Peripheral Venoarterial Extracorporeal Membrane Oxygenation Research Articles

Systemic Hemodynamics, Cardiac Mechanics, and Signaling Pathways Induced by Extracorporeal Membrane Oxygenation in a Cardiogenic Shock Model.

Peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used in patients suffering from refractory cardiogenic shock (CS). Although considered life-saving, peripheral VA-ECMO may also be responsible for intracardiac hemodynamic changes, including left ventricular overload and dysfunction. Venoarterial extracorporeal membrane oxygenation may also increase myocardial wall stress and stroke work, possibly affecting the cellular cardioprotective and apoptosis signaling pathways, and thus the infarct size. To test this hypothesis, we investigated the effects of increasing the peripheral VA-ECMO blood flow (25-100% of the baseline cardiac output) on systemic and cardiac hemodynamics in a closed-chest CS model. Upon completion of the experiment, the hearts were removed for assessment of infarct size, histology, apoptosis measurements, and phosphorylation statuses of p38 and protein Kinase B (Akt), and extracellular signal-regulated kinase mitogen-activated protein kinases (ERK-MAPK). Peripheral VA-ECMO restored systemic perfusion but induced a significant and blood flow-dependent increase in left ventricular preload and afterload. Venoarterial extracorporeal membrane oxygenation did not affect infarct size but significantly decreased p38-MAPK phosphorylation and cardiac myocyte apoptosis in the border zone.

Novel Left Ventricular Unloading Strategies in Patients on Peripheral Venoarterial Extracorporeal Membrane Oxygenation Support.

The purpose of this study was to evaluate left ventricular (LV) unloading strategies in patients supported with peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO). A retrospective review was conducted of all consecutive patients requiring VA-ECMO support for any indication, who underwent novel LV unloading strategies with either direct left atrial venoarterial (LAVA) cannulation or pulmonary artery venoarterial (PAVA) venting, in comparison to Impella and intra-aortic balloon pump (IABP). The primary outcome was successful bridge to transplant, LV assist device, or myocardial recovery. Forty-six patients (63% male, mean age 52.8 ± 17.6 years) were included. Fourteen patients (30%) underwent novel unloading with either LAVA or PAVA, 11 patients (24%) underwent IABP placement, and 21 patients (46%) underwent Impella insertion. In the novel LV unloading cohort, 10 patients (71%) survived to hospital discharge. Four patients (29%) were weaned from ECMO and eight patients (57%) underwent cardiac transplantation. Although a trend favoring cannula-based unloading for the primary outcome was noted, the cohort was too small for statistical significance (79% LAVA/PAVA, 57% Impella, 45% IABP; p = 0.21). However, probability of survival was greater in the LAVA/PAVA cohort compared to Impella and IABP ( p < 0.05). Thus, we demonstrate the efficacy of LA and PA cannulation as an alternative LV unloading strategy for patients supported with peripheral VA-ECMO.

A Novel Approach for Simultaneous Venoarterial Extracorporeal Membrane Oxygenation and Left Ventricular Decompression Therapy With Impella (ECPella)

Percutaneously placed veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is commonly used to support patients with refractory cardiac arrhythmias or arrest and worsening cardiogenic shock (CS). Peripheral VA-ECMO by retrograde flow of blood in the aorta results in a significant increase in left ventricle (LV) afterload. A severely dysfunctional LV may be unable to overcome this afterload to open the aortic valve and unload itself. This may lead to LV distension, increased left ventricular pressure, poor coronary blood circulation, increased left atrial pressures, pulmonary edema, and pulmonary hypertension. Moreover, it jeopardizes ventricular recovery, particularly in the presence of ischemia-induced myocardial impairment. Furthermore, if the aortic valve remains closed during the cardiac cycle, stasis of blood in the LV and aortic root may increase the risk of thrombus formation. These complications may preclude cardiac recovery and the patient from being a heart transplant candidate. In patients with CS, utilizing Impella with VA-ECMO, commonly referred to as ECPella, has consistently been shown to reduce mortality and improve outcomes. Patients who need prolonged ECPella support as a bridge to recovery or transplant may remain bed-bound since ambulation of patients with two mechanical circulatory support devices is challenging. We present the technique of ECPella placement through Y chimney graft anastomosis on the axillary artery for arterial cannula and Impella insertion and percutaneous cannulation of the right internal Jugular vein for venous cannula. This technique gives the ease of ambulation and decannulation of VA-ECMO under local anesthesia without requiring intubation or a trip to the operating room.

