Use Of VA-ECMO Research Articles

CT Angiography of Venoarterial Extracorporeal Membrane Oxygenation.

Imaging plays a central role in the workup of thromboembolic events and bleeding complications in patients treated with venoarterial extracorporeal membrane oxygenation (ECMO) (VA-ECMO), and radiologists should be familiar with the expected hemodynamic changes and flow-related artifacts associated with the VA-ECMO system. VA-ECMO is a form of temporary mechanical circulatory support for critically ill patients with acute, refractory cardiac or cardiopulmonary failure. As the use of VA-ECMO continues to increase, it is important to be aware of associated hemodynamic changes and challenges at imaging. Patients treated with VA-ECMO are at high risk for thromboembolic events and bleeding complications and, thus, often require evaluation with CT angiography (CTA). VA-ECMO can be implemented by using central or peripheral cannulation. The peripheral femorofemoral VA-ECMO circuit in particular alters the sequence and direction of contrast medium enhancement substantially, resulting in flow-related artifacts that can mimic or obscure disease at CTA. Nonopacification can be mistaken for spurious thrombus or simulate complete vascular occlusion, while mixing artifacts can mimic dissections. Misinterpretation of flow-related CTA artifacts can lead to inappropriate surgical or medical intervention. A methodical and multiphasic approach should be taken to CTA imaging strategies and interpretation for patients treated with VA-ECMO. There is no universal CTA protocol for patients on VA-ECMO. Each protocol must be designed for the study indication, with consideration of the configuration of the ECMO cannulas, contrast material injection site, region of interest, native cardiac output, and ECMO flow rate. The authors provide examples of common and unusual VA-ECMO-related artifacts, with a focus on strategies for optimizing CTA image acquisition. Online supplemental material is available for this article. ©RSNA, 2021.

Intraoperative support during lung transplantation.

The role of intraoperative mechanical support during lung transplantation (LTx) is essential to provide a safe hemodynamic and ventilatory status during critical intraoperative events. This hemodynamic and ventilatory stability is vital to minimize the odds of suboptimal outcomes, especially considering that, due to the scarcity of donors and the fact that more and more patients with significant comorbidities are being considered for this therapy, a more aggressive approach is often needed by the transplant centers. Hence, the attenuation of any potential injury that can happen during this complex event is paramount. While a thorough assessment of the donor and optimization of postoperative care is pursued, certainly protective intraoperative management would also contribute to better outcomes. Understanding each patient’s underlying anatomy and cardiopulmonary physiology, associated with awareness of critical events during a complicated procedure like LTx, is essential for a precise indication and safe use of support. Cardiopulmonary bypass (CPB) and veno-arterial extracorporeal membrane oxygenation (VA ECMO) have been the most common approaches used, with the latter gaining popularity more recently and we have used VA ECMO exclusively for the last decade. New technologies certainly contributed to more liberal use of VA ECMO intraoperatively, enabling a protecting and physiologic environment for the newly implanted grafts. In this setting, potential prophylactic use for lung protection during a critical period is also considered.

Clinical use and outcome of extracorporeal membrane oxygenation in patients with pulmonary embolism

Aim of the studyExtracorporeal membrane oxygenation (ECMO) is considered a life-saving treatment option for patients in cardiogenic shock or cardiac arrest undergoing cardiopulmonary resuscitation (CPR) due to acute pulmonary embolism (PE). We sought to analyze use and outcome of ECMO with or without adjunctive treatment strategies in patients with acute PE. MethodsWe retrospectively analyzed data on patient characteristics, treatments, and in-hospital outcomes for all PE patients (ICD-code I26) undergoing ECMO in Germany between 2005 and 2018. ResultsAt total of 1,172,354 patients were hospitalized with PE; of those, 2,197 (0.2%) were treated with ECMO support. Cardiac arrest requiring cardiopulmonary resuscitation was present in 77,196 (6.5%) patients. While more than one fourth of those patients were treated with systemic thrombolysis alone (n = 20,839 patients; 27.0%), a minority of patients received thrombolysis and VA-ECMO (n = 165; 0.2%), embolectomy and VA-ECMO (n = 385; 0.5%) or VA-ECMOalone (n = 588; 0.8%). A multivariable logistic regression analysis indicated the lowest risk for in-hospital death in patients who received embolectomy in combination with VA-ECMO (OR, 0.50 [95% CI, 0.41–0.61], p < 0.001), thrombolysis and VA-ECMO (0.60 [0.43–0.85], p = 0.003) or VA-ECMO alone (0.68 [0.57–0.82], p < 0.001) compared to thrombolysis alone (1.04 [0.99–1.01], p = 0.116). ConclusionOur findings suggest that the use of VA-ECMO alone or as part of a multi-pronged reperfusion approach including embolectomy or thrombolysis might offer survival advantages compared to thrombolysis alone in patients with PE deteriorating to cardiac arrest.

