VA ECMO Research Articles

Abstract 4135194: Safety and Efficacy of Mechanical Circulatory Support during VT ablation

Introduction: Ventricular arrythmias are prevalent in patients with advanced heart failure and associated with increased mortality. Outcomes of electrophysiology ablation on patients requiring mechanical circulatory support (MCS) are not well described. We aimed to analyze the safety and efficacy of ventricular tachycardia (VT) ablation in patients requiring MCS at the Emory system. Methods: Patients were identified via retrospective chart review from October 2022 through August 2023. Patients who underwent VT ablation with the support of Impella, left ventricular assist device (LVAD), intra-aortic balloon pump (IABP), and venoarterial extra-corpeal membrane oxygenation (VA ECMO), or any combination of these were included. Results: A total of 7 patients of average age 56 ± 10 years, predominantly male (85.7%), with cardiomyopathy of mean EF 18.6% +/- 8.5 (ischemic 71.4%) underwent MCS supported VT ablation. One patient had 2 separate VT ablation procedures for refractory VT. Of these 8 procedures, 4 utilized a single type of MCS (2 impella, 2 LVAD) while 4 used a second type of MCS in combination with an Impella (2 impella RP, 1 VA ECMO, 1 IABP). Success at time of ablation was present in 75% of cases. Average time of outpatient follow up was 82 ± 31 days. At time of follow up, 50% of patients remained free of VT or with a single VT episode not requiring implantable cardioverter-defibrillator (ICD) shock. One patient had gone on to undergo successful heart transplantation. Procedural complications were noted in one patient, who suffered cardioembolic cerebrovascular accident (CVA) 2 days post-op. Transthoracic echo (TTE) 5 days post-op revealed LV mural thrombus as likely etiology of CVA. Conclusion: While there are no clear guidelines directing the use of MCS during VT ablation, our single academic institution experience suggests safety and feasibility of its use to support select, high risk cases.

Vascular complications in patients with peripheral veno-arterial extracorporeal membrane oxygenation: clinical-echocardiographic characteristics and predictors

Abstract Introduction 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. Lower limb ischemia associated with peripheral VA ECMO is frequent, and is considered a serious complication with a significant impact on the morbidity and mortality. Purpose The aim of this study was to describe the clinical-echographic parameters and analyze predictors related to vascular complications in patients with peripheral VA ECMO. Methods The study was a single-center cohort analysis. It included all consecutive adult patients with peripheral femoro-femoral VA ECMO due to refractory cardiogenic shock (CS) or cardiac arrest (CA) between March 2014 and December 2022. Patients with central cannulation were excluded. The primary endpoint was evidence of vascular complications resulting in surgical intervention. A multivariate logistic regression model was used to adjust for variables of interest. Results The study included 83 patients (65± 12 years, 54% male). The main previous diagnosis was necrotic ischemic cardiomyopathy (33%), and the most frequent indication was postcardiotomy (40.9%), mainly in SCAI D (85.5%). Cardiopulmonary resuscitation was performed in 18.1%. Femoro-femoral cannulation was percutaneuos in 95.2%. Most patients had intra-aortic balloon pump (87.1%) and distal percutaneous cannula (88.8%). A total of 18 patients presented vascular complications (21.7%): 2 patients (11.1%) amputation, 5 patients (27.7%) compartment syndrome requiring fasciotomy, 9 patients (50.0%) thrombectomy, and 2 patients (11.1%) a surgical resolution post decannulation due to AV fistula. The median duration of VA ECMO was 5 days (IQR 2-8). Among the ultrasound variables, the systolic peak velocity (SPV) in the distal territory (tibioperoneal segment) had a median of 22 cm/sec (IQR 10-30). Pulsatile spectral Doppler flow in the cannulated limb was evidenced in 42 patients (50.6%) of total population, and only in 3 patients (16.6%) with vascular complications. The survival rate from VA ECMO was 57.8%, and the survival rate to discharge 42.1%. In-hospital mortality of patients with or without vascular complications did not show statistically significant differences (54.2 % vs 58.2 %, p= 0.26). After multivariate analysis, distal territory SPV less than 20 cm/sec (OR: 2.1, 95%CI: 1.3 – 12.1, p: 0.03), as well as history of previous vascular disease, were associated with a higher number of vascular complications (OR: 2.5, 95% CI: 1.5 – 10.1, P; 0.02). Conclusions Vascular complications in patients with femoro-femoral VA ECMO remain frequent and constitute an important cause of morbidity. Decreased peak systolic velocities in the cannulated tibio-peroneal territory, as well as a history of previous vascular disease were significantly associated with a higher rate of vascular complications.

