Prophylactic Extracorporeal Membrane Oxygenation Research Articles

Extracorporeal Membrane Oxygenation-Supported Patient Outcome Undergoing Transcatheter Aortic Valve Replacement.

The efficacy and safety of extracorporeal membrane oxygenation (ECMO) support during transcatheter aortic valve replacement (TAVR) remains unknown. We conducted a meta-analysis to compare benefit and risk of ECMO in TAVR patients. Bibliographic databases were searched from inception to January 1, 2024. Included studies involved patients ≥18 years old undergoing TAVR and using ECMO emergently or prophylactically. Mortality and procedure success were primary outcomes. Peri- or postoperative complications were the secondary outcomes. We identified 11 observational studies, including 2,275 participants (415 ECMO and 1,860 non-ECMO). The unadjusted mortality risk in ECMO-supported patient was higher than non-ECMO patients (odds ratio [OR] 1.73). The mortality unadjusted risk remained high (OR 3.89) and statistically significant for prophylactic ECMO. Prophylactic ECMO had lower mortality risk compared with emergent ECMO (OR 0.17). Extracorporeal membrane oxygenation-supported patients had lower procedural success rate (OR 0.10). Extracorporeal membrane oxygenation patients undergoing TAVR had significantly increased risk of bleeding (OR 3.32), renal failure (OR 2.38), postoperative myocardial infarction (OR 1.89), and stroke (OR 2.32) compared with non-ECMO patients. Clinical results are not improved by ECMO support in patients with high-risk TAVR. Prophylactic ECMO outperforms emergent. Overall, ECMO support increases mortality and postoperative complications. Transcatheter aortic valve replacement outcomes may improve with prophylactic ECMO in high-risk situations.

Successful implementation of prophylactic veno-venoarterial extracorporeal membrane oxygenation in high-risk trauma surgery: A case report.

Extracorporeal Membrane Oxygenation (ECMO) is increasingly utilized in trauma care, yet its elective use during high-risk surgeries remains unreported. We report a successful instance of prophylactic ECMO support via a Veno-Venoarterial (V-VA) configuration during high-risk surgery in a patient with extensive trauma, including severe thoracic damage and a highly unstable thoracic spine fracture. V-VA ECMO prevented complications such as hemodynamic and respiratory collapse associated with chest compression during the surgical procedure, as the patient should be in a prone position. The potential of ECMO as prophylactic support in high-risk surgery amongst trauma patients underscores a novel application of this technology. Complex configurations must be evaluated to avoid associated ECMO complications. Our case highlights the potential of prophylactic ECMO hybrid modes, indicating their safe application during high-risk procedures in select trauma patients.

Unplanned Intraoperative ECMO Support during Double Lung Transplantation: Risk-Factors and Outcome Analysis

Purpose The extracorporeal membrane oxygenation (ECMO) is a technical option to support cardiorespiratory function during double lung transplantation (DLT). To date, intraoperative ECMO support during DLT seems to give excellent results when planned and used prophylactically, on the other hand the need to use an emergency unplanned ECMO support seems to increase significantly the postoperative morbidity and mortality. The primary endpoint of our study was to search for any factors that could significantly influence the risk of unplanned intraoperative ECMO support. The perioperative and one-year outcome analysis of patients who underwent unplanned ECMO were the secondary endpoints. Methods Records of 95 patients who underwent DLT at our institution between January 2016 and December 2019 were retrospectively reviewed. Patients who underwent lung transplantation with elective intraoperative cardio-circulatory support were excluded from the study. Patients who underwent DLT with unplanned intraoperative ECMO (50 patients, Group A) were compared with no ECMO patients (45 patients, Group B). Results Group A patients showed more preoperative pulmonary artery hypertension (PAH), NYHA class>3, low cardiac-index, higher lactate and dose of inotropes during anesthesia induction. Group A more frequently received donors with higher PCO2 and with cerebral ischemic or hemorrhagic cause of death. After regression analyses PAH (OR7.42), PaCO2 of donors (OR6.29) were the major risk factors for unplanned ECMO. The postoperative period was more complicated for patients requiring intraoperative ECMO. The failure to wean from ECMO at the end of surgery further increase the risk of post-operative morbidity (OR8.43) and mortality (OR4.21). Group A showed a higher in-hospital mortality (24%vs7%, p Conclusion The PAH and a higher PaCO2 of the donor were risk factors for unplanned ECMO. These results support the hypothesis that resolving critical intraoperative events by an unplanned ECMO does allow the intervention to be completed but then is reflected in a worse outcome, in particular after weaning failure at the end of surgery. Identifying a preoperative risk profile could be useful to use prophylactic ECMO and thus avoid the establishment of critical intraoperative events.