CATASTROPHIC PULMONARY EMBOLISM SUCCESSFULLY TREATED WITH EXTRACORPOREAL MEMBRANE OXYGENATION

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) is increasingly recognized as a modality for cardiopulmonary support in high-risk pulmonary embolism (PE). We report a successful application of VA ECMO to support a patient following cardiac arrest secondary to massive saddle PE. CASE PRESENTATION: A 35 year old woman was admitted with new cranial nerve palsies, concerning for neurosarcoidosis versus lymphoma. On hospital day (HD) 11 she became dyspneic and desaturated to 88% on room air; other vitals remained stable. CT chest revealed bilateral pulmonary artery occlusion with right heart strain. NT-proBNP was 3086 pg/mL (ref <125). Multidisciplinary Pulmonary Embolism Response Team (PERT) stratified her as "intermediate-high risk" PE, and recommended therapeutic heparin infusion, with resultant clinical improvement. On HD16 she developed acute chest pain with new tachycardia (HR 130), hypotension (BP 87/65) and increased oxygen requirements. S1Q3T3 pattern was noted on EKG. PE Severity Index (PESI) was 125 (Class IV), and PERT elected for urgent catheter-directed thrombectomy. Prior to procedure she suffered a cardiac arrest, and received ACLS plus systemic thrombolytics, with return of spontaneous circulation after 20 minutes. Post-arrest suction thrombectomy removed large clot burden, but with persistent hypotension despite inhaled nitric oxide, vasopressor and inotropic support and severe right ventricle (RV) systolic dysfunction on echocardiogram, she was peripherally cannulated for VA-ECMO. Her ECMO course was complicated by renal failure requiring renal replacement therapy and hemoperitoneum requiring blood transfusion. Vasopressors were weaned off on ECMO day 4, and she was decannulated on ECMO day 6. She was discharged on HD42, neurologically intact and with recovered cardiac and renal function. DISCUSSION: High-risk PE, defined by acute PE with hemodynamic instability, shock, or cardiac arrest, is associated with high mortality. VA ECMO allows for maintenance of organ perfusion and oxygenation by mechanically bypassing and decompressing the failing RV and pulmonary circulation, offering hemodynamic and respiratory support to allow for reperfusion strategies or spontaneous thrombolysis on heparin. ECMO is increasingly available, with mobile teams allowing for rapid deployment. The literature on ECMO as a rescue therapy for catastrophic PE is limited to small case series, and recent meta analyses were unable to draw definitive conclusions (1, 2). 2019 European guidelines suggest that mechanical cardiopulmonary support may be helpful for high-risk PE with circulatory collapse (3). CONCLUSIONS: This case adds to reports of successful use of VA-ECMO for high-risk PE. Early ECMO consultation and timely appropriate use may prevent sudden cardiac death. Further research is needed to determine what role ECMO may play as an early intervention rather than a salvage procedure. REFERENCE #1: Pozzi, Matteo, et al. "Efficacy and safety of extracorporeal membrane oxygenation for high-risk pulmonary embolism: A systematic review and meta-analysis." Vascular Medicine 25.5 (2020): 460-467. REFERENCE #2: Baldetti, Luca, et al. "Use of extracorporeal membrane oxygenation in high-risk acute pulmonary embolism." Artificial Organs (2020). REFERENCE #3: Konstantinides, Stavros V., et al. "2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS) The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC)." European heart journal 41.4 (2020): 543-603. DISCLOSURES: no disclosure on file for Stephanie Nonas; No relevant relationships by Jonathan Taylor, source=Web Response

Veno-arterial Extracorporeal Membrane Oxygenation as Bridge to Heart Transplantation: The Way Forward.

Advanced heart failure (HF) represents a public health priority due to the increase of affected patients and the meaningful mortality. Durable mechanical circulatory support (MCS) and heart transplantation (HTx) are unique therapies for end-stage HF (ESHF), with positive early and long-term outcomes. The patients who underwent HTx have a 1-y survival of 91% and a median survival of 12-13 y, whereas the median survival of ESHF is <12 mo. Short-term MCS with veno-arterial extracorporeal membrane oxygenation (VA ECMO) can be used as a bridge to transplantation strategy. Patients bridged with VA ECMO have significantly lower survival in comparison with non-MCS bridged and left ventricular assist device-bridged patients. VA ECMO represents an effective, and sometimes unique, system to obtain rapid hemodynamic stabilization, but possible negative effects on patients' outcomes after HTx must be considered. Here, we discuss the use of VA ECMO as bridge to transplantation.

Utilization of ECMO in vascular surgery: A presentation of two cases.

IntroductionVeno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a form of temporary mechanical circulatory support commonly used during cardiothoracic interventions. Malperfusion during complex vascular procedures remains a significant risk that may potentially lead to multiple complications. Here, we report two cases highlighting the efficacy of VA-ECMO in both planned and emergent vascular interventions.Presentation of caseIn our first case, VA-ECMO was used to support an 82-year-old male during a high-risk thoracoabdominal aortic aneurysm repair. Our second case details an emergent pulmonary embolectomy in which VA-ECMO was used as a bridge to cardiopulmonary bypass. In both cases, the procedures were well-tolerated, and the patients were discharged 17 days postoperatively.DiscussionVA-ECMO has been increasingly used as a form of post-operative circulatory support following cardiothoracic and vascular interventions. However, only few instances of perioperative VA-ECMO use have been reported in the field of vascular surgery.ConclusionThe presented cases highlight that the perioperative use of VA-ECMO may be a viable modality for required perfusion during complex planned or emergent vascular procedures.

