VA ECMO Implantation Research Articles

Mitral bioprosthesis early dysfunction treated with transapical valvuloplasty during V-A ECMO.

We report the case of a 61-year-old male who had complications with a mitral valve (MV) bioprosthesis replacement by post-cardiotomy shock leading to VA ECMO implantation. The patient suffered early bioprosthetic valve failure owing to early thrombosis. The complication was successfully treated with a MV bioprosthesis transapical balloon valvuloplasty that restored normal leaflet mobility.

Femoro-axillary versus femoro-femoral veno-arterial extracorporeal membrane oxygenation for refractory cardiogenic shock: A monocentric retrospective study.

For veno-arterial extracorporeal membrane oxygenation (ECMO), the femoral artery is the preferred cannulation site (femoro-femoral: Vf-Af). This results in retrograde aortic flow, which increases the left ventricular afterload and can lead to severe pulmonary edema and thrombosis of the cardiac chambers. Right axillary artery cannulation (femoral-axillary: Vf-Aa) provides partial anterograde aortic flow, which may prevent some complications. This study aimed to compare the 90-day mortality and complication rates between VF-AA and VF-AF. Consecutive adult patients with cardiogenic shock who received peripheral VA-ECMO between 2013 and 2019 at our institution were retrospectively included. The exclusion criteria were refractory cardiac arrest, multiple VA-ECMO implantations due to vascular access changes, weaning failure, or ICU readmission. A statistical approach using inverse probability of treatment weighting was used to estimate the effect of the cannulation site on the outcomes. The primary endpoint was the 90-day mortality. The secondary endpoints were vascular access complications, stroke, and other complications related to retrograde blood flow. Outcomes were estimated using logistic regression analysis. VA-ECMO was performed on 534 patients. Patients with refractory cardiac arrest (n = 77 (14%)) and those supported by multiple VA-ECMO (n = 92, (17%)) were excluded. Out of the 333 patients studied (n = 209 Vf-Aa; n = 124 VF-AF), the main indications for VA-ECMO implantation were post-cardiotomy (33%, n = 109), dilated cardiomyopathy (20%, n = 66), post-cardiac transplantation (15%, n = 50), acute myocardial infarction (14%, n = 46) and other etiologies (18%, n = 62). The median SOFA score was 9 [7-11], and the crude 90-day mortality rate was 53% (n = 175). After IPTW, the 90-day mortality was similar in the Vf-Aa and VF-AF groups (54% vs 58%, IPTW-OR = 0.84 [0.54-1.29]). Axillary artery cannulation was associated with significantly fewer local infections (OR = 0.21, 95% CI:0.09-0.51), limb ischemia (OR = 0.37, 95% CI:0.17-0.84), bowel ischemia (OR = 0.16, 95% CI:0.05-0.51) and pulmonary edema (OR = 0.52, 95% CI:0.29-0.92) episodes, but with a higher rate of stroke (OR = 2.87, 95% CI:1.08-7.62) than femoral artery cannulation. Compared to VF-AF, axillary cannulation was associated with similar 90-day mortality rates. The high rate of stroke associated with axillary artery cannulation requires further investigation.

Our Experience in Using Extracorporeal Membrane Oxygenation in Patients with Refractory Cardiogenic Shock

Background Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is a critical care treatment option for patients with refractory cardiogenic shock. This method of temporary support of the cardiorespiratory system gives us and the patient time to restore organ function or is a «bridge» to other methods of treatment. Nevertheless, the issue of identifying the optimal time for VA ECMO implantation in patients with acute myocardial infarction complicated by refractory cardiogenic shock remains relevant.Aim To evaluate the efficiency of extracorporeal membrane oxygenation in various clinical situations in patients with acute myocardial infarction complicated by refractory cardiogenic shock and post-infarction damage to the valves of the heart.Material and method We present 3 patients with acute coronary syndrome complicated by refractory cardiogenic shock, of different age groups and comorbidities, who underwent veno-arterial extracorporeal oxygenation in various SCAI shock stages, and mechanical complications associated with acute myocardial infarction.Results In all the cases, stabilization of hemodynamics and heart function was achieved, and there were no hypoxic disorders of organs. In one case, a hemorrhagic complication associated with the VA ECMO procedure was noted. In one case, VA ECMO was performed as an intermediate stage for the correction of post-infarction mitral valve injury.Conclusion These clinical cases demonstrate the efficiency of the timely start of VA ECMO before the development of organ dysfunction, which allows restoring myocardial function, and helps maintain hemodynamic normalization before the cardiac surgical stage of treatment.