Strategy for prophylactic application of peripheral va-ecmo in transplantation involving expected extremely prolonged ischemia time

Heart transplantation (HT) with extremely prolonged (&gt;6 hours) graft ischemia is associated with severe cardiac graft dysfunction. The high efficiency of prophylactic (preoperative initiation) veno-arterial extracorporeal membrane oxygenation (VA-ECMO) to prevent severe hemodynamic disorders during cardiac surgery has been demonstrated. Objective: to determine the effect of prophylactic VA-ECMO on the perioperative period in HT with an expected graft ischemia &gt;6 hours. Materials and methods. Thirty-eight recipients (33 (86.8%) males and 5 (13.2%) females), age 11–66 (44.7 ± 12.0) years (median 48.0 years) were examined. Pre-transplant mechanical circulatory support (MCS) using peripheral VA-ECMO was applied in 15 (39.5%) recipients, in 6 of whom by prophylactic technique. The recipients (n = 38) were divided into 3 groups: 1) «no pre-HT VA-ECMO» (n = 23); 2) «pre-HT VA-ECMO» (n = 9) – pre-transplant VA-ECMO as a bridge to HT; 3) «prophylactic VA-ECMO» (n = 6). Results. In «prophylactic VA-ECMO» group, extracorporeal circulation (ECC) (94.0 [85.5; 102.8] min) and reperfusion time (20.0 [18.3; 27.6] min) were shorter (p &lt; 0.05) compared to «no pre-HT VA-ECMO» (161.0 [122; 191.5] and 60.0 [55.3; 70.5] min) and «pre-HT VA-ECMO» (127.0 [117; 150.3] and 35.0 [27.8; 48.8] min) groups. The vasoactive-inotropic score was lower (p &lt; 0.05) in «pre-HT VA-ECMO» and «prophylactic VAECMO» groups compared to recipients in «no pre-HT VA-ECMO» group, 12.1 [11.2; 14.0] and 12.5 [11.7; 14.8] vs. 16.0 [15.0; 18.5], respectively. The groups did not differ in terms of incidence of severe primary dysfunction. The «pre-HT VA-ECMO» and «prophylactic VA-ECMO» groups were characterized by shorter duration of mechanical ventilation (MV) compared with «no pre-HT VA-ECMO» group (11.7 [10.0; 16.5] and 12.7 [11.3; 18.4], respectively, vs. 14.5 [13.0; 19.3]). The «no pre-HT VA-ECMO» and «prophylactic VA-ECMO» groups did not differ in the need for postoperative MST, 21.7% and 16.7%, respectively. The groups did not differ in terms of length of stay in the intensive care unit (ICU) and in-hospital mortality – 0% («prophylactic VA-ECMO») and 8.7% («no pre-HT VA-ECMO») and 11.1% («pre-HT VA-ECMO»), respectively. Conclusion. Prophylactic VA-ECMO in HT with extremely prolonged cardiac graft ischemia reduces ECC duration, reperfusion period, postoperative mechanical ventilation period, and the need for inotropic therapy.

Single-vessel access venoarterial extracorporeal membrane oxygenation and Impella technique for acute cardiogenic shock complicated by lung congestion.

The combination of the Impella and peripheral venoarterial extracorporeal membrane oxygenation (Ecmella) is a promising treatment for critically ill patients. We report a single-access Ecmella approach using the brachiocephalic artery. A 65-year-old woman with acute myocardial infarction involving the left main coronary artery underwent intra-aortic balloon pump and peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) placement. Given the progression of pulmonary congestion and lower limb ischaemia, and an axillary artery diameter of 4.9 mm, we decided to perform a single Ecmella approach. A Y-shaped 9-mm Dacron woven graft was anastomosed to the brachiocephalic artery through a reverse T-shaped partial sternotomy. The Impella 5.5 and arterial cannula of VA-ECMO were introduced through each graft. Six days after, VA-ECMO was removed. Sixty-two days after the surgery, the patient received durable left ventricle assist device implantation. In conclusion, haemodynamic support using a single-access Ecmella through brachiocephalic artery allows for managing patients with narrow peripheral arteries.

