Use Of ECMO Research Articles

ECMO in the Burn Patient: the Time Has Come

The use of extracorporeal life support in the intensive care unit has exponentially increased in the last decade. Initially, its use in the burn population lagged behind the dramatic growth in other patient populations; however, in the last 2–3 years, there has been an increase in the number of publications related to its use in this population. In this article, we review the use of contemporary ECMO in the burn patient population and discuss future trends. Level 1 evidence for the use of ECMO in any patient population is scarce, and there is no level 1 evidence for the use of ECMO in burn patients. Recently, there has been an increase in case series and case reports describing the use of contemporary ECMO in burn patients. In addition, there are two large retrospective reviews of large registries utilizing ECMO in burn patients. The results from these studies all indicate that outcomes using ECMO in this critically ill patient population has survival rates at least comparable to the survival found in other patient populations. There are still many unanswered questions, and future focus needs to address patient selection, timing of initiation, management, and the duration of ECMO therapy.

A case report: Veno-venous extracorporeal membrane oxygenation for severe blunt thoracic trauma

IntroductionThe use of veno-venous extracorporeal membrane oxygenation (VV-ECMO) in trauma patients has been controversial, but VV-ECMO plays a crucial role when the lungs are extensively damaged and when conventional management has failed. VV-ECMO provides adequate tissue oxygenation and an opportunity for lung recovery. However, VV-ECMO remains contraindicated in patients with a risk of bleeding because of systemic anticoagulation during the treatment. The most important point is controlling the bleeding from severe trauma.CaseA 32-year-old male experienced blunt trauma due to a traffic accident. He presented with bilateral hemopneumothorax and bilateral flail chest. We performed emergency thoracotomy for active bleeding and established circulatory stability. After surgery, the oxygenation deteriorated under mechanical ventilation, so we decided to establish VV-ECMO. However, bleeding from the bilateral lung contusions increased after VV-ECMO was established, and the patient was switched to heparin-free ECMO. After conversion, we could control the bronchial bleeding, especially the lung hematomas, and the oxygenation recovered. The patient was discharged without significant complications. VV-ECMO and mechanical ventilation were stopped on days 10 and 11, respectively. He was discharged from the ICU on day 15.ConclusionWhen we consider the use of ECMO for patients with uncontrollable, severe bleeding caused by blunt trauma, it may be necessary to use a higher flow setting for heparin-free ECMO than typically used for patients without trauma to prevent thrombosis.

Transplantation of NAT+HCV Donor Lungs into Non-Infected Recipients Followed by Treatment with Sofosbuvir/Velpatasvir (S/V)