In-Hospital and Mid-Term Outcomes of ECMO Support During Coronary, Structural, or Combined Percutaneous Cardiac Intervention in High-Risk Patients – A Single-Center Experience

IntroductionEvidence regarding the impact of prophylactic implantation of Extracorporeal Membrane Oxygenation (ECMO) during coronary or structural procedures is limited. The purpose of this paper is to evaluate the in-hospital and medium term outcomes of ECMO support in complex percutaneous coronary or structural intervention. MethodsThe present is an observational prospective study including consecutive patients who underwent to prophylactic ECMO implantation for percutaneous coronary intervention (PCI), structural or combined interventions between July 2018 and July 2020 in Maria Pia Hospital GVM Care & Research, Turin, Italy. Primary endpoints were in-hospital and medium term all-cause death. Secondary endpoints were vascular complication, bleeding and procedural success. Results27 patients were included with a mean age of 80 ± 6 years, 10 (37%) being diabetics and 19 (70%) with severe left ventricle dysfunction. Mean Logistic Euroscore was 28.7 ± 18.7. Seven patients (26%) underwent complex coronary revascularization, 7 (26%) combined PCI + TAVI, 5 (19%) combined PCI + Mitraclip, 5 (19%) TAVI alone and finally 3 (11%) combined TAVI + Mitraclip. The procedural success was 96%, with only one in-hospital death due to major vascular complication at the ECMO vascular access. At a mean follow-up of 11 ± 6.8 months 4 deaths were recorded (3 from not cardiovascular causes). ConclusionsProphylactic use of ECMO may be beneficial for high risk patients undergoing complex combined coronary/structural percutaneous interventions with good in-hospital and mid-term outcomes in term of safety and procedural success.

Protected complex percutaneous coronary intervention and transcatheter aortic valve replacement using extracorporeal membrane oxygenation in a high-risk frail patient: a case report

BackgroundTranscatheter aortic valve replacement has become a routine procedure for patients with severe symptomatic aortic stenosis at increased surgical risk. Not much is known about using prophylactic support with venoarterial extracorporeal membrane oxygenation in patients undergoing transcatheter aortic valve replacement and eventually concomitant complex percutaneous coronary intervention.Case presentationWe present a successful procedure of transcatheter aortic valve replacement and high-risk percutaneous coronary intervention utilizing venoarterial extracorporeal membrane oxygenation for hemodynamic support in a very frail 88-year-old Caucasian woman with severe symptomatic aortic stenosis and coronary bypass grafting in the past.Echocardiography revealed a “low-flow low-gradient” aortic stenosis (mean transvalvular gradient 30 mmHg, aortic valve area 0.4 cm2, significant calcification), a left ventricular ejection fraction of 35%, severe mitral regurgitation with moderate stenosis (mean transvalvular gradient 7 mmHg), with a systolic pulmonary artery pressure of 80 mmHg. Moreover, pre-interventional coronary angiography exposed a severe left main ostial stenosis and sequential subtotal heavily calcified stenosis of the left anterior descending artery . Computed tomographic angiography showed no heavy tortuosity but moderate calcification of the iliofemoral arteries.The procedure was performed under general anesthesia in our hybrid operating room. Extracorporeal membrane oxygenation was established by left femoral percutaneous cannulation using a 21-Fr venous and 15-Fr arterial cannula. Subsequently, complex percutaneous coronary intervention with implantation of two drug-eluting stents from the left main into the left anterior descending artery was performed via a right femoral arterial 7F sheath. Thereafter, a 23-mm Sapien 3 aortic valve prosthesis (Edwards, Irvine, CA, USA) was implanted via right femoral artery in the usual manner, whereby the arterial pigtail catheter for marking the aortic annulus during transcatheter aortic valve replacement was inserted over a Check-Flo® Hemostasis Assembly (Cook Medical, Bloomington, IN, USA) on a Y-adapter via the arterial extracorporeal membrane oxygenation cannula. After extracorporeal membrane oxygenation decannulation, vascular closure was easily performed using the MANTA vascular closure device in order to reduce procedural time and risk of access site complications.ConclusionsIn summary, we demonstrate the feasibility of elective prophylactic extracorporeal membrane oxygenation implementation in selected very high-risk and frail patients undergoing transcatheter aortic valve replacement and percutaneous coronary intervention in order to avoid intraprocedural complications.

