non-ECMO Group Research Articles

Heparin-free veno-arterial extracorporeal membrane oxygenation in lung transplantation: a retrospective cohort study

BackgroundIn lung transplantation (LTx) surgery, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide mechanical circulatory support to patients with cardiopulmonary failure. However, the use of heparin in the administration of ECMO can increase blood loss during LTx. This study aimed to evaluate the safety of heparin-free V-A ECMO strategies.MethodsFrom September 2019 to April 2022, patients who underwent lung transplantation at the First Affiliated Hospital of Guangzhou Medical University were retrospectively reviewed. A total of 229 patients were included, including 117 patients in the ECMO group and 112 in the non-ECMO group.ResultThere was no significant difference in the incidence of thrombus events and bleeding requiring reoperation between the two groups. The in-hospital survival rate after single lung transplantation (SLTx) was 81.08%in the ECMO group and 85.14% in the Non-ECMO group, (P = 0.585). The in-hospital survival rate after double lung transplantation (DLTx) was 80.00% in the ECMO group and 92.11% in the Non-ECMO groups (P = 0.095).ConclusionsIn conclusion, the findings of this study suggest that the heparin-free V-A ECMO strategy in lung transplantation is a safe approach that does not increase the incidence of perioperative thrombotic events or bleeding requiring reoperation.

Ambulatory Extracorporeal Membrane Oxygenation Use in Patients Listed for Lung Transplant.

There has been an increase in the use of extracorporeal membrane oxygenation (ECMO) to bridge critically ill patients to lung transplant (LTX). This study evaluates how ambulatory status on ECMO affected waitlist and post-LTX outcomes. The United Network of Organ Sharing (UNOS) database was queried for patients aged of greater than or equal to 18 years and between 2016 and 2021 to identify pre-LTX patients supported by ECMO. The patients were classified in venous-arterial (VA) ECMO and veno-venous (VV) ECMO cohorts and further classified as ambulatory (AMB) and non-AMB (nAMB). Each cohort was controlled against the non-ECMO patients. Univariate statistical tests, as well as Kaplan-Meier survival curves, were used for analysis. The 90 day waitlist survival was the highest among the non-ECMO group (96%), but both AMB VV and VA groups had superior survival compared to the nAMB group (85% vs. 75%, 78% vs. 65%, p < 0.01). After adjusting for the median lung allocation score (LAS) (88) in the VV ECMO group, the waitlist survival was superior in the AMB VV ECMO compared to those not on ECMO (86% vs. 78%, p > 0.01). The 1 year post-LTX survival between non-ECMO and AMB VV ECMO was comparable (88% vs. 88%, p = 0.66). Ambulating patients or use of physical therapy while on ECMO can help improve lung transplant outcomes.

Reducing Vancomycin Dosage in Children on ECMO with Renal Impairment.

Extracorporeal membrane oxygenation (ECMO) can influence pharmacokinetics. We investigated the vancomycin dosage in children on ECMO compared to critically ill children to determine the necessary dosage adjustment on ECMO. Eight-year, single-center, retrospective cohort study at a tertiary heart center's pediatric cardiac intensive care unit (ICU) of children undergoing ECMO support. Our control group (non-ECMO) was critically ill children with delayed sternal closure after cardiac surgery. We included consecutively all children undergoing vancomycin administration. The starting dose was 10 to 15 mg/kg BW per dose, every 8 to 12 hours depending on age. The vancomycin trough level was maintained in the 10 to 20 μg/ml range. 85 total courses on ECMO and 99 non-ECMO courses were included. The ECMO group's daily vancomycin dose was significantly lower than non-ECMO's at a median of 33.3 and 38.5 mg/kg/d, respectively (p < 0.001). Vancomycin serum trough levels were similar between groups and within the target range. The ECMO group's daily vancomycin dose dropped faster over time, with a dose on day 3 of 28.7 and 33.7 mg/kg/d, respectively. The impact of renal function on vancomycin dosing was more apparent in the ECMO group. If the renal function was reduced at the start of treatment, the vancomycin dose was lower in the ECMO group compared to the non-ECMO group with renal impairment (22.5 vs. 42.1 mg/kg/d; p < 0.001). When renal function was normal, the doses were similar between groups. In children on ECMO with impaired renal function at treatment initiation, lower vancomycin doses were necessary. Early therapeutic drug monitoring, even before reaching a steady state, should be considered.