Purpose One of the most promising strategies to increase organ donation is the use of organs from donors with Hepatitis C (HCV). We evaluated the safety of transplanting NAT+HCV donors into non-infected lung recipients. Methods Between Oct 2017 and Oct 2018, NAT+HCV donors in North America were considered. Recipients consented to receive such organs under study protocol NCT03112044. Exclusion criteria included existence of liver disease or multi-organ transplant. Outcomes of study recipients were compared to patients receiving non-infected donors. Primary endpoints were survival and HCV status at 6 months after transplantation. All patients becoming viremic received S/V starting at least 2 weeks after transplantation. Results During the one-year study period 200 lung transplant procedures were performed at our center. Of these, 20 (10%) were from NAT+ HCV donors. Compared to standard donors, HCV donors were significantly younger (33y vs. 52y, p=0.002), more likely to be located in the United States vs. Canada (75% vs 5%, p=0.001), and more likely to be smokers (95% vs. 47%, p=0.0001). Donor P/F ratio (383 mmHg vs. 424 mmHg) and proportion of DCD (10% vs. 27%) were not statistically different between the 2 groups. Recipient age, lung disease, urgency status and positive donor HLA crossmatch were similar between the 2 groups. There was a significantly higher proportion of single lung transplants in the HCV group (55% vs. 15%, p=0.002). Post-transplant time on ventilation, ICU and hospital length of stay, use of ECMO and survival (100% in HCV group) were similar between the 2 groups. All patients, except 1 became viremic within 1 week after transplantation. 12 weeks treatment with S/V started at a median of 21 days after transplantation (range 14-71). All patients achieved negative HCV PCR from 2 to 6 weeks after treatment initiation. Two patients presented with HCV relapse within 3 months after S/V termination. One of the relapses was associated with alteration in liver enzymes. Conclusion Excellent intermediate-term clinical outcomes were achieved using NAT+HCV donors to non-infected recipients and this practice should continue to be encouraged. However, a higher relapse rate (10% to date) than previously reported in non-lung transplant patients was observed and novel strategies aiming at prevention of transmission should be further studied. One of the most promising strategies to increase organ donation is the use of organs from donors with Hepatitis C (HCV). We evaluated the safety of transplanting NAT+HCV donors into non-infected lung recipients. Between Oct 2017 and Oct 2018, NAT+HCV donors in North America were considered. Recipients consented to receive such organs under study protocol NCT03112044. Exclusion criteria included existence of liver disease or multi-organ transplant. Outcomes of study recipients were compared to patients receiving non-infected donors. Primary endpoints were survival and HCV status at 6 months after transplantation. All patients becoming viremic received S/V starting at least 2 weeks after transplantation. During the one-year study period 200 lung transplant procedures were performed at our center. Of these, 20 (10%) were from NAT+ HCV donors. Compared to standard donors, HCV donors were significantly younger (33y vs. 52y, p=0.002), more likely to be located in the United States vs. Canada (75% vs 5%, p=0.001), and more likely to be smokers (95% vs. 47%, p=0.0001). Donor P/F ratio (383 mmHg vs. 424 mmHg) and proportion of DCD (10% vs. 27%) were not statistically different between the 2 groups. Recipient age, lung disease, urgency status and positive donor HLA crossmatch were similar between the 2 groups. There was a significantly higher proportion of single lung transplants in the HCV group (55% vs. 15%, p=0.002). Post-transplant time on ventilation, ICU and hospital length of stay, use of ECMO and survival (100% in HCV group) were similar between the 2 groups. All patients, except 1 became viremic within 1 week after transplantation. 12 weeks treatment with S/V started at a median of 21 days after transplantation (range 14-71). All patients achieved negative HCV PCR from 2 to 6 weeks after treatment initiation. Two patients presented with HCV relapse within 3 months after S/V termination. One of the relapses was associated with alteration in liver enzymes. Excellent intermediate-term clinical outcomes were achieved using NAT+HCV donors to non-infected recipients and this practice should continue to be encouraged. However, a higher relapse rate (10% to date) than previously reported in non-lung transplant patients was observed and novel strategies aiming at prevention of transmission should be further studied.