Echocardiographic evaluation of ventricular performance in VA-ECMO weaning: results from a observational monocentric prospective study

Abstract Background Although temporary mechanical circulatory support (MCS) devices are increasingly used in the management of cardiogenic shock (CS), several open question regarding the kind of support and timing of institution/weaning remains open. Echocardiography is widely applied to drive the weaning process and decision although there are no standardized protocols for the trial nor accordance on the parameters to apply. Purpose We sought to evaluate the overall accuracy of echocardiographic indices in predicting successful weaning from VA ECMO in patients with CS. Specifically, we tested total isovolumic time (tIVT), an index of ventricular performance, and longitudinal function (MAPSE) on top of the commonly used parameters (left ventricular ejection fraction, LVEF; left ventricular velocity time integral, LV VTI; TAPSE; right ventricular S’ at tissue Doppler imaging, RV S’). Methods Monocentric prospective study on adults receiving VA-ECMO due to refractory CS and/or cardiac arrest (CA) from 2012 to 2020. Echocardiography was performed at VA-ECMO placement and during the weaning trials. Weaning trials were performed daily, starting 48 hours after VA-ECMO institution, when patients were hemodynamically stable: mean arterial pressure >65 mmHg, no or minimum adrenergic support (vasoactive inotropic score <10), heart rate <110 bpm, lactate <2 mmol/L, and no signs of respiratory distress. Weaning trials were performed with a stepwise decrease of VA-ECMO blood flow until reaching 1 or 1.5 L/min under adequate anticoagulation. Successful weaning was defined as removal of VA-ECMO with no requirement for further MCS in the following 30 days. Results 76 patients were enrolled (23.8% female, 54.2±10.6 years-old), 52.6% due to CA. Median duration of VA-ECMO was 58 hours; 47 (61.8%) had intra-aortic balloon pump (IABP) inserted upfront. In-hospital mortality was 62.4% overall, 40% for CS without CA. 6 of the 32 weaned patients died for multiorgan failure due to septic shock. The baseline echocardiographic parameters associated with successful weaning were (table): stroke volume >13.9 mL (p 0.002), tIVT >23.6 min/sec (p 0.053), LV VTI >6.6 cm (p<0.001), MAPSE >6.15 mm (p 0.001), TAPSE >11 mm (p 0.023), RV S’ >10 cm/s (p 0.012). LVEF did not reach the statistical significance. Figure shows Kaplan-Meier analysis on echocardiographic indices collected at time of cannulation (panel A) and during the last weaning trial (panel B). Conclusions Echocardiography is pivotal in defining cardiac recovery and monitoring the weaning trial. Indices reflecting ventricular performance and delivered flow from LV were associated with weaning success both at VA-ECMO institution and throughout the weaning trials. Considering the known limitations of LVEF (heart rate, loading and left ventricular dyssynchrony dependence), tIVT and MAPSE should be introduced in the standard evaluation of patients in the acute setting.TableFigure

The clinical outcome reflects the heart rhythm profile after defibrillation for shockable rhythm in refractory out-of-hospital cardiac arrest

