Use Of Extracorporeal Membrane Oxygenation Research Articles

The Role of Extracorporeal Membrane Oxygenation in the Complex Treatment of Acute Chemical Poisoning

Aim of study. Analysis of literature data on the use of extracorporeal membrane oxygenation in acute chemical poisoning.Material and methods. The search for domestic publications was carried out in the Elibrary database, foreign publications — in the MEDLINE / PubMed, Google Scholar databases for the period of 2010–2023. The terms used as a search query were according to the official MeSH terms: “Extracorporeal Membrane Oxygenation” OR “Membrane Oxygenation, Extracorporeal” OR “ECMO Treatment” AND “poisoning”.Results. This review provides information on the outcomes of the use of veno-arterial and veno-venous extracorporeal membrane oxygenation (ECMO) for refractory cardiogenic shock, cardiac arrest and severe ARDS in acute chemical poisoning.Conclusion. Data analysis showed that in patients with acute chemical poisoning, the incidence of complications and mortality was lower when ECMO/ECMOCPR was included in the complex therapy compared with patients in whom other reasons (not related to acute poisoning) served as indications for the use of this technique. This is probably due to the fact that patients in the group with acute poisoning are younger, they have fewer concomitant diseases; and ECMO is required, as a rule, for a shorter period of time before the toxicant is eliminated from the body using the methods of their elimination and restoration of disturbed functions.

Two cases of extracorporeal membrane oxygenation for ventilator-dependent infants with bronchopulmonary dysplasia and pulmonary hypertension

Bronchopulmonary dysplasia (BPD) and pulmonary hypertension (PH) are potentially fatal complications in prematurely born infants. Extracorporeal membrane oxygenation (ECMO) may be a life-saving option for managing infants with BPD and PH. We present 2 patients who were successfully weaned off mechanical ventilators (MVs) through the application of ECMO. The patients were transferred to our institution after receiving MV care for 8 and 10 months, respectively, for BPD and PH. We were able to remove the patients from MVs after a period of ECMO-mediated lung rest. Although more research is required to determine specific criteria for ECMO use in patients with BPD and PH, our clinical experiences may contribute to the early application of ECMO in MV-dependent patients.

Outcomes associated with prolonged ECMO in COVID-19 associated ARDS: A single center experience.

The COVID-19 pandemic has led to a significant increase in the use of veno-venous extracorporeal membrane oxygenation (V-V ECMO) as a bridge to transplantation versus recovery. Unlike other etiologies of acute respiratory distress syndrome (ARDS), utilization of V-V ECMO in COVID-19 has been associated with longer duration of ECMO support requirements. Our team sought to evaluate outcomes associated with prolonged duration of ECMO support in this patient population. Single-center retrospective review of patients who were placed on ECMO due to COVID-19 associated ARDS. Specifically examining outcomes-transplant free survival, mortality and discharge rates-of patients requiring V-V ECMO support for greater than 50days. The median age of the cohort was 48years and 13 patients (72%) were males. The median duration of ECMO support was 84days (IQR 55-106). 11 patients (61%) had right ventricular dysfunction and 13 patients (72%) had pneumothoraces. There was a 33% percent (n = 6) mortality rate within cohort. One patient continues to require ECMO support at time of abstract submission. 11 patients (61%) patients were discharged, of which 3 patients required a lung transplant. Prolonged V-V ECMO can be associated with comparable outcomes to conventional V-V ECMO runs that are relatively shorter in duration. With availability of device and staffing, prolonged ECMO runs can potentially be justified in a highly selected patient population.