Developing DSA Post-Lung Transplant - Identifying Risk Factors

Purpose Donor specific antibodies (DSA) to mismatched human leukocyte antigens have been reported to adversely affect the outcomes of lung transplantation. This study aimed to identify the risk factors for the development of DSA within 1-year post-transplant and examine its impact on recipients’ medium-term survival. Methods Recipients’ age, type of transplantation (single lung or bilateral lungs), pre-existing antibodies, post-op DSA, method of transplantation (ECMO, off-pump or on-pump), primary graft failure (PGD) grade 3 at 72hrs, blood transfusion, post-op ITU stay, ECMO usage and renal support, and survival status were collected from the unit's database. Binary logistic regression was used to identify risk factors for the development of post-op DSA within 1-year post-transplant. Multivariable Cox regression was performed to identify risk factors for survival. Results From January 2012 to October 2017, 259 adult patients received lung transplantation in our unit and 242 (93.4%) survived beyond 30-day post-op. Recipients who died within 30-day post-transplant were not included, as the causes of their death were less likely to be influenced by or associated with post-op DSA. Among these 242 recipients, 46 (19.0%) had pre-existing antibodies and 129 (53.3%) had DSA detected within 1-year post-transplant. Among all the potential risk factors, transplantation performed with ECMO (p = 0.007, OR 3.06, 95% CI: 1.36-6.90) are significantly associated with post-op DSA within 1-year post-transplant. Age (p = 0.009, OR 1.03, 95% CI: 1.01-1.05), post-op renal support (p = 0.015, OR 2.23, 95% CI: 1.17-4.26), PGD grade 3 at 72hrs (p = 0.001, OR 2.79, 95% CI: 1.54-5.05), and red blood cell transfusion (p < 0.001, OR 1.17, 95% CI: 1.11-1.23) are associated with worse medium-term survival, but neither pre-existing antibodies (p = 0.454) or post-op DSA (p = 0.479) has an impact on survival. Conclusion Use of ECMO for lung transplantation is associated with DSA development within 1-year post-transplantation. However, the presence of DSA within 1-year post-transplant has no impact on medium-term survival in this cohort. Further study is required to look at the effect of DSA on the development of chronic lung allograft dysfunction and long-term survival. Donor specific antibodies (DSA) to mismatched human leukocyte antigens have been reported to adversely affect the outcomes of lung transplantation. This study aimed to identify the risk factors for the development of DSA within 1-year post-transplant and examine its impact on recipients’ medium-term survival. Recipients’ age, type of transplantation (single lung or bilateral lungs), pre-existing antibodies, post-op DSA, method of transplantation (ECMO, off-pump or on-pump), primary graft failure (PGD) grade 3 at 72hrs, blood transfusion, post-op ITU stay, ECMO usage and renal support, and survival status were collected from the unit's database. Binary logistic regression was used to identify risk factors for the development of post-op DSA within 1-year post-transplant. Multivariable Cox regression was performed to identify risk factors for survival. From January 2012 to October 2017, 259 adult patients received lung transplantation in our unit and 242 (93.4%) survived beyond 30-day post-op. Recipients who died within 30-day post-transplant were not included, as the causes of their death were less likely to be influenced by or associated with post-op DSA. Among these 242 recipients, 46 (19.0%) had pre-existing antibodies and 129 (53.3%) had DSA detected within 1-year post-transplant. Among all the potential risk factors, transplantation performed with ECMO (p = 0.007, OR 3.06, 95% CI: 1.36-6.90) are significantly associated with post-op DSA within 1-year post-transplant. Age (p = 0.009, OR 1.03, 95% CI: 1.01-1.05), post-op renal support (p = 0.015, OR 2.23, 95% CI: 1.17-4.26), PGD grade 3 at 72hrs (p = 0.001, OR 2.79, 95% CI: 1.54-5.05), and red blood cell transfusion (p < 0.001, OR 1.17, 95% CI: 1.11-1.23) are associated with worse medium-term survival, but neither pre-existing antibodies (p = 0.454) or post-op DSA (p = 0.479) has an impact on survival. Use of ECMO for lung transplantation is associated with DSA development within 1-year post-transplantation. However, the presence of DSA within 1-year post-transplant has no impact on medium-term survival in this cohort. Further study is required to look at the effect of DSA on the development of chronic lung allograft dysfunction and long-term survival.

Longitudinal Impact of Temporary Mechanical Circulatory Support on Durable Left Ventricular Assist Device Outcomes: An IMACS Registry Analysis

Purpose To characterize longitudinal outcomes of durable LVAD patients presenting with preoperative cardiogenic shock according to temporary circulatory support (TCS) management strategy. Methods Patients (n=13813) enrolled into IMACS (2013-2017) supported with continuous flow LVADs were analyzed. Patients were grouped according to use of TCS vs. no TCS by Profile. TCS patients were subgrouped according to support type (ECMO, IABP, other-TCS) and morbidity and mortality were analyzed. Results TCS was used in 5631 (42%) patients in IMACS. Of these, ECMO was used in 1138 (20%), IABP in 3901 (69%), and other-TCS in 595 (11%). More patients on ECMO had ischemic cardiomyopathy (52% ECMO, 44% IABP, 42% Other-TCS, 40% no-TCS, p Conclusion In cardiogenic shock patients, the use of ECMO prior to LVAD was associated with lower survival, longer ICU stay and more RV failure compared to other TCS. ECMO patients with persistent RV failure have the worst prognosis.