Impact of a multidisciplinary team "ECMO Team" on the prognosis of patients undergoing veno-arterial extracorporeal membrane oxygenation for refractory cardiogenic shock and cardiac arrest

Veno-arterial Extracorporeal membrane oxygenation (VA ECMO) is a salvage intervention in patients with cardiogenic shock (CS), and cardiac arrest (CA) refractory to standard therapies. The design of ECMO Teams has achieved the standardization of processes, although its impact on survival and prognosis is unknown. We aimed to analyze whether the creation of an ECMO Team has modified the prognosis of patients undergoing VA ECMO for refractory CS or CA. . We conducted a single-center retrospective cohort study. Patients with refractory CS or CA who underwent VA ECMO were divided in two consecutive periods: from 2014 to April 2019 (pre-ECMO T) and from May 2019 to December 2022 (Post ECMO T). The main outcomes were survival on ECMO, in-hospital survival, complications, and annual ECMO volume. Eighty-three patients were included (36 pre-ECMO T and 47 post-ECMO T). The mean age was 53 +/-13 years. The most common reason for device indication was different: postcardiotomy shock (47.2%) pre-ECMO T and refractory cardiogenic shock (29.7%) post-ECMO T. The rate of extracorporeal cardiopulmonary resuscitation was 14.5%. The median duration of VA ECMO was longer after ECMO team implementation: 8 days (IQR 5-12.5) vs. five days (IQR 2-9, p=0.04). Global in-hospital survival was 45.8% (38.9% pre-ECMO T vs. 51.1% post-ECMO T; p=0.37), and the survival rate from VA ECMO was 60.2% (55.6% pre-ECMO T vs 63.8% post-ECMO T; p= 0.50). The volume of VA ECMO implantation was significantly higher in the post-ECMO team period (13.2 +/3.5 per year vs. 6.5 +/-3.5 per year, p: 0.02). The rate of complications was similar in both groups. After the implementation of an ECMO team, there was no statistical difference in the survival rate of patients treated with VA ECMO. However, a significant increase in the number of patients supported per year was observed after the implementation of this multidisciplinary team. Post-ECMO T, the most common reason for device indication was cardiogenic shock, with longer run times and a higher rate of extracorporeal cardiopulmonary resuscitation.

Should the Vasoactive Inotropic Score be a Determinant for Early Initiation of VA ECMO in Postcardiotomy Cardiogenic Shock?

The authors investigated the role of early venoarterial extracorporeal membrane oxygenation (VA ECMO) implantation in patients with postcardiotomy cardiogenic shock (PCS) on mortality and morbidity when integrating vasoactive-inotropic score (VIS) and type of catecholamine support. A retrospective, multicenter, observational study with propensity-weight matching. Four university-affiliated intensive care units. Patients with PCS in the operating room. Early VA ECMO support. Of 2,742 patients screened during the study period, 424 (16%) patients were treated with inotropic drugs, and 75 (3%) patients were supported by VA ECMO in the operating room. Patients supported by VA ECMO had a higher use of vasopressor and inotropic drugs, with a higher VIS score. After propensity matching (integrating VIS and catecholamines type), mortality (56% v 20%, p < 0.001) and morbidity (cardiac, renal, transfusion) were higher in patients supported by VA ECMO than in a matched control group. When matching integrated the pre-ECMO VIS and the type of catecholamines, VA ECMO remained associated with high mortality and morbidity, suggesting that VIS alone should not be used as a main determinant of VA ECMO implantation.

Validation of SAVE score and the value of serum lactate in patients admitted for cardiogenic shock treated with VA-ECMO

Abstract Introduction Veno-Arterial extracorporeal membrane oxygenation (VA-ECMO) is a treatment option to provide circulatory and pulmonary support to patients with cardiogenic shock. However, a risk profile assessment is essential for an adequate selection of patients for this type of therapy. The aim of this study was to 1) validate the SAVE score in a Portuguese cohort of patients treated with VA-ECMO due to cardiogenic shock; 2) evaluate the prognostic impact of the maximum serum lactate level pre-VA-ECMO implantation; 3) assess the ability of lactate to improve risk stratification by the SAVE score. Methods We conducted a single-center retrospective analysis of patients treated with VA-ECMO due to cardiogenic shock from 2017 until 2022. Variable assessments were considered before VA-ECMO implantation. The primary outcome analyzed was in-hospital mortality. Results A total of 61 patients were included (52±12 years, 74% male, 40% with acute myocardial infarction, 54% with an ejection fraction &amp;lt;20%, and 74% in SCAI stage D pre-implantation). Overall, 38 (62%) died during hospitalization. The mean SAVE score was -1.7±7.2 points, and the median maximum serum lactate before ECMO implantation was 5.8 [2.7; 11.8] mmol/L. SAVE score showed a statistically significant association (1±5 vs. -4±7; OR 0.872 [0.789; 0.964] per each point increase; p=0.008) and good discriminative power (AUC 0.710; p=0.006) to predict in-hospital mortality. When grouping patients according to this score, 25 (41%) were classified as SAVE risk class I or II, and 36 (59%) as SAVE class III, IV, or V. Maximum serum lactate before VA-ECMO implantation also showed a significant association (4.5±3.1 vs. 9.6±6.6; OR 1.264 [1.066;1.498] per each 1mmol/l increase; p=0.007) and good discriminative power (AUC 0.771; p=0.001) to predict the primary outcome. The best lactate cut-off to identify high mortality risk was 5 mmol/l with a sensitivity of 74% and a specificity of 76%. Additionally, taking into account this threshold, lactate significantly enhanced the SAVE score group stratification, with a net reclassification improvement of 36.7% (p=0.021). Conclusion In this cohort of patients, the SAVE score was significantly associated with in-hospital mortality. Maximum serum lactate before VA-ECMO implantation was a strong predictor of in-hospital mortality and significantly improved SAVE score risk stratification.