Abstract Background The prognosis of refractory out-of-hospital cardiac arrest (OHCA) is generally poor. A recent Prague OHCA study has demonstrated that an invasive approach (including extracorporeal cardiopulmonary resuscitation, ECPR) is a feasible treatment strategy in refractory OHCA. Post-hoc analysis of Prague OHCA showed that patients with initial ventricular fibrillation (VF) had manifested better clinical outcomes than those with non-shockable rhythms irrespective of cardiopulmonary resuscitation (CPR) strategy. However, initial shockable rhythm could deteriorate to a non-shockable rhythm during CPR, mainly after defibrillation. The study aimed to stratify the prognosis of patients according to rhythm profile after initial VF in refractory OHCA during pre-hospital and early hospital periods. Methods The analysis enrolled patients with a witnessed OHCA of presumed cardiac cause, with initial VF, and without early recovery of spontaneous circulation. The primary outcome was a composite of survival with Cerebral Performance in Category (CPC) 1 or 2 at 180 days. Results 155 (median age 56y, 10 % females) patients with initial VF were enrolled. The median (IQR) duration of resuscitation was 54 (33-69) minutes. Overall survival with CPC 1 or 2 was 40.4 %. 71 patients were randomized to invasive CPR arm and 84 subjects were treated with conventional CPR. Out of all invasively treated patients, ECPR (veno-arterial extracorporeal membrane oxygenation, VA ECMO) was used in 56 cases without stable recovery of spontaneous circulation and 8 patients primary allocated in conventional group. A proportion of survival with CPC 1 or 2 varied by rhythm course: ongoing VF (9 / 28; 32 %), recovery of organized rhythm (43 / 63; 68 %), documentation of pulseless electrical activity (7 / 30; 23%), and progression to asystole (4 / 34; 12 %); P < 0.05. Tables 1 and 2 show differences in primary endpoint according to rhythm profile between invasive and conventional study arms. Conclusion Deterioration of initial shockable rhythm to asystole bears a poor prognosis in refractory OHCA even when ECPR is readily available. An invasive approach (including VA ECMO) seems to be beneficial in patients with ongoing VF and with regular electrical activity regardless of effective pulsation.

Effects of veno-arterial extracorporeal membrane oxygenation return cannula side hole structure on aortic hemodynamic features under different perfusion levels.

The interaction between primary left ventricular output and Veno-arterial extracorporeal membrane pulmonary oxygenation (VA ECMO) flow may impede the perfusion of aortic vessels with hyperoxic blood, leading to differential oxygenation. ECMO return cannula design significantly influences the perfusion level of blood supplied via ECMO. This study aimed to investigate the impact of various cannula designs (side hole number) on intravascular flow patterns under different blood perfusion conditions. Six return cannula models with different side hole number and three cardiac output waveforms were designed based on clinical data for comparative analysis. The position of the blood mixing zone (MZ) was influenced by the flow-volume ratio of the heart output (CO/(CO+Qec)) and cannula design. As the CO/(CO+Qec) and the number of side holes in the cannula increased, the MZ shifted from the ascending aorta to the descending aorta. Concurrently, aortic wall and scalar shear stress on the impact side of ECMO cannulation reduced progressively. Return cannula with side holes effectively mitigated discrepancies in the perfusion of the renal artery and inadequate perfusion of the lower limb vessels on the cannula side while simultaneously reducing damage to the vessel walls and blood. However, increasing the number of side holes in the return cannulas resulted in diminished perfusion of the aortic arch bifurcation vessels by hyperoxic blood supplied via ECMO. Increasing the number of return cannula side holes for VA ECMO femoral artery cannulation improves hypoxic perfusion in the lower limb and reduces vascular endothelial injury, but may also lead to inadequate hypoxic perfusion in the upper body.

Unraveling the challenges in spontaneous coronary artery dissection: a case series of VA ECMO support and heart transplantation.

Unraveling the challenges in spontaneous coronary artery dissection: a case series of VA ECMO support and heart transplantation.

Identification of Early Risk Factors for Mortality in Pediatric Veno-Arterial Extra Corporeal Membrane Oxygenation: The Patient Matters.