Abstract 13333: Review of Simultaneous Kidney and Heart Transplant After 2018: UNOS Data

Introduction: In October 2018, the Organ Procurement and Transplant Network (OPTN) adopted a 6-tier system for organ allocation where priority was given to critically ill patients, especially those on Extra Corporeal Membrane Oxygenation (ECMO) support. The guideline lacks information about multiorgan transplant due to weak evidence on Simultaneous Kidney and Heart transplant (SKHT) data. Hence with this study, we aim to review outcomes of patients on ECMO at the time of SKHT. Method: This was a retrospective study of adult SKHT recipients between 2018-2022 from the OPTN database. The study excluded individuals who underwent simultaneous multiple organ transplants, isolated heart transplants, as well as those with incomplete outcome information. The cohort was stratified by ECMO need at the time of transplant. Univariate cox regression analysis was performed for predictors of worse outcomes. Patient survival was compared using Kaplan Meier (KM) curve and log rank test. Results: A total of 1383 patients were included in this study, of which 72 (5.2%) were on ECMO bridge. On review of baseline characteristics, patients on ECMO had mean wait time of 65 (± 190) days with higher mortality rate post-transplant and a lower mean survival time as compared to the non-ECMO counterparts (398 (± 404) vs 545 (± 462) days, p= 0.008). On analysis of KM curve, SKHT recipients on ECMO bridge had higher mortality within the first 10 months of transplant and plateaued after that. The only predictors associated with worst outcomes among ECMO recipients were dialysis requirement and development of stroke post-transplant. On the contrary, Left Ventricular assisted device (LVAD) use prior to transplant was associated with 70% reduction in mortality in non-ECMO group (HR: 0.30 (95% CI: 0.11 - 0.83, p=0.02)) in this cohort. Conclusion: Following the change in guidelines, around 5.2% of the total SKHT recipients were on the ECMO bridge. Dialysis requirement and development of stroke post-transplant was independently associated with higher mortality compared to non ECMO group. On the contrary, patients on LVAD support at the time of transplant have had better outcomes.Figure 1:

Extracorporeal Membrane Oxygenation Support and Critically Ill COVID-19 Patient Outcomes: A Population-Based Cohort Study.

We selected critically ill patients with coronavirus disease 2019 (COVID-19) who were receiving extracorporeal membrane oxygenation (ECMO) support and had been transferred to experienced centers. Thus, we aimed to evaluate factors that were associated with receiving ECMO support and factors that were associated with patient mortality. Using data from the National Health Insurance Service and Korea Disease Control and Prevention Agency in South Korea, adult patients admitted to an intensive care unit from October 8, 2020, to December 31, 2021, with a main diagnosis of COVID-19 were included. They were divided into two groups: ECMO group (n = 455) and non-ECMO group (n = 12,648). Receiving ECMO support was less associated with old age [odds ratio (OR), 0.95; 95% confidence interval (CI), 0.94-0.96; p < 0.001], underlying severe disabilities (OR, 0.49; 95% CI, 0.29-0.83; p = 0.008), and booster vaccination status (second: OR, 0.61; 95% CI, 0.39-0.94; p = 0.024; third: OR, 0.40; 95% CI, 0.25-0.65; p < 0.001). In addition, after adjusting for various variables, low mortality in patients with ECMO support was associated with having previously received a second booster vaccination (OR, 0.33; 95% CI, 0.14-0.77; p = 0.010). Vaccination and booster therapy may lower the need for ECMO support and lower mortality among critically ill patients with COVID-19 with ECMO support.

Comparison of nutritional adequacy in adult patients with acute respiratory distress syndrome with and without veno-venous extracorporeal membrane oxygenation: a single-center experience

Objectives: Limited data is available regarding nutrition practices for patients with acute respiratory distress syndrome (ARDS) who are also receiving veno-venous-extracorporeal membrane oxygenation (VV-ECMO). The aim of the study was to describe the nutritional status of patients receiving VV-ECMO and compared with those who did not. Methods: Patients (&amp;gt;18 years-old) diagnosed with ARDS who received VV-ECMO (≥72 hours) were included in this retrospective study. The daily achievement of an energy target (%) and average protein intake during 2 weeks after initiation of VV-ECMO were calculated. Adequate feeding was defined as achieving 80-110% of the calculated target. The duration before initiating parenteral (PN) and enteral nutrition (EN), feeding route, length of intensive care, and hospital stay were evaluated. Data was compared between groups. Results: In this study, 24 patients were included, of whom 12 received VV-ECMO. EN was started in a median 1.5 and 1 days in the VV-ECMO and non-ECMO groups, respectively. In the VV-ECMO group, 75% of the patients could achieve nutritional adequacy (&amp;gt;80% energy goal) and 83.3% in the non-ECMO group (p = 0.615). PN being required in 4 (33.3%) patients who received VV-ECMO and 3 (25%) patients who did not (p = 0254). Ten of all patients experienced inadequate EN because of hemodynamic instability (n = 3), prone position (n=4), gastric distension (n = 2) and diarrhea (n = 1). Conclusions: VV-ECMO was not an obstacle for adequate nutrition, but prone position and hemodynamic instability were common causes of enteral feeding interruptions and inadequate energy delivery.