Outcomes of Veno-Arterial Extracorporeal Membrane Oxygenation With Percutaneous Left Ventricular Unloading in Fulminant Myocarditis.

Fulminant myocarditis requiring peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has a high mortality rate. We investigated clinical outcomes of combined use of VA-ECMO and percutaneous left ventricular assist device (VAD) (Impella) for fulminant myocarditis in 104 consecutive patients enrolled in the Japan Registry for Percutaneous VAD (J-pVAD) between October 2017 and January 2020. Patients were followed until hospital discharge and predictors of survival were analyzed with a Cox proportional hazards model. The median support duration of combined use of VA-ECMO and Impella (ECMO/Impella) was 6 days, and the median left ventricular ejection fraction improved from 15% to 52% during support ( p < 0.0001). Overall, 66 patients (63%) survived to discharge. Multivariate analysis revealed ECMO/Impella support at a transplant center as an independent predictor of survival ( p = 0.0231). Patients treated at transplant centers had better 60 days survival rates when compared to nontransplant centers (83% vs. 55%, p = 0.005). However, baseline characteristics and treatment strategies differed between the two groups. This real-world national registry database suggested the difference in survival after ECMO/Impella support for fulminant myocarditis between transplant and nontransplant centers, which may indicate hospital variations regarding patient management, although further controlled studies are needed.

Central Extracorporeal Membrane Oxygenation Support Following Calcium Channel Blocker Overdose in Children.

Refractory vasodilatory shock (RVS) following massive calcium channel blocker (CCB) overdose remains a challenging clinical entity. Peripheral venoarterial extracorporeal membrane oxygenation (ECMO) has proven useful in several cases of CCB intoxication, however, its use in the pediatric population poses unique challenges given the generally small size of pediatric peripheral vasculature in comparison to the high flow rates necessary for adequate mechanical circulatory support. As a result of these challenges, our group has adopted a "primary" central ECMO cannulation approach to the treatment of children and adolescents admitted to our center with profound RVS after CCB ingestion. We present four cases within the last year using this approach. All patients were successfully discharged from the hospital with no late morbidity at most recent follow-up. Central ECMO support in cases of massive vasodilatory shock following CCB overdose is safe and effective and should be considered early in the clinical course of these critically ill patients.

Veno-arterial extracorporeal membrane oxygenation for cardiogenic shock: one-year outcomes from a cardiac intensive care unit led shock team program

Abstract Background Mechanical circulatory support (MCS) with peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used for severe cardiogenic shock (CS). Purpose To describe the initial experience with peripheral VA-ECMO within a cardiac intensivist team led program. Methods Retrospective analysis of a short-term MCS prospective registry, from 1 September 2021 to 1 December 2022. Clinical and device related variables were reviewed and reported. We assessed both patient outcomes as well as ECMO-related complications. Results A total of 21 patients were included in this analysis (50 ± 13 years-old, 80% male), ranging from SCAI-C (n = 8) to E (n = 5) and with a median predicted mortality by SAVE score of -4 points [IQ -6 - 0] (corresponding to 30% in-hospital survival). All cannulations were done percutaneously, mostly by trained cardiac intensivists and while at the CICU (n = 12). A femoro-femoral configuration was used for all patients. One patient was cannulated at the referring hospital and retrieved to our unit for further care. Three patients were cannulated during intra-hospital cardiac arrest and one patient was cannulated while breathing spontaneously (awake-ECMO). Mean venous and arterial cannula sizes were 22 ± 1.9 Fr and 17 ± 1.6 Fr, respectively. A 7 French (Fr) arterial limb reperfusion cannula was used in 85% of cases. The most frequent etiology was acute decompensation of chronic heart failure (n = 7), followed by acute myocardial infarction related CS (n = 5), fulminant myocarditis (n = 2) and massive pulmonary thromboembolism (n = 2). A left ventricle venting device was used in 70% of patients [intra-aortic balloon pump (n = 10); percutaneous microaxial pump ( n = 2)] and upgrade to a veno-arterio-venous configuration was necessary in one patient due to differential hypoxemia. Mean ECMO-run duration was 8.4 ± 4.8 days while mean CICU length of stay was 22 ± 17.9 In-hospital mortality was 40%. In survivors, decannulation was surgical in all but one patient. The most frequent strategy was bridge to recovery (n = 14). One patient was bridged directly to heart transplant, one to a temporary centrifugal left ventricular assist device (LVAD) and one to a durable magnetically levitated LVAD. Complications were common and included bleeding from cannula insertion sites (n = 19), renal replacement therapy requirement (n= 10), Harlequin syndrome (n = 2), cardiac tamponade (n = 2), intestinal ischemia (n = 3) and limb ischemia (n = 2). Conclusion VA-ECMO performed by cardiac intensivists is a feasible MCS strategy for severe cardiogenic shock patients in whom mortality, while high, was similar to large international published series. Further experience will allow for improvement in patient selection and minimization of device related complications.ECMO VA 1 year single-center experience