The impact of pulmonary hypertension on early postoperative period after lung transplantation with particular emphasis on kidney function

Abstract Background A special group of lung transplantation (LTx) recipients are patients diagnosed with pulmonary hypertension (PH) in the form of idiopathic pulmonary arterial hypertension (IPAH) or chronic lung diseases associated PH (CLD-PH). Acute left heart failure is a major complication observed in the early post-transplant period of patients with PH. To avoid post-transplant cardiac failure, the following measures may be implemented: use of intraoperative veno-arterial extracorporeal membrane oxygenation, administration of inotropic agents, a restrictive fluid management or use of continuous renal replacement therapy. Although, it remains unclear whether such a therapy affects long-term kidney function and patient survival. Purpose To analyze the influence of pulmonary hypertension diagnosis on early postoperative outcome including deterioration of renal function defined as the change in eGFR that occurred between baseline eGFR and the first and seventh day of observation post-LTx. Methods Retrospective data analysis of 79 patients undergoing lung transplantation in 2015-2018 in our institution with diagnosis of PH. Exclusion criterium was absence of 7 days observation post LTx or lack of PH diagnosis. The comparison of pre- and postoperative data was performed between IPAH (N=7) and CLD-PH (N=43) patients. Results We found differences in preoperative serum creatinine levels between IPAH and CLD-PH group (109,5 umol/l (70-126) vs 62,3 umol/l (49,3-73,4), respectively), p<0.05. The greatest decline of eGFR in the early postoperative period was demonstrated on day 7 in both groups (ΔeGFR=42,2±6,7 for CLD-PH group and 56,5±9,8 for IPAH group). Patients did not differ according to age, sex and BMI values. In IPAH group operation tend to last longer (657,9±78,2 min vs 539,6±111,6 min, p<0.05), all of them were performed with the use of cardiopulmonary bypass. All patients from IPAH group and 95,6% from CLD-PH group received inotropic support during LT procedure and early postoperative days. Duration of mechanical ventilation was statistically shorter among CLD-PH patients (2,9 days (0,8-1,4) vs 6,1 days (3,3-39), p<0.001). Conclusion It seems to be probable that pulmonary hypertension could be significant risk factor of kidney deterioration after lung transplantation. Identification of factors modifying renal insufficiency development in lung transplant recipients needs further investigations.

Cardiac energetics and end-organ perfusion with veno-arterial extracorporeal membrane oxygenation versus ecmella for cardiogenic shock in a large animal model

Abstract Background The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is in severe cases of left ventricular (LV) failure associated with pulmonary edema due to inadequate LV emptying. In clinical practice VA-ECMO may be combined with Impella CP (ECMELLA), to unload the LV. We hypothesized that ECMELLA improves cardiac energetics without compromising end-organ perfusion compared to VA-ECMO alone in a porcine model of cardiogenic shock (CS). Methods Land-race pigs (weight 70 kg) were instrumented, including a LV conductance catheter and a carotid artery Doppler flow probe. Arterial blood samples were analyzed for lactate level. CS was induced with embolization in the left main coronary artery and was defined as a reduction of 50% or more in cardiac output (CO) or mixed oxygen saturation (SvO2) or a SvO2 < 30%. VA-ECMO was initiated at CS and embolization was continued until arterial pulse pressure was below 10 mmHg. At this point, Impella CP was placed in the ECMELLA arm. Support was maintained for four hours. Results CS was induced in 15 pigs (VA-ECMO n=7, ECMELLA n=8) and at CS the CO declined from 6.1 L/min (0.8) to 2.5 L/min (1.1) in the VA-ECMO arm and from 5.2 L/min (SD: 0.6) to 2.0 L/min (SD: 0.7) in the ECMELLA arm. The pressure-volume area (PVA) was comparable at CS, but significantly higher with VA-ECMO compared to ECMELLA after four hours (9567 SD: 1733 versus 6921 SD: 0536 mmHg*mL, p=0.014). Carotid blood flow increased from CS and was similar in VA-ECMO and ECMELLA (239 mL/min SD: 97 versus 213mL/min SD: 133) at four hours p=0.6. Arterial lactate was equally elevated in both groups at four hours (VA-ECMO 5.2 SD: 3.4 versus 4.2 SD: 2.9 mmol/l for ECMELLA), p=0.5). Conclusion In a porcine model of CS, we found lower PVA with the ECMELLA configuration compared to VA-ECMO, yet similar lactate levels after four hours of mechanical circulation. These findings indicate that ECMELLA better cardiac energetics without compromising systemic perfusion.Central hemodynamicsEnd-organ perfusion