ADP-induced platelet reactivity and bleeding events in patients with acute myocardial infarction complicated by cardiogenic shock

While previous reports showed ADP-induced platelet reactivity to be an independent predictor of bleeding after PCI in stable patients, this has never been investigated in patients with cardiogenic shock. The association of bleeding events with respect to ADP-induced platelet aggregation was investigated in patients undergoing primary PCI for acute myocardial infarction complicated by cardiogenic shock and with available on-treatment ADP-induced platelet aggregation measurements. Out of 233 patients, 74 suffered from a severe BARC3 or higher bleed. ADP-induced platelet aggregation was significantly lower in patients with BARC≥3 bleedings (p < .001). Multivariate analysis identified on-treatment ADP-induced platelet aggregation as an independent risk factor for bleeding (HR = 0.968 per AU). An optimal cutoff value of <12 AU for ADP-induced platelet aggregation to predict BARC≥3 bleedings was identified via ROC analysis. Moreover, the use of VA-ECMO (HR 1.972) or coaxial left ventricular pump (HR 2.593), first lactate (HR 1.093 per mmol/l) and thrombocyte count (HR 0.994 per G/l) were independent predictors of BARC≥3 bleedings. In conclusion, lower on-treatment ADP-induced platelet aggregation was independently associated with severe bleeding events in patients with AMI-CS. The value of platelet function testing for bleeding risk prediction and guidance of anti-thrombotic treatment in cardiogenic shock warrants further investigation.

Use and clinical outcome of veno-arterial extracorporeal membrane oxygenation in patients with acute pulmonary embolism and cardiopulmonary resuscitation

Abstract Funding Acknowledgements Type of funding sources: None. Background Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy for patients with acute pulmonary embolism (PE) and concomitant cardiac arrest with the necessity of cardiopulmonary resuscitation (CPR). Little is known about the use and clinical outcome of veno-arterial (VA)-ECMO and adjunctive treatment strategies in patients with acute PE and CPR. Purpose In this context, we aimed to investigate the use of VA-ECMO alone or after systemic thrombolysis and its impact on in-hospital outcomes of patients with acute PE and CPR. Methods We analyzed data on the characteristics, treatments and in-hospital outcomes for all patients with acute PE (ICD-code I26) and CPR in Germany between the years 2005 and 2018 (source: Research Data Center (RDC) of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005-2018, own calculations). Results Between 2005 and 2018, 1,172,354 patients with acute PE (53.5% females) were included in this analysis; of those, 77,196 (6.5%) presented with cardiac arrest and CPR. While more than one fourth of those patients were treated with systemic thrombolysis alone (n = 20,839 patients; 27.0%), a minority received a combination of thrombolysis + VA-ECMO (n = 165; 0.2%) or singular approach with VA-ECMO treatment alone (n = 588; 0.8%). The overall in-hospital mortality rate of PE patients with cardiac arrest was high with 83.8%. Non-survivors were considerable older than survivors (74 [IQR 63-81] vs. 69 [58-77]). In patients treated with VA ECMO alone the mortality rate was 71.1% and 69.7% when patients received Thrombolysis + VA-ECMO. Patients, who received thrombolysis without VA-ECMO had a higher mortality rate (83.8%). In order to investigate the impact of those different treatment strategies, a multivariate logistic regression analysis (adjusted for age, sex and comorbidities) demonstrated the lowest risk for in-hospital death in patients, who underwent the combination of Thrombolysis + VA-ECMO (OR, 0.61 [95% CI, 0.43-0.86], P = 0.004) or VA-ECMO alone (OR, 0.70 [0.58-0.84], P &amp;lt; 0.001) compared to patients without VA-ECMO and without thrombolysis. Use of thrombolysis alone in patients with PE and CPR lowering the risk regarding in-hospital death as well (OR, 0.95 [0.91-0.99], P = 0.013). Regarding temporal trends, the annual use of VA-ECMO increased from 0 in the year 2005 to the number of 138 in 2018 (ß 6.13 (4.62-6.76); p &amp;lt; 0.001) as well as for the combined treatment Thrombolysis + VA-ECMO (from 0 to 39 [ß 4.28 (3.68-4.89); p &amp;lt; 0.001]). Conclusion Patients with acute PE and CPR had a very high in-hospital mortality rate. Our data suggest, that VA-ECMO alone or after systemic thrombolysis should be considered as an option in this outstanding life-threatening situation to improve in-hospital outcome. Furthermore, our data highlight a marked increase in the number of PE patients treated with VA-ECMO indicating the structural health care progress between 2005 and 2018.