Cardiac Troponin T level is not a predictor of mortality in patients with post-cardiotomy shock supported with venoarterial extracorporeal membrane oxygenation

Abstract Background The prognostic significance of a dominant biomarker of cardiac injury, troponin, is unexplored in patients with post-cardiotomy cardiogenic shock supported with venoarterial extracorporeal membrane oxygenation (PCCS–VA-ECMO). Aims We sought to investigate the association of early postoperative troponin T with short- and long-term mortality in patients supported with VA-ECMO in the postoperative period. Methods We analyzed 1457 troponin measurements of 102 patients with PCCS–VA-ECMO treated between 2013–2018 in a cardiosurgical and transplantation centre. We focused on the relation of troponin concentration 24–48 hours after surgery and 24–48 hours after VA-ECMO implantation and peak troponin value with VA-ECMO weaning, 90-day and one-year mortality. Results The median troponin T 24–48 hours following VA-ECMO implantation was 1338 ng/L [Q1–Q3: 526–2727, 90-day survivors 1529 ng/L (Q1–Q3: 836–5791) vs. non-survivors 1294 ng/L (Q1–Q3: 316–2657); P = 0.146]. The median peak troponin was 3583 ng/L [Q1–Q3: 1710–9238, 90-day survivors 3337 ng/L (Q1–Q3: 1863–12305) vs. non-survivors 3666 ng/L (Q1-Q3: 1462–9238); P = 0.709]. Multivariate models of troponin analysis: for VA-ECMO explanation, in-hospital, 90-day and 1-year mortality showed no relation between troponin and mortality. Age, urgency, type and number of procedures, left ventricle ejection fraction before surgery, Euroscore II result, cardiac arrest prior to VA-ECMO implantation or duration of VA-ECMO did not correlate with the extent of troponin release. The strongest risk factor for short- and long-term mortality was the need for hemodiafiltration [HR 2.4]. Conclusions Isolated early Troponin T release and peak troponin T were not associated, while organ complications were linked with VA-ECMO weaning or short- and long-term prognosis. The results underscore the multiorgan implications of PCCS in determining survival.

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&amp;lt;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.

Predictors of successful weaning from VA-ECMO: the role of CS etiology and related treatment

