Preoperative Extracorporeal Membrane Oxygenation Research Articles

Timely extracorporeal membrane oxygenation assist reduces mortality after bypass surgery in patients with acute myocardial infarction

Patients with acute myocardial infarction (AMI) are at high risk when undergoing emergency coronary artery bypass graft (CABG)-surgery. Their outcome remains poor despite increased use of extracorporeal membrane oxygenation (ECMO). We investigated the impact of timing for perioperative ECMO-support in these patients. In this retrospective double-center study, we evaluated 201 patients with AMI undergoing CABG, dividing them into the following groups: No-ECMO (n = 101), preoperative ECMO (pre-ECMO, n = 6), intraoperative ECMO (ECC-ECMO, n = 67), and postoperative ECMO (post-ECMO, n = 27). We evaluated the impact of ECMO timing on postoperative mortality, organ function, and length of stay, comparing these to predicted outcome using different risk-scores. Post-ECMO patients showed lowest 30-day-survival (40.7%), while earlier ECMO-start was associated with better outcome (50.7% in extracorporeal circulation [ECC]-ECMO and 66.7% in pre-ECMO patients). On admission, only pre-ECMO and ECC-ECMO patients showed higher surgery- and intensive-care-unit (ICU)-related risk-scores. In pre- and ECC-ECMO patients, the first significant increase in lactate-levels (>4 mmol/L) was observed preoperatively, while this occurred 1 hour postoperatively in post-ECMO patients. Bilirubin was increased in all patients, decreasing after 3 and 12 days in pre- and ECC-ECMO patients, respectively, but only after 18 days in post-ECMO patients. Multiple ICU risk-scores did not discriminate survival-probability correctly. Only the ECMO-related survival after veno-arterial-ECMO-score correctly predicted the significantly lower survival in post-ECMO patients. Our study shows that timely ECMO-support is associated with earlier bilirubin-downtrend and higher survival in patients with AMI after CABG. Lactate-increase greater than 4 mmol/L seems to be a helpful threshold to trigger the timely onset of ECMO-therapy, providing better survival.

Primary Graft Dysfunction and Early Mortality in Heart Transplants from Drug Overdose Donors

Introduction Over the last two decades, there has been a 24-fold rise in solid organ donation due to drug overdose deaths. One-year survival in recipients of a heart transplant from a drug overdose donor (DOD) has been reported to be similar to that of donor deaths from trauma or other medical causes (non-DOD). However, the incidence of primary graft dysfunction (PGD) requiring mechanical circulatory support (MCS) and early post-transplant mortality in these patients has not been established. Hypothesis Heart donation from a DOD results in higher rates of PGD and early post-transplant mortality than donation from a non-DOD. Methods We performed a retrospective analysis of consecutive orthotopic heart transplants (OHT) at a single center from January 2013 to December 2018. Patients with PGD requiring MCS in the form of extracorporeal membrane oxygenation (ECMO) within 48 hours of OHT were analyzed with respect to the cause of death of the donor. Patients on ECMO prior to transplant surgery were excluded. Baseline characteristics were compared using Chi-square test for categorical variables and t-test for continuous variables. Results Of 154 consecutive heart transplants, 5 were excluded due to pre-operative recipient ECMO support. Among the 149 analyzed transplants, 38 (25.5%) received a heart from a DOD. DOD had a lower initial pH (7.15 vs. 7.28, p=0.001), a higher rate of hepatitis C infection (15.8% vs. 1.8%, p=0.001) and were more likely to have received CPR (91.7% vs.32%, p Conclusions In this single-center study, there was a trend towards an increased risk of PGD when the donor had died from a drug overdose, possibly due to ischemic graft injury related to hypoxia. However, survival to hospital discharge was similar between the DOD and non-DOD groups. Given the rapid increase in the number of DODs, further investigation in larger populations is warranted as it may help inform donor selection.