Mid-Term Results of Lung Transplantation (LTx) after Bridging with Extracorporeal Membrane Oxygenation - Influence of Concomitant Invasive Mechanical Ventilation (iMV)

Purpose ECMO as a bridge to LTx became over the last decade a standard approach in rapidly deteriorating patients in selected centres. Recent analysis revealed that pre-transplant iMV rather than ECMO by itself is an independent risk factor. In this study we compare our cohort of mechanically and self- ventilated patients bridged to LTx with ECMO. Methods Between 07.2011 and 10.2018 32 patients underwent first time LTx being on ECMO support preoperatively due to a rapidly progressing exacerbation. They were divided into 2 groups: 1-mechanically ventilated (N-11) and 2-self-ventilated (N-21) for more than 50% of support duration. Recipients’ and donors’ demographics, peri-operative variables and outcomes were compared. Survival estimate using a Kaplan-Meier method was performed from the day of LTx. Results Donors’ and recipients’ characteristics and intra-operative variables were comparable except for duration of preoperative iMV during ECMO support (mean±SD): group 1 vs. 2 - 14.5±15 vs. 2.4±6 days (p=0.003). There were no differences observed in recipients’ post-transplant duration of iMV, prevalence of grade 3 primary graft dysfunction , ECMO use, intensive care unit length of stay (LOS) and prevalence of any episode of acute rejection (AR). Hospital LOS was shorter in group 1: 23.5±15.5 vs. 43.6±29.6 days (p=0.047). Significantly higher rate of chronic lung allograft dysfunction (CLAD) was observed in group 1: 52 vs. 6.2 % (p=0.028). Estimated three-month, 1-year and 5-year survival was significantly worse in ventilated patients: 36.4 vs. 84.3; 36.4 vs. 84.3 and 36.4 vs. 63.2 % (Log rank p= 0.001). Conclusion Early implantation of ECMO in rapidly deteriorating patients on transplant waiting list facilitates a bridging without invasive mechanical ventilation . Lung transplantation in self ventilated patients bridged to Ltx with ECMO is safe and effective strategy providing an excellent early and mid-term results.

Differences in Post-Thoracotomy Outcomes in Patients Implanted off ECMO

Purpose There is a growing trend toward the use of less invasive, non-sternotomy approaches in all fields of cardiac surgery, including implantation of left ventricular assist devices (LVADs). The less invasive, thoracotomy procedure has been successfully used worldwide, with an estimated 25% of implants performed internationally using this approach. This approach is also used more frequently in varying patient populations, including those coming into the procedure on ECMO. With the new UNOS transplant listing criteria, ECMO use may change, and understanding the impact on subsequent procedures in this population is of increasingly important. We present here a comparison of outcomes of HVAD implants by a thoracotomy approach in patients either on or off ECMO at baseline. Methods This Retrospectively analysis of clinical data and outcomes of 281 patients implanted with the HVAD Pump via a thoracotomy approach at high volume thoracotomy implanting centers in Europe in a real-world setting. Implants were performed both on and off pump, and with standard and alternative outflow graft locations. Patients were implanted directly from ECMO in 17%. Results Compared to patients implanted with an HVAD without baseline ECMO, those implanted directly from ECMO experienced a higher rate of bleeding events (0.30 vs. 0.11 events per patient year (EPPY), p value = 0.02, respectively), more renal dysfunction (0.19 vs. 0.05 EPPY, p value = 0.03) and a trend toward few cardiac arrythmias (0.19 vs. 0.07 EPPY, p value = 0.08). Overall survival at one year post implant was 81% in the non-ECMO thoracotomy group, compared to 56% in the group implanted directly from ECMO (p value = 0.0003). Conclusion The analysis of real world use of the HVAD implanted using a thoracotomy approach demonstrates that there is significantly worse survival and adverse event profile in patients undergoing implants off ECMO. However, these results do not appear to be worse than previous reports of LVAD implants off ECMO via a sternotomy approach.