Abstract 17180: Association of Arterial Return Cannula Size With Survival in Adults Undergoing Venoarterial Extracorporeal Membrane Oxygenation: An ELSO Registry Analysis

Introduction: Peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used to support critically ill adults with cardiogenic shock (CS), but the impact of arterial cannula size on survival remains poorly understood. Hypothesis: A smaller arterial return cannula will be associated with similar survival. Methods: We queried the ELSO registry for adults undergoing VA-ECMO from 2017-2022 and stratified them into small (&lt;16 Fr) versus large (≥16Fr) arterial cannula size. We restricted the cohort to patients with body surface area (BSA) 1.8-2.2 m 2 and excluded patients with a concomitant left ventricular venting device, central cannulation, and multiple ECMO runs. The primary outcome was 30-day in-hospital mortality and secondary outcomes included 24-hour lactate clearance and rates of on-support acute renal and liver injury. Results: Among 2963 adults receiving peripheral VA-ECMO without a concomitant left ventricular venting device, 491 (16.6%) patients had a small arterial cannula and 2,472 (83.4%) had a larger cannula. Patients with a larger cannula were more often male, had marginally higher BSA, a higher incidence of pre-ECMO organ failures, and more often had a distal perfusion cannula (Figure, panel A). There was no difference in 30-day mortality between patients with small (40.3%) versus large (42.9%) arterial cannula, p= 0.295 (Figure, panel B), which persisted after multivariable modeling: adjusted hazard ratio 0.97 (95% CI: 0.79-1.19, p= 0.78). Lactate clearance at 24 hours of ECMO support (Figure, panel C) and the rates of acute renal injury (37% vs 41%, p = 0.024) and hyperbilirubinemia (4.3% vs 4.3%, p = 0.96) were similar between the two arterial cannula size cohorts. Conclusion: For adult patients undergoing peripheral VA-ECMO support, the use of a smaller (&lt;16F) versus larger (≥16F) arterial return cannula was associated with similar rates of in-hospital mortality and metrics of end-organ perfusion.

Bilateral Femoral Cannulation Is Associated With Reduced Severe Limb Ischemia-Related Complications Compared With Unilateral Femoral Cannulation in Adult Peripheral Venoarterial Extracorporeal Membrane Oxygenation: Results From the Extracorporeal Life Support Registry.

Peripheral venoarterial extracorporeal membrane oxygenation (ECMO) with femoral access is obtained through unilateral or bilateral groin cannulation. Whether one cannulation strategy is associated with a lower risk for limb ischemia remains unknown. We aim to assess if one strategy is preferable. A retrospective cohort study based on the Extracorporeal Life Support Organization registry. ECMO centers worldwide included in the Extracorporeal Life Support Organization registry. All adult patients (≥ 18 yr) who received peripheral venoarterial ECMO with femoral access and were included from 2014 to 2020. Unilateral or bilateral femoral cannulation. The primary outcome was the occurrence of limb ischemia defined as a composite endpoint including the need for a distal perfusion cannula (DPC) after 6 hours from implantation, compartment syndrome/fasciotomy, amputation, revascularization, and thrombectomy. Secondary endpoints included bleeding at the peripheral cannulation site, need for vessel repair, vessel repair after decannulation, and in-hospital death. Propensity score matching was performed to account for confounders. Overall, 19,093 patients underwent peripheral venoarterial ECMO through unilateral ( n = 11,965) or bilateral ( n = 7,128) femoral cannulation. Limb ischemia requiring any intervention was not different between both groups (bilateral vs unilateral: odds ratio [OR], 0.92; 95% CI, 0.82-1.02). However, there was a lower rate of compartment syndrome/fasciotomy in the bilateral group (bilateral vs unilateral: OR, 0.80; 95% CI, 0.66-0.97). Bilateral cannulation was also associated with lower odds of cannulation site bleeding (bilateral vs unilateral: OR, 0.87; 95% CI, 0.76-0.99), vessel repair (bilateral vs unilateral: OR, 0.55; 95% CI, 0.38-0.79), and in-hospital mortality (bilateral vs unilateral: OR, 0.85; 95% CI, 0.81-0.91) compared with unilateral cannulation. These findings were unchanged after propensity matching. This study showed no risk reduction for overall limb ischemia-related events requiring DPC after 6 hours when comparing bilateral to unilateral femoral cannulation in peripheral venoarterial ECMO. However, bilateral cannulation was associated with a reduced risk for compartment syndrome/fasciotomy, lower rates of bleeding and vessel repair during ECMO, and lower in-hospital mortality.