Prognostic value of the PaO2/FiO2 ratio determined at the end‐surgery stage of a double‐lung transplantation

We evaluated the prognostic role of the arterial oxygen partial pressure/fractional inspired oxygen ratio (PaO2 /FiO2 ratio) measured at the end of double-lung transplantation (DLT). This was a monocentric cohort study of all consecutive DLT patients between January 1, 2012, and January 1, 2016, except patients with preoperative extracorporeal membrane oxygenation (ECMO), intraoperative cardiopulmonary bypass, postoperative ECMO, large patent foramen ovale, redo transplantation during the study period, and multiorgan transplantation. A total of 164 patients were included in the study; 45 had a PaO2 /FiO2 ratio <200, 39 a ratio in the range 200-300, and 80 a ratio >300. The risk of being in the lower ratio group is positively related to body mass index, preoperative pulmonary hypertension, and fibrosis. It is negatively related to emergency surgery, age, and intraoperative institution of ECMO. There was a trend for more grade 3 pulmonary graft dysfunction at day 3 in the worst PaO2 /FiO2 ratio group. Mortality at 1000days was similar for all patients and even after exclusion of patients who had required intraoperative ECMO. PaO2 /FiO2 ratio measured at the end of DLT does not forecast 1000-day mortality.

Role of ECMO as Bridge to VAD Therapy in Critically Ill Pediatric Patients - An Analysis of the STS Pedimacs Database

Purpose Extra-corporeal membrane oxygenation (ECMO) as bridge to ventricular assist device (EB-VAD) therapy is frequently used for initial resuscitation of critically ill pediatric patients (INTERMACS 1 & 2). Data regarding outcomes with this strategy is limited. Methods INTERMACS 1 & 2 patients enrolled in Pediatric Interagency Registry for Mechanical Circulatory Support (PEDIMACS) between September 19th, 2012 & December 31st, 2017 constituted the study group. Of 370 patients, 271 received primary VAD (P-VAD) implantation & EB-VAD was utilized in 99 patients. Patient characteristics, durable VAD outcomes & time to first adverse event with & without preoperative ECMO bridge were compared. Sub-analysis of INTERMACS 1 patients was conducted. Results Lower age (p=0.0001) & critical cardiogenic shock(p tube feeding , mechanical ventilation & paralytics (p Conclusion In INTERMACS 1 & 2 patients EB-VAD strategy is associated with poor early & late post-implant survival. Within INTERMACS 1 early survival is comparable with both strategies. EB-VAD could potentially benefit high risk INTERMACS 1 patients

Hybrid Palliation: Outcomes After the Comprehensive Stage 2 Procedure

The comprehensive stage 2 procedure (CS2) follows initial hybrid stage 1 palliation for patients with single-ventricle physiology. The goal of this study was to describe CS2 outcomes and differences between survivors of CS2 (s-CS2) and nonsurvivors (nons-CS2). All patients in The Society of Thoracic Surgeons Congenital Heart Surgery Database who underwent CS2 as index operation from 2010 to 2016 were included. Preoperative, operative, and postoperative data were analyzed, stratified by operative mortality (in-hospital or within 30 days of the operation), with univariate comparisons using χ2, Fisher exact, or Wilcoxon rank sum tests. Of 209 patients (49 centers) who met inclusion criteria, 141 patients had the diagnosis of hypoplastic left heart syndrome. Overall operative mortality was 12.4% (26 of 209). s-CS2 had a lower prevalence of preoperative extracorporeal membrane oxygenation use (0.0% vs 7.7%, p= 0.02) and less frequently underwent concomitant tricuspid valve procedures at the time of the operation (1.1% vs 11.5%, p= 0.01) than nons-CS2. Postoperatively, the prevalence of any of six The Society of Thoracic Surgeons Congenital Heart Surgery Database major complications was higher in nons-CS2 than in s-CS2 (53.9% vs 23.0%, p < 0.01), including a higher prevalence of renal failure (7.7% vs 0.6%, p= 0.04) and postoperative extracorporeal membrane oxygenation use (46.2% vs 2.7%, p < 0.01). There were no other preoperative, operative, or postoperative differences between the two groups. Operative mortality associated with the CS2 procedure is substantial, especially for patients receiving extracorporeal membrane oxygenation support after CS2. No obvious modifiable variables were noted between patients who died and those who survived.

Outcomes of perioperative extracorporeal membrane oxygenation use in patients undergoing lung transplantation.