Application of in Vitro Membrane Pulmonary Oxygenation Technology (ECMO) in Neonatal Respiratory Failure

Objective: To explore the application of Extracorporeal Membrane Oxygenation technology (ECMO) in neonatal respiratory failure and provide guidance for future ECMO technology for critically ill newborns. Methods: Retrospective analysis of the basic data, ECMO support process, and long-term neurological development of nine children supported by ECMO at Zhongshan People’s Hospital from January 2015 to August 2021. Results: From January 2015 to August 2021, the number of admissions to the neonatal department of our hospital was 10,325, with 433 cases of neonatal respiratory failure, which was in line with ECMO support indication of 21 cases, of which 12 were non-ECMO groups and 12 were ECMO groups. In nine cases, the differences in sex, birth weight, gestational age, birth pattern, Apgar score, NCIS score, OI value, hospitalization days, mortality rate, and incidence of intracranial bleeding were not statistically significant (P&gt;0.05). However, the average daily hospitalization cost for children in the ECMO group was significantly higher than that in the non-ECMO group, and the difference was statistically significant (P&lt;0.05). ECMO after 12 h operation, arterial oxygen pressure, and intravenous oxygen saturation are substantially enhanced, while arterial carbon dioxide pressure oxygenation index is considerably reduced, with a statistically significant difference (P&lt;0.05). ECMO pre-operation survival group lactic acid (6.46±2.70) was lower than the death group (17.66±14.62), after operation lactic acid decreased significantly, and after ECMO operation of the death group lactic acid showed an increase in conductivity. During the early stage of ECMO establishment, PT and APTT rapidly rise, while FIB decline. The ACT of both groups of children increased in the early stages of ECMO establishment and then gradually declined. In the ECMO group, seven children survived to discharge, six had no neurological developmental problems, and one had residual neurological sequelae. Conclusion: ECMO can be employed as a complementary supportive treatment for newborns with respiratory failure, and the oxygenation condition can be effectively improved for newborns with respiratory failure who have failed to respond to traditional treatment.

Voriconazole Pharmacokinetics in Critically Ill Patients and Extracorporeal Membrane Oxygenation Support: A Retrospective Comparative Case-Control Study.

Voriconazole, an antifungal agent, displays high intra- and inter-individual variability. The predictive pharmacokinetic (PK) index requires a minimum plasma concentration (Cmin) in patient serum of between 1-5.5 mg/L. It is common to encounter fungal infections in patients undergoing extracorporeal membrane oxygenation (ECMO) support, and data regarding voriconazole PK changes during ECMO are scarce. Our study compared voriconazole PKs in patients with and without ECMO support in a retrospective cohort of critically-ill patients. Fifteen patients with 26 voriconazole Cmin determinations in the non-ECMO group and nine patients with 27 voriconazole Cmin determinations in the ECMO group were recruited. The ECMO group had lower Cmin (0.38 ± 2.98 vs. 3.62 ± 3.88, p < 0.001) and higher infratherapeutic Cmin values (16 vs. 1, p < 0.001) than the non-ECMO group. Multivariate analysis identified ECMO support (-0.668, CI95 -0.978--0.358) and plasma albumin levels (-0.023, CI95 -0.046--0.001) as risk factors for low Cmin values. When comparing pre- and post-therapeutic drug optimisation samples from the ECMO group, the dose required to achieve therapeutic Cmin was 6.44 mg/kg twice a day. Therapeutic drug optimisation is essential to improve target attainment.