Pediatric Veno-Arterial Extra Corporeal Membrane Oxygenation (VA ECMO) is a life saving technology associated with high mortality. A successful VA ECMO course requires attention to multiple aspects of patient care, including ECMO and patient parameters. Early, potentially modifiable, risk factors associated with patient mortality should be analyzed and adjusted for when assessing VA ECMO risk profiles. Retrospective single center experience of pediatric patients requiring VA ECMO from January 2021 to October 2023. Laboratory and ECMO flow parameters were extracted from the patients record and analyzed. Risk factors were analyzed using a Cox proportion hazard regression. There were 45 patients studied. Overall survival was 51%. Upon uncorrected analysis there were no significant differences between the patients who survived and those who died. Utilizing a Cox proportion hazard regression, platelet count, fibrinogen level and creatine level were significant risk factors within the first twenty-four hours of a patient's ECMO course. Although we did not find a significant difference among ECMO flow parameters in this study, this work highlights that granular ECMO flow data can be incorporated to risk analysis profiles and potential modeling in pediatric VA ECMO. This study demonstrated, that when controlling for ECMO flow parameters, kidney dysfunction and clotting regulation remain key risk factors for pediatric VA ECMO mortality.

Paediatric survivors of extracorporeal life support functional outcomes at one-year follow-up.

To investigate functional outcomes in children who survived extracorporeal life support at 12 months follow-up post-discharge. Some patients who require extracorporeal life support acquire significant morbidity during their hospitalisation. The Functional Status Scale is a validated tool that allows quantification of paediatric function. A retrospective study that included children placed on extracorporeal life support at a quaternary children's hospital between March 2020 and October 2021 and had follow-up encounter within 12 months post-discharge. Forty-two patients met inclusion criteria: 33% female, 93% veno-arterial extracorporeal membrane oxygenation (VA ECMO), and 12% with single ventricle anatomy. Median age was 1.7 years (interquartile range 10 days-11.9 years). Median hospital stay was 51 days (interquartile range 34-91 days), and median extracorporeal life support duration was 94 hours (interquartile range 56-142 hours). The median Functional Status Scale at discharge was 8.0 (interquartile range 6.3-8.8). The mean change in Functional Status Scale from discharge to follow-up at 9 months (n = 37) was -0.8 [95% confidence interval (CI) -1.3 to -0.4, p < 0.001] and at 12 months (n = 34) was -1 (95% confidence interval -1.5 to -0.4, p < 0.001); the most improvement was in the feeding score. New morbidity (Functional Status Scale increase of ≥3) occurred in 10 children (24%) from admission to discharge. Children with new morbidity were more likely to be younger (p = 0.01), have an underlying genetic syndrome (p = 0.02), and demonstrate evidence of neurologic injury by electroencephalogram or imaging (p = 0.05). In survivors of extracorporeal life support, the Functional Status Scale improved from discharge to 12-month follow-up, with the most improvement demonstrated in the feeding score.

Effect of upper body venoarterial ECMO on systemic hemodynamics and oxygenation: A computational study

BackgroundThis study seeks to quantify the effects of upper body veno-arterial extracorporeal membrane oxygenation (VA ECMO) on the anatomical distribution of oxygen delivery in the setting of hypoxic respiratory failure and provide new insights that will guide clinical use of this support strategy to bridge patients to lung transplant. MethodsEmploying a patient-specific vascular geometry and a quantitative model of oxygen transport, computational simulations were performed to determine hemodynamics and oxygen delivery in the ascending and descending aorta, left and right coronary arteries, and great vessels during upper body VA ECMO support. Oxygen content in ECMO circuit blood flow was varied while considering different degrees of lung failure severity. Using lumped parameter models to dynamically apply perfusion boundary conditions, hemodynamic parameters and oxygen content were analyzed to assess the effect of ECMO supply titration. ResultsThe results emphasize the importance of anatomical distribution for tissue oxygen delivery in severe lung failure, with ECMO-derived flow primarily augmenting oxygen content in specific vascular beds. They also demonstrate that although cannulating the subclavian artery can enhance cerebral oxygen delivery, its ability to ensure sufficient oxygen delivery to the coronary circulation seems to be comparatively restricted. ConclusionsThe oxygen delivery to a specific vascular area is primarily determined by the oxygen content in the source of perfusion. Caution is advised with upper body VA ECMO for patients with hypoxic respiratory failure and right ventricle dysfunction, due to potential coronary ischemia. Management of these patients is challenging due to disease progression and organ availability uncertainties.