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a short-term mechanical circulatory support for refractory cardiogenic shock (CS). Successful weaning from VA ECMO is defined as device removal without further requirement for re-cannulation over the following 30 days. Few data exist regarding timing and reliable parameters for weaning from VA-ECMO: most study focused on echocardiographic and invasively monitored parameters during weaning trial(1,2). No data exist concerning pharmacological support and standard haemodynamic parameters in the first 24 hours since VA-ECMO implantation. Purpose We sought to evaluate hemodynamic predictors of VA-ECMO weaning. Methods Single-center retrospective observational study of patients with refractory CS who underwent VA-ECMO insertion from 2013 to 2020 in Intensive Care Unit (ICU). Primary endpoint was successful weaning from VA ECMO. Demographic, clinical, hemodynamic data within the first 24 hours and outcome were collected. We also recorded maximum dose of each vasoactive medication, Vasoactive Inotropic Score (VIS)(3) after VA-ECMO implantation and the total amount of time exposition to vasoactive drugs. Results 100 patients (26% female; 52,6±12,6 y.o.) who underwent VA-ECMO cannulation were enrolled (Table 1). 31 were successfully weaned (31%) at a median time of 140,0 [74,3-229,0] hours; 30-days mortality was 47%. 79 (79%) patients were admitted for cardiac arrest (CA); 48 (48%) had acute myocardial infarction (AMI)-CS. CA patients were less likely to be weaned: 20,3% of CA patients had successful VA-ECMO removal while 79,4% was not weaned (p &amp;lt;0,001). In the weaned group, mean blood pressure was significantly higher (75,3±18,2 vs 61,4±18,3 mmHg; p &amp;lt;0,01).Patients who successfully removed VA-ECMO had lower serum lactate (8,8±5,2 vs 11,3±5,0 mmol/L; p &amp;lt;0,05), lower fluid balance (+2,3 [0,5-5,5] vs +4,1 [1,7-8,3] L/die; p &amp;lt;0,05) and lower Sequential Organ Failure Assessment (SOFA) score (11,2±2,6 vs 13,2±3,4; p &amp;lt;0,01). Lower doses of norepinephrine was administered in patient successfully weaned (0,27±0,17 vs 0,44±0,25 mcg/kg/min; p &amp;lt;0,01). Despite not significant, lower VIS and time to exposition to vasoactive drugs amongst weaned patients were observed (p=0,08 and p=0,09, respectively). Stepwise logistic regression confirmed the worst outcome of CA patients (OR 0,64; p &amp;lt;0,001), SOFA score (OR 0,81; p &amp;lt;0,05) and time to exposition to vasoactive drugs (OR 0,81; p &amp;lt;0,05) on successful weaning from VA-ECMO. Conclusions Mortality of patients undertaking VA-ECMO still remains high. Amongst the data in the model, the strongest negative association with successful weaning from VA-ECMO was found for CA, according to the latest classification entailing CA as CS severity modifier(4). Other results show higher requirement of norepinephrine and fluid administration for vasoplegia mostly related to hypoxic organ injury and related infection (i.e. bowel translocation).

Veno-arterial extracorporeal membrane oxygenation for cardiogenic shock after acute myocardial infarction: Insights from a French nationwide database

BackgroundWe aimed to analyze the impact of timing of implantation (strategy-outcome relationship) and volume of procedures (volume-outcome relationship) on survival of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for cardiogenic shock complicating acute myocardial infarction (AMI). MethodsWe conducted an observational retrospective study through two propensity score-based analyses using a nationwide database between January 2013 and December 2019. We classified patients into early implantation (VA ECMO on the day of primary percutaneous coronary intervention [PCI]) and delayed implantation (VA ECMO beyond the day of PCI) groups. We classified patients into low- or high-volume groups based on the median hospital volume. ResultsDuring the study period 649 VA ECMO were implanted across 20 French hospitals. Mean age was 57.1 ± 10.4 years, 80% were male. Overall, 90-day mortality was 64.3%. Patients in the early implantation group (n = 479, 73.8%) did not show a statistical difference in 90-day mortality than in the delayed group (n = 170, 26.2%) (HR: 1.18; 95% CI 0.94–1.48; p = 0.153). The mean number of VA ECMO implanted during the study period by low-volume centers was 21.3 ± 5.4 as compared to 43.6 ± 11.8 in high-volume centers. There was no significant difference in 90-day mortality between high-volume and low-volume centers (HR: 1.00; 95% CI: 0.82–1.23; p = 0.995). ConclusionsIn this real-world nationwide study, we did not find a significant association between early VA ECMO implantation as well as high-volume centers and lower mortality in AMI-related refractory cardiogenic shock.

A new machine learning algorithm to predict veno-arterial ECMO implantation after post-cardiotomy low cardiac output syndrome

BackgroundPost-cardiotomy low cardiac output syndrome (PC-LCOS) is a life-threatening complication after cardiac surgery involving a cardiopulmonary bypass (CPB). Mechanical circulatory support with veno-arterial membrane oxygenation (VA-ECMO) may be necessary in the case of refractory shock. The objective of the study was to develop a machine-learning algorithm to predict the need for VA-ECMO implantation in patients with PC-LCOS. Patients and methodsPatients were included in the study with moderate to severe PC-LCOS (defined by a vasoactive inotropic score (VIS) > 10 with clinical or biological markers of impaired organ perfusion or need for mechanical circulatory support after cardiac surgery) from two university hospitals in Paris, France. The Deep Super Learner, an ensemble machine learning algorithm, was trained to predict VA-ECMO implantation using features readily available at the end of a CPB. Feature importance was estimated using Shapley values. ResultsBetween January 2016 and December 2019, 285 patients were included in the development dataset and 190 patients in the external validation dataset. The primary outcome, the need for VA-ECMO implantation, occurred respectively, in 16% (n = 46) and 10% (n = 19) in the development and the external validation datasets. The Deep Super Learner algorithm achieved a 0.863 (0.793−0.928) ROC AUC to predict the primary outcome in the external validation dataset. The most important features were the first postoperative arterial lactate value, intraoperative VIS, the absence of angiotensin-converting enzyme treatment, body mass index, and EuroSCORE II. ConclusionsWe developed an explainable ensemble machine learning algorithm that could help clinicians predict the risk of deterioration and the need for VA-ECMO implantation in moderate to severe PC-LCOS patients.