TOP6: Ambulatory Extra Corporeal Membrane Oxygenation as a Bridge to Lung Transplant

Background: Mechanical circulatory support, including both veno-venous (VV) and veno-arterial (VA) extra corporeal membrane oxygenation (ECMO), is being used more frequently to bridge critically ill patients to lung transplant (LTX). This study evaluates post LTX survival outcomes of patients bridged by ECMO. Methods: The United Network for Organ Sharing (UNOS) thoracic organ transplant database was queried for patients aged >/= 18 years between year 2016 and 2021 to identify pre-transplant patients supported by ECMO. Patients supported by both VA and VV-ECMO were excluded. The patients initially classified in VA-ECMO and VV-ECMO cohorts and further classified as ambulatory (AMB) and non-ambulatory (nAMB) within their respective ECMO cohorts. Each cohort was controlled against the non-ECMO patients. Univariate statistical tests as well as Kaplan-Meier survival curves were used for analysis. Results: Of total 14,369 LTX patients, 13,470 were non-ECMO, 702 were VV-ECMO (44% AMB, 56% nAMB) and 197 were VA-ECMO (47% AMB, 53% nAMB). Table 1A (non-ECMO v. AMB VV-ECMO v. nAMB VV-ECMO at time of LTX) and 1B (non-ECMO v. AMB VA-ECMO v. nAMB VA-ECMO at time of LTX) shows higher age (62 v. 52 v. 50) lower O2 requirement (4 v. 15 v. 10), LAS (44 v. 88 v. 89) and lesser likelihood of COVID etiology (1% v. 22% v. 6%) in non-ECMO group compared to VV-ECMO and VA-ECMO. Within the ECMO groups AMB and nAMB patients were comparable except idiopathic fibrosis was more common in nAMB. The 1-year post LTX survival between non-ECMO and AMB VV-ECMO was comparable (88% v. 88%, p=0.66) which was better than nAMB VV-ECMO patients (88% v. 88% v. 81% (nAMB VV-ECMO), p<.01, F1A). The 1-year (71% v. 78% v. 88%) survival was better for AMB VA-ECMO patients than nAMB VA-ECMO patients, and better for non-ECMO patients than AMB VA-ECMO patients (p<.01, F1B). A Cox proportional hazard model showed that compared to non-ECMO patients, the nAMB VV-ECMO patients (HR = 1.25, p=0.02) had higher risk of post LTX mortality whereas post LTX risk for AMB VV-ECMO patients (HR = 0.95, p=0.71) was similar. Conclusion: Although ambulatory VV-ECMO patients have higher LAS and O2 requirements at time of transplant, their post LTX survival is comparable to the non-ECMO patients. Survival amongst the VA-ECMO patients continued to be poor compared to the non-ECMO patients irrespective of their ambulatory status. Strategies to ambulate ECMO patients could be associated better post LTX outcomes. Figure 1. Survival by ECMO ambulationTable 1. Patient Characteristics at time of LTX

Use of Perioperative Extracorporeal Membranous Oxygenation in Pulmonary Endarterectomy Cases: A Systematic Review and Meta-Analysis.

Introduction: Pulmonary endarterectomy (PEA) is known to be a curative intervention for chronic thromboembolic pulmonary hypertension (CTEPH). Its complications include endobronchial bleeding, persistent pulmonary arterial hypertension, right ventricular failure, and reperfusion lung injury. Extracorporeal membranous oxygenation (ECMO) is a perioperative salvage method for PEA. Although risk factors and outcomes have been reported in several studies, overall trends remain unknown. We performed a systematic review and study-level meta-analysis to understand the outcomes of ECMO utilization in the perioperative period of PEA. Methods: We performed a literature search with PubMed and EMBASE on 11/18/2022. We included studies including patients who underwent perioperative ECMO in PEA. We collected data including baseline demographics, hemodynamic measurements, and outcomes such as mortality and weaning of ECMO and performed a study-level meta-analysis. Results: Eleven studies with 2632 patients were included in our review. ECMO insertion rate was 8.7% (225/2,625, 95% CI 5.9-12.5) in total, VV-ECMO was performed as the initial intervention in 1.1% (41/2,625, 95% CI 0.4-1.7) (Figure 3), and VA-ECMO was performed as an initial intervention in 7.1% (184/2,625, 95% CI 4.7-9.9). Preoperative hemodynamic measurements showed higher pulmonary vascular resistance, mean pulmonary arterial pressure, and lower cardiac output in the ECMO group. Mortality rates were 2.8% (32/1238, 95% CI: 1.7-4.5) in the non-ECMO group and 43.5% (115/225, 95% CI: 30.8-56.2) in the ECMO group. The proportion of patients with successful weaning of ECMO was 72.6% (111/188, 95% CI: 53.4-91.7). Regarding complications of ECMO, the incidence of bleeding and multi-organ failure were 12.2% (16/79, 95% CI: 13.0-34.8) and 16.5% (15/99, 95% CI: 9.1-28.1), respectively. Conclusion: Our systematic review showed a higher baseline cardiopulmonary risk in patients with perioperative ECMO in PEA, and its insertion rate was 8.7%. Further studies that compare the use of ECMO in high-risk patients who undergo PEA are anticipated.

