Peripheral Extracorporeal Membrane Oxygenation Research Articles

Nosocomial Infections During Extracorporeal Membrane Oxygenation: Incidence, Etiology, and Impact on Patients' Outcome.

To study incidence, type, etiology, risk factors, and impact on outcome of nosocomial infections during extracorporeal membrane oxygenation. Retrospective analysis of prospectively collected data. Italian tertiary referral center medical-surgical ICU. One hundred five consecutive patients who were treated with extracorporeal membrane oxygenation from January 2010 to November 2015. None. Ninety-two patients were included in the analysis (48.5 [37-56] years old, simplified acute physiology score II 37 [32-47]) who underwent peripheral extracorporeal membrane oxygenation (87% veno-venous) for medical indications (78% acute respiratory distress syndrome). Fifty-two patients (55%) were infected (50.4 infections/1,000 person-days of extracorporeal membrane oxygenation). We identified 32 ventilator-associated pneumonia, eight urinary tract infections, five blood stream infections, three catheter-related blood stream infections, two colitis, one extracorporeal membrane oxygenation cannula infection, and one pulmonary-catheter infection. G+ infections (35%) occurred earlier compared with G- (48%) (4 [2-10] vs. 13 [7-23] days from extracorporeal membrane oxygenation initiation; p < 0.001). Multidrug-resistant organisms caused 56% of bacterial infections. Younger age (2-35 years old) was independently associated with higher risk for nosocomial infections. Twenty-nine patients (31.5%) died (13.0 deaths/1,000 person-days of extracorporeal membrane oxygenation). Infected patients had higher risk for death (18 vs. 8 deaths/1,000 person-days of extracorporeal membrane oxygenation; p = 0.037) and longer ICU stay (32.5 [19.5-78] vs. 19 [10.5-27.5] days; p = 0.003), mechanical ventilation (36.5 [20-80.5] vs. 16.5 [9-25.5] days; p < 0.001), and extracorporeal membrane oxygenation (25.5 [10.75-54] vs. 10 [5-13] days; p < 0.001). Older age (> 50 years old), reason for connection different from acute respiratory distress syndrome, higher simplified acute physiology score II, diagnosis of ventilator-associated pneumonia, and infection by multidrug-resistant bacteria were independently associated to increased death rate. Infections (especially ventilator-associated pneumonia) during extracorporeal membrane oxygenation therapy are common and frequently involve multidrug-resistant organisms. In addition, they have a negative impact on patients' outcomes.

O34-1 - A Case Suspected of Stone Heart

Stone heart is ischemic myocardial contracture, known as a rare but devastating complication of cardiopulmonary bypass. We report a case suspected stone heart requiring biventricular assist device (BiVAD). A 54-year old man with mitral valve regurgitation received mitral valve plasty. At the termination of cardio-pulmonary bypass, myocardium became contracted and unable to wean from cardio-pulmonary bypass. Cardioplegia was re-infused antegradely and retrogradely, and intra aortic balloon pumping (IABP) and peripheral extracorporeal membrane oxygenation (pECMO) were immediately installed. He was transferred to our institution for further treatment. Echocardiography showed no systolic contraction with marked thickening of myocardium and substantial decreases in left ventricular cavity. Coronary angiography showed no significant stenosis. Based on these findings, he was diagnosed with stone heart and pECMO was converted to central ECMO. However, no contractility resumed in both ventricle, and a biventricular assist device (BiVAD) was implanted on the 15th day. Histologic examination from right ventricle revealed interstitial and replacement fibrosis associated with mild lymphocyte infiltration. Tl-201 scintigraphy showed perfusion defect at anterior and posterior wall. After tracheotomy, he received systemic care and comprehensive rehabilitation program to become a candidate for heart transplantation. Despite all these maximal efforts, he died of repeated hemorrhagic strokes on the 59th day. Macroscopic findings at autopsy showed extensive necrosis around the heart.

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.

Cannulation techniques for extracorporeal life support.

