complications, were considered as the primary outcome. Univariable and multivariable logistic analyses were performed to identify independent risk factors for adverse outcomes. Propensity score-matched (PSM) analysis was also conducted to minimize the confounding factors.ResultsA total of 596 children were included in the study, of which 64 (10.7%) experienced adverse outcomes. Hb*SpO2 < aaHb was identified as an independent risk factor for adverse outcomes (OR = 2.241, 95% CI = 1.276–3.934, P = 0.005) after univariable and multivariable logistic analyses. PSM analysis further confirmed the association between Hb*SpO2 < aaHb and adverse outcomes. Patients with Hb*SpO2 < aaHb had a significantly higher incidence of postoperative adverse outcomes, longer time of mechanical ventilation, and hospital stay, as well as higher in-hospital costs.ConclusionsHb*SpO2 < aaHb is significantly associated with adverse outcomes in children undergoing corrective surgery for TOF. Clinicians can use this parameter to early identify high-risk children and optimize their postoperative management.

Urine output as one of the most important features in differentiating in-hospital death among patients receiving extracorporeal membrane oxygenation: a random forest approach

BackgroundIt is common to support cardiovascular function in critically ill patients with extracorporeal membrane oxygenation (ECMO). The purpose of this study was to identify patients receiving ECMO with a considerable risk of dying in hospital using machine learning algorithms.MethodsA total of 1342 adult patients on ECMO support were randomly assigned to the training and test groups. The discriminatory power (DP) for predicting in-hospital mortality was tested using both random forest (RF) and logistic regression (LR) algorithms.ResultsUrine output on the first day of ECMO implantation was found to be one of the most predictive features that were related to in-hospital death in both RF and LR models. For those with oliguria, the hazard ratio for 1 year mortality was 1.445 (p < 0.001, 95% CI 1.265–1.650).ConclusionsOliguria within the first 24 h was deemed especially significant in differentiating in-hospital death and 1 year mortality.

Hospital-administered ECPR for out-of-hospital cardiac arrest: an observational cohort study

BackgroundExtracorporeal cardiopulmonary resuscitation (ECPR) is a treatment method for refractory out-of-hospital cardiac arrest (OHCA) requiring a complex chain of care.MethodsAll cases of OHCA between 1 January 2016 and 31 December...

Extracorporeal membrane oxygenation in the surgical management of large mediastinal masses: a narrative review.

The management of large mediastinal tumors requires a complex multidisciplinary approach, particularly in the perioperative setting due to increased risk of hemodynamic compromise. The utilization of extracorporeal membrane oxygenation (ECMO) provides a useful adjunct in the surgical management for biopsy and resection of these mediastinal masses. The objective of this article is to review indications and implementation of ECMO in the surgical management of mediastinal disease. A literature review of the PubMed database was completed evaluating articles discussing 'extracorporeal circulation', 'cardiopulmonary bypass', 'anesthesia', 'mediastinal disease', and 'mediastinal cancer'. These articles were evaluated for contribution to the discussion of indications and implementation of ECMO in the management of these patients. Large mediastinal tumors place patients at risk of hemodynamic collapse on induction of anesthesia due to compression of vascular structures, tracheobronchial tree and creation of V/Q mismatch. Patients may be stratified regarding their risk of perioperative complications by evaluation of postural symptoms, cross sectional imaging findings and pulmonary function tests. Those patients at elevated perioperative risk may benefit from the utilization of ECMO, most commonly veno-arterial (V-A) ECMO. Guidewires or ECMO cannulas may be placed under local anesthesia prior to induction. Those patients with hemodynamic compromise may receive mechanical circulatory support to allow completion of the operation. The use of a multidisciplinary team consisting of surgeons, anesthesiologists, perfusionists and OR team is critical to the success in the use of ECMO in the resection of mediastinal masses. With diligent preparation, these high-risk patients may be optimally managed at the time of resection.