A multidisciplinary multistage complete mega aorta replacement and utilization of extracorporeal membrane oxygenation in thoracoabdominal aneurysm repair.

A 49-year-old woman underwent a 11-month multistage complete replacement of a mega aorta. Replacement stages included ascending aorta and arch replacement in conjunction with a frozen elephant trunk thoracic endovascular aortic repair, extension of thoracic endovascular aortic repair to zone 5, and open repair of the thoracoabdominal aneurysm with the use of venoarterial extracorporeal membrane oxygenation for circulatory support. This case illustrates the complexity of repairing a mega aorta, the multidisciplinary care and staging needed for repair, and the use of peripheral venoarterial extracorporeal membrane oxygenation for circulatory perfusion during thoracoabdominal aneurysm repair.

Ultrasound-guided closure of the femoral artery during venoarterial decannulation using a large-bore closure device.

Peripheral femoro-femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO) is viable for fast hemodynamic assistance during cardiogenic shock. Ultrasound-guided closure with a large-bore device (MANTA®) is a feasible option potentially replacing surgical arteriotomy closure in peripheral VA-ECMO decannulation. This retrospective study included patients weaning from percutaneously inserted femoro-femoral VA-ECMO at the Helsinki University Hospital, Finland in 2012-2020. The primary endpoints were access-site complications, a composite of hematomas/seromas/surgical site infections (SSIs), and the safety endpoint of vascular complications (VCs). A total of 100 consecutive percutaneously implanted and weaned VA-ECMO patients were stratified into two groups by decannulation strategy: percutaneous ultrasound-guided MANTA device (n = 21, 21.0%) or surgical approach (n = 79, 79.0%). The mean age of the cohort was 51 ± 13 years and females represented 25.0%. The technical success rate of the percutaneous ultrasound-guided MANTA technique was 95.2%. In multivariate analysis, surgical closure was associated with a higher incidence of combined access site hematomas/seromas/SSIs compared to percutaneous ultrasound-guided deployment of MANTA device (44.3% versus 9.5%, odds ratio (OR): 7.162, 95% confidence interval (CI): 1.544-33.222; p = 0.012). Similarly, access-site complications necessitating interventions were more frequent in the surgical closure group compared to US-MANTA (ultrasound-guided MANTA) group (26.6% versus 0.0%, p = 0.005). VCs were infrequent in both groups without any significant intergroup difference (p > 0.99). Percutaneous ultrasound-guided MANTA closure of the femoral artery after VA-ECMO decannulation was associated with high technical success rate and low incidence of VCs. Compared to surgical closure, access-site complications were significantly less frequent, along with access-site complications necessitating interventions.

Outcomes With Peripheral Venoarterial Extracorporeal Membrane Oxygenation for Suspected Acute Myocarditis: 10-Year Experience From the Extracorporeal Life Support Organization Registry.