The article reviews cannulation strategy for different modes of extracorporeal life support. Technical aspects, pitfalls and complications are discussed for central and peripheral extracorporeal membrane oxygenation (VA, VV, VAV, VVA), biventricular assist device support and extracorporeal CO2 removal.

Survival from Septic Shock Secondary to Disseminated Group A Streptococcal Infection after Central Extracorporeal Membrane Oxygenation

Objective The objective of this study was to describe a case of severe life-threatening acute respiratory distress syndrome (ARDS) and septic shock in a child who responded to a prolonged extracorporeal membrane oxygenation (ECMO) support course utilizing different cannulation techniques depending on the physiological derangement until he recovered. Design This is a case report. Setting This study was done at the medical–surgical pediatric intensive care unit in an academic freestanding children's hospital. Patient A previously healthy 4-year-old boy was presented with respiratory distress and fever. He was diagnosed with respiratory syncytial viral upper respiratory tract infection and group A β-hemolytic Streptococcus septic shock. Interventions The patient was referred to peripheral ECMO for hemodynamic, ventilatory, and oxygenation support; conversion to central ECMO to augment blood flow; and transition to extracorporeal carbon dioxide removal before successful wean off extracorporeal support. Measurements and Main Results Patient experienced severe pediatric ARDS and septic shock that were refractory to maximal medical therapy. Patient was able to be decannulated after 75 days of extracorporeal support. He was weaned completely off of mechanical ventilation and oxygen after 6 months. The only neurological deficit he exhibited was poor fine motor skills of his hands for which he continued to receive physical therapy. Conclusion Central ECMO may benefit children with pediatric ARDS and septic shock who require higher flows than what can be provided from peripheral ECMO. Extracorporeal membrane carbon dioxide removal may be an effective option in children who do not respond to mechanical ventilation alone.

Anesthetic management during the first combined heart-liver transplant performed in Korea: a case report.

Herein, we describe the anesthetic management during the first combined heart-liver transplant (CHLT) performed in Korea. Though CHLT is a rare procedure, accumulating evidence suggests that it is a feasible option for patients with coexisting heart and liver failure. A 45-year-old female patient presented with severe cardiac dysfunction requiring extracorporeal membrane oxygenation (ECMO) support and secondary congestive hepatopathy. The patient underwent consecutive heart and liver transplantation using extracorporeal circulatory devices—heart transplant with cardiopulmonary bypass, and liver transplant with peripheral ECMO. In this case report, we focus on the specific anesthetic considerations for CHLT pertaining to the challenges associated with dual pathophysiology.

A 20-year multicentre outcome analysis of salvage mechanical circulatory support for refractory cardiogenic shock after cardiac surgery.

BackgroundRefractory post-cardiotomy cardiogenic shock (PCCS) is a relatively rare phenomenon that can lead to rapid multi-organ dysfunction syndrome and is almost invariably fatal without advanced mechanical circulatory support (AMCS), namely extra-corporeal membrane oxygenation (ECMO) or ventricular assist devices (VAD). In this multicentre observational study we retrospectively analyzed the outcomes of salvage venoarterial ECMO (VA ECMO) and VAD for refractory PCCS in the 3 adult cardiothoracic surgery centres in Scotland over a 20-year period.MethodsThe data was obtained through the Edinburgh, Glasgow and Aberdeen cardiac surgery databases. Our inclusion criteria included any adult patient from April 1995 to April 2015 who had received salvage VA ECMO or VAD for PCCS refractory to intra-aortic balloon pump (IABP) and maximal inotropic support following adult cardiac surgery.ResultsA total of 27 patients met the inclusion criteria. Age range was 34–83 years (median 51 years). There was a large male predominance (n = 23, 85 %). Overall 23 patients (85 %) received VA ECMO of which 14 (61 %) had central ECMO and 9 (39 %) had peripheral ECMO. Four patients (15 %) were treated with short-term VAD (BiVAD = 1, RVAD = 1 and LVAD = 2). The most common procedure-related complication was major haemorrhage (n = 10). Renal failure requiring renal replacement therapy (n = 7), fatal stroke (n = 5), septic shock (n = 2), and a pseudo-aneurysm at the femoral artery cannulation site (n = 1) were also observed. Overall survival to hospital discharge was 40.7 %. All survivors were NYHA class I-II at 12 months’ follow-up.ConclusionAMCS for refractory PCCS carries a survival benefit and achieves acceptable functional recovery despite a significant complication rate.