Central versus peripheral VA ECMO for cardiogenic shock: an 8-year experience of a tertiary cardiac surgery center in Greece

BackgroundVenoarterial extracorporeal membrane oxygenation (VA ECMO) has emerged as an effective rescue therapy in patients with cardiogenic shock refractory to standard treatment protocols, and its use has been rising worldwide in the last decade. Although experience and availability are growing, outcomes remain poor. There is need for evidence to improve clinical practice and outcomes. MethodsWe retrospectively reviewed the medical records of all patients who were supported with VA ECMO for cardiogenic shock at our institution between January 2015 and January 2023. The study purpose was to compare outcomes between patients who were supported with central versus peripheral configuration. ResultsECMO was applied in 108 patients, 48 (44%) of whom received central configuration and 60 (56%) peripheral. Patients supported with central VA ECMO were more likely to be supported for post-cardiotomy shock (odds ratio [OR] 4.6 [95% confidence interval (CI) 2.03–10.41]), while patients in the peripheral group were predominantly treated for chronic heart failure decompensation (OR 9.4 [95% CI 1.16–76.3]). Central VA ECMO had lower survival rates during ECMO support (29.2% versus 51.7%, p = 0.018) and at discharge (8% versus 37%, p = 0.001). These patients were at high risk of complications, such as acute kidney injury (AKI) (OR 2.37 [95% CI 1.06–5.3], p = 0.034) and major bleeding (OR 3.08 [95% CI 1.36–6.94], p < 0.001). ConclusionsPatients on central VA ECMO were supported mainly for post-cardiotomy shock, presented with more complications such as major bleeding and AKI, and had worse survival to hospital discharge compared with patients on peripheral VA ECMO. Patient selection, timing of implementation, cannulation strategy, and configuration remain the main determinants of clinical outcome.

170: Higher Vasoactive Infusion Score and Lower pH during VA ECMO Trial Off Associated with Mortality in Neonates

170: Higher Vasoactive Infusion Score and Lower pH during VA ECMO Trial Off Associated with Mortality in Neonates

253: Use of Peripheral VA ECMO and Impella CP in a 50-Year-Old Male with Advanced Cardiovascular Complications Secondary to Kawasaki Disease

253: Use of Peripheral VA ECMO and Impella CP in a 50-Year-Old Male with Advanced Cardiovascular Complications Secondary to Kawasaki Disease

255: VA ECMO Expected Progression: Implementation of an Adult Cardiogenic Shock Goal-Oriented Patient Management Guideline

255: VA ECMO Expected Progression: Implementation of an Adult Cardiogenic Shock Goal-Oriented Patient Management Guideline

247: VA ECMO for Recurrent Thyrotoxicosis-Induced Cardiogenic Shock

247: VA ECMO for Recurrent Thyrotoxicosis-Induced Cardiogenic Shock

Vascular Complications in Extracorporeal Membrane Oxygenation-A Narrative Review.

The establishment of a peripheral ECMO circuit can lead to significant arterial and venous complications in 10-30% of patients. Vascular complications, particularly acute limb ischemia, are associated with worsening overall outcomes. Limb ischemia occurs significantly more frequently in the early stages of VA ECMO than in VV ECMO. Mechanisms of limb ischemia include arterial obstruction, cannulation injury, loss of pulsatile flow, thromboembolism, venous stasis from compressive obstruction with large venous cannulas, and systemic vasoconstriction due to shock and pharmacologic vasoconstriction. The care team may use several mitigation strategies to prevent limb ischemia. Arterial and venous complications can be mitigated by careful access site selection, minimizing cannula size, placement of distal perfusion and/or outflow catheter(s), and continuous NIRS monitoring. Rapid intervention, when ischemia or compartment syndrome occurs, can reduce limb loss but may not affect the mortality and morbidity of the ECMO patient in the long term due to their underlying conditions and the etiology of the ECMO need.