Veno-arterial extracorporeal membrane oxygenation as direct bridge to heart transplantation in a low and middle income country

Abstract Introduction The use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) as a direct bridge to heart transplantation (BTT) is not common in adults worldwide. BTT with ECMO is associated with increased early/mid-term mortality compared with other interventions. In low- and middle-income countries (LMIC), where no other type of short-term mechanical circulatory support is available, its use is widespread and increasingly used as rescue therapy in patients with cardiogenic shock (CS) as a direct bridge to heart transplantation (HT). Objective To assess the outcomes of adult patients using VA ECMO as a direct bridge to heart transplantation in a LMIC and compare them with international registries. Methods We conducted a single-center study analyzing consecutive adult patients requiring VA-ECMO as BTT due to refractory CS or cardiac arrest (CA) in a cardiovascular center in Argentina between January 2014 and December 2022. Survival and adverse clinical events after VA-ECMO implantation were evaluated. Results Of 86 VA-ECMO, 22 (25.5%) were implanted as initial BTT strategy and 52.1% finally underwent HT. Mean age was 46 years (SD 12); 59% were male. ECMO was indicated in all cases for CS and the most common underlying condition was coronary artery disease (30%), followed by idiopathic dilated cardiomyopathy (15%). Patient outcomes are described in Figure 1. Overall in-hospital mortality for VA ECMO as BTT was 50%. Survival to discharge was 83% in those who achieved HT and 10% in those who did not, p<0.001. In those who did not achieve HT, the main cause of death was haemorrhagic complications (44%), followed by thrombotic complications (33%). The median duration of VA ECMO was 6 days (IQR 3-16). There were no differences in the number of days on ECMO between those who received a transplant and those who did not. In the Spanish registry (Barge Caballero et al 2018), in-hospital survival after HT was 66.7%, the United Network of Organ Sharing registry (Fukuhara et al 2018) estimated post-transplant survival at 73.1% ± 4.4%, and in the French national registry (Jasserson et al 2016), 1-year post-transplant survival was 70% in the VA ECMO group. Conclusions In adult patients with cardiogenic shock, VA-ECMO as a direct BTT allowed successful HT in half of the patients. HT provided a survival benefit in listed patients on VA-ECMO. VA-ECMO can be used to bridge critically ill candidates directly to HT in a setting where no other circulatory support is available, as a salvage strategy with acceptable mortality in a high-volume specialized center. We present a single center experience with results comparable to registries in Spain, France and the United States.

Outcomes of ECLS-SHOCK Eligibility Criteria Applied to a Real-World Cohort.

Cardiogenic shock (CS) exhibits high (~50%) in-hospital mortality. The recently published Extracorporeal life Support in Cardiogenic Shock (ECLS-SHOCK) trial demonstrated the neutral effects of the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) on all-cause death, as well as on all secondary outcomes in subjects presenting with myocardial-infarction (MI)-related CS. Here, we compared ECLS-SHOCK eligibility criteria with a real-world cohort of CS patients. ECLS-SHOCK eligibility criteria were applied to a prospective single-center CS registry (the PREPARE CS registry) consisting of 557 patients who were consecutively admitted to the catheterization laboratory (cath lab) of the Medical University of Graz, Austria, due to CS (SCAI C-E). Overall use of mechanical circulatory support (MCS) in this cohort was 19%. Sixty-nine percent of the entire cohort had MI-related CS, 38% of whom would have met ECLS-SHOCK eligibility criteria, thus representing only 27% of the PREPARE CS registry. Exclusion from the ECLS-SHOCK trial was based on patients with initial lactate values below 3 mmol/L (n = 168; 43.6%), aged over 80 years (n = 65; 16.9%), and with a duration of cardiopulmonary resuscitation (CPR) exceeding 45 min (n = 22; 5.7%). The 30-day mortality of patients of the PREPARE CS registry who met the ECLS-SHOCK eligibility criteria was 57.0%, compared to 48.4% of patients in the ECLS-SHOCK trial. The patients' baseline characteristics, however, differed considerably with respect to type of infarction, age, and gender. In a real-world cohort of patients with MI-related CS, only 38% of patients met the eligibility criteria of the ECLS-SHOCK trial. Thus, the impact of the use of VA-ECMO on outcome parameters in MI-related CS, as observed in the ECLS-SHOCK trial, may differ in a more heterogeneous real-world CS population of the PREPARE CS registry.

