Venoarterial Extracorporeal Membrane Oxygenation Patients Research Articles

Echocardiographic recovery changes in patients supported with veno-arterial extracorporeal membrane oxygenator and weaning success

Abstract Introduction The weaning from veno-arterial extracorporeal membrane oxygenation (VA-ECMO) decision involves a meticulous evaluation of different factors, among which echocardiography is a decisive factor. Purpose Evaluate echocardiographic changes from the beginning of the support to the weaning test. Methods Analysis of VA-ECMO cases in a referral hospital which completed a weaning test. We evaluated the changes of echocardiographic parameters during the VA-ECMO support (initial and during weaning test) and successful weaning (survival >24h after explant and no mortality from cardiogenic shock/heart failure or cardiac arrest during admission). Results 85 out of 134 VA-ECMO patients were included from 2013 to Oct-2020 (table 1.1). Successful weaning was achieved in 61.2% and final survival at discharge 49.4%. We observed a significant increase in left ventricular ejection fraction (LVEF), left ventricular outflow tract time–velocity integral (LVOT VTI), tricuspid annular plane systolic excursion (TAPSE) and the percentage of patients with normal qualitative right ventricular function and 1:1 aortic valve opening from the initial to the weaning echocardiography (table 1.2), without significant changes in ventricular diameters. Among these changes, the increase in LVOT VTI was the only parameter that was related to weaning success (p=0.037, table 1.2). A higher LVEF increase from the initial value showed a trend to greater successful VA-ECMO disconnection (p=0.053 table 1.2). Conclusion Left and right ventricular function parameters improved significantly from baseline to weaning test echocardiography in VA-ECMO supported patients. Of these changes, the increase in LVOT VTI was related to successful disconnection from VA-ECMO and the LVEF improvement showed a trend to weaning success. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Instituto de Salud Carlos III in Spain (Co-funded by European Social Fund “Investing in your future”). Characteristics ECMO-VA patients

PROGNOSTIC FACTORS OF VENO-ARTERIAL ECMO PATIENTS: A MULTIPLE LOGISTIC REGRESSION ANALYSIS

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: Several mortality prediction models exist for patients on Veno-arterial (VA) extracorporeal membrane oxygenation (ECMO), including the Survival after VA ECMO (SAVE) Score. Whether additional characteristics, such as body surface area (BSA), race, gender, Hispanic ethnicity, and dialysis history, affect mortality of VA ECMO patients are not as well understood. This study thus assessed such prognostic factors in these patients. METHODS: A retrospective single-institutional study collected all consecutive non-pediatric patients who received VA ECMO between 2016-2020. 410 patients were identified. We excluded 13 patients who were transitioned to or from VA ECMO. Univariate and multivariate analyses were performed. The risk factors affecting survival to hospital discharge were determined by multiple logistic regression analysis. RESULTS: 264 (64.4%) of VA ECMO patients did not survive until hospital discharge. Median age amongst VA ECMO patients was 59 years old, and median BSA was 2.10 m2. 339 (82.7%), 55 (13.4%), and 16 (3.90%) of patients were white, black, and of other race, respectively. 13 (3.17%) were of Hispanic ethnicity and 130 (31.7%) were female. 158 (38.5%) and 31 (7.56%) had undergone a cardiotomy or heart transplant, respectively. A multiple logistic regression model assessing survival to hospital discharge was created, incorporating 11 covariates and with a model Likelihood Ratio chi-square test of 61.8 (p < 0.001). Patient age less than 55 years old was significantly associated with improved odds of survival to hospital discharge (adjusted odds ratio, 3.07; 95% confidence interval, 1.88 to 5.04). Two covariates were significantly associated with decreased odds of survival to hospital discharge: history of dialysis (adjusted odds ratio, 0.31; 95% confidence interval 0.11 to 0.99); and, if patient had a cardiac arrest (adjusted odds ratio, 0.42; 95% confidence interval 0.23 to 0.78). CONCLUSIONS: Age < 55 years old was associated with improved prognosis, while history of dialysis and presence of cardiac arrest were associated with worse prognosis. Race, gender, BSA, and history of cardiotomy or heart transplant were not significantly associated with survival to hospital discharge in this cohort of VA ECMO patients. CLINICAL IMPLICATIONS: Additional factors affecting prognosis of VA ECMO patients were identified. These variables, such as history of dialysis, can be incorporated into an existing or new risk prediction model to better assess a patient’s clinical course. In addition, certain social disparities of health, such as race and gender, were not found to be associated with VA ECMO outcomes, although more research is needed. DISCLOSURES: No relevant relationships by Rohun Bhagat, source=Web Response No relevant relationships by Jay Hwang, source=Web Response No relevant relationships by Andrew Jones, source=Web Response No relevant relationships by Clauden Louis, source=Web Response No relevant relationships by Kevin McGann, source=Web Response

Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part II, Intraoperative Management and Troubleshooting.