The aim of this single-center study is to review the transplant outcomes of patients receiving lung transplantation (LTx) using intraoperative extracorporeal membrane oxygenation (ECMO) according to the perioperative use of ECMO. We retrospectively reviewed the transplant outcomes of 107 consecutive patients who underwent LTx using intraoperative ECMO between March 2013 and August 2016 at Severance Hospital of Yonsei University (Seoul, Korea). Patients were divided into the following three groups according to the use of perioperative ECMO: only intraoperative ECMO (n=47) or extended post-operative ECMO but no bridging and no postoperative ECMO re-implantation (secondary ECMO; n=28) as Group A (n=75); bridging ECMO without secondary ECMO (n=14) as Group B; and secondary ECMO with (n=7) or without (n=11) bridging as Group C. Baseline demographics were comparable among the three groups. The mean duration of preoperative ECMO bridging was 16.4±15.6 (n=21). After a median of 17.7 months (range, 3.1-40.9 months) for survivors, the one year overall survival (OS) rates after LTx for the three groups were 76.3%±5.2% for Group A, 59.9%±14.3% for Group B, and 14.0%±9.0% for Group C (P<0.0001). The secondary ECMO (Group C) was established a mean of 7.9±5.3 days after LTx. The main cause of secondary ECMO was acute respiratory failure from pneumonia, and the main cause of death was infection-related events. Our data suggests that the use of perioperative ECMO, including its extended postoperative use during LTx, is feasible and has favorable outcomes. However, as shown by the poor survival outcome after secondary ECMO, the development of solid strategy to reduce the need for secondary ECMO implantation after LTx seems important.

Risk Factor Analysis for Intraoperative Extracorporeal Membrane Oxygenation Weaning Failure After Lung Transplantation

Extracorporeal membrane oxygenation (ECMO) has been widely used for hemodynamic support during lung transplantation (LTx). We evaluated the risk factors associated with failure of weaning from ECMO in the operating room during LTx. We retrospectively reviewed 74 consecutive patients who had undergone LTx from March 2013 to February 2016. Patients who underwent single LTx, multiorgan transplantation, and LTx for pulmonary hypertension were excluded. All operations were performed under ECMO support. Clinical data of donor, recipient, and intraoperative parameters were reviewed. Younger donors (40 ± 11 versus 45 ± 10 years, p= 0.047), donors with shorter mechanical ventilation (125 ± 74 versus 160 ± 80 minutes, p= 0.066) and donors with higher Pao2 at 100% oxygen (455 ± 87 mm Hg versus 399 ± 88 mm Hg, p= 0.008) were significantly different in the ECMO weaning group than in the weaning failure group. Of the recipients, the number of patients who had preoperative ECMO support were significantly fewer in the successful weaning group than in the weaning failure group (11.9% versus 34.4%, p= 0.061). The operation time was significantly shorter in the weaning group than in the weaning failure group (392 ± 66 versus 435 ± 82 minutes, p= 0.014). In multivariate logistic regression analysis, the independent risk factors for ECMO weaning were donor age (odds ratio 1.101, 95% confidence interval: 1.030 to 1.177, p= 0.005), donor Pao2 (odds ratio 0.992, 95% confidence interval: 0.984 to 0.999, p= 0.034), and operation time (odds ratio 1.010, 95% confidence interval: 1.000 to 1.019, p= 0.043). Our results showed that younger donor age, high Pao2, and shorter operation time were factors related to successful ECMO weaning in the operating room after LTx.

Early Right Ventricular Assist Device Use in Patients Undergoing Continuous-Flow Left Ventricular Assist Device Implantation: Incidence and Risk Factors From the Interagency Registry for Mechanically Assisted Circulatory Support.

To investigate preimplant risk factors associated with early right ventricular assist device (RVAD) use in patients undergoing continuous-flow left ventricular assist device (LVAD) surgery. Patients in the Interagency Registry for Mechanically Assisted Circulatory Support who underwent primary continuous-flow-LVAD surgery were examined for concurrent or subsequent RVAD implantation within 14 days of LVAD. Risk factors for RVAD implantation and the combined end point of RVAD or death within 14 days of LVAD were assessed with stepwise logistic regression. We compared survival between patients with and without RVAD using Kaplan-Meier method and Cox proportional hazards modeling. Of 9976 patients undergoing continuous-flow-LVAD implantation, 386 patients (3.9%) required an RVAD within 14 days of LVAD surgery. Preimplant characteristics associated with RVAD use included interagency registry for mechanically assisted circulatory support patient profiles 1 and 2, the need for preoperative extracorporeal membrane oxygenation or renal replacement therapy, severe preimplant tricuspid regurgitation, history of cardiac surgery, and concomitant procedures other than tricuspid valve repair at the time of LVAD. Hemodynamic determinants included elevated right atrial pressure, reduced pulmonary artery pulse pressure, and reduced stroke volume. The final model demonstrated good performance for both RVAD implant (area under the curve, 0.78) and the combined end point of RVAD or death within 14 days (area under the curve, 0.73). Compared with patients receiving an isolated LVAD, patients requiring RVAD had decreased 1- and 6-month survival: 78.1% versus 95.8% and 63.6% versus 87.9%, respectively (P<0.0001 for both). The need for RVAD implantation after LVAD is associated with indices of global illness severity, markers of end-organ dysfunction, and profiles of hemodynamic instability.