Abstract 13383: Extracorporeal Membrane Oxygenation for COVID-19-associated Acute Respiratory Distress Syndrome: A Nationwide Analysis

Introduction: While extracorporeal membrane oxygenation (ECMO) has been used for patients with COVID-19-associated acute respiratory distress syndrome (ARDS), its benefit in the nationwide setting is unknown. Aim: To evaluate the association between the use of ECMO and outcomes of COVID-19-associated ARDS in the nationwide setting. Methods: Using the United States National Inpatient Sample in 2020, we identified adults hospitalized and mechanically ventilated for COVID-19 with ARDS and divided them into three groups according to the use of ECMO (i.e., no-ECMO, venovenous [VV]-ECMO, and venoarterial [VA]-ECMO). The primary outcome was in-hospital mortality, and the secondary outcomes were the length of hospital stay (LOS) and the total costs during hospitalization. We applied a multivariable logistic regression model for the primary outcome, adjusting for baseline characteristics and underlying comorbidities. Results: Of the total of 72,415 included patients, 68,795, 3,280, and 340 patients received no-, VV-, and VA-ECMO, respectively (Table) . The crude mortality was the highest in the no-ECMO group (59.8%; 41,110/68,795), followed by VA-ECMO (47.1%; 160/340), and VV-ECMO groups (44.8%; 1,470/3,280). LOS was the longest in VV-ECMO group, followed by VA-ECMO, and no-ECMO groups. Similarly, the total costs during hospitalization were the highest in VV-ECMO group, followed by VA-ECMO, and no-ECMO groups. After adjusting for the covariates, VV- or VA-ECMO was not associated with lower mortality compared to no-ECMO (adjusted odds ratio [95% confidence interval]: 0.98 [0.82-1.18] and 1.12 [0.62-2.04], respectively). Conclusions: In the nationwide setting, ECMO was not associated with improved mortality in patients with COVID-19-associated ARDS but was associated with longer LOS and higher costs. Future studies exploring the characteristics of suitable candidates for ECMO are warranted.

Abstract 15445: Extracorporeal Membrane Oxygenation and Reperfusion Strategies in High-Risk Pulmonary Embolism Hospitalizations

Introduction: Extracorporeal membrane oxygenation (ECMO) offers potentially life-saving circulatory support in patients with high-risk pulmonary embolism (PE) and refractory hemodynamic instability. Optimal reperfusion strategies in combination are unclear. Hypothesis: To investigate the contemporary use of ECMO in conjunction with reperfusion strategies in high-risk PE. Methods: We identified high-risk PE hospitalizations in the Nationwide Inpatient Sample (years 2016-2020) and investigated the use of ECMO in conjunction with thrombolysis-based (systemic thrombolysis or catheter-directed thrombolysis) and mechanical (surgical embolectomy or catheter-based thrombectomy) reperfusion strategies with regards to in-hospital mortality and major bleeding. Results: Among 122,735 hospitalizations for high-risk PE ECMO was used in 2,805 (2.3%); stand-alone in 1.4%, with thrombolysis-based reperfusion in 0.4%, and with mechanical reperfusion in 0.5%. Compared to neither reperfusion nor ECMO, ECMO plus thrombolysis-based reperfusion was associated with reduced in-hospital mortality (adjusted OR, 0.60; 95% CI, 0.38-0.97), whereas no difference was found with ECMO plus mechanical reperfusion (1.02; 0.66-1.59), and ECMO stand-alone was associated with increased in-hospital mortality (1.59; 1.21-2.09). In the cardiac arrest subgroup, ECMO was associated with reduced in-hospital mortality (0.71; 0.53-0.93). Among all patients on ECMO, thrombolysis-based reperfusion was significantly associated (0.54; 0.32-0.90), and mechanical reperfusion showed a trend (0.74; 0.47-1.18) towards reduced in-hospital mortality compared to no reperfusion, without increases in major bleeding. Conclusions: In patients with high-risk PE and refractory hemodynamic instability, ECMO may be a valuable supportive treatment in conjunction with reperfusion treatment but not as stand-alone treatment especially for patients suffering from cardiac arrest.