Rewarming Young Children After Drowning-Associated Hypothermia and Out-of-Hospital Cardiac Arrest: Analysis Using the CAse REport Guideline.

Extracorporeal membrane oxygenation (ECMO) is recommended in adults with drowning-associated hypothermia and out-of-hospital cardiac arrest (OHCA). Our experience of managing a drowned 2-year-old girl with hypothermia (23°C) and cardiac arrest (58 min) prompted this summary using the CAse REport (CARE) guideline to address the question of optimal rewarming procedure in such patients. Following the CARE guideline, we identified 24 reports in the "PubMed database" describing children less than or equal to 6 years old with a temperature less than or equal to 28°C who had been rewarmed using conventional intensive care ± ECMO. Adding our patient, we were able to analyze a total of 57 cases. The two groups (ECMO vs non-ECMO) differed with respect to submersion time, pH and potassium but not age, temperature or duration of cardiac arrest. However, 44 of 44 in the ECMO group were pulseless on arrival versus eight of 13 in the non-ECMO group. Regarding survival, 12 of 13 children (92%) undergoing conventional rewarming survived compared with 18 of 44 children (41%) undergoing ECMO. Among survivors, 11 of 12 children (91%) in the conventional group and 14 of 18 (77%) in the ECMO group had favorable outcome. We failed to identify any correlation between "rewarming rate" and "outcome." In this summary analysis, we conclude that conventional therapy should be initiated for drowned children with OHCA. However, if this therapy does not result in return of spontaneous circulation, a discussion of withdrawal of intensive care might be prudent when core temperature has reached 34°C. We suggest further work is needed using an international registry.

The effect of extracorporeal membrane oxygenation on neurodevelopmental outcomes in children after repair of congenital heart disease: A pilot study from Turkey.

Extracorporeal membrane oxygenation (ECMO) is widely used after congenital heart surgery. The purpose of this study is to analyze the neurodevelopmental (ND) outcomes in patients who receivedECMO support after congenital cardiac surgery. Between January 2014 and January 2021, 111 patients (5.8%) receivedECMO support after congenital heart operations, and 29 (26,1%) of these patients were discharged. Fifteen patients who met the inclusion criteria were included. A propensity score matching (PSM) analysis model was established using eight variables (age, weight, sex, Modified Aristotle Comprehensive Complexityscores, seizures, cardiopulmonary bypass duration, number of operations, and repair method) with 1:1 matching. According to the PSM model, 15 patients who underwent congenital heart operations were selected as the non-ECMO group. The Ages & Stages Questionnaire Third Edition (ASQ-3) was used for ND screening;it includes communication, physical skills (gross and fine motor), problem-solving, and personal-social skills domains. There were no statistically significant differences between the patients' preoperative and postoperative characteristics. All patients were followed up for a median of 29 months (9-56 months). The ASQ-3 results revealed that communication, fine motor, and personal-social skills assessments were not statistically different between the groups. Gross motor skills (40 vs. 60), problem-solving skills (40 vs. 50), and overall scores (200 vs. 250) were better in the non-ECMO patients (P = 0.01, P = 0.03, and P = 0.03, respectively). Nine patients (%60) in the ECMO group and 3 patients (%20) in the non-ECMO group were with neurodevelopmental delay (P = 0,03). ND delay may occur in congenital heart surgery patients who receivedECMO support. We recommend ND screening in all patients with congenital heart disease, especially those who receivedECMO support.