Perioperative factors associated with 1-year mortality after lung transplantation: a single-center experience in Korea.

Most studies about the risk factors of 1-year mortality after lung transplantation were performed on non-Asians. This study aimed to evaluate the perioperative factors related to the 1-year mortality after lung transplantation in Korea. Sixty-eight consecutive patients who underwent lung transplantation without preoperative extracorporeal membrane oxygenation treatment at 1 tertiary hospital in South Korea between October 24, 2012, and October 16, 2015, were analyzed retrospectively. Forty-four patients (64.7%) lived for >1 year after lung transplantation. The median age of all patients was 55 years (range, 16-75 years), and men accounted for 57.4%. The major cause of lung transplantation was idiopathic pulmonary fibrosis (48.5%); the other causes were interstitial lung disease related to connective tissue disease (17.6%) and bronchiolitis obliterans after stem cell transplantation (14.7%). In univariate analysis, higher median age (52 vs. 61.5 years, P<0.001), male sex (45.5% vs. 79.2%, P=0.007), lower preoperative albumin level (<3 g/dL) (22.7% vs. 45.8%, P=0.049), need for renal replacement therapy (RRT) after surgery (4.5% vs. 37.5%, P=0.001), and postoperative delta neutrophil index (DNI) >5.5 higher than the preoperative DNI (22.7% vs. 70.8%, P<0.001) were significantly related to 1-year mortality. After adjustments, old age, postoperative increased DNI, and need for RRT after transplantation were the independent perioperative risk factors for 1-year mortality after lung transplantation. Recipients with advanced age should be carefully selected, and patients who need RRT or with increased DNI after transplantation should be managed accordingly.

Postinfarction left ventricular free wall rupture: a 17-year single-centre experience.

Left ventricular free wall rupture (LVFWR) is a catastrophic complication following acute myocardial infarction with an estimated incidence of 0.2-7.6% and mortality can be as high as 60%. This study aimed to identify the risk factors for morbidity and mortality in patients affected by LVFWR. This is a retrospective study of 35 patients who underwent surgery for LVFWR between January 2000 and December 2016 at our institution. The mean age of patients was 68.3 years. The in-hospital survival was 65.7% (n = 23), and 13% of survived patients presented with cardiac arrest. The following characteristics were associated with in-hospital mortality at univariable analysis: pre-existing hypertension (P = 0.02), need for inotropes (P = 0.02) and cardiac arrest (P < 0.0001) at presentation, cardiopulmonary resuscitation (P = 0.004), preoperative extracorporeal membrane oxygenation (P = 0.004), technique of LVFWR repair (P = 0.013), operation on extracorporeal membrane oxygenation (P = 0.005) and postoperative extracorporeal membrane oxygenation (P = 0.001). In the multivariable analysis, cardiac arrest at presentation was an independent predictor of in-hospital mortality (odds ratio 11.7, 95% confidence interval 2.352-59.063; P = 0.003). The overall mean postoperative follow-up was 8.3 ± 1.3 years. Overall survival rates at 5 and 10 years were 53.2 ± 8.6% and 49.1 ± 8.9%, respectively. Among the survivors, only 6 (26.1%) patients died during follow-up with a 5-year and 10-year overall survival rate of 80.9 ± 8.7% and 74.7 ± 10%, respectively. These data suggest a trend towards long-term benefit in patients surviving high-risk surgery for LVFWR repair. Considering the high lethality of LVFWR, the urgency and complexity of the primary surgical intervention early diagnosis and prompt surgery play a key role in the management of this complication.

125 Outcome of patients with lung re-transplantation requiring preoperative extracorporeal membrane oxygenation

125 Outcome of patients with lung re-transplantation requiring preoperative extracorporeal membrane oxygenation

Examining Mortality and Rejection in Combined Heart-Lung Transplantations.