The impact of a care bundle with an emphasis on hemodynamic assessment on the short-term outcomes in neonates with congenital diaphragmatic hernia.

To evaluate the short-term outcomes of implementing a care bundle emphasizing frequent hemodynamic assessments by echocardiography in neonates with congenital diaphragmatic hernia (CDH). This was a retrospective cohort study of infants with CDH admitted to a quaternary perinatal unit from January 2013 to March 2021. The primary composite outcome was defined as mortality or use of extracorporeal membrane oxygenation or need for respiratory support at discharge. We identified 37 and 20 CDH infants in Epoch I and II, respectively. More patch repairs (50% vs. 21.9%, p = 0.035) and echocardiograms (6[4-8] vs. 1[0-5], p = 0.003) were performed in Epoch II. While there were no differences in the primary outcome, there was a reduction in mortality in Epoch II (0% vs. 27%, p = 0.01). With the implementation of a CDH care bundle with an emphasis on hemodynamic assessment, we demonstrated a significant reduction in mortality.

Abstract 14654: Contemporary Gender Differences in Clinical Outcomes of Patients With Takotsubo Cardiomyopathy - A United States National Inpatient Sample Database Analysis

Introduction: Takotsubo cardiomyopathy (TCM) is classically more prevalent in females, however whether gender differences exist in clinical outcomes of patients with TCM need further clarification. Given the lower prevalence of TCM in males, limitations of previous research included small sample size and demographic disproportion between groups. The purpose of our study is to analyze gender differences in clinical outcomes of TCM hospitalizations using national inpatient sample (NIS). Methods: We searched the 2020 NIS for TCM hospitalizations using ICD 10 code I51.81. Multivariable logistic regression model adjusted for patient and hospital level confounders was used to compare the clinical outcomes between genders. Results: We identified 41,290 TCM hospitalizations in 2020. Of these 19.9% were males (mean age = 63 years, mean charlson comorbidity index = 3.2) and 80.1% were females (mean age = 68 years, mean charlson comorbidity index = 2.7). Females had a lower risk of inpatient mortality (OR: 0.49, 95% CI 0.41-0.58, p < 0.001), cardiac arrest (OR: 0.58, 95% CI 0.43-0.79, p = 0.001) and cardiogenic shock (OR: 0.67, 95% CI 0.55-0.82, p < 0.001). There was no gender difference in the use of intra-aortic balloon pump (IABP), Impella assist system, or extra-corporeal membrane oxygenation (ECMO) Figure 1. Conclusion: Our findings indicate that despite a higher prevalence of TCM in females, clinical outcomes were worse in males. In our analysis, there was no gender difference in the use of IABP, Impella or ECMO. Future research is needed to better understand clinical predictors of adverse cardiac events in male patients hospitalized with TCM to improve outcomes.

Argatroban Use in Pediatric Patients Supported by Paracorporeal Ventricular Assist Devices.