Impact of extra-corporeal membrane oxygenation on outcome of aluminium phosphide poisoning complicated with myocardial dysfunction

Background: Aluminium phosphide (AlP) poisoning is associated with a high mortality rate when patients are complicated with myocardial dysfunction and refractory shock or severe metabolic acidosis. We studied the role of veno-arterial extra-corporeal membrane oxygenation (VA-ECMO) in patients of AlP poisoning induced myocardial dysfunction.Methods and results: This is a tertiary care, single-centre, retrospective study. Between January 2011 and June 2016, total of 107 patients with AlP poisoning were identified and of those 67 were categorised in high-risk category as per the criteria. The in-hospital mortality of patients who received ECMO (n = 35) was compared to those who received conventional treatment (n = 32) only. The use of ECMO in addition to conventional treatment has reduced the in-hospital mortality from 84.4% to 40% (odds ratio: 0.47; 95% confidence interval 0.31–0.73). Among survivors, the ECMO group had a significantly lower baseline left ventricular ejection fraction (LVEF; median: 24%; IQR: 22–29 vs. median: 32%; IQR: 32–33.5; p < .003) but a non-significantly higher LVEF at the time of discharge (median: 52%; IQR: 48–60 vs. median: 48%; IQR: 47–49; p: .064) than did the conventional group. On logistic regression analysis the higher sequential organ failure assessment (SOFA) score, lower pH and the non-usage of ECMO were found to be the independent predictors of mortality.Conclusion: The use of ECMO in high-risk patient of AlP poisoning has resulted in a significant reduction in the mortality. A high baseline SOFA score has been found to be the independent predictor of mortality.

TRENDS AND OUTCOMES OF ECMO SUPPORT IN CARDIOGENIC SHOCK DUE TO ACUTE MYOCARDIAL INFARCTION: ANALYSIS OF NATIONWIDE INPATIENT SAMPLE

Acute Coronary Syndrome (ACS) complicated by Cardiogenic Shock (CS) is associated with high mortality. There is paucity of data from large national studies on the trends and outcomes of ECMO use in patients with CS due to Acute Myocardial Infarction. Nationwide Inpatient Sample database was

Use of ECMO support in pediatric patients with severe thoracic trauma

BackgroundExtracorporeal membrane oxygenation (ECMO) has been used in the non-trauma setting for over 30 years. However, the use of ECMO in trauma remains a difficult question, as the risk of bleeding must be weighed against the benefits of cardiopulmonary support. MethodsRetrospective review of children who sustained severe thoracic trauma (chest abbreviated injury score ≥3) and required ECMO support between 2009 and 2016. ResultsOf the 425 children who experienced severe thoracic trauma, 6 (1.4%) underwent ECMO support: 67% male, median age 4.8 years, median ISS 36, median GCS 3, and overall survival 83%. The median hospital day of ECMO initiation was 2 with a median ECMO duration of 7 days. All cannulations occurred through the right neck regardless of the size of the child. Five initially had veno-venous support with 1 requiring conversion to veno-arterial (VA) support. Both children on VA support suffered devastating cerebrovascular accidents, one of which ultimately led to withdrawal of care and death. Complications in the cohort included: paraplegia (1), neurocognitive defects/dysphonia (1), infected neck hematoma (1), deep femoral venous thrombosis (1), bilateral lower extremity spasticity (1). ConclusionThis small cohort supports the use of ECMO in children with severe thoracic injuries as a potentially lifesaving intervention, however, not without significant complication. Level of EvidenceIV.

Management preferences in ECMO mode for congenital diaphragmatic hernia

PurposeThe purpose of this study was to identify management preferences that may exist in the care of infants with CDH receiving ECMO with emphasis on VV-ECMO. MethodsA survey was created to measure treatment preferences regarding ECMO use in CDH. The survey was distributed to all APSA and ELSO/Euro-ELSO members via e-mail. Survey results were summarized using descriptive statistics. ResultsThe survey had 230 respondents. The survey participants were surgeons (75%), neonatologists/intensivists (23%), and “other” (2%). The mean annual center volume was 11.6(±9.6) CDH cases, and the average number treated with ECMO was 4.5 (±6.4) cases/yr. The most agreed upon criteria for ECMO initiation were preductal O2 saturation <80% refractory to ventilator manipulation and medical therapy (89%), oxygenation index >40 (80%), severe air-leak (79%), and mixed acidosis (75%). Over 60% of respondents agreed the VV-ECMO would be optimum for average risk neonates. However, this preference diminished as the pre-ECMO level of cardiac support increased. When asked about why each respondent would choose VA-ECMO over VV-ECMO, the responses varied significantly between surgeons and non-surgeons. ConclusionWhile there seem to be areas of consensus among practitioners, such as criteria for initiation of ECMO, this survey revealed substantial variation in individual practice patterns regarding the use of ECMO for CDH. Type of StudyQualitative, Survey. Level of EvidenceIV.