Early Gait Function After Lung Transplantation in Patients With and Without Pretransplant Extracorporeal Membrane Oxygenation Support

We aimed to investigate the recovery of gait function, muscle strength, and the achievement of an independent gait after lung transplantation (LT) in patients with and without pretransplant extracorporeal membrane oxygenation (ECMO) support. We retrospectively reviewed the medical records of 33 inpatients who underwent bilateral LT and received physical therapy. We assessed the Functional Ambulatory Category (FAC) and Manual Muscle Test (MMT) scores at baseline, 1 month, and 3 months of rehabilitation and the time it took to achieve a FAC score of 3 within 3 months of LT surgery in ECMO and non-ECMO patients. The FAC and MMT scores were generally improved during the first 3 months after LT. The number of patients who achieved a FAC score of 3 at 3 months did not significantly differ between the ECMO and non-ECMO groups (P = .193). At 1 month, significantly fewer patients had reached a FAC of 3 in the ECMO group than in the non-ECMO group (P = .042). There were no significant differences in the FAC (P = .398) and MMT scores (P = .079) at 3 months between the 2 groups. Both groups' gait function and muscle strength were continuously restored 3 months after LT. At 1 month, the gait function was assessed by the FAC score, and the rate to achieve a FAC of 3 was higher in the non-ECMO group than in the ECMO group, but at 3 months, the difference was not significant between the 2 groups.

Impact of extracorporeal membrane oxygenation in immunocompetent children with severe adenovirus pneumonia

BackgroundSevere adenovirus (Adv.) pneumonia can cause significant mortality in young children. There has been no worldwide consensus on the impact of extracorporeal membrane oxygenation (ECMO) in immunocompetent children with severe Adv. pneumonia. This study aimed to assess the impact of ECMO in immunocompetent children with severe Adv. pneumonia.MethodsThis study evaluated the medical records of 168 hospitalized children with severe Adv. pneumonia at the Guangzhou Women and Children’s Medical Center between 2019 and 2020.Nineteen patients in the ECMO group and 149 patients in the non-ECMO group were enrolled.ResultsBetween these two groups, there were no differences in host factors such as sex, age (all P > 0.05). Significant differences were observed in shortness of breath/increased work of breathing; cyanosis; seizures; tachycardia; the partial pressure of oxygen in arterial blood (PO2); the ratio of PaO2 to the fraction concentration of oxygen in inspired air (FiO2; P/F); white blood cell, lymphocyte, monocytes, lactate dehydrogenase (LDH), serum albumin, and procalcitonin levels; and, pulmonary consolidation (all P < 0.05). There were significant differences in the parameters of mechanical ventilation (MV) therapy and complications such as respiratory failure, acute respiratory distress syndrome, septic shock, length of hospitalization, and death (all P < 0.05). The maximum axillary temperatures, respiratory rates, heart rates and LDH levels after receiving ECMO were significantly lower than those before ECMO (all P < 0.05). Additionally, SPO2, PO2, and P/F were significantly higher than those before ECMO (all P < 0.05). In MV therapy, FiO2, PIP, and PEEP were significantly lower than those before ECMO (all P < 0.05).ConclusionsIn our study, the clinical conditions of the patients in the ECMO group were much more severe than those in the non-ECMO group. Our study showed that ECMO might be beneficial for the patients with severe Adv. pneumonia.

Extracorporeal Membrane Oxygenation versus Conventional Ventilator Support in COVID-19 Patients with Acute Respiratory Distress Syndrome

Background: Acute respiratory distress syndrome (ARDS) is an undesirable outcome of severe coronavirus disease 2019 (COVID-19). Although venovenous extracorporeal membrane oxygenation (VV-ECMO) has been widely accepted as a rescue therapy for severe ARDS, its use in COVID19-associated ARDS is still debated. Objective: To compare the clinical outcomes of COVID-19 patients treated with VV-ECMO or conventional ventilator support. Materials and Methods: The authors conducted a retrospective study in Bangkok Heart Hospital, Thailand, between March and September 2021. Patients were divided into ECMO and non-ECMO or conventional ventilator support groups. The primary outcome was in-hospital mortality, and the secondary outcomes were complications, length of ICU stay, recovery time after extubation, and total length of hospital stay. Results: Of the 3,053 COVID-19 patients, 36 (1.18%) developed severe ARDS, which 12 were treated with VV-ECMO and 24 with a conventional ventilator. In-hospital mortality was non-significantly lower in the ECMO group at 58.3% versus 83.3% (p=0.126). Upper gastrointestinal bleeding was non-significantly more common in the ECMO group at 41.7% versus 25.0% (p=0.306) but there were no cases of deep vein thrombosis in the ECMO group at 0% versus 20.8% (p=0.088). There were no significant differences in any other complications. Six patients, including four in the ECMO group and two in the non-ECMO group underwent cytokine removal via HA330 hemoperfusion, but interleukin-6 did not decrease in these patients. Conclusion: VV-ECMO in COVID-19-associated ARDS patients did not significantly decreased mortality compared to conventional ventilator therapy. A multidisciplinary team should develop an optimal treatment plan for each COVID-19-associated ARDS patient. Keywords: SARS-CoV-2; Intensive care unit, Artificial respiration