Direct thrombin inhibitor (DTI) use has been associated with decreased stroke and death rates in children on ventricular assist devices (VADs). Most information about DTI use for children on VADs has focused on bivalirudin with limited data on argatroban. We hypothesized that, compared to unfractionated heparin (UFH), argatroban would be associated with decreased bleeding, stroke, and death rates in children on VADs. We retrospectively collected data from patients <18 years old on paracorporeal VADs at Children's Wisconsin between January 1, 2010 and July 1, 2021. We divided patients into cohorts based on anticoagulation strategy with heparin or argatroban. Definitions of bleeding and neurologic events were the same as in other published reports on this population. We compared categorical variables with the χ 2 or Fisher's exact test, and continuous variables with the Mann-Whitney U test. Nineteen children were anticoagulated with argatroban, and 16 with heparin. Demographics between groups were not significantly different. Stroke, bleeding, and death rates did not differ between patients treated with UFH versus argatroban. The study population was complex with a high rate of extracorporeal membrane oxygenation (ECMO) use before VAD support, which likely impacted our findings. Our study does not support argatroban as a superior alternative anticoagulant compared to UFH in children requiring VADs.

Autopsy Histopathologic Lung Findings in Patients Treated With Extracorporeal Membrane Oxygenation.

Extracorporeal membrane oxygenation (ECMO) is increasingly used in the treatment of respiratory and cardiac failure, but data describing lung histopathology in ECMO recipients are limited. To examine pulmonary histopathologic findings in patients who underwent venovenous (VV) ECMO for pulmonary reasons or venoarterial (VA) ECMO for cardiac indications shortly before death, and to determine if the pulmonary changes provided insights into therapy that may prevent complications and improve outcome. We conducted a retrospective study of lung autopsies, from VV and VA ECMO recipients and patients with acute respiratory distress syndrome (ARDS) and non-ECMO treatment, between 2008 and 2020 in Silesia Center for Heart Diseases in Zabrze, Poland. Among 83 ECMO patients (42-64 years; men, 57 [68.7%]), the most common histopathologic findings were bronchopneumonia (44 [53.0%]), interstitial edema (40 [48.2%]), diffuse alveolar damage (DAD; 32 [38.6%]), hemorrhagic infarct (28 [33.7%]), and pulmonary hemorrhage (25 [30.1%]). DAD was associated with longer ECMO treatment and longer hospital stay. The use of VV ECMO was a predictor of DAD in patients with ARDS and undergoing ECMO, but it also occurred in 21 of 65 patients (32.3%) in the VA ECMO group, even though VA ECMO was used for heart failure. Although DAD was significantly more common in lung autopsies of VV ECMO patients, one-third of VA ECMO patients had histopathologic changes characteristic of ARDS. The presence of DAD in lung autopsies of patients treated with VA ECMO indicates that in these patients, protective lung ventilation should be considered.

An International Survey of Extracorporeal Membrane Oxygenation Education and Credentialing Practices.

The use of extracorporeal membrane oxygenation (ECMO) has grown rapidly over the past decades because of evolving indications, advances in circuit technology, and encouraging results from modern trials. Because ECMO is a complex and highly invasive therapy that requires a multidisciplinary team, optimal education, training, and credentialing remain a challenge. The primary objectives of this study were to investigate the prevalence and application of ECMO education and ECMO practitioner credentialing at ECMO centers globally. In addition, we explored differences among education and credentialing practices in relation to various ECMO center characteristics. We conducted an observational study of ECMO centers worldwide using a survey querying participants in two major domains: ECMO education and ECMO practitioner credentialing. Of note, the questionnaire included ECMO program characteristics, such as type and size of hospital and ECMO experience and volume, to explore the association with the two domains. A total of 241 (32%) of the 732 identified ECMO centers responded to the survey, representing 41 countries across the globe. ECMO education was offered at 221 (92%) of the 241 centers. ECMO education was offered at 105 (98.0%) high-ECMO volume centers compared with 136 (87.5%) low-ECMO volume centers (P = 0.005). Credentialing was established at 101 (42%) of the 241 centers. Credentialing processes existed at 52 (49.5%) high-ECMO volume centers compared with 51 (37.5%) low-ECMO volume centers (P = 0.08) and 101 (49.3%) Extracorporeal Life Support Organization centers compared with 1 (2.7%) non-Extracorporeal Life Support Organization center (P < 0.001). We found significant variability in whether ECMO educational curricula are offered at ECMO centers. We also found fewer than half of the ECMO centers surveyed had established credentialing programs for ECMO practitioners. Future studies that assess variability in outcomes among centers with and without standardized educational and credentialing practices are needed.

