VA ECMO Patients Research Articles

Incidence and risk factors of groin lymphocele formation after venoarterial extracorporeal membrane oxygenation in cardiogenic shock patients

ObjectiveVenous-arterial extracorporeal membrane oxygenation (VA-ECMO) is a well-established therapy for refractory cardiopulmonary failure. Femoral cannulation offers a quick and effective means of providing circulatory support but is not without complication. Inflammation or lymphatic disruption at the site of cannulation can cause the formation of lymphoceles, leading to the patient's discomfort and possibly necessitating intervention. The purpose of this study was to evaluate the incidence of in-hospital lymphocele formation in VA-ECMO patients and to identify predictors for their development. MethodsWe conducted a single-center retrospective review of 192 patients who underwent femoral VA-ECMO insertion and subsequent decannulation from March 2007 to August 2016 for cardiogenic shock. Baseline demographics, risk factors, and cannulation strategies were examined. Groin lymphocele formation was assessed as the primary outcome. ResultsMedian age was 58 years (interquartile range, 48-67 years) with a median duration of support of 4 days (interquartile range, 2-6 days). Lymphocele formation was identified in 31 patients (16%). Patients who developed lymphoceles were more likely to have post-heart transplantation primary graft dysfunction (PGD) as an indication for ECMO support compared with those who did not (54.2% vs 8%; P < .001). ECMO duration was similar between groups, but lymphocele patients were more likely to have undergone femoral cutdown procedures (68% vs 42%; P = .010). Compared with those PGD patients who did not develop lymphoceles, PGD lymphocele patients had higher rates of diabetes mellitus preoperatively (62% vs 8%; P = .006). Thirteen (42%) patients required surgical incision and drainage, and 4 of these patients (31%) required repeated surgical intervention. ConclusionsLymphocele formation is relatively common after femoral VA-ECMO. There was a significantly higher incidence of lymphocele formation in diabetic patients requiring support for PGD after heart transplantation.

Influence of low-flow time on survival after extracorporeal cardiopulmonary resuscitation (eCPR)

BackgroundVenoarterial extracorporeal membrane oxygenation (VA-ECMO) support under extracorporeal cardiopulmonary resuscitation (eCPR) is the last option and may be offered to selected patients. Several factors predict outcome in these patients, including initial heart rhythm, comorbidities, and bystander cardiopulmonary resuscitation (CPR). We evaluated outcomes of all VA-ECMO patients treated within the last 5 years at our center in respect to low-flow duration during CPR.MethodsWe report retrospective registry data on all patients with eCPR treated at a university hospital between October 2010 and May 2016.ResultsA total of 133 patients (mean age 58.7 ± 2.6 years, Simplified Acute Physiology Score II score at admission 48.1 ± 3.4) were included in the analysis. The indication for eCPR was either in-hospital or out-of-hospital cardiac arrest without return of spontaneous circulation (n = 74 and 59, respectively). There was a significant difference in survival rates between groups (eCPR in-hospital cardiac arrest [IHCA] 18.9%, eCPR out-of-hospital cardiac arrest [OHCA] 8.5%; p < 0.042). Mean low-flow duration (i.e., duration of mechanical CPR until VA-ECMO support) was 59.6 ± 5.0 minutes in all patients and significantly shorter in IHCA patients than in OHCA patients (49.6 ± 5.9 vs. 72.2 ± 7.4 minutes, p = 0.001). Low-flow time strongly correlated with survival (p < 0.001) and was an independent predictor of mortality.ConclusionsTime to full support is an important and alterable predictor of patient survival in eCPR, suggesting that VA-ECMO therapy should be established as fast as possible in the selected patients destined for eCPR.

Dual Antiplatelet Therapy (DAPT) versus No Antiplatelet Therapy and Incidence of Major Bleeding in Patients on Venoarterial Extracorporeal Membrane Oxygenation.

AimsBleeding is a frequent complication in patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO). An indication for dual antiplatelet therapy due to coronary stent implantation is present in a considerable number of these patients. The objective of this retrospective study was to evaluate if dual antiplatelet therapy (DAPT) significantly increases the high intrinsic bleeding risk in patients on VA-ECMO.Methods and ResultsA total of 93 patients were treated with VA-ECMO between October 2010 and October 2013. Average time on VA-ECMO was 58.9 ± 1.7 hours. Dual antiplatelet therapy was given to 51.6% of all patients. Any bleeding was recorded in 60.2% of all patients. There was no difference in bleeding incidence in patients on DAPT when compared to those without any antiplatelet therapy including any bleeding (66.7% vs. 57.1%, p = 0.35), BARC3 bleeding (43.8% vs. 33.3%, p = 0.31) or pulmonary bleeding (16.7% vs. 19.0%, p = 0.77). This holds true after adjustment for confounders. Rate of transfusion of red blood cells were similar in patients with or without DAPT (35.4% vs. 28.6%, p = 0.488).ConclusionsBleeding on VA-ECMO is frequent. This registry recorded no statistical difference in bleeding in patients on dual antiplatelet therapy when compared to no antiplatelet therapy. When indicated, DAPT should not be withheld from VA ECMO patients.