Outcomes of Extracorporeal Membrane Oxygenation for Primary Graft Dysfunction After Lung Transplantation

Primary graft dysfunction (PGD) is the leading cause of death in the first 30 days after lung transplantation and is also associated with worse long-term outcomes. Outcomes of patients with PGD grade 3 requiring extracorporeal membrane oxygenation (ECMO) support after lung transplantation have yet to be well described. We sought to describe short- and long-term outcomes for patients with PGD grade 3 who required ECMO support. This is a single-center retrospective cohort study of patients undergoing lung transplantation. We stratified patients with PGD grade 3 into non-ECMO, venoarterial (VA) ECMO, and venovenous (VV) ECMO groups after transplantation. We then compared the outcomes between the groups. Of 773 lung transplant recipients, PGD grade 3 developed in 204 (26%) at any time in the first 72 hours after lung transplantation. Of these, 13 (5%) required VA ECMO and 25 (10%) required VV ECMO support. The 30-day, 1-year, and 5-year survival in the VA ECMO group was 62%, 54%, and 43% compared with 96%, 84%, and 65% in the VV ECMO group and 99%, 94%, and 71% in the non-ECMO group. Multivariable Cox regression analysis showed that VA ECMO was associated with increased mortality (hazard ratio, 2.37; 95% CI, 1.06-5.28; P= .04). Patients who required VA ECMO support for PGD grade 3 have significantly worse survival compared with those who did not require ECMO and those who required VV ECMO support. This suggests that VA ECMO treatment of patients with PGD grade 3 after lung transplantation can be a predictable risk factor for mortality.

Direct Extracorporeal Membrane Oxygenation Bridged Heart Transplantation: The Importance of Multi-Organ Failure.

Recently, approximately 40% of all heart transplantation (HTx) in South Korea are performed using the direct extracorporeal membrane oxygenation (ECMO) bridging method. We conducted a study to examine the clinical outcome of direct ECMO-bridged HTx and to investigate the impact of multi-organ failure (MOF). From June 2014 to September 2022, a total of 96 adult patients who underwent isolated HTx at a single tertiary hospital were included in the study. The patients were sub-grouped into ECMO (n=48) and non-ECMO group (n=48), and the ECMO group was subdivided into awake (n=22) and non-awake (n=26) groups based on mechanical ventilator (MV) dependency. Baseline characteristics, 30-day, and 1-year mortality were analyzed retrospectively. The 1-year survival rate was significantly lower in the ECMO group (72.9% vs. 95.8%, p=0.002). There was a significant difference in the 30-day survival rate between the awake and non-awake ECMO groups (81.8% vs. 65.4%, p=0.032). In the univariate analysis of logistic regression for 1-year mortality, the odds ratio was 8.5 for ECMO bridged HTx compared to the non-ECMO group, 12.3 in patients who required MV (p=0.003), and 23 with additional hemodialysis (p<0.001). Patients who required MV in ECMO bridged HTx showed higher preoperative MOF rates and early mortality than those extubated. When considering ECMO bridged HTx, the severity of MOF should be thoroughly investigated, and careful patient selection is necessary.

Outcome of extracorporeal membrane oxygenation use in severe accidental hypothermia with cardiac arrest and circulatory instability: A multicentre, prospective, observational study in Japan (ICE-CRASH study)