The validity of SOFA score to predict mortality in adult patients with cardiogenic shock on Veno-Arterial Extracorporeal Membrane Oxygenation

Abstract Funding Acknowledgements Type of funding sources: None. Background veno-arterial ECMO is increasingly used in resuscitation of adults patients with cardiogenic shock with variable mortality reports worldwide. Our objectives were to study the variables associated with hospital mortality and to determine the validity of the Sequential Organ Failure Assessment (SOFA) score for prediction of hospital mortality . Results : one hundred and six patients were retrospectively included in our study between 2015 and 2019 with in-hospital mortality of 56.6% . The mean age of patients was 40.2 ± 14.4 years and mostly males (69.8%) with a mean BMI of 26.5 ± 7 . Presence of CKD , chronic AF , cardiotomies were significantly more frequent in the non-survivors group . The non-survivors had more frequent AKI , more haemodialysis , more GI bleeding , more ICH, higher peak and 24 hours blood lactate and less ICU days as compared to the survivors group. Initial SOFA score ≥ 13 had a 85 % sensitivity and 73.9 % specificity [AUROC = 0.862 , 95% CI: 0.791 – 0.932 ; p &amp;lt;0.001 ] while SOFA score ≥ 13 at day 3 had 100 % sensitivity and 91.3 % specificity for predicting mortality [AUROC =0.995 , 95% CI : 0.986 – 1 ; p &amp;lt;0.001 ]. SOFA score ≥ 15 at day 5 had 98 % sensitivity and 100 % specificity for predicting mortality [AUROC =0.994 , 95% CI : 0.982 – 1 ; p &amp;lt;0.001 ]. The Δ 1 SOFA (3-1) ≥ 2 had 95% sensitivity and 93.5% specificity [AUROC = 0.958 , 95% CI: 0.913 – 1 ; p &amp;lt;0.001 ] while the Δ 2 SOFA (5-1) ≥ 2 had 90% sensitivity and 97.8% specificity for predicting hospital mortality [AUROC = 0.958 , 95% CI: 0.909 – 1 ; p &amp;lt;0.001 ] . Increasing Δ 1 SOFA score (OR = 2.506, 95% CI : 1.681 – 3.735,p &amp;lt; 0.001) and increasing lactate level (OR = 1.388 , 95% CI : 1.015 – 1.898 , p = 0.04) were significantly associated with hospital mortality . Conclusion: the use of VA-ECMO in adult patients with cardiogenic shock is still associated with high mortality . Serial evaluation with SOFA score during first few days of VA-ECMO support is a good predictor of hospital mortality . Increase of SOFA score after 48 hours and hyperlactataemia are significantly associated with increased hospital mortality. Predictors of hospital mortality.Studied variablesP valueOR95% CI for ORCentral VA-ECMO0.2483.1020.455 - 21.154lactate peak level0.0401.3881.015 - 1.898Haemodialysis0.7121.6140.127 - 20.473Δ 1 SOFA (3-1)&amp;lt; 0.0012.5061.681 - 3.735GI bleeding0.9170.8910.102 - 7.815ICH0.42414.5850.020 - 204.51Abstract Figure. SOFA scoring of studied VA-ECMO patients

ADP-induced platelet reactivity and bleeding events in patients with acute myocardial infarction complicated by cardiogenic shock

Abstract Funding Acknowledgements Type of funding sources: None. Background While previous reports showed ADP-induced platelet reactivity to be an independent predictor of bleeding after PCI in stable patients, this has never been investigated in patients with cardiogenic shock (CS). Methods The association of bleeding events with respect to ADP-induced platelet aggregation was investigated in patients undergoing primary PCI for acute myocardial infarction complicated by cardiogenic shock (AMI-CS) and with available on-treatment ADP-induced platelet aggregation measurements. Results Out of 233 patients, 74 suffered from a severe BARC 3 or higher bleed. ADP-induced platelet aggregation was significantly lower in patients with BARC≥3 bleedings (10 AU [IQR 3 - 13] vs. 15 AU [IQR 9 - 25], p &amp;lt; 0.001). Multivariate analysis identified on-treatment ADP-induced platelet aggregation as an independent risk factor for bleeding (HR = 0.968 per AU, 95% confidence interval (CI) 0.942-0.994). An optimal cut-off value of &amp;lt;12 AU for ADP-induced platelet aggregation to predict BARC≥3 bleedings was identified via ROC analysis. Moreover, use of VA-ECMO (HR 1.972, 95% CI 1.003-3.879) or coaxial left ventricular pump (HR 2.593, 95% CI 1.509-4.455), first lactate (HR 1.093 per mmol/l, 95% CI 1.037-1.152) and thrombocyte count (HR 0.994 per G/l, 95% CI 0.990-0.998) were independent predictors of BARC≥3 bleedings. There was no significant difference in survival nor ischemic events between patients with low and high on-treatment platelet reactivity. Conclusion: Lower on-treatment ADP-induced platelet aggregation was independently associated with severe bleeding events in patients with AMI-CS. The value of platelet function testing for bleeding risk prediction and guidance of anti-thrombotic treatment in CS warrants further investigation.