Initial Egyptian ECMO experience

IntroductionExtracorporeal membrane oxygenation (ECMO) is considered a rescue therapy in severe cases of acute cardiac and or respiratory failure. Aim of the workWe describe our initial experience at the first ECMO center in Egypt. MethodsOur adult ECMO program started in January 2014. Since then we supported eleven respiratory failure patients on ECMO indicated according to ELSO guidelines and one case of ECMO CPR. Respiratory failure patients were subjected to VV ECMO when lung injury score (LIS) was above 3 and PaO2/FiO2 <100 on protective lung strategy mechanical ventilation according to ARDS net protocol and or severe hypercapnia with pH<7.2 with trial of prone positioning in the indicated cases. Percutaneous cannulation was done in all patients using single lumen cannulae, additional cannula was added when needed. Cardiohelp (Maquet, Germany) and Rotaflow (Maquet, Germany) ECMO consoles were used with centrifugal pump. ECMO circuits PLS for Rotaflow and HLS for Cardiohelp were changed when indicated. The ECMO CPR patient was a primary PCI for acute inferior STEMI complicated by left main occlusion, VA ECMO instituted in the cath-lab after 20min of CPR. Percutaneous (and or surgical) tracheostomy was done after 14days of mechanical ventilation. ResultsA total of twelve patients received ECMO between January 2014 and June 2015. The mean age was 35.9years. (range 13–65years), 8 males, with VV ECMO in 10 patients, and VA ECMO in 2 patients. Out of ten patients of VV ECMO, one had H1N1 pneumonia, one had advanced vasculitic lung, four had bacterial pneumonia, two traumatic lung contusions and one with organophosphorus poisoning, and one undiagnosed etiology leading to severe ARDS. Lung injury score range was 3–3.8, PaO2/FiO2 (20–76) mechanical ventilation duration before ECMO 1–14days, Femoro-jugular cannulation in 7 patients and femoro-femoral in 2 patients and femoro-subclavian in 1 patient; all patients were initially sedated and paralyzed for (2–4days) and ventilated on pressure controlled ventilation with Pmax of 25cmH2O and PEEP of 10cmH2O. In VA ECMO patients were cannulated percutaneously using femoro-femoral approach. One patient showed no neurologic recovery and died after 24h, the other had CABG on ECMO however the heart didn’t recover and died after 9days. Heparin intravenous infusion was used initially in all patients and changed to Bivalirudin in 2 patients due to possible HIT. Pump flow ranged from 2.6 to 6.5L/min. Average support time was 12days (range 2–24days). Seven patients (63.3%) were successfully separated from ECMO and survived to hospital discharge. Hospital length of stay ranged from 3 to 42days, tracheostomy was done percutaneously in 5 patients and surgically in 3. Gastrointestinal bleeding occurred in 6 patients, VAP in 7 patients, neurologic complications in 1 patient with complete recovery, cardiac arrhythmias in 3 patients, pneumothorax in 9 patients, and deep venous thrombosis in 2 patients.

Completeness of Revascularisation Increases Survival and Weaning Success in Patients with Myocardial Infarction-Induced Cardiogenic Shock Requiring Extracorporeal Membrane Oxygenation Support