The effectiveness of extracorporeal membrane oxygenation in a patient with post myocardial infarct ventricular septal defect

BackgroundPost infarction ventricular septal defect (VSD) is an uncommon but life threatening complication of acute myocardial infarction.Case presentationA 62-year-old woman was admitted with acute myocardial infarction (AMI). However, the day after angioplasty and stenting, Transthoracic echocardiography (TTE) showed post infarction VSD. We decided to insert an extracorporeal membrane oxygenation (ECMO) device for stabilization purposes before surgical repair. After 4 days from the implantation, we performed surgical repair successfully.ConclusionsWhen optimal medical treatment fails to stabilize a patient in cardiogenic shock, peripheral ECMO could be used as a bridge to definitive surgical therapy.

Role of Intra-Aortic Balloon Pump and Extracorporeal Membrane Oxygenation in Early Graft Failure After Cardiac Transplantation.

Early graft failure (EGF) is a major risk factor for death after heart transplantation (Htx). We investigated the predictive risk factors for moderate-to-severe EGF requiring an intra-aortic balloon pump (IABP) or extracorporeal membrane oxygenation (ECMO) circulatory support as treatment after Htx. Between January 2000 and December 2014, 412 consecutive adult patients underwent isolated Htx at our institution. Moderate and severe EGF were defined as the need for IABP and ECMO support, respectively, within 24 h after Htx. All available recipient and donor variables were analyzed to assess the risk of EGF occurrence. Overall, moderate-to-severe EGF occurred in 46 (11.1%) patients. Twenty-nine (63.04%) patients required peripheral or central ECMO support in the treatment of severe EGF and 17 (36.9%) patients required IABP support for the treatment of moderate EGF. The predictive risk factors for moderate-to-severe EGF in recipients, as assessed by logistic regression analysis, were a preoperative transpulmonary gradient > 12 mmHg (odds ratio [OR] 5.2; P = 0.023), a preoperative inotropic score > 10 (OR 8.5; P = 0.0001), and preoperative ECMO support (OR 4.2; P = 0.012). For donors, the predictive risk factor was a donor score ≥ 17 (OR 8.3; P = 0.006). The absence of EGF was correlated with improved long-term survival: 94% at 1 year and 81% at 5 years without EGF versus 76% and 36% at 1 year (P < 0.001), and 70% and 28% at 5 years (P < 0.001) with EGF requiring IABP and ECMO support, respectively. In-hospital weaned and survived patients after IABP or ECMO treatment for moderate-to-severe EGF had a similar 5-year conditional survival rate as transplant patients who had not suffered EGF: 88% without EGF versus 84% with EGF treated with mechanical circulatory support devices (P = 0.08). The occurrence of EGF is a multifactorial deleterious event that depends on donor and recipient profiles. IABP and ECMO support are reliable treatment strategies, depending on the grade of EGF. Furthermore, surviving patients treated with IABP or ECMO have the same long-term conditional survival rate as patients who have not suffered EGF.

Does a distal perfusion cannula reduce ischaemic complications of extracorporeal membrane oxygenation?