Predictors of weaning failure in case of VA ECMO implantation

The use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for the treatment of refractory cardiogenic shock has increased significantly. Nevertheless, early weaning may be advisable to reduce the potential for severe complications. Only a few studies focusing on ECMO weaning predictors are currently available. Our objective was to evaluate factors that may help predict failure during VA ECMO weaning. We included 57 patients on VA ECMO support previously considered suitable for weaning based on specific criteria. Clinical, haemato-chemical and echocardiographic assessment was considered before and after a “weaning test” (ECMO flow < 2 L/min for at least 60 min). ECMO removal was left to the discretion of the medical team blinded to the results. Weaning failure was defined as a patient who died or required a new VA ECMO, heart transplant or LVAD 30 days after ECMO removal. Thirty-six patients (63.2%) were successfully weaned off VA ECMO, of whom 31 (54.4%) after the first weaning test. In case of first test failure, 3 out of 7 patients could be weaned after a 2nd test and 3 out of 4 patients after a 3rd test. Pre-existing ischemic heart disease (OR 9.6 [1.1–83]), pre-test left ventricular ejection fraction (LVEF) ≤ 25% and/or post-test LVEF ≤ 40% (OR 11 [0.98–115]), post-test systolic blood pressure ≤ 120 mmHg (OR 33 [3–385]), or length of ECMO support > 7 days (OR 24 [2–269]) were predictors of weaning failure. The VA ECMO weaning test failed in less than 40% of patients considered suitable for weaning. Clinical and echocardiographic criteria, which are easily accessible by a non-expert intensivist, may help increase the probability of successful weaning.

Indications, outcomes and complications after ECMO implantation in the cath lab - a single-center retrospective study

Abstract Funding Acknowledgements Type of funding sources: None. Background Despite the increase of extracorporeal membrane oxygenation (ECMO) employment around the globe over the last decades, studies describing the emergency use of venoarterial (VA)-ECMO in the cardiac catheterization laboratory (CCL) are scarce. Purpose The aim of this study was to describe the patient population that received ECMO in the CCL of a tertiary care center and the associated complications and outcomes. Methods In this single-center retrospective study we reviewed the baseline clinical and laboratory characteristics, indications and outcomes of adult patients, who received VA-ECMO between 2011 and 2019. Results In the given time period, ECMO use in the CCL increased drastically. Mean age of the 83 patients was 58.3 ± 12.5 years, 78.3% were male. From 2011 to 2018 ECMO-use in the CCL increased drastically. The most common indication for ECMO implantation was cardiac arrest (66%), followed by cardiogenic shock (12%), high-risk PCI (11%), and procedure-related complications (10%). While 30-day mortality in the total study population was 69%, it varied greatly depending on the underlying indication for ECMO therapy (cardiac arrest 78%, cardiogenic shock 20%, high-risk PCI 44%, procedure-related complications 88%). The most commonly occurring complications were acute kidney injury (20%) and cannula site bleeding (20%), followed by extremity complications (19%), sepsis (18%), major bleeding (10%) and stroke (8%). Of interest, patients receiving ECMO therapy after in-hospital cardiac arrest showed greater survival rates (28.2%) as compared to patients after out of hospital cardiac arrest (18.2%; p=0.045). High serum lactate levels (p=0.018) and low baseline pH values (p=0.001) at baseline were associated with a significantly increased 30-day mortality after ECMO implantation. Conclusion The emergency use of VA-ECMO in the CCL increased over the last years and was associated with a high 30-day mortality in our study population. Still, a &amp;gt;20% survival rate in the group of patients with refractory cardiac arrest, an otherwise futile situation, suggests that VA-ECMO implantation is reasonable in selected patients. As high admission serum lactate levels and the baseline pH are strong predictors of outcome, such parameters may be used to guide decision making.