Objectives: Aim of this study was to investigate the prognostic outcome of patients with AMI and profound CS in patients receiving emergency veno-arterial extracorporeal membrane oxygenation (va-ECMO). Methods: A consecutive series of 81 patients with AMI and severe CS receiving emergency va-ECMO from 1997 to 2015 in was investigated. Outcome evaluation regarding in-hospital mortality, “bridge to recovery” and long-term outcome in patients with successful weaning from va-ECMO was performed. Kaplan Meier survival analysis was performed to identify relevant prognostic parameters predicting weaning from va-ECMO and patient survival. Permission to perform this study was obtained from the local IRB. Results: Mean patient age was 58.8 ± 10.0 years and 77.8% were male gender. Out-of-hospital mechanical cardiopulmonary resuscitation (CPR) was performed in 7 patients (8.9%), within the cath-laboratory in 18 patients (24.1%) and during surgical insertion of va-ECMO in 20 patients (25.3%). Initial installation of intra-aortic-balloon counter-pulsation (IABP) was sustained in 33 patients (41.8%). De novo MI was responsible for 43 (53.1%) of cases, acute stent thrombosis in 13 (16.0%), and complications resulting from PCI were responsible for MI in 30.9%. Mean duration of va-ECMO support was 5.9 ± 5.4 days. Mean time from onset of MCI to reperfusion was 5.4 ± 3.9 hours. Mean “door-to-reperfusion-time” was 1.35 ± 1.2 hours. Actuarial 30-day survival was 52.6%, 43.8% at 1 year and 36.4% at 5 years. Restoration of spontaneous circulation enabling bridge to recovery and weaning from va-ECMO was possible in 33 patients (46.8%) and was significantly higher in patients with complete revascularisation (p = 0.026). Bridge to recovery was significantly higher in patients with va-ECMO and consecutive coronary artery bypass grafting (CABG) versus patients with culprit lesion PCI (p = 0.011). In patients successfully weaned from ECMO, CABG patients demonstrated significantly higher long term survival than PCI patients (log-rank: p = 0.04). Conclusion: AMI complicated by cardiogenic shock is associated with a high in-hospital mortality even in patients undergoing emergency va-ECMO. Complete revascularisation significantly improves weaning success from va-ECMO and long term survival. Complete revascularisation seems to be better provided by CABG rather than PCI only - therefore weaning and long term prognosis is significantly improved by consecutive CABG rather than PCI or consecutive conservative management.

A local network for extracorporeal membrane oxygenation in refractory cardiogenic shock.

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) represents a therapeutic option in patients with refractory cardiogenic shock (RCS). This strategy is limited to a restricted number of centres with capabilities for implanting VA ECMO and management patients on this support. We report on the initial experience of our ECMO referral centre for patients with RCS. We retrospectively analysed our ECMO data registry for RCS of 14 patients treated with VA ECMO, consecutively admitted to our intensive cardiac care unit (ICCU), which is an ECMO referral centre. Six patients (6/14, 42%) came from peripheral centres, four were transferred to our ICCU directly. During ICCU stay, four patients died (28.5%) due to multi-organ failure, seven showed a complete recovery while one underwent cardiac transplantation. The remaining two patients died while waiting for cardiac transplantation because of cerebral haemorrhage. The 30-day overall mortality rate was 42.8%, all survivors showed a good neurologic outcome. In our series, the survival rate of RCS patients supported by VA ECMO is high (57%) and the transfer of RCS patients is feasible and safe. Our data support that a network for RCS is needed to transfer patients in well experienced centres even on ECMO support.

Prime time for veno-arterial extracorporeal membrane oxygenation in 24-7 interventional cardiology center?

Prime time for veno-arterial extracorporeal membrane oxygenation in 24-7 interventional cardiology center?

Emergency and prophylactic use of miniaturized veno‐arterial extracorporeal membrane oxygenation in transcatheter aortic valve implantation

To report our center's experience using veno-arterial extracorporeal membrane oxygenation (vaECMO) in transcatheter aortic valve implantation (TAVI). In TAVI, short-term mortality closely relates to life threatening procedural complications. VaECMO can be used to stabilize the patient in emergency situations. However, for the prophylactic use of vaECMO in very high-risk patients undergoing TAVI there is no experience. From January 2009 to August 2011, we performed 131 TAVI. Emergency vaECMO was required in 8 cases (7%): ventricular perforation (n = 3), hemodynamic instability/cardiogenic shock (n = 4), hemodynamic deterioration due to ventricular tachycardia (n = 1). Since August 2011, during 83 procedures, prophylactic vaECMO was systematically used in very high-risk patients (n = 9, 11%) and emergency ECMO in one case (1%) due to ventricular perforation. Median logistic EuroScore in prophylactic vaECMO patients was considerably higher as compared to the remaining TAVI population (30% vs. 15%, P = 0.0003) while in patients with emergency vaECMO it was comparable (18% vs. 15%, P = 0.08). Comparing prophylactic to emergency vaECMO, procedural success and 30-day mortality were 100% vs. 44% (P = 0.03) and 0% vs. 44% (P = 0.02), respectively. Major vascular complications and rate of life threatening bleeding did not differ between both groups (11% vs. 11%, P = 0.99 and 11% vs. 33%, P = 0.3) and were not vaECMO-related. Life-threatening complications during TAVI can be managed using emergency vaECMO but mortality remains high. The use of prophylactic vaECMO in very high-risk patients is safe and may be advocated in selected cases.