Background There is a paucity of data on outcomes related to combined heart-lung transplantations (HLTs). Our objective was to identify variables associated with mortality and rejection in HLT. Methods The United Network for Organ Sharing database was reviewed for HLT performed between 1993 and 2008. Long-term survivors (survival > 5 years) were compared with short-term survivors (survival < 5 years). Factors associated with rejection were examined. Risk-adjusted multivariable Cox's proportional hazards regression analysis was performed to examine variables associated with mortality and rejection. Results Multivariable analysis revealed that recipient male gender was associated with mortality at 1 year (hazard ratio [HR]: 1.68, 95% confidence interval [CI]: 1.11-2.54, p = 0.01) and 5 years (HR: 1.41, 95% CI: 1.05-1.89, p = 0.02). Preoperative extracorporeal membrane oxygenation (ECMO) was associated with mortality at 1 year (HR: 7.55, 95% CI: 2.55-22.30, p < 0.01) and 5 years (HR: 3.14, 95% CI: 1.19-8.32, p = 0.02). Preoperative mechanical ventilation (MV) was associated with mortality at 1 year (HR: 3.51, 95% CI: 1.77-6.98, p < 0.01) and at 5 years (HR: 2.70, 95% CI: 1.51-4.85, p < 0.01). Multivariable analysis showed that male gender (HR: 1.78, 95% CI: 1.03-3.09, p = 0.04) and cytomegalovirus (CMV) positivity in the recipient and donor (HR: 3.09, 95% CI: 1.59-6.01, p < 0.01) were associated with rejection. Clinical infection in the donor (HR: 2.05, 95% CI: 1.16-3.61, p = 0.01) was also associated with rejection. Conclusion Survival was affected by recipient male sex and need for preoperative ECMO or MV. Risk factors for rejection included male sex, CMV positivity in the donor and recipient, and donor with clinical infection.

Impact of cardiac arrest resuscitated donors on heart transplant recipients' outcome

ObjectiveTo evaluate the influence of cardiac arrest−resuscitated donors (CARDs) on the outcome of heart recipients. MethodsPatients transplanted between July 2004 and December 2012 were divided into 2 groups according to the history of cardiac arrest in donors and their clinical records were retrospectively reviewed. ResultsA total of 584 heart transplantations were performed during the study period, and 117 recipients received an organ from a CARD. There were no differences between the 2 groups with regards to recipient age, sex, cardiomyopathy, preoperative extracorporeal membrane oxygenation, national high emergency waiting list, and redo surgery. Donors who sustained a cardiac arrest were significantly younger (44 [32-51] vs 49 [41-56] years; P < .001), their main cause of death was anoxia (57% vs 1%; P < .001), and they had significantly greater troponin T peak levels (0.51 [0.128-3.108] vs 0.11 [0.04-0.43] ng/mL; P < .001). Median cardiac arrest duration was 15 minutes (5-25). No difference was noted in donors with regards to left ventricular ejection fraction at time of organ procurement (62% ± 8% vs 63% ± 8%; P = .2). There were no differences between the 2 groups with regards to ischemic time (179 ± 60 vs 183 ± 59 minutes; P = .43), need for postoperative extracorporeal membrane oxygenation for primary graft failure (31% vs 30%; P = .993) and 30-days mortality. Recipients receiving an organ from a CARD had a significantly better 10 year survival (69.4% vs 50.4%; P = .017). ConclusionsHistory of cardiac arrest in donors with a preserved left ventricular ejection fraction at time of organ procurement doesn't affect outcome of heart recipients.

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.

Delayed Sternal Closure After Continuous Flow Left Ventricle Assist Device Implantation: Analysis of Risk Factors and Impact on Outcomes and Costs.