Impact of Mitral Valve Prosthesis on Stroke after Insertion of Veno-Arterial Membrane Oxygenation for Postcardiotomy Shock

Purpose Veno-arterial membrane oxygenation (VA-ECMO) is used in profound postcardiotomy shock (PCS). Previous study raised the possibility that use of VA-ECMO after mitral valve replacement (MVR) may pose a risk of valve thrombosis and embolism including stroke likely due to low transvalvular flow. This study focused on stroke after valve surgery requiring VA-ECMO. Methods Of 482 adult patients undergoing VA-ECMO from January 2011 to July 2020, 113 received VA-ECMO for PCS: coronary artery bypass Grafting (CABG): N=44; Mitral valve repair: N=12; Aortic valve replacement (AVR), N=28; MVR, N=29. Precautions taken to limit thromboembolism included: (1) low VA-ECMO flows were maintained between 1.5-2.2 L /min/m2, if possible, to provide hemodynamic support while maximizing trans-valvular flow and prosthesis washing; (2) anticoagulation was initiated within 24 hours postoperatively; (3) A bioprosthesis was used for 98.2% of valve replacements. The incidence of stroke and survival to discharge were primary outcomes. Results Peripheral VA-ECMO cannulation was performed in 87.6% (CABG, 79.5%; MV repair, 100%; AVR, 96.4%; and MVR 86.2%, p=0.483). Of these, 65.7% of peripheral cannulation was axillary VA-ECMO. The overall survival for PCS was 57.5%, with an incidence of stroke of 11.5% (CABG, 6.8%; MV repair, 8.3%; AVR, 10.7%; and MVR 20.7%; CABG or MV repair vs MVR, p=0.066; CABG or MV repair vs. AVR, p=0.889). Median support length of VA-ECMO was 6 days. In 6 patients who had stroke after MVR, 5 patients (83.3%) developed stroke after decannulation with a median interval of 1 day. The incidence of postoperative atrial fibrillation was 15.9%, 25%, 28.6%, and 32.1%, respectively (P=0.405). In univariable logistic regression analysis, MVR was a predisposing factor for postoperative stroke (odds ratio: OR, 3.39: p=0.078), but AVR (OR, 1.56: p=0.579) and central cannulation (OR, 3.03: p=0.178) were not. Conclusion The incidence of stroke after MVR was significant in PCS requiring VA-ECMO which suggests that an intracardiac embolic source may cause stroke with recovery of heart function. An alternative mechanical support or treatment strategy may be considered after MVR given the high rate of stroke during VA-ECMO support.

Changes in Waitlist Survival for Patients Bridged by VA-ECMO in the United States

<h3>Purpose</h3> Patients supported by VA-ECMO are prioritized for heart transplantation under the new United States donor allocation system, which is intended to decrease their waitlist mortality. The use of VA-ECMO as a bridge to transplant (BTT) has increased under the new system, which may lead to shifts in the characteristics of the VA-ECMO BTT population. We hypothesize that 1) the rate of waitlist death or delisting for VA-ECMO BTT is lower under the new allocation system and 2) this improvement is mediated by a shorter waitlist duration. <h3>Methods</h3> Using the United Network for Organ Sharing database, we analyzed all adult patients listed for heart transplant between 1/1/2014 and 6/12/2020 who were on VA-ECMO at listing. Waitlist entry after October 18, 2018 defined the new allocation system. We used Fine-Gray competing risk models to analyze the subdistribution relative hazard (_sdRH) of death or delisting while accounting for the competing risk of successful transplant, with adjustment for baseline characteristics. Risk of death may increase with additional waitlist duration, so we compared separate models conditional on survival (without transplant) to days 7 and 14. <h3>Results</h3> VA-ECMO was present at listing in 238 patients in the old system and 163 in the new system, with comparable baseline characteristics. Under the old system, waitlist death or delisting occurred in 125 patients (53%), with 108 (45%) transplanted and median time to transplant 51 days (IQR 11 to 228). In the new system, death or delisting occurred in 29 patients (18%), with 125 (77%) transplants and median time to transplant 4 days (IQR 2 to 7). The adjusted risk of death or delisting decreased by 73% in the new system (_sdRH 0.27, 95%CI 0.17-0.42, P<0.001) (<b>Figure</b>). In time-updated models, this improvement was mediated entirely by a shorter time to transplant. <h3>Conclusion</h3> For patients bridged to heart transplant with VA-ECMO, the risk of waitlist death or delisting is significantly lower in the new allocation system. This improvement is mediated by a shorter time to transplant.

Five-year survival after post-cardiotomy veno-arterial extracorporeal membrane oxygenation.

Veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) support for post-cardiotomy cardiogenic shock (PCS) after adult cardiac surgery is associated with satisfactory hospital survival. However, data on long-term survival of these critically ill patients are scarce. Between January 2010 and March 2018, 665 consecutive patients received VA-ECMO for PCS at 17 cardiac surgery centres and herein we evaluated their 5-year survival. The mean follow-up of this cohort was 1.7 ± 2.7 years (for hospital survivors, 4.6 ± 2.5 years). In this cohort, 240 (36.1%) patients survived to hospital discharge. Five-year survival of all patients was 27.7%. The PC-ECMO score was predictive of 5-year survival in these patients (0 point, 50.9%; 1 point, 44.9%; 2 points, 40.0%; 3 points, 34.7%; 4 points, 21.0%; 5 points, 17.6%; ≥6 points, 10.7%; P < 0.0001). Age was among factors independently associated with late survival, patients >70 years old having a remarkably poor 5-year survival (<60 years: 39.2%; 60-69 years: 29.9%; 70-79 years: 12.3%; ≥80 years: 13.0%, P < 0.0001). Implantation of a ventricular assist device or heart transplant was performed in 3.2% of patients and their 5-year survival was 42.9% (for heart transplant, 63.6%). Veno-arterial extracorporeal membrane oxygenation for PCS is associated with satisfactory 5-year survival in young patients without critical pre-ECMO conditions. The use of VA-ECMO for PCS in patients >70 years should be considered only after a judicious scrutiny of patient's life expectancy. Future studies should evaluate whether satisfactory mid-term survival of these patients translates into a good functional outcome. Clinicaltrials.gov-NCT03508505.