Outcomes of patients requiring extracorporeal membrane oxygenation in transcatheter aortic valve implantation: a clinical case series.

Transcatheter aortic valve implantation (TAVI) has been established as a low-invasive therapy for aortic stenosis, but circulatory collapse necessitating mechanical circulatory support could occur during TAVI due to procedure itself or procedural complications. The purpose of this study is to describe the outcomes of patients requiring extracorporeal membrane oxygenation (ECMO) in TAVI. Among 384 consecutive patients undergoing TAVI from April 2010 to July 2017 in Sakakibara Heart Institute, we evaluated seven patients (1.8%) who required ECMO during procedure. The definitions of outcome were derived from Valve Academic Research Consortium-2 criteria. The indication of ECMO included bridge to emergent surgery due to mechanical complication (n = 3) [aortic root rupture (n = 2), and left-ventricle rupture (n = 1); emergent use], bridge to recovery from cardiac stunning (n = 3; emergent use), and circulatory support for cardiogenic shock (n = 1; prophylactic use). All patients were cannulated from femoral artery and vein, and there was no ECMO-related complication. Six out of seven patients were weaned from ECMO during the TAVI procedure, whereas the other patient with annulus rupture died the following day after TAVI. Five patients survived to discharge [postoperative hospital stay: 27.6 ± 24.3 (23) days]. During mean follow-up of 253days, a total of three patients died due to annulus rupture, refractory heart failure, and pneumonia, respectively. ECMO is effective and a safe mechanical support device during TAVI. The mid-term outcomes of patients who needed ECMO were unfavorable. Further evolution of transcatheter heart valve is essential, and prophylactic ECMO may contribute to better prognosis in selected patients.

Extracorporeal membrane oxygenation in transcatheter aortic valve replacement.

Background Patients undergoing transcatheter aortic valve replacement can experience severe perioperative complications leading to hemodynamic instability and death. Venoarterial extracorporeal membrane oxygenation can be used to provide cardiorespiratory support during this time. Methods From 2012 to 2015, of 247 patients who underwent transcatheter aortic valve replacement, 6 (2.42%) required extracorporeal membrane oxygenation support. Their mean age was 82 ± 7.4 years, mean Society of Thoracic Surgeons score was 9.4 ± 6.6, and mean aortic gradient was 28.3 ± 12 mm Hg. Rescue extracorporeal membrane oxygenation was required for hemodynamic instability due to ventricular fibrillation ( n = 1), respiratory failure ( n = 1), left ventricular wall rupture ( n = 2), and aortic annulus rupture ( n = 1). In one patient, prophylactic extracorporeal membrane oxygenation was required due to advanced heart failure. Additional procedures included valve-in-valve implantation ( n = 1), conversion to an open procedure ( n = 3), and intraaortic balloon pump insertion ( n = 1). Results The median hospital stay was 20 days. There were 2 hospital deaths in patients whose hospital course was complicated by left ventricular wall rupture or aortic annulus rupture with resulting tamponade. Among the 4 survivors, one required continuous ventilator support following discharge, and 3 experienced no major complications during the first month after discharge. Conclusions Extracorporeal membrane oxygenation can be considered a viable option for high-risk patients undergoing transcatheter aortic valve replacement and those who develop cardiac complications following this procedure and require cardiorespiratory support.