Patient and institutional factors predictive of delayed sternal closure (DSC) practice and its impact on clinical and cost outcomes when compared with primary sternal closure (PSC) following continuous-flow left ventricular assist device (CF-LVAD) implantation were examined. Statewide Society of Thoracic Surgeons and hospital cost data on CF-LVADs implanted were analyzed. Between January 2007 and December 2013, 558 CF-LVADs were implanted (PSC = 464, 83.2%; DSC = 94, 16.8%). Among the six institutions implanting CF-LVADs, DSC practice ranged from 3.1% to 37.8%. Compared with PSC, the DSC group had higher body mass index (BMI), renal failure, anemia, IIb/IIIa inhibitor use, emergency surgery, and extracorporeal membrane oxygenation (ECMO) support. Delayed sternal closure patients had significantly longer bypass time (139 ± 63 min vs. 107.6 ± 42 min) and higher use of intraoperative blood products (82% vs. 69%) and right ventricular assist device (RVAD) support (4.3% vs. 0.2%). Postoperative morbidities and mortality (23.4% vs. 6.5%; p ≤ 0.0001) were higher in the DSC group compared with PSC. Mean hospital costs for DSC were higher than PSC ($249,144 ± 123,273 vs. $155,915 ± 95,032; p ≤ 0.0001). Multivariate predictors of DSC include institution with higher DSC practice, preoperative ECMO support, use of IIb/IIIa inhibitors, tricuspid valve surgery, and intraoperative red blood cell transfusion. Delayed sternal closure was an independent risk factor for postoperative mortality, odds ratio 3.0 (1.2-7.2).

Veno-Arterial ECMO in the Setting of Post-Infarct Ventricular Septal Defect: A Bridge to Surgical Repair.

Extracorporeal membrane oxygenation (ECMO) is a complex rescue therapy utilised to provide circulatory and/or respiratory support to critically ill patients who have failed maximal conventional therapy. The use of ECMO in adult cardiac surgery is not routine, occurring in a minority of critically ill patients, typically postoperatively. Presented here are three cases of post-infarct ventricular septal defect with cardiogenic shock managed preoperatively with ECMO support as a bridge to definitive surgical closure. We present a review of ECMO in the adult cardiac surgical population and highlight the potential role of preoperative ECMO for cardiogenic shock in the setting of post-infarct ventricular septal defect (PI VSD) as a bridge to definitive closure.

Impact of preoperative extracorporeal membrane oxygenation on vasoactive inotrope score after implantation of left ventricular assist device.

The purpose of this study was to elucidate the difference in inotrope use between patients who underwent left ventricular assist device (LVAD) implantation with preoperative extracorporeal membrane oxygenation (ECMO) and those who underwent LVAD implantation without preoperative ECMO. One hundred and eight patients who underwent LVAD implantation were enrolled in this study. Prior to LVAD implantation, 27 patients received ECMO support (ECMO group) and the other 81 patients did not (non-ECMO group). Cardiac index (CI), mean arterial pressure (MAP), mixed venous oxygen saturation (SvO2), and the vasoactive inotropic score (VIS) were recorded at weaning from cardiopulmonary bypass (CPB), 30 min after weaning from CPB (min after CPB), 60 min after CPB, and at the end of surgery. MAP and VIS were also recorded before induction of anesthesia (baseline). The modified VIS was defined as: (dopamine µg/kg/min × 1 + dobutamine µg/kg/min × 1 + epinephrine µg/kg/min × 100 + noradrenaline µg/kg/min × 100 + milrinone µg/kg/min × 10 + olprinone µg/kg/min × 25). There were no significant differences between the ECMO group and the non-ECMO group in terms of hemodynamic parameters such as MAP, CI, and SvO2. However, the ECMO group had higher VIS and noradrenaline doses than that of non-ECMO group (p = 0.030 and p = 0.044, respectively). VIS was significantly higher in ECMO group at 30 min after CPB (p = 0.03), 60 min after CPB (p = 0.003), and at the end of the surgery (p < 0.001). The doses of noradrenaline were significantly higher in ECMO group at 60 min after CPB (p = 0.013), and at the end of surgery (p = 0.002). Patients who received ECMO support prior to LVAD implantation required significantly more noradrenaline to maintain normal levels of hemodynamic parameters compared with patients without ECMO.

Perioperative Risk Factors associated with Immediate Postoperative Extracorporeal Membrane Oxygenation in Lung Transplants