Combined use of VA-ECMO and IMPELLA (ECPELLA) as a possible strategy to improve outcomes in patients who underwent E-CPR

Abstract Background Extracorporeal Cardio-Pulmonary Resuscitation (E-CPR) is an effective tool for patients with refractory cardiac arrest (CA). Since VA-ECMO provides strong afterload, IABP is often used to increase left ventricular load. Recently, in Japan, the effectiveness of VA-ECMO in combination with IMPELLA, a forward flow mechanical circulatory support device (ECPELLA) is gaining attention. Purpose We investigated usefulness of ECPELLA in patients with refractory CA. Method We reviewed 133 patients that had E-CPR from January 2012 through January 2020 {mean age: 67±15 years, male 65%, Out of hospital Cardiac Arrest (OHCA) 35%, Acute coronary Syndrome (ACS) 54%}. We divided these patients into ECMO with IMPELLA (ECPELLA group), ECMO with IABP (IABP group) and ECMO alone (ECMO alone group). The primary endpoint is 30-day survival and good neurological prognosis defined as CPC (cerebral performance categories) 1 or 2. Result During the study period, of the 133 patients, there were 20 in the ECPELLA group, 78 in the IABP group, 35 in the ECMO alone group. There were no significant differences in age in all three groups. There were more males, shockable rhythm, OHCA and ACS in the ECPELLA and IABP groups compared to the ECMO alone group. But there was no significant difference between the ECPELLA and IABP groups. Compared with other groups, ECPELLA had the shortest time from cardiac arrest to ECMO placement. Regarding endpoints, the rate of 30-day survival and favorable neurological prognosis were higher in the ECPELLA group, followed by the IABP group and then the ECMO alone group. (ECPELLA: 55% vs. IABP: 23% vs. ECMO alone: 9%; P=0.0009, ECPELLA: 35% vs. IABP: 13% vs. ECMO alone: 9%; P=0.04) Next, Kaplan Meier analysis was performed to analyze 30-day all-cause mortality. The ECPELLA group had a significantly higher survival rate (P=0.01 by log-rank test). Multivariate cox proportional hazard analysis including the age, OHCA, shockable rhythm, ACS, Collapse-to-ECMO under 60 min revealed that the age (hazard ratio [HR], 1.28 (10 years increase), 95% confidence interval [CI], 1.08–1.53, P=0.004) and Collapse-to-ECMO under 60 min (HR, 0.37, 95% CI, 0.21–0.68, P=0.001) or ECPELLA (HR, 0.46, 95% CI, 0.20–0.694, P=0.03) were significantly associated with mortality. Conclusion ECPELLA used with E-CPR is an effective tool to improve mortality and neurologic status. Funding Acknowledgement Type of funding source: None

The Validity of SOFA Score to Predict Mortality in Adult Patients with Cardiogenic Shock on Venoarterial Extracorporeal Membrane Oxygenation.

Background Venoarterial ECMO is increasingly used in resuscitation of adult patients with cardiogenic shock with variable mortality reports worldwide. Our objectives were to study the variables associated with hospital mortality in adult patients supported with VA-ECMO and to determine the validity of repeated assessments of those patients by the Sequential Organ Failure Assessment (SOFA) score for prediction of hospital mortality. We retrospectively studied adult patients admitted to the cardiac surgical critical care unit with cardiogenic shock supported with VA-ECMO from January 2015 to August 2019 in our tertiary care hospital. Results One hundred and six patients supported with VA-ECMO were included in our study with in-hospital mortality of 56.6%. The mean age of studied patients was 40.2 ± 14.4 years, and the patients were mostly males (69.8%) with a mean BMI of 26.5 ± 7 without statistically significant differences between survivors and nonsurvivors. Presence of CKD, chronic atrial fibrillation, and cardiac surgeries was significantly more frequent in the nonsurvivors group. The nonsurvivors had more frequent AKI (p < 0.001), more haemodialysis use (p < 0.001), more gastrointestinal bleeding (p = 0.039), more ICH (p = 0.006), and fewer ICU days (p = 0.002) compared to the survivors group. The mean peak blood lactate level was 11 ± 3 vs 16.7 ± 3.3, p < 0.001, and the mean lactate level after 24 hours of ECMO initiation was 2.2 ± 0.9 vs 7.9 ± 5.7, p < 0.001, in the survivors and nonsurvivors, respectively. Initial SOFA score ≥13 measured upon ICU admission had a 85% sensitivity and 73.9% specificity for predicting hospital mortality [AUROC = 0.862, 95% CI: 0.791–0.932; p < 0.001] with 81% PPV, 79.1% NPV, and 80.2% accuracy while SOFA score ≥13 at day 3 had 100% sensitivity and 91.3% specificity for predicting mortality with 93.8% PPV, 100% NPV, and 96.2% accuracy [AUROC = 0.995, 95% CI: 0.986–1; p < 0.001]. The ∆1 SOFA (3-1) ≥2 had 95% sensitivity and 93.5% specificity for predicting hospital mortality [AUROC = 0.958, 95% CI: 0.913–1; p < 0.001] with 95% PPV, 93.5% NPV, and 94.3% accuracy. SOFA score ≥15 at day 5 had 98% sensitivity and 100% specificity for predicting mortality with 99% accuracy [AUROC = 0.994, 95% CI: 0.982–1; p < 0.001]. The ∆2 SOFA (5-1) ≥2 had 90% sensitivity and 97.8% specificity for predicting hospital mortality [AUROC = 0.958, 95% CI: 0.909–1; p < 0.001] with 97.8% PPV, 90% NPV, and 94.8% accuracy. Multivariable regression analysis revealed that increasing ∆1 SOFA score (OR = 2.506, 95% CI: 1.681–3.735, p < 0.001) and increasing blood lactate level (OR = 1.388, 95% CI: 1.015–1.898, p = 0.04) were significantly associated with hospital mortality after VA-ECMO support for adults with cardiogenic shock. Conclusion The use of VA-ECMO in adult patients with cardiogenic shock is still associated with high mortality. Serial evaluation of those patients with SOFA score during the first few days of ECMO support is a good predictor of hospital mortality. Increase in SOFA score after 48 hours and hyperlactataemia are significantly associated with increased hospital mortality.