Acute myocarditis can result in severe hemodynamic compromise requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO). Outcomes and factors associated with mortality among myocarditis patients are not well described in the modern ECMO era. We queried the Extracorporeal Life Support Organization registry from 2011 to 2020 for adults with suspected acute myocarditis undergoing peripheral VA-ECMO support. The primary outcome was in-hospital mortality and was compared to all-comers receiving VA-ECMO in the registry over the same period. Secondary outcomes were rates of bridging to advanced therapies and ECMO complications. We used multivariable logistic regression to examine factors associated with in-hospital mortality. Among 850 patients with suspected acute myocarditis receiving peripheral VA-ECMO, the mean age was 41 years, 52% were men, 39% Asian race, and 14.8% underwent extracorporeal cardiopulmonary resuscitation. During the study period, in-hospital mortality steadily declined and was 58.3% for all all-comers receiving VA-ECMO compared with 34.9% for patients with myocarditis (P<0.001). After multivariable modeling, risk factors for mortality were earlier year of support, older age, higher weight, Asian race, need for extracorporeal cardiopulmonary resuscitation, sepsis, and lower mean arterial pressure and pH prior to ECMO initiation. ECMO complications including bleeding, limb ischemia, infections and ischemic stroke were more common among nonsurvivors and significantly declined during the study period. Compared with all-comers supported with VA-ECMO, in-hospital mortality for patients with acute myocarditis is significantly lower, with nearly two-thirds of patients surviving to discharge. Major modifiable risk factors for mortality were ongoing cardiopulmonary resuscitation requiring ECMO and markers of illness severity prior to ECMO.

Distal perfusion cannula on VA-ECMO: do not blindly trust! A case report

Distal perfusion cannulas, DPCs, are increasingly used to prevent limb ischemia, frequent and potentially serious complication on peripheral veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support. We report the case of a patient treated with femoro-femoral V-A ECMO who developed a sudden, significant asymmetric decrease in cannulated limb regional oxygen saturation, rSO2, signal, despite the presence of a DPC. This finding, noticed within 6 hours after the implementation of extracorporeal cardiopulmonary resuscitation (ECPR) in a patient experiencing refractory intra-hospital cardiac arrest (IHCA), suggested ongoing limb ischemia. After careful monitoring, a clot was detected in the line supplying DPC, which appeared completely kinked at dressing removal. Line patency and reperfusion were promptly re-established. No additional ischemic episodes occurred, and the patient was successfully weaned from extracorporeal support, and experienced full functional recovery, with no sensory or motor deficit. This case highlights the strict need for a careful, continuous monitoring of limb perfusion during V-A ECMO, even if limb perfusion through DPC is implemented, in order to prevent severe limb complications, negatively impacting on outcome.

Percutaneous decannulation of venoarterial extracorporeal membrane oxygenation using the Manta vascular closure device: A systematic review and meta-analysis.

To perform a systematic review and meta-analysis of the techniques and outcomes associated with percutaneous decannulation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) using the Manta vascular closure device. Peripheral VA-ECMO can be used to treat critically ill patients with conditions such as refractory cardiogenic shock. After percutaneous implantation of VA-ECMO, VA-ECMO can also be decannulated completely percutaneously by using a vascular closure device. The Manta vascular closure device is a dedicated device used in the closure of large-bore arteriotomies by sandwiching the arteriotomy with an intra-arterial toggle and an extraluminal collagen plug. We performed a thorough literature search using various electronic databases. We included studies that reported outcomes after peripheral femorofemoral VA-ECMO decannulation with the Manta vascular closure device. We performed a meta-analysis of proportions on outcome measures, including technical success, bleeding complications, vascular complications, wound complications, major amputation, and procedural-related deaths. We included seven studies with a total of 116 patients. The overall technical success of percutaneous decannulation of VA-ECMO with the Manta vascular closure device was 93.7%. The overall incidence of bleeding, vascular and wound complications was 1.7%, 13.8%, and 3.4%, respectively. No patient required lower limb amputation or died due to VA-ECMO decannulation. Percutaneous decannulation with the Manta vascular closure device is an effective and safe procedure that should be considered in suitable patients on VA-ECMO.