Background: Extracorporeal membrane oxygenation (ECMO) is administered for a few days after lung transplantation (LTx) in recipients who are expected to have early graft dysfunction. Despite its life-saving potential, immediate postoperative ECMO has lifethreatening complications such as postoperative bleeding. We investigated the risk factors related to the use of immediate postoperative ECMO. Methods: We retrospectively reviewed the records of 60 LTx patients who were at our institution from October 2012 to May 2015. Perioperative variables associated with postoperative ECMO were compared between the two groups. Results: There were 26 patients who received postoperative ECMO (ECMO group) and 34 patients who did not (control group). Multivariate regression analysis revealed preoperative ECMO (odds ratio [OR] 12.55, 95% confidence intervals [CI] 1.34 – 117.24, p = 0.027) and lower peripheral pulse oxymetry saturation (SpO2) at the end of surgery (OR 0.71, 95% CI 0.54 – 0.95, p = 0.019) were independent risk factors for postoperative ECMO in LTx patients. The incidences of complications, such as re-operation, tracheostomy, renal failure and postoperative atrial fibrillation, were higher in the ECMO group. There was no difference in the duration of postoperative intensive care unit stay or postoperative 30-day mortality between the two groups. Conclusions: The preoperative ECMO and lower SpO2 at the end of surgery were associated with postoperative ECMO. Further, postoperative adverse events were higher in the ECMO group compared with the control group. This study suggests that determination of postoperative ECMO requires careful consideration because of the risks of postoperative ECMO in LTx patients.

Five-year experience with intraoperative extracorporeal membrane oxygenation in lung transplantation: Indications and midterm results

Since April 2010, extracorporeal membrane oxygenation (ECMO) has replaced cardiopulmonary bypass for intraoperative support during lung transplantation at our institution. The aim of this study was to present our 5-year experience with this technique. Records of patients who underwent transplantation between April 2010 and January 2015 were retrospectively reviewed. Patients who underwent transplantation without ECMO formed Group A. Patients in whom the indication for ECMO support was set a priori before the beginning of the operation formed Group B. The remaining patients in whom the indication for ECMO support was set during transplantation formed Group C. Among 595 patients, 425 (71%) patients (Group A) did not require intraoperative ECMO; the remaining 170 (29%) patients did. Among these patients, 95 (56%) patients formed Group B, and the remaining 75 (44%) patients comprised Group C. Pulmonary fibrosis and pre-operative dilated or hypertrophied right ventricle emerged as risk factors for the indication of non-a priori intraoperative ECMO. Patients in Groups B and C showed a higher pre-operative risk profile and higher prevalence of post-operative complications than patients in Group A. Overall survival at 1 year was 93%, 83%, and 82% and at 4 years was 73%, 68%, and 69% in Groups A, B, and C (p = 0.11). The intraoperative use of ECMO did not emerge as a risk factor for in-hospital mortality or mortality after hospital discharge. Intraoperative ECMO filled the gap between pre-operative and post-operative ECMO in lung transplantation. Although complications and in-hospital mortality were higher in patients who received ECMO, survival was similar among patients who underwent transplantation with or without ECMO.

Prenatal diagnosis of transposition of the great arteries over a 20-year period: improved but imperfect.

To evaluate temporal trends in the prenatal diagnosis of transposition of the great arteries with intact ventricular septum (TGA/IVS) and its impact on neonatal morbidity and mortality. We included in this study cohort newborns with TGA/IVS who were referred for surgical management to our center over a 20-year period (1992-2011). The study period was divided into five 4-year periods and the primary outcome was rate of prenatal diagnosis. Secondary outcomes included neonatal preoperative status and perioperative survival. Of the 340 patients with TGA/IVS, 81 (23.8%) had a prenatal diagnosis. The rate of prenatal diagnosis increased over the study period, from 6% in 1992-1995 to 41% in 2008-2011 (P < 0.001). Compared to patients with a postnatal diagnosis, balloon atrial septostomy (BAS) was performed earlier in patients with a prenatal diagnosis (0 days after delivery vs 1 day after delivery, respectively; P < 0.001) and fewer prenatally diagnosed neonates required mechanical ventilation (55.6% vs 68.0%; P = 0.03). Between patients with a prenatal or postnatal diagnosis of TGA/IVS, there were no statistically significant differences in the incidence of preoperative acidosis (16.0% vs 25.5%; P = 0.1), need for preoperative extracorporeal membrane oxygenation (2.5% vs 2.7%; P = 1.0) or mortality (one preoperative and no postoperative deaths among prenatally diagnosed patients compared with four preoperative and six postoperative deaths among postnatally diagnosed patients). The prenatal detection rate of TGA/IVS has improved but still remains below 50%, suggesting the need for strategies to increase detection rates. The mortality rate was not statistically significantly different between prenatally and postnatally diagnosed patients, however, there were significant preoperative differences with regard to earlier BAS and fewer neonates that required mechanical ventilation. Ongoing work is required to ascertain whether prenatal diagnosis confers long-term benefits.