Venoarterial Extracorporeal Membrane Oxygenation Therapy in Patients with Sickle Cell Disease: Case Series and Review for Intensive Care Physicians.

Sickle cell disease (SCD) is associated with substantial morbidity and early mortality in afflicted adults. Cardiopulmonary complications that occur at increased frequency in SCD such as pulmonary embolism, pulmonary arterial hypertension, and acute chest syndrome can acutely worsen right ventricular function and lead to cardiogenic shock. Mechanical circulatory support including venoarterial extracorporeal membrane oxygenation (VA ECMO) is being increasingly utilized to treat hemodynamic collapse in various patient populations. However, a paucity of literature exists to guide the use of mechanical circulatory support in adults with SCD where disease-related sequela and unique hematologic aspects of this disorder may complicate extracorporeal therapy and must be understood. Here, we review the literature and describe three cases of adult patients with SCD who developed cardiogenic shock from acute decompensated right heart failure and were treated clinically with VA ECMO. Using an in vitro ECMO system, we investigate a potential increased risk of systemic fat emboli in patients with SCD who may be experiencing vaso-occlusive events with bone marrow involvement given the high-volume shunting of blood from venous to arterial systems with VA ECMO. The purpose of this study is to describe available extracorporeal life support experiences, review potential complications, and discuss the special considerations needed to further our understanding of the utility of VA ECMO in those with SCD.

An analytic method to investigate hemodynamics of the cardiovascular system: Biventricular system.

Previously, we found analytic solutions for single ventricular system based on the lumped parameter model (LPM). In this study, we generalized the method to biventricular system and derived its analytic solutions. LPM is just a set of differential equations, but it is difficult to solve due to time-varying ventricular elastance and high order. Mathematically, there exist no elementary solutions for time-varying equations. It turns out that instead of differential equations, according to volume conservation, a set of algebraic equations can be carried out. The solutions of the set of equations are just physiological states at end of systolic and diastolic phases such as end systolic/diastolic pressure/volume of left ventricle. As a preliminary application, the method is utilized to deduce the hemodynamic effects of VA ECMO. Left ventricular (LV) distension, a serious complication of VA ECMO, is usually attributed to factors such as increased afterload, inadequate LV unloading, reduced myocardial contractility or aortic valve regurgitation (AR), bronchial and Thebesian return in the absence of aortic valve (AoV) opening. Among these, reduced contractility and AR are strongly associated with LV distension. However, in the absence of reduced contractility or AR, it is less clear whether increased afterload or inadequate LV unloading alone can cause LV distension. This leads to the critical question: under what conditions does LV distension occur in the absence of reduced contractility or AR? The analytic formulas derived in this study give conditions for LV distension. Furthermore, the results show that the analytic hemodynamics are coincident with simulated results.

Acute kidney injury and cardiogenic shock severity for mortality risk stratification in patients supported with VA ECMO.