A numerical study of the hemodynamic behavior and gas transport in cardiovascular systems with severe cardiac or cardiopulmonary failure supported by venoarterial extracorporeal membrane oxygenation.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been extensively demonstrated as an effective means of bridge-to-destination in the treatment of patients with severe ventricular failure or cardiopulmonary failure. However, appropriate selection of candidates and management of patients during Extracorporeal membrane oxygenation (ECMO) support remain challenging in clinical practice, due partly to insufficient understanding of the complex influences of extracorporeal membrane oxygenation support on the native cardiovascular system. In addition, questions remain as to how central and peripheral venoarterial extracorporeal membrane oxygenation modalities differ with respect to their hemodynamic impact and effectiveness of compensatory oxygen supply to end-organs. In this work, we developed a computational model to quantitatively address the hemodynamic interaction between the extracorporeal membrane oxygenation and cardiovascular systems and associated gas transport. Model-based numerical simulations were performed for cardiovascular systems with severe cardiac or cardiopulmonary failure and supported by central or peripheral venoarterial extracorporeal membrane oxygenation. Obtained results revealed that: 1) central and peripheral venoarterial extracorporeal membrane oxygenation modalities had a comparable capacity for elevating arterial blood pressure and delivering oxygenated blood to important organs/tissues, but induced differential changes of blood flow waveforms in some arteries; 2) increasing the rotation speed of extracorporeal membrane oxygenation pump (ω) could effectively improve arterial blood oxygenation, with the efficiency being especially high when ω was low and cardiopulmonary failure was severe; 3) blood oxygen indices (i.e., oxygen saturation and partial pressure) monitored at the right radial artery could be taken as surrogates for diagnosing potential hypoxemia in other arteries irrespective of the modality of extracorporeal membrane oxygenation; and 4) Left ventricular (LV) overloading could occur when ω was high, but the threshold of ω for inducing clinically significant left ventricular overloading depended strongly on the residual cardiac function. In summary, the study demonstrated the differential hemodynamic influences while comparable oxygen delivery performance of the central and peripheral venoarterial extracorporeal membrane oxygenation modalities in the management of patients with severe cardiac or cardiopulmonary failure and elucidated how the status of arterial blood oxygenation and severity of left ventricular overloading change in response to variations in ω. These model-based findings may serve as theoretical references for guiding the application of venoarterial extracorporeal membrane oxygenation or interpreting in vivo measurements in clinical practice.

Experience with percutaneous right ventricular support in the early post-left ventricular assist device implantation period (clinical case report and literature reviews)

Implantable left ventricular assist device (LVAD) is a state-of-the-art treatment for adults and children with end-stage heart failure. The early and late period after LVAD implantation can be severely complicated. Right ventricular failure (RVF) still remains a common complication after LVAD implantation. RVF is the cause of reduced post-implant survival. We suggest that an additional temporary or permanent right ventricular assist device (RVAD) is an effective treatment for LVAD-associated RVF. In this clinical case report, we describe the medical history of a pediatric patient (14 years old) with severe heart failure (PediMACS Level 1) against a background of dilated cardiomyopathy. The patient required peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) prior to urgent LVAD (HM3) implantation. In the early post-LVAD implantation (1 POD) period, the patient presented with hemodynamic and echocardiographic events of acute RVF that was resistant to drug therapy (inotropic/vasopressor support, iNO) and required mechanical circulatory support (MCS) with a preoperatively implanted VA-ECMO. In the LVAD-associated RVF scenario, VA-ECMO as a means of total cardiac bypass is a non-physiological MCS method and, therefore, undesirable. In this clinical situation, our solution was to use a paracorporeal centrifugal blood pump for temporary right heart support. A RVAD was assembled using percutaneous cannulation in two sites and a modification of the pre-existing VA-ECMO circuit. For RVAD, we used an ECMO cannula previously installed through the femoral vein (26 F) and added a reverse venous cannula (22 F) through the right internal jugular vein into the pulmonary trunk. To facilitate the passage of the return cannula into the pulmonary artery, we used a contralateral sheath (6 F, 40 cm) and an Amplatz Super Stiff guidewire under radiological control. The oxygenator was removed from the circuit on day 2 of RVAD. Central hemodynamics (reduction in right atrial pressure (RAP) to 10 mm Hg, increase in pulmonary capillary wedge pressure (PCWP) to 14 mm Hg), as well as right ventricular (RV) and left ventricular (LV) volume characteristics all improved. These observations allowed us to optimize the performance of the implantable LVAD (increase in flow rate to 4.2 l/min or 2.1 l/min/m2). The duration of paracorporeal RVAD after LVAD implantation was 7 days with an average flow rate of 2.3 ± 0.2 l/min. Postoperative treatment in the intensive care unit (ICU) lasted for 15 days. The patient was discharged from the hospital on postoperative day 34.

Off-Hours versus Regular-Hours Implantation of Peripheral Venoarterial Extracorporeal Membrane Oxygenation in Patients with Cardiogenic Shock.