Multiorgan recovery in a cadaver body using mild hypothermic ECMO treatment in a murine model

BackgroundTransplant candidates on the waiting list are increasingly challenged by the lack of organs. Most of the organs can only be kept viable within very limited timeframes (e.g., mere 4–6 h for heart and lungs exposed to refrigeration temperatures ex vivo). Donation after circulatory death (DCD) using extracorporeal membrane oxygenation (ECMO) can significantly enlarge the donor pool, organ yield per donor, and shelf life. Nevertheless, clinical attempts to recover organs for transplantation after uncontrolled DCD are extremely complex and hardly reproducible. Therefore, as a preliminary strategy to fulfill this task, experimental protocols using feasible animal models are highly warranted. The primary aim of the study was to develop a model of ECMO-based cadaver organ recovery in mice. Our model mimics uncontrolled organ donation after an “out-of-hospital” sudden unexpected death with subsequent “in-hospital” cadaver management post-mortem. The secondary aim was to assess blood gas parameters, cardiac activity as well as overall organ state. The study protocol included post-mortem heparin–streptokinase administration 10 min after confirmed death induced by cervical dislocation under full anesthesia. After cannulation, veno-arterial ECMO (V–A ECMO) was started 1 h after death and continued for 2 h under mild hypothermic conditions followed by organ harvest. Pressure- and flow-controlled oxygenated blood-based reperfusion of a cadaver body was accompanied by blood gas analysis (BGA), electrocardiography, and histological evaluation of ischemia–reperfusion injury. For the first time, we designed and implemented, a not yet reported, miniaturized murine hemodialysis circuit for the treatment of severe hyperkalemia and metabolic acidosis post-mortem.ResultsBGA parameters confirmed profound ischemia typical for cadavers and incompatible with normal physiology, including extremely low blood pH, profound negative base excess, and enormously high levels of lactate. Two hours after ECMO implantation, blood pH values of a cadaver body restored from < 6.5 to 7.3 ± 0.05, pCO2 was lowered from > 130 to 41.7 ± 10.5 mmHg, sO2, base excess, and HCO3 were all elevated from below detection thresholds to 99.5 ± 0.6%, − 4 ± 6.2 and 22.0 ± 6.0 mmol/L, respectively (Student T test, p < 0.05). A substantial decrease in hyperlactatemia (from > 20 to 10.5 ± 1.7 mmol/L) and hyperkalemia (from > 9 to 6.9 ± 1.0 mmol/L) was observed when hemodialysis was implemented. On balance, the first signs of regained heart activity appeared on average 10 min after ECMO initiation without cardioplegia or any inotropic and vasopressor support. This was followed by restoration of myocardial contractility with a heart rate of up to 200 beats per minute (bpm) as detected by an electrocardiogram (ECG). Histological examinations revealed no evidence of heart injury 3 h post-mortem, whereas shock-specific morphological changes relevant to acute death and consequent cardiac/circulatory arrest were observed in the lungs, liver, and kidney of both control and ECMO-treated cadaver mice.ConclusionsThus, our model represents a promising approach to facilitate studying perspectives of cadaveric multiorgan recovery for transplantation. Moreover, it opens new possibilities for cadaver organ treatment to extend and potentiate donation and, hence, contribute to solving the organ shortage dilemma.

Invasive Pulmonary Aspergillosis After Sars-CoV-2 Infection as Limitation of Contemporary Transplantology: A Case Report

Invasive fungal infections are uncommon in pediatric heart transplant recipients. Risk and mortality are highest in the first 6 months post-transplant, especially in patients with previous surgery and those requiring mechanical support. There is a possibility that prior SARS-CoV-2 infection may cause a more severe course of pulmonary aspergillosis, especially in immunosuppressed individuals. This report describes a female patient, eight years of age, who was admitted to the pediatric cardiac surgery department with symptoms of end-stage heart failure in urgent need of mechanical circulatory support (MCS). A left ventricular assist device (LVAD) was implanted as a bridge to transplantation. During over a year on the waiting list, LVAD was replaced twice due to the presence of fibrin on the inlet valve. While staying in the ward, the patient underwent SARS-CoV-2 infection. An orthotopic heart transplant was successfully performed after 372 days of MCS with LVAD. One month after transplantation, the girl developed severe pulmonary aspergillosis complicated by sudden cardiac arrest and implantation of venovenous extracorporeal membrane oxygenation (VV ECMO) used for 25 days. Unfortunately, a few days after weaning from VV ECMO, the patient died due to intracerebral bleeding.

P69: ECMO mobilizing device

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