A case report of thrombotic complete obstruction of the ascending aorta as a complication of Venoarterial extracorporeal membrane oxygenation support: steps to prevent thrombosis

BackgroundVenoarterial extracorporeal membrane oxygenation (VA-ECMO) is an essential device in the field of emergency and intensive-care medicine. However, long-term use of VA-ECMO has various severe complications, including thrombosis.Case presentationA 60-year-old man underwent his third aortic root replacement using a homograft because of infectious endocarditis. Although the operation was difficult because of severe adhesion caused by the two previous interventions, aortic root replacement using a homograft was performed. At the time of withdrawal from cardiopulmonary bypass, the maintenance of hemodynamics was difficult because of bleeding from the surgical site, leading to hypovolemic shock. Cardiac function subsequently deteriorated; therefore, VA-ECMO was established and the operation was finished. Three days later, thrombus was formed inside the homograft and completely occluded ascending aorta. Evacuation of hematoma was performed, however, cardiac function was not ameliorated. Eventually, the patient had brain infarction and died. To prevent thrombus formation in very severe low cardiac output cases under VA-ECMO management after surgery, to prevent the stagnation of the blood flow from VA-ECMO will be necessary because anticoagulant therapy will be difficult. Impella ventricular assist device which is recently used widely generates anterograde blood flow and effectively prevents stagnation.ConclusionsTo prevent thrombus formation in cases of very severe low cardiac output, Impella® should be combinatorially introduced from the beginning of VA-ECMO establishment to prevent thrombosis.

Therapeutic management of severe hypothermia with veno-arterial ECMO: where do we stand? Case report and review of the current literature

BackgroundSevere accidental hypothermia is associated with high morbidity and mortality. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides an efficient rewarming method with complete cardiopulmonary support. The use of VA-ECMO for this indication has greatly improved the vital and functional prognosis of patients.Case presentationWe report a case of a 46-year-old patient who was treated for severe hypothermia with a temperature of 22.4 °C along with initial cardiac arrest, whose progression was favorable after the implementation of VA-ECMO support. Two months after initial cardiac arrest, the patient was reassessed and showed signs of complete recovery with regard to his mental and physical capacities.ConclusionsThe recent international publications and groups of experts recommend the use of VA ECMO as the gold standard therapy to treat severe hypothermia. Therefore, it seems suitable to update the current knowledge on the topic by analysing the latest international publications. The performance of this technique calls into question ethical and economic factors. Two distinct medical teams tried to identify and regroup prognosis factors in predictive survival scores. They raise the question of the utility of these scores in clinical practice. Indeed, according to which survival rate should we proceed to prolonged resuscitation and implement VA-ECMO? Additional studies will be needed for external approval of these survival scores, and additional reflection by experts will be required.

Extracorporeal Membrane Oxygenation for Early Graft Dysfunction Following Heart Transplantation: A Systematic Review and Meta-Analysis

Early graft dysfunction (EGD) is a major cause of morbidity and mortality following heart transplantation (HT). The rate of severe EGD requiring inotropes and/or mechanical circulatory support such as veno-arterial extracorporeal membrane oxygenation (VA ECMO) ranges from 8-20%. Our objective was to systematically review studies that reported on mortality in adult HT recipients who developed severe EGD requiring VA ECMO and conduct a meta-analysis. A systematic search of the literature was conducted until June 1, 2019. Eligible studies included full texts and abstracts published after 2009, ≥10 adults post-HT who developed EGD requiring VA ECMO and reported on mortality. The primary outcome of short-term mortality was defined as death at 30 days and/or hospital discharge and was analysed using a random effects model. A meta-regression analysis to explore heterogeneity based on a priori defined factors was performed. The quality of the evidence was assessed using the GRADE framework. Of 17 305 publications screened, 22 observational studies identified 242 deaths in 670 patients from 1987-2018 (Figure). 21 studies (95%) were retrospective and most (86%) were conducted at a single centre. The quality of the evidence was rated as moderate. 14 studies (64%) included patients requiring VA ECMO within 24h post-HT; the rest included an extended early post-HT period (up to 7 days). The median age of patients was 49 yrs (IQR 36-62), 18% (IQR 13-29) were female, 47% (IQR 39-77) had a prior sternotomy, and ischemic time was 198 (IQR 191-224) min. Pooled short-term mortality was 36.8% (95% CI 28.7-43.3, I2 =70%). In the meta-regression, short-term mortality was higher in studies with a higher proportion of females. The use of VA ECMO for EGD post-HT is associated with significant clinical benefit with acceptable short-term survival. Future studies are needed to identify factors that may further improve outcomes for patients who experience EGD.