Concurrent initiation of intra-aortic balloon pumping with extracorporeal membrane oxygenation reduced in-hospital mortality in postcardiotomy cardiogenic shock

BackgroundVeno-arterial extracorporeal membrane oxygenation (VA-ECMO) is widely used in postcardiotomy cardiac shock (PCS). The factors that affect mortality in patients who receive ECMO for PCS remain unclear. In this study, we analyzed the outcomes, predictive factors and complications of ECMO use for PCS.MethodsA total of 152 adult subjects who received VA-ECMO for PCS in Fuwai Hospital were consecutively included. We retrospectively collected the baseline characteristics, outcomes and complications. Baseline characteristics were compared between survivors with non-survivors, and logistic regression was performed to identify predictive factors for in-hospital mortality.ResultsThe mean age of the subjects was 49.5 ± 14.1 years, with a male dominancy of 73.7%. The main surgical procedures were heart transplantation (32.2%), coronary artery bypass graft (17%) and valvular surgery (11.8%). Intra-aortic balloon pumping (IABP) was initiated concurrently with ECMO in 32.2% subjects and sequentially in 18.4% subjects. The ECMO weaning rate was 56.6%, and the in-hospital mortality was 52.0%. When compared with non-survivors, survivors had less hypertension (15.1% vs. 35.4%, p = 0.004), secondary thoracotomy before ECMO initiation (19.2% vs. 39.2%, p = 0.007), pre-ECMO cardiac arrest/ventricular fibrillation (11.0% vs. 34.2%, p = 0.001), bedside implantation of ECMO (11.0% vs. 41.8%, p < 0.001), and more transplant procedure (45.2% vs. 20.3%, p = 0.001), concurrent IABP initiation with ECMO (41.1% vs. 24.1%, p = 0.025). Multivariate logistic regression indicated concurrent IABP initiation with ECMO was the only independent protective factor for in-hospital mortality (OR = 0.375, p = 0.041, 95% CI 0.146–0.963). Concurrent IABP initiation with ECMO had less need for continuous renal replacement therapy (30.6% vs. 49.3%, p = 0.039) and less neurological complications (8.2% vs. 22.7%, p = 0.035), but more thrombosis complications (18.4% vs. 2.7%, p = 0.007).ConclusionConcurrent initiation of IABP with ECMO provides better short-term survival for PCS, with reduced peripheral perfusion complications.

The use of ECMO in ICU. Recommendations of the Spanish Society of Critical Care Medicine and Coronary Units

The use of extracorporeal membrane oxygenation systems has increased significantly in recent years; given this reality, the Spanish Society of Critical Intensive Care Medicine and Coronary Units (SEMICYUC) has decided to draw up a series of recommendations that serve as a framework for the use of this technique in intensive care units. The three most frequent areas of extracorporeal membrane oxygenation systems use in our setting are: as a cardiocirculatory support, as a respiratory support and for the maintenance of the abdominal organs in donors. The SEMICYUC appointed a series of experts belonging to the three working groups involved (Cardiological Intensive Care and CPR, Acute Respiratory Failure and Transplant work group) that, after reviewing the existing literature until March 2018, developed a series of recommendations. These recommendations were posted on the SEMICYUC website to receive suggestions from the intensivists and finally approved by the Scientific Committee of the Society. The recommendations, based on current knowledge, are about which patients may be candidates for the technique, when to start it and the necessary infrastructure conditions of the hospital centers or, the conditions for transfer to centers with experience.Although from a physiopathological point of view, there are clear arguments for the use of extracorporeal membrane oxygenation systems, the current scientific evidence is weak, so studies are needed that define more precisely which patients benefit most from the technique and when they should start.