To assess the stage of acute kidney injury (AKI), as an index of organ perfusion, combined with shock severity, measured by the Society for Cardiovascular Angiography and Interventions (SCAI) shock stage classification, to stratify the risk of mortality in patients diagnosed with cardiogenic shock (CS) and supported with venoarterial extracorporeal membrane oxygenation (VA ECMO). From January 2018 to December 2020, consecutive adult patients diagnosed with CS and received VA ECMO were retrospectively evaluated. The highest AKI stage within 48h after ECMO initiation was assessed using the Kidney Disease: Improving Global Outcomes criteria. We included 216 patients with a mean age of 58.8years and 31.0% were females. 88.4% of patients received ECMO for postcardiotomy, while 11.6% for medical CS. The total in-hospital mortality was 53.2%. AKI occurred in 182 (84.3%) patients receiving ECMO for CS. AKI stage 0, 1, 2, and 3 were present in 15.7%, 17.6%, 18.1%, and 48.6% of patients with in-hospital mortality of 26.5%, 26.3%, 61.5%, and 68.6%, respectively (P<0.001). The AKI stage (P<0.001), SCAI shock stage before ECMO (P=0.008), and NYHA ≥ Class III on admission (P=0.044) were independent predictors of in-hospital mortality. The area under the receiver operating characteristic curve of 0.754 (95% confidence interval: 0.690 to 0.811) for AKI stage combined with SCAI shock stage was better than those for AKI stage (0.676), SCAI shock stage (0.657), serum lactate level (0.682), SOFA score (0.644), SVAE score (0.582), and VIS score (0.530) prior to ECMO. In this single-center CS population who received VA ECMO for circulatory support, predominantly postcardiotomy cases, AKI occurred in 84.3% of the patients. AKI stage, as an index of organ perfusion combined with shock severity measured by the SCAI shock classification, demonstrates a good correlation with in-hospital mortality.

Contemporary Bridge to Heart Transplantation With Venoarterial Extracorporeal Membrane Oxygenation.

Objective: In October 2018, the United Network for Organ Sharing changed their heart allocation criteria to prioritize patients on temporary mechanical circulatory support. This study assesses outcomes of patients bridged to orthotopic heart transplantation (OHT) with venoarterial extracorporeal membrane oxygenation (VA ECMO) since this change. Methods: We conducted a retrospective single-center study of adults (≥18 years) supported with VA ECMO at the time of OHT (October 1, 2018, to December 31, 2021). The primary outcome was midterm survival. Results: During the study period, 117 patients underwent OHT including 52 adults ≥18 years (44%) and 65 children <18 years (56%). Among adults, 8 (15%) were supported with VA ECMO at the time of OHT and are included in this study; 75% were male (n = 6), and the median age was 52.5 (interquartile range [IQR] = 23.5 to 57.25) years. Most patients were peripherally cannulated (75%, n = 6) and supported with an intra-aortic balloon pump during the pretransplant period (87.5%, n = 7). The median ECMO duration was 7 (IQR = 4.5 to 25.25) days. Three patients experienced complications on ECMO (37.5%), including thromboembolic bowel infarction (12.5%, n = 1) and bleeding requiring reintervention (25%, n = 2). All patients survived to discharge without posttransplantation complications and were alive at the latest follow-up. The median follow-up time was 24.8 (IQR = 19.5 to 28.2) months. Conclusions: Patients can be successfully bridged with VA ECMO directly to OHT with excellent midterm results. Key contributors to our outcomes include early extubation, use of bivalirudin over heparin, ambulation, and rehabilitation while on ECMO.

Routine Versus Selective Distal Perfusion Catheter Use in Venoarterial Extracorporeal Membrane Oxygenation

Although current studies support the use of prophylactic distal perfusion catheters (DPCs) to decrease limb ischemia in patients on venoarterial extracorporeal membrane oxygenation (VA ECMO), methods for monitoring limb ischemia differ between studies. We evaluated the safety of a selective rather than prophylactic DPC strategy at a single center with a well-established protocol for limb ischemia monitoring. Distal perfusion catheters were placed selectively if there was evidence of hypoperfusion at any point until decannulation. All patients were followed daily by vascular surgery with continuous regional saturation monitoring. Of 188 patients supported with VA ECMO, there were no significant differences in baseline characteristics between patients with upfront, delayed, and no DPC. Thirty day mortality was highest in patients with an upfront DPC (56% in the upfront DPC group, 19% in the delayed DPC group, and 22% in the no-DPC group, p &lt; 0.001). The incidence of major bleeding, fasciotomy, and amputation in the entire cohort was 3.7%, 3.7%, and 0%, respectively. With strict adherence to a protocol for limb ischemia monitoring, a selective rather than prophylactic DPC strategy is safe and may obviate the risks of an additional arterial catheter.