Extracorporeal membrane oxygenation (ECMO) provides support to patients with severe but reversible cardiac or pulmonary failure. Vascular complications of ECMO are well recognized. We performed a retrospective review of 70 patients (mean age 48 years; 15-85) who received peripheral veno-arterial ECMO from 2004 to 2010 in a single centre. For statistical analysis, chi-squared test and multivariate binary logistic regression analysis were used to assess for association between response variables (i.e. limb ischaemia, ECMO site bleeding and deep vein thrombosis (DVT)) and possible predictive variables. There were 14 (20%) cases of acute limb ischaemia with no statistically significant relationship between acute limb ischaemia and independent variables. Thirty-three patients received distal limb cannulas (47%). There was no statistically significant association between limb ischaemia and presence of distal limb cannula (P = 0.8). Multivariate binary logistic regression analysis identified insertion by cutdown as a predictor of lower probability of insertion site bleeding (n = 12, odds ratio 0.24, P = 0.04). Seven cases of DVT were identified; multivariate binary logistic regression analysis identified insertion by cutdown (odds ratio 0.08, P = 0.03) and days of ECMO less than five (odds ratio 0.08, P = 0.04) as predictive factors for reduced rates of DVT. Ischaemic complications of ECMO are common and occur despite the presence of a distal limb-perfusing cannula; however in our study the distal limb cannula was a limb-salvaging intervention in six patients. Prolonged time on ECMO is a risk factor for DVT, and a high index of suspicion must be maintained. Percutaneous insertion was associated with higher rates of bleeding and DVT.

Peripheral Veno-Arterial Extracorporeal Membrane Oxygenation as a Bridge to Decision for Pediatric Fulminant Myocarditis.

It is essential to establish an appropriate initial treatment strategy for pediatric fulminant myocarditis. We reviewed eight cases of pediatric fulminant myocarditis that required extracorporeal membrane oxygenation (ECMO) from 2012 to 2015. The median age was 8 years (range 3 months-13 years), and the median body surface area was 0.89 m(2) (range 0.35-1.34 m(2) ). Peripheral veno-arterial ECMO was initially applied, and we evaluated whether heart decompression was sufficient. If the pump flow was insufficient, central cannulation was performed via median sternotomy (central ECMO). The need for subsequent ventricular assist device (VAD) support was determined 72 h after ECMO initiation. Six patients were bridged to recovery using peripheral ECMO support only (for 3-11 days), whereas two required VAD support. One patient was switched to central ECMO before VAD implantation. Three patients died of multiorgan failure, even though cardiac function recovered in two of those patients. The duration from hospital arrival to ECMO initiation was shorter in the survival (3.3 ± 1.3 h; range 1.6-4.7 h) than in the nonsurvival group (32 ± 28 h; range 0.7-55 h). Peripheral ECMO can be useful as a bridge to decision for pediatric fulminant myocarditis, which is frequently followed by a successful bridge to recovery. It is important to determine whether ECMO support should be initiated before organ dysfunction advances to preserve organ function, which provides a better bridge to subsequent VAD therapy and heart transplant or recovery.

Secondary abdominal compartment syndrome required decompression laparotomy during minimally invasive mitral valve repair.

We treated a 77-year-old patient with secondary abdominal compartment syndrome that caused failure to maintain cardiopulmonary bypass while undergoing elective minimally invasive right mini-thoracotomy mitral valve and tricuspid valve repair procedures. During the operation, a decompression laparotomy was needed to relieve elevated intraabdominal pressure that caused instability of the cardiopulmonary bypass. Due to poor oxygenation and the long cardiopulmonary bypass time, the patient required peripheral extracorporeal membrane oxygenation before recovery. We alert surgeons to this rare complication that can occur even in patients undergoing minimally invasive surgery with a right mini-thoracotomy.

Extracorporeal membrane oxygenation for failed tPA therapy of pulmonary embolism

Background: Pulmonary embolism may cause cardiac arrest secondary to obstruction of blood flow. Traditional treatment strategies include anticoagulation, thrombolysis, and mechanical extraction. Some advocate for support with extra corporeal membrane oxygenation; however, surgical therapies are contraindicated following thrombolytics. Methods: We describe the emergent use of peripheral extra corporeal membrane oxygenation following thrombolytic therapy for a saddle pulmonary embolism associated with multiple episodes of cardiac arrest. Results: The patient was stabilized with peripheral extra corporeal membrane oxygenation, anticoagulated and subsequently weaned from extra corporeal membrane oxygenation without any major bleeding complications. Conclusion: The administration of thrombolytics should not be a contraindication for extra corporeal membrane oxygenation in patients with massive pulmonary embolism associated with hemodynamic instability.