Use veno-venous extra corporeal membrane oxygenation in elderly patients with post-cardiotomy hypoxia: the changing paradigm of respiratory support in adult respiratory distress syndrome

BackgroundVeno-venous extracorporeal membrane oxygenation (VV-ECMO) support for ARDS treatment after cardiac surgery has progressed remarkably in the last 20 years. However, one of the limitations of a successful recover is age, being a powerful predictor of mortality.Case presentationIn this case report we discuss a 78-year-old man who underwent aortic valve and aortic root replacement. The postoperative period was complicated by ARDS following aspiration pneumonia treated with VV-ECMO weaned after 6 days. At two-year follow up, the patient made an excellent recover, being the second oldest person to survive VV-ECMO following cardiac surgery in the world.ConclusionIn the literature there is no consensus regarding a specific age limit and results, in the use of ECMO in the elderly are scarce and inconsistent. We do not think advanced age is a contraindication to the use of ECMO.

Successful use of percutaneous ECMO and intra-aortic balloon support for a rescue valve in valve TAVR procedure in a patient in cardiogenic shock

Successful use of percutaneous ECMO and intra-aortic balloon support for a rescue valve in valve TAVR procedure in a patient in cardiogenic shock

Veno-arterial extracorporeal membrane oxygenation and prolonged use of mechanical compression device combine for good outcome after hypothermic cardiac arrest: a case report

The use of mechanical compression devices to deliver chest compressions in conjunction with veno-arterial extracorporeal membrane oxygenation (VA ECMO) in the setting of cardiac arrest is growing. Herein, we report a case of hypothermic cardiac arrest requiring VA ECMO and prolonged use of an external compression device. A 38-year-old morbidly obese male (BMI 66.5) was admitted after being found down by a river. The patient was hypothermic (27.4 ℃; outside temperature 4 ℃) and in active asystolic cardiac arrest. A LUCAS chest compression system (Jolife, Lund, Sweden) was placed and transesophageal echo (TEE) was performed. This revealed cardiac standstill and suboptimal placement of the LUCAS device which was repositioned under TEE guidance. After difficult VA-ECMO cannulation, LV venting was required but coagulopathy, hypothermia, and body habitus precluded immediate endovascular mechanical unloading device placement. Therefore, the LUCAS was continued. After 380 minutes of VA ECMO, 460 minutes of LUCAS device support, and gradual rewarming to normothermia, the patient was cardioverted to sinus tachycardia and an Impella CP was placed. Over the next 96 hours infusions were reduced and biventricular function normalized. The Impella CP was removed on day 7, VA ECMO on day 12, and extubation occurred on day 15. He discharged with no neurologic deficits on day 34, a right sided above knee amputation his only notable hospital complication. The combined support of an external compression device and VA ECMO allowed for return of spontaneous circulation despite a downtime greater than 100 minutes. Further, TEE guidance allowed for optimal LUCAS positioning.

Survival after heart transplantation in patients on ECMO support at the time of transplant improved over time in a high-volume center

Pre-heart transplantation (HTx) ECMO support has been associated with poor short-term post-transplant outcomes without improvement over time. To analyze post-HTx outcomes in patients on ECMO support at the time of transplant at our center according to the year of transplant. Selection and patients’ care in case of pre-HTx ECMO support changed over time: exclusion of emergency access to HTx of pre-ECMO HTx patients with creatinine clearance below 40 ml/min, systematic use of reperfusion line, frequent use of intra-aortic balloon pump in association to ECMO, continuation of ECMO support after HTx… We performed a retrospective single-center observational study. We included all consecutive heart transplantation performed at our center between 2008 and 2016. We aimed to compare outcomes between patients under ECMO support at the time of HTx to patients without. We compared two periods of time: 2008/2012 and 2013/2016. The primary outcome was all-cause mortality after HTx. A total of 682 patients met the inclusion criteria, including 161 patients (23.6%) under ECMO support at the time of HTx; 342 and 340 HTx were preformed in the period 2008–2012 and 2013–2016 respectively. Patients were mostly males (78.5%) and mean age was 49.9 ± 12.8 years. The use of pre-HTx ECMO increased over time (17% to 30%, P < 0.01). ECMO patients were younger but had a longer ischemic time compared to other patients. Whereas the survival after HTx was similar between the two periods in patients without pre-HTx ECMO support (1-year survival: 79% compared to 81%), we observed a significant improvement in survival for patients on ECMO in the 2013–2016 period compared to the 2008–2012 period (1-year survival: 73% compared to 85%, P = 0.02, Fig. 1 ). HTx in patients under ECMO support at the time of transplant achieved favorable outcomes with a significantly better survival in the most recent era.