Extracorporeal membrane oxygenation for very high-risk transcatheter aortic valve implantation

Introduction: Transcatheter aortic valve implantation (TAVI) can cause profound haemodynamic perturbation in the peri-operative period. Veno-arterial extracorporeal membrane oxygenation (ECMO) can be used to provide cardiorespiratory support during this time, either prophylactically or emergently. Methods: 100 TAVI procedures were performed between 2009 and 2013 in our institution. ECMO was used in 11 patients, including 8 prophylactic and 3 rescue cases. Rescue ECMO was required for ventricular fibrillation after valvuloplasty, and aortic annulus rupture. The criteria for prophylactic ECMO included heart failure requiring stabilisation pre-TAVI, haemodynamic instability with balloon aortic valvuloplasty performed to improve heart function pre-TAVI, moderate or severe left and/or right ventricular failure, or borderline haemodynamics at procedure. Differences in preoperative characteristics and postoperative outcomes between ECMO and non-ECMO TAVI patients were compared, and significant results were further assessed controlling for EuroSCORE. Results: Compared to TAVI patients who did not require ECMO, ECMO patients had significantly higher mean EuroSCORE (51 vs. 30%, p<.05). All-cause mortality occurred in nil prophylactic ECMO patients, one rescue ECMO patient, and two non-ECMO patients. The difference in mortality between ECMO and non-ECMO patients was not significantly different (9 vs. 2%; p>.05). Other non-significant outcomes (p<.05) included peri-procedural and spontaneous myocardial infarction (0 vs. 2% and 0 vs. 0%, respectively); disabling and non-disabling stroke (0 vs. 0% and 0 vs. 2%, respectively); transient ischaemic attack (0 vs. 0%); life-threatening, major and minor bleeding (12 vs. 3%, 0 vs. 12% and 38 vs. 13%, respectively); and major and minor vascular complications (12 vs. 5% and 0 vs. 13%, respectively). ECMO patients were more likely to develop acute renal failure than non-ECMO patients (36 vs. 8%, p<.05), which was most likely due to haemodynamic collapse and end-organ dysfunction in patients that required emergent ECMO rescue. Discussion: ECMO, in both prophylactic and rescue settings, is effective at providing cardiorespiratory support in very-high risk TAVI patients, and may have contributed to the low mortality in this series. Instituting prophylactic ECMO in an elective, controlled setting may help avoid consequences of intraoperative complications such as systemic hypoperfusion and acute renal failure, compared to emergent ECMO with rapid setup and cannulation. Limitations of this study include small patient sample size and observational nature. Future studies performed in a prospective, randomised fashion are required to evaluate the use of prophylactic ECMO, and to determine the ideal selection criteria.

Extracorporeal Membrane Oxygenation for Very High-risk Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) can cause profound haemodynamic perturbation in the peri-operative period. Veno-arterial extracorporeal membrane oxygenation (ECMO) can be used to provide cardiorespiratory support during this time, either prophylactically or emergently. 100 TAVI procedures were performed between 2009 and 2013 in our institution. ECMO was used in 11 patients, including eight prophylactic and three rescue cases. Rescue ECMO was required for ventricular fibrillation after valvuloplasty, and aortic annulus rupture. The criteria for prophylactic ECMO included heart failure requiring stabilisation pre-TAVI, haemodynamic instability with balloon aortic valvuloplasty performed to improve heart function pre-TAVI, moderate or severe left and/or right ventricular failure, or borderline haemodynamics at procedure. Differences in preoperative characteristics and postoperative outcomes between ECMO and non-ECMO TAVI patients were compared, and significant results were further assessed controlling for EuroSCORE. Compared to TAVI patients who did not require ECMO, ECMO patients had significantly higher mean EuroSCORE (51 vs. 30%, p<.05). Postoperative outcomes, however, were largely comparable between the two groups. All-cause mortality occurred in nil prophylactic ECMO patients, one rescue ECMO patient, and two non-ECMO patients. The difference in mortality between ECMO and non-ECMO patients was not significantly different (9 vs. 2%; p>.05). ECMO patients were more likely to develop acute renal failure than non-ECMO patients (36 vs. 8%, p<.05), which was most likely due to haemodynamic collapse and end-organ dysfunction in patients that required ECMO rescue. Instituting prophylactic ECMO in selected very high-risk patients may help avoid consequences of intra-operative complications and the need for emergent rescue ECMO.