0330: Impact of extra-corporeal membrane oxygenation in high-urgency cardiac transplantation

We evaluated the use of extra-corporeal membrane oxygenation (ECMO) support as a direct bridge for heart transplantation in high-urgency (SuperUrgence 1) adult recipients. Between January 2005 and December 2012, 81 patients supported with ECMO underwent high-urgency cardiac transplantation at our Institution (group SU1 ECMO). They were compared to 131 cardiac recipients who high-urgency transplantation during the same period (group SU1 NoECMO). Forty-four patients were supported with a peripheral ECMO, while 37 patients were supported with a central ECMO. Mean duration of support before transplantation was 17±12 days. The following characteristics were significantly different between group SU1 NoECMO and group SU1 ECMO: among the recipients, age, 49 years vs. 44 years, p<0.01; age older than 50 years, 61% vs. 42%, p<0.01; waiting time >15 days, 45% vs. 16%, p<0.01; ischemic etiology, 24% vs. 40%, p=0.02; prior sternotomy, 14% vs. 59%, p<0.01; preoperative Implantable Cardioverter Defibrillator (ICD), 50% vs. 16%, p<0.01; preoperative ventilation, 6% vs. 41%, p<0.01; preoperative inotropes, 84% vs. 67%, p<0.01, glomerular filtration rate (GFR) 76 vs. 108, p<0.01. Donor characteristics were similar in both groups. The occurrence of primary graft dysfunction and one-year mortality in group SU1 NoECMO and group SU1 ECMO were 18% vs. 42%, p<0.01 and 23% vs. 28%, p=0.37. Five-year survival was 72% (group SU1 NoECMO) and 66% (SU1 ECMO), p=0.45. A period analysis of SU1 ECMO patients is resumed in Table 1. In our experience, ECMO support is a reliable option for direct bridge to heart transplantation and it resulted in satisfactory outcomes as other high-urgency transplanted patients. Abstract 0330 – Table: Period Analysis of SU1 ECMO Patients Era I (2005-2008) Era II (2009-2012) P RECIPIENT Etiology DCM 27% 53% 0,02 Central ECMO 66% 25% <0,01 Prior Sternotomy 78% 40% <0,01 Preoperative Ventilation 56% 25% <0.01 GFR 92 124 0,03 DONOR Age >50 44% 23% 0,04 RESULTS Primary Graft Failure 32% 53% 0,06 1-Year Mortality 27% 30% 0,75

Extracorporeal Membrane Oxygenation for 67 Days as a Bridge to Heart Transplantation in a Postcardiotomy Patient with Failing Heart and Mediastinitis

We report a case of successful heart transplantation after 67 days of support with venoarterial extracorporeal membrane oxygenation (ECMO) in a patient who underwent surgery for type A aortic dissection and myocardial infarction complicated by irreversible myocardial damage and a deep sternal wound infection. During ECMO support, left heart vent and distal limb perfusion were performed. Mediastinitis was treated with mediastinal washout and irrigation. Multiple complications from peripheral ECMO were successfully managed.

Perioperative extracorporeal membrane oxygenation bridging in patients undergoing pulmonary endarterectomy.