The "weekend effect" has been associated with worse clinical outcomes. Our aim was to compare off-hours vs. regular-hours peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) in cardiogenic shock patients. We analyzed in-hospital and 90-day mortality among 147 consecutive patients treated with percutaneous VA-ECMO for medical reasons between July 1, 2013, and September 30, 2022, during regular-hours (weekdays 8:00 a.m.-10:00 p.m.) and off-hours (weekdays 10:01 p.m.-7:59 a.m., weekends, and holidays). The median patient age was 56 years (interquartile range [IQR] 49-64 years) and 112 (72.6%) were men. The median lactate level was 9.6 mmol/L (IQR 6.2-14.8 mmol/L) and 136 patients (92.5%) had a Society for Cardiovascular Angiography and Interventions (SCAI) stage D or E. Cannulation was performed off-hours in 67 patients (45.6%). In-hospital mortality was similar in off-hours and regular hours (55.2% vs. 56.3%, p = 0.901), as was the 90-day mortality (58.2% vs. 57.5%, p = 0.963), length of hospital stay (31 days [IQR 16-65.8 days] vs. 32 days [IQR 18-63 days], p = 0.979), and VA-ECMO related complications (77.6% vs. 70.0%, p = 0.305). Off-hours and regular-hours percutaneous VA-ECMO implantation in cardiogenic shock of medical cause have similar results. Our results support well-designed 24/7 VA-ECMO implantation programs for cardiogenic shock patients.

Association Between Shock Etiology and 5-Year Outcomes After Venoarterial Extracorporeal Membrane Oxygenation

BackgroundOutcomes of patients requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) vary greatly by etiology, but large studies that incorporate the spectrum of shock supported with ECMO are rare. ObjectivesThe purpose of this study was to describe the etiology-related outcome of patients with shock supported with peripheral VA-ECMO. MethodsAll consecutive adults with peripheral VA-ECMO between January 2015 and August 2018 at Pitié-Salpêtrière Hospital (Paris, France) were included in this retrospective observational study. The indication for VA-ECMO was cardiogenic shock. Rates of hospital death and neurological, renal, and pulmonary complications were evaluated according to etiology. ResultsAmong 1,253 patients, hospital and 5-year survival rates were, respectively, 73.3% and 57.3% for primary graft failure, 58.6% and 54.0% for drug overdose, 53.2% and 45.3% for dilated cardiomyopathy, 51.6% and 50.0% for arrhythmic storm, 46.8% and 38.3% for massive pulmonary embolism, 44.4% and 42.4% for sepsis-induced cardiogenic shock, 37.9% and 32.9% for fulminant myocarditis, 37.3% and 31.5% for acute myocardial infarction, 34.6% and 33.3% for postcardiotomy excluding primary graft failure, 25.7% and 22.8% for other/unknown etiology, and 11.1% and 0.0% for refractory vasoplegia shock. Renal failure requiring hemodialysis developed in 50.0%, neurological complications in 16.0%, and hydrostatic pulmonary edema in 9.0%. ConclusionsAlthough the outcome differs depending on etiology, this difference is related more to the severity of the situation associated with the cause rather than the cause of the shock per se. Survival to 5 years varied by cause, which may reflect the natural course of the chronic disease and illustrates the need for long-term follow-up.

Less Invasive Left Ventricular Unloading With Impella May Improve the Clinical Outcomes of Fulminant Myocarditis.

Fulminant myocarditis (FM) requiring temporary mechanical circulatory support (t-MCS) has a high mortality rate. Peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and intra-aortic balloon pump (IABP) are sometimes insufficient to induce cardiac recovery. For patients with FM refractory to VA-ECMO with IABP, we have applied a biventricular assist device (BIVAD) or Impella to unload the left ventricle and to fully support the systemic circulation. In the last 10 years, 37 refractory FM patients histologically diagnosed with myocarditis and who did not recover with VA-ECMO were treated with BIVAD (n = 19) or Impella (n = 18). No significant difference was found between the Impella and BIVAD groups in preoperative findings other than serum creatinine level. Seventeen of 18 patients in the Impella group were successfully weaned from t-MCS in 9 (6-12) days. Conversely, the temporary BIVAD was removed in 21 (11-38) days in 10 of 19 patients. Six patients died while on temporary BIVAD because of multiple organ failure and cerebral bleeding, and three patients required conversion to implantable VAD. Compared with BIVAD, left ventricular unloading with Impella could be less invasive and could promote cardiac recovery in refractory FM patients. The Impella has the potential to provide effective temporary MCS for FM patients.