Role of ECMO in life threatening intoxication

Acute severe poisoning may lead to life threatening situation or death due to cardiovascular dysfunction or stunning, arrhythmia or cardiogenic shock. These substances include medications, substances used for addiction, house hold chemicals, industrial, plants and animal or vegetable toxicants. The poison profile varies in different parts of world; drugs with cardiotoxic potential are the common poisoning substances while pesticides and other house hold toxins are common in the other part of the world. Irrespective of the type of the poison, these patients are relatively young and usually healthy. Extracorporeal Life Support (ECLS) has become popular in the management of acute severe intoxication induced cardiogenic shock, arrhythmia or cardiac arrest as bridge therapy. The management of poisoning include further reduction of absorption or enhancing the elimination; antidote administration (if available); and supportive therapies including resuscitation. ECMO helps in maintaining adequate cardiac output and tissue perfusion and enhances the toxic substance metabolism. However most of the available literature is based on case reports, case series and retrospective cohort study. In spite of high mortality with severe poisoning and encouraging outcome with use of ECMO, it is underutilized modality across the world. The available literature shows a favourable outcome with ECMO in severely intoxicated patients with cardiovascular collapse, however, there are no clear guidelines for the time of initiation of ECMO on the basis of clinical, metabolic and echocardiographic parameters. Even prognostication prior to initiation of ECMO is difficult to predict. ELSO (Extracorporeal Life Support Organization) may support the global data collection on acute intoxication requiring ECMO, which may address some of these issues.

Creation of an empiric tool to predict ECMO deployment in pediatric respiratory or cardiac failure

PurposeTo create a real-time prediction tool to predict probability of ECMO deployment in children with cardiac or pulmonary failure. Materials and methodsPatients ≤18 years old admitted to an ICU that participated in the Virtual Pediatric Systems database (2009–2015) were included. Logistic regression models using adaptive lasso methodology were used to identify independent factors associated with ECMO use. ResultsA total of 538,202 ICU patients from 140 ICUs qualified for inclusion. ECMO was deployed in 3484 patients (0.6%) with a mortality of 1450 patients (41.6%). The factors associated with increased probability of ECMO use included: younger age, pulmonary hypertension, congenital heart disease, high-complexity cardiac surgery, cardiomyopathy, acute lung injury, shock, renal failure, cardiac arrest, use of nitric oxide, use of either conventional mechanical ventilation or high frequency oscillatory ventilation, and higher annual ECMO center volume. The area under the receiver operating curve for this model was 0.90 (95% CI: 0.85–0.93). This tool can be accessed at https://soipredictiontool.shinyapps.io/ECMORisk/. ConclusionsHere, we present a tool to predict ECMO deployment among critically ill children; this tool will help create real-time risk stratification among critically ill children, and it will help with benchmarking, family counseling, and research.

Extracorporeal Membrane Oxygenation for ARDS: Optimization of Lung Protective Ventilation.

The use of extracorporeal membrane oxygenation in the management of ARDS has grown considerably in the past decade, largely as a consequence of improvements in extracorporeal technology and management techniques. Recently published data has helped clarify the use of ECMO in ARDS, and its role in optimizing lung-protective ventilation and minimizing ventilator-induced lung injury has the potential to have a substantial impact on ARDS management and outcomes. In the future, novel extracorporeal management strategies may lead to a new paradigm in our approach to patients with ARDS.