Chronic thromboembolic pulmonary hypertension is the only curable form of pulmonary arterial hypertension. Pulmonary endarterectomy (PEA) has been established as the treatment of choice in these patients producing very satisfying results. Some patients develop severe cardiorespiratory decompensation before PEA or during weaning from cardiopulmonary bypass. This might be due to acute reperfusion oedema and/or right ventricular failure caused by residual hypertension. Extracorporeal membrane oxygenation (ECMO) support has been established as a bridging therapy in cardiorespiratory failure. At our department, we used peripheral veno-arterial ECMO in patients deteriorating before PEA and in patients where weaning from cardiopulmonary bypass was not possible. We conducted a retrospective analysis of all the patients undergoing PEA who needed pre- and/or postoperative veno-arterial ECMO support. Outcomes including survival, morbidity and haemodynamic improvement were compared between patients surviving and non-surviving after ECMO support. Further, we analysed survival and risk factors of patients requiring ECMO versus patients without ECMO support. Between January 2001 and March 2013, a total of 161 patients underwent PEA at our institution. Thirty-one patients (19.3%) required support with peripheral veno-arterial ECMO, either both, pre- and postoperatively (n = 2), or only postoperatively (n = 29). Twenty-eight patients received ECMO directly in the theatre and 1 patient received ECMO at the ICU after successful weaning from cardiopulmonary bypass after PEA. Twenty-eight patients (90.3%) were successfully weaned from ECMO and 20 patients left the hospital alive giving a salvage rate of 64.5%. For those not requiring ECMO support, in-house mortality was 3.1% (n = 4). In the 3 patients where weaning from ECMO was not possible, lung transplantation was performed as a rescue therapy. Long-term survival in the patients requiring ECMO who survived was worse than survival in the non-ECMO patient group. The only significant risk factor for the use of ECMO was a pulmonary vascular resistance higher than 1000 dynes cm s(-5). Pre- and postoperative ECMO bridging in patients undergoing PEA is a feasible option to stabilize patients in a critical pre- and/or postoperative situation and to improve outcome in these patients who would otherwise probably not survive the procedure.

Commentary on: Trans-diaphragmatic left ventricular venting during peripheral venous-arterial extracorporeal membrane oxygenation.

Commentary on: Trans-diaphragmatic left ventricular venting during peripheral venous-arterial extracorporeal membrane oxygenation.

Trans-diaphragmatic left ventricular venting during peripheral venous-arterial extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) has proven to be an invaluable method of cardiopulmonary support in cases of severe cardiogenic shock. In an emergency, femoral artery and vein cannulation is the easiest and quickest access to initiate support. Often, with peripheral venous-arterial ECMO (VA ECMO), an inadequate reduction in left ventricular end-diastolic pressure (LVEDP) is present secondary to increased afterload from retrograde flow, inadequate RV drainage or persistent bronchial circulation. Elevated LVEDP has been known to be associated with poor myocardial recovery, LV thrombus formation and significant pulmonary edema. A cannulation strategy to achieve partial ventricular unloading is of paramount importance when considering ECMO support following cardiogenic shock to increase the potential for myocardial recovery. We present a novel case of emergent peripheral VA ECMO cannulation with a trans-diaphragmatic left ventricular (LV) vent in a 61-year-old, 79 kg male with end-stage liver disease and hepatitis B cirrhosis who suffered cardiac arrest during orthotopic liver transplantation.

Using Near-Infrared Spectroscopy to Monitor Lower Extremities in Patients on Venoarterial Extracorporeal Membrane Oxygenation

Patients on peripheral extracorporeal membrane oxygenation (ECMO) are at risk for lower extremity ischemia. Effective monitoring is needed to identify complications quickly and allow timely correction. Near-infrared spectroscopy has been used extensively in cerebral monitoring during cardiac surgery. We present its use in monitoring lower extremity perfusion in patients on ECMO. Five patients on ECMO had near-infrared spectroscopy monitors placed on the calf of both lower extremities. Continuous real-time tissue oxygen saturation data (stO2) was displayed and recorded. Two patients had lower extremity complications in the leg with the arterial cannula. The patients with complications had lower stO2 in the cannulated leg at the time of ECMO insertion, larger differences in stO2 between the legs at the time of insertion, lower nadir stO2s, and larger peak differences in stO2 between the legs than patients without limb complications. The use of near-infrared spectroscopy for continuous monitoring of tissue oxygenation in the lower extremities in patients on ECMO may allow early identification of patients with lower extremity complications.

Lower limb overflow syndrome in extracorporeal membrane oxygenation

Peripheral extracorporeal membrane oxygenation (ECMO) is associated with a not negligible rate of vascular morbidity. Most vascular complications are related to limb ischaemia mainly due to insufficient limb perfusion or embolic events. To the best of our knowledge, this is the first report of a severe epidermolysis and overflow syndrome as a result of an overperfusion phenomenon through an unknown femoral arterio-venous fistula in a patient requiring ECMO support.