Use of mechanical pulmonary reperfusion and fibrinolysis in acute massive pulmonary embolism requiring extracorporeal membrane oxygenation support: A systematic review and meta-analysis

The optimal pulmonary revascularization strategy in acute massive pulmonary embolism (PE) requiring the implantation extra corporeal membrane oxygenation remains controversial, and data are sparse. We conducted a systematic review and meta-analysis of available evidence regarding the use of mechanical reperfusion (i.e. surgical or catheter-based embolectomy) and fibrinolytic strategies (i.e. systemic fibrinolysis, catheter-directed fibrinolysis, or as stand-alone therapy) in terms of mortality and bleeding outcomes. The literature search identified 835 studies, 17 of which were included or a total of 321 PE patients with ECMO. In total, 31.1% were treated with mechanical pulmonary reperfusion, while 78.9% received fibrinolytic strategies. The mortality rate was 23.0% in the mechanical reperfusion group and 43.1% in the fibrinolysis group ( Fig. 1 ). The pooled OR for mortality with mechanical reperfusion was 0.46 (95% CI: 0.213–0.997; I2 = 28.3%) versus fibrinolysis. The rate of bleeding in PE patients under ECMO was 29.1% in the mechanical reperfusion group and 26.0% in the fibrinolytic reperfusion (OR: 1.09; 95% CI: 0.46–2.54; I2, 0.0%) among 10 eligible studies with available bleeding data. The meta-regression model did not identify any relationship between the covariates “more than one pulmonary reperfusion therapy” and “ECMO implantation before pulmonary reperfusion therapy”, and outcomes. The results of the present meta-analysis and meta-regression suggest that surgical embolectomy yields the best results, regardless of the timing of VA-ECMO implantation in the reperfusion timeline, and regardless of whether fibrinolysis has been administered or not.

Consequences of adding standardized levosimendan infusion in VA-ECMO weaning protocol

Abstract Introduction Employment of VA-ECMO in the treatment of refractory cardiogenic shock is increasing. Weaning rates are highly variable between studies. Methods We designed a retrospective observational single-centre study in order to analyse procedural success rate after including scheduled and standardized levosimendan infusion as part of our weaning protocol. Procedural success rate includes weaning from VA-ECMO, bridging to other mechanical circulatory support (MCS) or transplantation. Results A total of 37 VA-ECMO were managed in our Cardiac Intensive Care Unit (CICU) between January 2019 and March 2021. Most frequent aetiologies are reflected in table 1. Ventricular unloading was accomplished in 62.2% (23). We included four phases in our weaning protocol as described in figure 1. Second phase was used to select patients who could benefit from levosimendan infusion. This group included patients who accomplished the following criteria: appropriate aetiological treatment of shock, tolerance for 50% VA-ECMO flow reduction, noradrenaline dose &amp;lt;0,5 ug/kg/min, inotropic score &amp;lt;10 and correction of blood lactate, kidney and liver function parameters. Levosimendan was administered in 62.2% (23). 5 patients (13.5%) were not considered candidates to benefit from levosimendan (2 of them had early systolic function recovery and 3 patients seemed to have no chance to recover). Average time from VA-ECMO implantation to levosimendan infusion was 3.6 days, with a medium dose of 0,1 ug/kg/min. Norepinephrine medium dose was 0,12 mg/kg/min, with a medium inotropic score of 3 and vasoactive-inotropic score of 16,1. Levosimendan infusion did not cause any major side effects and was well tolerated by entire cohort even though norepinephrine dose had to be slightly increased in some cases. Whole sample procedural success rate reached 64.9% (24) whereas weaning rate from VA-ECMO without further support was 51.4% (19). 5 patients were upgraded to another MCS and 4 of them survived after transplantation. The subgroup which meets inclusion criteria to levosimendan reached a procedural success rate of 82.6% (19) and a weaning rate of 73.9% (19). Differences between patients with and without levosimendan treatment were statistically significant (procedural success rate: 82.6% vs 35.7%, p 0.006, weaning rate: 73.9% vs 14.3%, p&amp;lt;0.001). Meanwhile there were no significant differences regarding in-hospital mortality rate: 47.8% (11) vs 71.4% (10), p 0.160, even though there was a downward trend in levosimendan treated patients. Most frequent causes of death are shown in table 1. Only 3 patients died due to cardiac failure (1 was rejected for cardiac surgery and 2 were not candidates to other advanced therapies). Conclusions Standardized levosimendan infusion as part of VA-ECMO weaning protocol could enhance myocardial recovery and significantly increase procedural success rate. Randomized or propensity score matching studies would be desirable to prove this hypothesis. Funding Acknowledgement Type of funding sources: None. Table 1Weaning protocol

Use of mechanical pulmonary reperfusion and fibrinolysis in acute massive pulmonary embolism requiring extracorporeal membrane oxygenation support: a systematic review and meta-analysis