National Trends for Temporary Mechanical Circulatory Support Utilization in Patients With Cardiogenic Shock From Decompensated Chronic Heart Failure: Incidence, Predictors, Outcomes, and Cost

BackgroundTrends in temporary mechanical circulatory support (tMCS) use with associated outcomes and cost in cardiogenic shock secondary to decompensated chronic heart failure (HF-CS) remains poorly understood. We describe trends in tMCS use, associated outcomes, and cost in HF-CS. MethodsWe included adults enrolled in a national insurance claims dataset with HF-CS who received intra-aortic balloon pump (IABP), Impella, or extracorporeal membrane oxygenation (ECMO) without acute coronary syndrome, or postcardiotomy shock. We identified predictors of device use, associated outcomes, and inflation-adjusted costs. ResultsWe studied 2722 HF-CS patients receiving tMCS: 1799 (66%) male, 1771 (65%) White, and 1836 (67%) with ischemic cardiomyopathy. Rate of tMCS use increased from 2010-2019. Impella use showed the largest increase (Δ+344%), followed by ECMO (Δ+112%). Patients receiving ECMO had a higher comorbidity burden, and patients receiving IABP were more likely to have valvular heart disease. Compared with IABP, 30-day mortality rate was no different for Impella (adjusted odds ratio, 1.24; 95% CI, 0.93-1.66) but was higher with ECMO (adjusted odds ratio, 3.08; 95% CI, 2.22-4.27). Adjusted hospitalization cost was highest for ECMO (median, $191,079 [IQR, $165,760-$239,373]), followed by Impella (median, $142,518 [IQR, $126,845-$179,938]), and IABP (median, $132,060 [IQR, $113,794-$160,244]). We observed a linear association between price standardized cost-quartile and complications, but not for 30-day mortality. ConclusionsThe use of Impella and ECMO is increasing with an associated cost increase. The use of ECMO coincided with higher 30-day mortality compared with IABP in HF-CS. These findings likely reflect increasing disease severity and evolving practice patterns rather than causation.

Safety and Efficacy of Extracorporeal Membrane Oxygenation Heating Units.

Patient temperature during extracorporeal membrane oxygenation (ECMO) is commonly managed by dedicated heating units (HUs) that are integrated into ECMO circuitry. Currently, no HU has received approval for ECMO by the FDA in the United States. Older FDA-approved HUs have been implicated in life-threatening patient infections and are no longer manufactured or available for use in the United States. We performed laboratory tests to evaluate the safety and efficacy of the Micro-Temp and the HTP-1500 HU systems that are potentially suitable for use in ECMO and describe our initial experience with the HTP-1500 HU after being placed in clinical service. Both units demonstrated similar heating efficacy, with the HTP-1500 achieving steady-state temperature approximately 5 h earlier than the Micro-Temp. Microorganisms were detected in the water compartment of all HUs prior to and after performing the manufacturer's recommended cleaning procedure, and after implementation of the HTP-1500 into clinical use we observed a decrease in the rate of bloodstream infection/ECMO days which did not reach statistical significance. Based on the results of this analysis and our institutional experience, we believe that integration of the HTP-1500 HU, an easily replaceable HU, into ECMO systems may reduce the risk of bacterial contamination and thus nosocomial infection when the devices are cleaned and maintained according to manufacturer's guidelines.

The Roles of Venopulmonary Arterial Extracorporeal Membrane Oxygenation.