AimTo elucidate the effectiveness of extracorporeal membrane oxygenation (ECMO) in accidental hypothermia (AH) patients with and without cardiac arrest (CA), including details of complications. MethodsThis study was a multicentre, prospective, observational study of AH in Japan. All adult (aged ≥18 years) AH patients with body temperature ≤32 °C who presented to the emergency department between December 2019 and March 2022 were included. Among the patients, those with CA or circulatory instability, defined as severe AH, were selected and divided into the ECMO and non-ECMO groups. We compared 28-day survival and favourable neurological outcomes at discharge between the ECMO and non-ECMO groups by adjusting for the patients’ background characteristics using multivariable logistic regression analysis. ResultsAmong the 499 patients in this study, 242 patients with severe AH were included in the analysis: 41 in the ECMO group and 201 in the non-ECMO group. Multivariable analysis showed that the ECMO group was significantly associated with better 28-day survival and favourable neurological outcomes at discharge in patients with CA compared to the non-ECMO group (odds ratio [OR] 0.17, 95% confidence interval [CI]: 0.05–0.58, and OR 0.22, 95%CI: 0.06–0.81). However, in patients without CA, ECMO not only did not improve 28-day survival and neurological outcomes, but also decreased the number of event-free days (ICU-, ventilator-, and catecholamine administration-free days) and increased the frequency of bleeding complications. ConclusionsECMO improved survival and neurological outcomes in AH patients with CA, but not in AH patients without CA.

APPLICATION OF “FAST-TRACK” PATHWAY FOR VENTRICULAR TACHYCARDIA CATHETER ABLATION

<h3>Objective</h3> "Fast-track" pathway has been successfully applied in low- and intermediate-risk patients during catheter ablation. Catheter ablation is one of the treatment for patients suffering sustained ventricular tachycardia (VT). Patients with reduced cardiac function and patient presented with VT storm may have life threatening reduction in cardiac output. Using veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for circulatory support during high-risk VT ablations can mitigate the risk of hemodynamic instability. The present study describes the application of "Fast-track" pathway in the high-risk patients underwent catheter VT ablation with and without ECMO support. <h3>Methods</h3> The study included patients undergoing catheter VT ablation between 2017 and 2022 at a high volume tertiary center in Israel. A prospective observational design was used. The patients were divided to two groups, Group I (non-ECMO group) and Group II (ECMO support group). In ECMO group cannulations was performed directly by the ECMO team, which include cardiac surgeon, perfusionist and operating nurse in the cardiac catheterization laboratory. Veno-arterial ECMO cannulations were inserted percutaneously using the Seldinger technique with ultrasound guidance. "Fast track" pathway defined as general Anesthesia or sedation using short-acting agent, early extubation, early decannulation (in ECMO group), early ICU discharge on Day 1 and early hospital discharge on Day 4. <h3>Results</h3> From the 87 procedures, Group I (non-ECMO) included 52 patients and Group II (ECMO support group) 35 patients."Fast-track" pathway was successful in 54.5% and 37.3%, respectively. On multiple logistic regression analysis, VT storm and ASA class IV-V were independent risk factors for failed "Fast-track" <h3>Conclusions</h3> "Fast-track" pathway may be safely applied in selected high-risk patients underwent VT ablation. Using ECMO support during catheter VT ablation should not exclude otherwise qualified candidates from consideration for "Fast-track" pathway.

Experience with intraoperative extracorporeal membrane oxygenation in lung transplantation: intraoperative indicators

Background/Aim: Intraoperative extracorporeal membrane oxygenation (ECMO) is being used with increasing frequency in lung transplantation. However, the factors associated with the use of intraoperative ECMO in lung transplant patients are not yet conclusive. In this study, we aimed to determine the effective factors for providing intraoperative ECMO support in patients undergoing lung transplantation. In addition, we aimed to evaluate the effect of ECMO support on morbidity and mortality. Methods: In this retrospective cohort study evaluating lung transplant patients, patients were divided into two groups: those who received intraoperative ECMO support and those who did not. Demographic data, the lung allocation score (LAS) and pulmonary arterial pressure (PAP), intraoperative data, postoperative complications, duration of mechanical ventilation (MV), length of stay (LOS) in intensive care and hospital, and mortality rates were recorded for both groups. Factors affecting entry to ECMO were analyzed by Multivariate Logistic Regression. Results: In this period, 51.9% of 87 patients who underwent lung transplantation required intraoperative ECMO. The mean age, LAS, and PAP of the ECMO group were significantly higher than the non-ECMO group (P = 0.043, P = 0.007, and P = 0.007, respectively). In multivariate analysis, it was found that lower MAP averages were a predictive parameter in intraoperative ECMO requirements (OR: 1.091; CI: 1.009-1.179; P = 0.028). The ECMO group’s mechanical ventilation time and hospital mortality were significantly higher than the other group (P = 0.004 and P = 0.025, respectively). Conclusion: Preoperative indicators of intraoperative ECMO support were determined as age, LAS, and PAP elevation. In addition, low MAP levels and high lactate levels were always determined as intraoperative indicators in lung transplantation until the transition to ECMO support.