Abstract Background and objectives The optimal pulmonary revascularization strategy in acute massive pulmonary embolism (PE) requiring the implantation extra corporeal membrane oxygenation remains controversial, and data are sparse. Methods We conducted a systematic review and meta-analysis of available evidence regarding the use of mechanical reperfusion (i.e. surgical or catheter-based embolectomy) and fibrinolytic strategies (i.e. systemic fibrinolysis, catheter-directed fibrinolysis, or as stand-alone therapy) in terms of mortality and bleeding outcomes. Results The literature search identified 835 studies, 17 of which were included or a total of 321 PE patients with ECMO. In total, 31.1% were treated with mechanical pulmonary reperfusion, while 78.9% received fibrinolytic strategies. The mortality rate was 23.0% in the mechanical reperfusion group and 43.1% in the fibrinolysis group (Figure). The pooled OR for mortality with mechanical reperfusion was 0.46 (95% CI, 0.213–0.997; I2=28.3%) versus fibrinolysis. The rate of bleeding in PE patients under ECMO was 29.1% in the mechanical reperfusion group and 26.0% in the fibrinolytic reperfusion (OR, 1.09; 95% CI, 0.46–2.54; I2=0.0%) among 10 eligible studies with available bleeding data. The meta-regression model did not identify any relationship between the covariates “more than one pulmonary reperfusion therapy” and “ECMO implantation before pulmonary reperfusion therapy”, and outcomes. Conclusions The results of the present meta-analysis and meta-regression suggest that surgical embolectomy yields the best results, regardless of the timing of VA-ECMO implantation in the reperfusion timeline, and regardless of whether fibrinolysis has been administered or not. Funding Acknowledgement Type of funding sources: None.

Emergency veno-arterial extracorporeal membrane oxygenation (VA ECMO)-supported percutaneous interventions in refractory cardiac arrest and profound cardiogenic shock

AimsWe investigated the spectrum of emergency veno-arterial extracorporeal membrane oxygenation (VA ECMO)-supported interventions including percutaneous coronary intervention (PCI), transcatheter aortic valve implantation (TAVI) and invasive electrophysiology (EP). Methods and resultsBetween June 2010 and February 2020, 52 consecutive patients underwent VA ECMO implantation for refractory cardiac arrest (E-CPR) and 78 for profound cardiogenic shock. Percutaneous interventions on VA ECMO included PCI (n = 29), TAVI (n = 4) and EP (n = 1). Surgical interventions were cardiac (n = 36) or non-cardiac (n = 5). During PCI, ECMO flow was maintained at 2.7 ± 1.0 L/min. Of the 40 treated lesions, 48% were located on left anterior descending and 20% on the left main artery. An average 2.0 ± 1.8 DES/patient with diameter 3.2 ± 0.5 mm and stented length 41 ± 35 mm were implanted. PCI success was 83%. TAVI was performed in 4 patients with left ventricular ejection fraction 21 ± 10% and mean aortic valve gradient 41 ± 5 mmHg. After successful valve implantation supported by 1.4 ± 0.1 L/min ECMO flow, mean gradient decreased to 11 ± 5 mmHg without significant aortic regurgitation. In one patient radiofrequency ablation of His bundle followed by permanent pacemaker implantation was performed under ECMO flow of 2.8 L/min. Overall survival to hospital discharge with good neurological recovery was 29% in E-CPR and 44% in profound cardiogenic shock. ConclusionsOur study showed feasibility and effectiveness of VA ECMO-supported percutaneous interventions in patients with profound hemodynamic collapse.

Adequate anticoagulation and ECMO therapy in COVID-19 patients with severe pulmonary embolism

SARS-CoV-2 (COVID-19) infections have been recently shown to be associated with a high rate of thromboembolic events due to pro-coagulative mechanisms that have not yet been fully understood. This paper reports on a 55-year-old female COVID-19 patient with severe ARDS and pulmonary embolism (PE) complicated by cardiogenic shock after 12 days of hospitalization under initial prophylactic anticoagulation with low molecular weight heparin (LMWH). An ultima-ratio va (veno-arterial) ECMO implantation and subsequent rapid upgrade to vvaECMO due to insufficient oxygenation was performed. The patient developed severe coagulopathy with intrapulmonary bleeding. The present report aims to highlight and discuss the pros and cons of various anticoagulation strategies in COVID-19 patients focusing on current scientific debates to address this frequently observed complication in the current situation worldwide.