Concise definitive review of the use of venopulmonary arterial extracorporeal membrane oxygenation (V-PA ECMO) support in patients with cardiopulmonary failure. Original investigations identified through a PubMed search with search terms "percutaneous right ventricular assist device," "oxy-RVAD," "V-PA ECMO," and "veno-pulmonary arterial ECMO" were reviewed and evaluated for relevance. Studies that included more than three patients supported with V-PA ECMO were included. Clinically relevant data from included studies, including patient-important outcomes, were summarized and discussed. We identified four groups of patients where V-PA ECMO has been studied: acute respiratory distress syndrome, right ventricular dysfunction after left ventricular assist device placement, bridge to lung transplantation, and pulmonary embolism. Most identified works are small, single center, and retrospective in nature, precluding definitive conclusions regarding the efficacy of V-PA ECMO. There have been no clinical trials evaluating the efficacy of V-PA ECMO for any indication. V-PA ECMO is a promising form of extracorporeal support for patients with right ventricular dysfunction. Future work should focus on identifying the optimal timing and populations for the use of V-PA ECMO.

Effect of CPAP therapy on the reperfusion lung injury after transluminal balloon angioplasty of the pulmonary arteries in patients with chronic thromboembolic pulmonary hypertension

Aim. To evaluate the effect of non-invasive ventilation (NIV) in CPAP (continuous positive airway pressure) mode on the development of reperfusion pulmonary edema after percutaneous balloon pulmonary angioplasty (BPA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH).Materials and methods. The study included 70 patients with CTEPH who underwent the first stage of BPA. Prevention of reperfusion edema was carried out using NIV in the CPAP mode starting from the early postoperative period in combination with oxygen and diuretic therapy (as nedeed). The presence and severity of pulmonary edema was assessed based on clinical signs and data from computed tomography or chest radiography.Results. Patients after BPA were on CPAP therapy: average pressure: 10.0±0,7 hPa. During 1st day, the average time of use was: 990±417 minutes. Prolongation of CPAP therapy &gt;1 day occurred in 26 (37%) patients. Depending on the severity of reperfusion edema to the lungs, patients were divided into 2 groups: group 1 (grade 1, n=42) and group 2 (grade 3-4, n=12). During the observation period, there were no cases of severe reperfusion edema (grade 5), and no cases required the use of invasive ventilation or extracorporeal membrane oxygenation. No complications of CPAP therapy were recorded. The number of PA segments and ΔPFG did not differ, but the PEPSI index was higher in group 2: 41,9 [16,0; 57,9] vs 80.5 [52,5; 111,25], p=0,0146. The number of days before discharge after BPA in patients of group 2 was higher: 4.0 [3,9; 5,5] vs 7,0 [4,6; 10,0] days, p=0,013. Despite the development of reperfusion edema, before discharge the SpO2 values in group 2 were comparable to the baseline: 93,0 [89,9; 94,2] vs 93,0 [89,7; 94,4]Conclusion. Preventive use of NIV in the CPAP mode, starting from the early postoperative period, is safe and makes it possible to achieve optimal clinical results in patients even with moderate and severe lung reperfusion edema after large volumes of surgical intervention.

2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.

ECMO in trauma care: What you need to know.

Over the past 10 years, extracorporeal membrane oxygenation (ECMO) use in trauma patients has increased significantly. This includes adult and pediatric trauma patients and even combat casualties. Most ECMO applications are in a venovenous (VV ECMO) configuration for acute hypoxemic respiratory failure or anatomic injuries that require pneumonectomy or extreme lung rest in a patient with insufficient respiratory reserve. In this narrative review, we summarize the most common indications for VV ECMO and other forms of ECMO support used in critically injured patients, underscore the importance of early ECMO consultation or regional referral, review the technical aspects of ECMO cannulation and management, and examine the expected outcomes for these patients. In addition, we evaluate the data where it exists to try to debunk some common myths surrounding ECMO management.