Eating Cheerios on ECMO: The Use of VA ECMO as a Bridge to Lung Transplant in an Infant

Pulmonary veno-occlusive disease (PVOD) is a rare cause of pulmonary hypertension. In PVOD the pulmonary venous vessels are obliterated resulting in obstructive pulmonary vascular disease, increase in pulmonary vascular resistance, right heart failure and death. Pulmonary hypertension is the most common reason for lung transplant in infants. Lung transplant is the only therapy for PVOD. Prolonged intubation, deconditioning and extra corporeal life support are associated with poor outcomes after lung transplant. We present a case of PVOD in an infant who had successful lung transplant using a novel veno-arterial extracorporeal membrane oxygenation (VA ECMO) configuration. A previously healthy 15-month-old male presented with cough and tachypnea. Cardiomegaly and pulmonary edema were seen on chest x-ray. Echocardiogram revealed severe pulmonary hypertension. Cardiac catheterization study and chest computed tomography revealed PVOD. He was unable to be extubated after cardiac catheterization and was transferred to our institution for lung transplant evaluation. He had severely depressed right ventricular function, requiring vasopressors to maintain hemodynamic stability. Respiratory status was tenuous, requiring sedation and paralysis. He was evaluated and listed for lung transplant. The patient was centrally cannulated for VA ECMO using cannulae for a ventricular assist device (Berlin ExCor) that were exteriorized on the abdomen. "Venous" inflow cannula was placed in the main pulmonary artery to provide afterload reduction for the right ventricle. After starting VA ECMO, vasopressor support, respiratory support, paralysis and sedation were weaned. He was woken up, extubated; and intensive physical and occupational rehabilitation began. He regained strength, was able to sit, stand and take steps. He also regained his milestones, was able to babble, wave and eat simple foods. The patient remained on VA ECMO for 61 days until he successfully underwent lung transplantation. Our case highlights the successful use of a novel VA ECMO configuration as a bridge to lung transplant in an infant with PVOD. To our knowledge this is the youngest patient to undergo awake VA ECMO reported. The use of a unique cannulation allowed for rehabilitation while on VA ECMO. Though challenging, VA ECMO remains an option as a bridge to lung transplant in infants with PVOD.

2498 ECMO: A Bridge to Liver Transplant

INTRODUCTION: ECMO has been rarely used in the perioperative setting during liver transplantation (LT) and there is scarce data on its use. Many patients requiring LT have cardiopulmonary compromise due to complications of liver disease or other co-morbidities. We present a use of VA-ECMO as cardiopulmonary support during LT in a patient with pulmonary hypertension. CASE DESCRIPTION/METHODS: A 57-year-old man with a medical history of ETOH cirrhosis complicated by recurrent ascites, portal hypertension, and hypothyroidism was admitted for management of fluid overload despite compliance with low-salt diet and diuretics. He had multiple prior hospitalizations for fluid overload which were managed with intravenous diuretics. He was listed for liver and kidney transplant in New York. He was eventually started on hemodialysis for end stage kidney failure secondary to hepatorenal syndrome. He also had severe pulmonary hypertension (PH). He had an offer for liver transplant and went to the operating room (OR). However, a Swan-Ganz catheter was placed and showed mean PA pressure of 47 mm Hg with high cardiac output despite the use of vasodilators. After careful evaluation, his transplantation was aborted. Few weeks later, he was taken back to the OR for liver transplant and was placed on VA-ECMO electively. His cardiopulmonary status was carefully monitored and remained stable with VA-ECMO support during the procedure even with severe PH. His transplantation was successful, after which his hemodynamics improved significantly and the ECMO was removed in the OR. Subsequently, he underwent kidney transplant and his PH improved postoperatively. DISCUSSION: Severe cardiac and pulmonary dysfunction is a contraindication for LT. Hepatopulmonary syndrome is a complication of liver failure and can cause pulmonary hypertension, which was the case with our patient. Intraoperative use of ECMO, both VA and VV, have been used sparingly. However, over the recent years, the use of ECMO peri-operatively has had wider use although poor outcomes are still reported. Bleeding risk is extremely high due to the coagulopathic nature of liver disease as well as the anti-coagulation necessity during ECMO so it is imperative to limit the duration of ECMO. In conclusion, VV or VA- ECMO can be a useful therapeutic option in patients undergoing transplantation with significant cardiac or pulmonary compromise especially in New York where the waiting period for transplant is long.