Early and long-term outcomes of extracorporeal membrane oxygenation support in refractory cardiogenic shock for non-surgical patients: nine years experience at our Institute

Abstract Purpose Venoarterial extracorporeal membrane oxygenation (VA-ECMO) support is ultimately applied in refractory cardiogenic shock and is associated with high in-hospital mortality. We sought to describe the characteristics and analyze early and long-term outcomes of patients with refractory cardiogenic shock at our institution as well as our approach to patient selection. Methods This single-center retrospective study used the ECMO database from the cardiac surgery department to identify all patients with refractory cardiogenic shock at our Institute. VA-ECMO for patients with postcardiotomy shock, on-going cardiopulmonary resuscitation and venovenous ECMO were excluded. Primary endpoint was in-hospital mortality after VA-ECMO. Secondary outcomes were early complications on VA-ECMO and long-term survival after hospital discharge. Refractory cardiogenic shock was defined by either hypotension or end-organ failure despite adequate inotropic support. Results All patients with refractory cardiogenic shock were admitted to our cardiological ICU and our Heart team was systematically consulted. This team was mainly composed of transplant and LVAD cardiologists and cardiac surgeons specialized in ECMO. After case discussion, the decision for VA-ECMO implantation as a bridge therapy was made if the patient was deemed candidate to advance heart failure treatment. VA-ECMO was rapidly implanted by cardiac surgeons at bedside or in operating room with a median time from decision to implantation of 150 minutes (IQR: 100–233). Fifty-nine patients underwent VA-ECMO for refractory cardiogenic shock between 2010–2019. Patients were 52.1±14.5 years old, 75% were male and more than 90% were not known for any prior cardiac history. The indication for VA-ECMO support was acute myocardial infarction in 34 patients (58%) with reduced LVEF, mitral regurgitation, arrhythmia storm or ventricular septal defect. Myocarditis occurred in 19% of patients. The median LVEF was 13% (IQR: 10–31). Peripheral cannulation was most frequently implanted (92%). During VA-ECMO support, 43 patients survived and 16 patients died. Figure 1 shows weaning strategies for patients who survived VA-ECMO support. Of these, 37 patients survived up to discharge (86%). After a median follow-up of 2.9 years (IQR: 1.8–4.8), 92% were alive. The median time on VA-ECMO support was 4.9 days (IQR 3.5–7.6). Complications were bleeding needing reoperation (41%), pneumonia (41%), renal failure requiring dialysis (39%) and limb ischemia (17%). Conclusion In our experience, venoarterial ECMO is a feasible and acceptable alternative to support patients with refractory cardiogenic shock despite inotropic agents. Interestingly, the survival rate was particularly high as compared to the literature. This could be explained by patient selection and early VA-ECMO implantation. Evolution of patients after ECMO Funding Acknowledgement Type of funding source: None

Is primary graft failure still a challenge in time of venoarterial extracorporeal membrane oxygenation?

Abstract Introduction Primary graft failure (PGF) is the leading cause of early mortality after heart transplantation (HT). Its increasing incidence during the last decade may be triggered by the disbalance between receptors and donors that forces the acceptance of suboptimal organs. Purpose The aim of our work was to analyse the mechanical circulatory support (MCS) with VA-ECMO in refractory to inotropes PGF and determinate its impact in terms of graft function recovery and survival. Methods A retrospective study, analyzing our database of circulatory assist devices between 2009 and 2019. During this period, 252 devices have been implanted (154 ECMOs and 98 ventricular assist devices) and 201 patients have received a HT. We describe the characteristics and evolution of all PGF cases managed with VA-ECMO. Results Thirty nine patients (19.4%) developed PGF, defined as significant left, right or biventricular systolic dysfunction in the first 24 hours after HT, associated with hemodynamic instability and requiring high dose of inotropes, intra-aortic balloon pump (IABP) or VA-ECMO. Twenty two cases (56.4%) underwent a VA-ECMO implantation by peripheral cannulation as a bridge to recovery. The median age was 50.8 (44.3–57.3) years and 77% were male. Biventricular dysfunction was observed in 50% and isolated right ventricular dysfunction in the remaining 50%. At the time of implantation, 59% had IABP and the median of inotropic score was 24 (8–40). Two complications occurred during implantation (one because of a complex vascular access and one due to a malposition of the venous cannula). Anticoagulation was started after a median of 19 hours (10–28; 59% sodic heparin and 36% bivalirudin). The median support duration was 6.2 days (3–9.2). Graft function was recovered in 90%, making it possible to withdraw the device successfully in 82% of patients. The remaining 18% deceased during the support (2 because of multiorgan failure and 2 due to absence of function recovery).The median hospital length of stay was 63 days (33–93) and hospital and 1-year survival was 68.1%. Conclusion The support with VA-ECMO allowed graft function recovery in 90% of severe PGF cases, with a similar survival rate to other centres with MCS. In a scenario with a mortality rate superior to 50%, the MCS programs have managed to increase survival, avoid retransplantation in times of donor shortage and handle the use of suboptimal donors with better chances of success. Funding Acknowledgement Type of funding source: None