In the second part of the Society of Cardiovascular Anesthesiologists Extracorporeal Membrane Oxygenation (ECMO) working group expert consensus statement, venoarterial (VA) and venovenous (VV) ECMO management and troubleshooting in the operating room are discussed. Expert consensus statements are provided about intraoperative monitoring, anesthetic drug dosing, and management of intraoperative problems in VA and VV ECMO patients.

Comparison of Success Rate and Complications of Totally Percutaneous Decannulation in Patients With Veno-Arterial Extracorporeal Membrane Oxygenation and Endovascular Aneurysm Repair.

Background: Total percutaneous closure for the site of femoral arterial puncture using Perclose ProGlide (PP) has become prevalent post-percutaneous endovascular aortic repair (EVAR) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO).Objective: To evaluate the safety and efficacy of total percutaneous closure of the femoral artery access site post-EVAR compared with VA-ECMO.Methods: This was a retrospective observational study conducted over 4 years, including 88 patients who underwent EVAR (64 patients) and VA-ECMO (24 patients). Perclose ProGlide devices were used in the femoral artery puncture sites closed percutaneously. In this study, technical success was defined as successful arterial closure of the common femoral artery (CFA) without additional surgical or endovascular procedures to prevent vessel leaking. Access site complications, including overt bleeding requiring transfusion or surgical intervention, minor bleeding, tinea cruris, pseudoaneurysm, and lymphocele, were recorded 24 h and 30 days after arterial closure.Results: Each group's technical success rates were 95.8% (VA-ECMO) and 92.2% EVAR, respectively. There were no differences in the periprocedural complications of major bleeding, pseudoaneurysm, minor bleeding, acute limb ischemia, and groin infection. Furthermore, we did not observe any complications such as arterial thrombosis, dissection, stenosis, arteriovenous fistula, hematoma, groin infection, or lymphocele at the access site by following-up an ultrasound examination. There was no significant difference in the technical success rate of percutaneous closure by the PP device in the EVAR and VA-ECMO oxygenation groups. Also, no periprocedural or 30-day complications were observed at the access site of the EVAR and VA-ECMO patients.

Fibrinogen\u2013Albumin-Ratio is an independent predictor of thromboembolic complications in patients undergoing VA-ECMO

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) supports patients suffering from refractory cardiogenic shock. Thromboembolic complications (TeC) are common in VA-ECMO patients and are associated with increased morbidity and mortality. Valid markers to predict TeC in VA-ECMO patients are lacking. The present study investigated the predictive value of baseline Fibrinogen–Albumin-Ratio (FAR) for in-hospital TeC in patients undergoing VA-ECMO. This retrospective cohort study included patients who underwent VA-ECMO therapy due to cardiogenic shock at the University Hospital Duesseldorf, Germany between 2011 and 2018. Main exposure was baseline FAR measured at initiation of VA-ECMO therapy. The primary endpoint was the in-hospital incidence of TeC. In total, 344 patients were included into analysis (74.7% male, mean age 59 ± 14 years). The in-hospital incidence of TeC was 34%. Receiver operating characteristics (ROC) curve of FAR for in-hospital TeC revealed an area under the curve of 0.67 [95% confidence interval (CI) 0.61–0.74]. Youden index determined a cutoff of 130 for baseline FAR. Multivariate logistic regression revealed an adjusted odds-ratio of 3.72 [95% CI 2.26–6.14] for the association between FAR and TeC. Baseline FAR is independently associated with in-hospital TeC in patients undergoing VA-ECMO. Thus, FAR might contribute to the prediction of TeC in this cohort.

Monocyte Dysfunction Detected by the Designed Ankyrin Repeat Protein F7 Predicts Mortality in Patients Receiving Veno-Arterial Extracorporeal Membrane Oxygenation.

Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used for critically ill patients requiring hemodynamic support but has been shown to induce an inflammatory response syndrome potentially leading to severe complications and poor outcome. Monocytes are comprised of different subsets and play a central role in the innate immune system. The unique small binding proteins, Designed Ankyrin Repeat Protein “F7” and single chain variable fragment “MAN-1,” specifically detect the activated conformation of the leukocyte integrin Mac-1 enabling the highly sensitive detection of monocyte activation status. The aim of this study was to characterize monocyte function and heterogeneity and their association with outcome in VA-ECMO patients.Methods: VA-ECMO patients were recruited from the ICUs of the University Hospital in Freiburg, Germany. Blood was sampled on day 0 and day 3 after VA-ECMO placement, after VA-ECMO explantation and from healthy controls. Monocyte subset distribution, baseline activation and stimulability were analyzed by flow cytometry using the unique small binding proteins F7 and MAN-1 and the conventional activation markers CD163, CD86, CD69, and CX3CR1. Furthermore, expression of monocyte activation markers in survivors and non-survivors on day 0 was compared. Simple logistic regression was conducted to determine the association of monocyte activation markers with mortality.Results: Twenty two patients on VA-ECMO and 15 healthy controls were recruited. Eleven patients survived until discharge from the ICU. Compared to controls, baseline monocyte activation was significantly increased, whereas stimulability was decreased. The percentage of classical monocytes increased after explantation, while the percentage of intermediate monocytes decreased. Total, classical, and intermediate monocyte counts were significantly elevated compared to controls. On day 0, baseline binding of F7 was significantly lower in non-survivors than survivors. The area under the ROC curve associated with mortality on day 0 was 0.802 (p = 0.02).Conclusions: Distribution of monocyte subsets changes during VA-ECMO and absolute classical and intermediate monocyte counts are significantly elevated compared to controls. Monocytes from VA-ECMO patients showed signs of dysfunction. Monocyte dysfunction, as determined by the unique tool F7, could be valuable for predicting mortality in patients receiving VA-ECMO and may be used as a novel biomarker guiding early clinical decision making in the future.

Precannulation International Normalized Ratio is Independently Associated With Mortality in Veno-Arterial Extracorporeal Membrane Oxygenation

To explore whether precannulation international normalized ratio (INR) is associated with in-hospital mortality in venoarterial extracorporeal membrane oxygenation (VA-ECMO) patients. A retrospective, observational cohort study. A quaternary care academic medical center. Patients with cardiogenic shock on VA-ECMO for >24 hours. None, observational study. A total of 188 patients who were on VA-ECMO were included over three years. Patients were stratified into three groups based on their pre-ECMO INR: INR <1.5, INR 1.5 to 1.8, and INR >1.8. For all patients, demographics, comorbidities, and ECMO details were recorded. The study's primary outcome was in-hospital mortality and secondary outcomes included major bleeding, minor bleeding, allogeneic transfusion, ischemic stroke, intracranial hemorrhage, acute renal failure, acute liver failure, gastrointestinal bleeding, intensive care unit and hospital lengths of stay. A multivariate logistic regression was used to determine whether precannulation INR was associated independently with in-hospital mortality. In-hospital mortality differed significantly by INR group (51.6% INR >1.8 v 42.3% INR 1.5-1.8 v 24.3% INR <1.5; p=0.004). In a multivariate logistic regression model, precannulation INR >1.8 was associated independently with an increased odds of mortality (odds ratio, 2.48; 95% confidence interval, 1.05-6.04) after controlling for sex, Survival after VA- ECMO score, and ECMO indication. An INR within 1.5 to 1.8 did not confer an increased mortality risk. An INR >1.8 before VA-ECMO cannulation is associated independently with in-hospital mortality. Precannulation INR should be considered by clinicians so that ECMO resources can be better allocated and risks of organ failure and intracranial hemorrhage can be better understood.

Ankle-brachial index to monitor limb perfusion in patients with femoral venoarterial extracorporeal membrane oxygenation.

Limb ischemia is a major complication of femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO). Use of ankle-brachial index (ABI) to monitor limb perfusion in VA-ECMO has not been described. We report our experience monitoring femoral VA-ECMO patients with serial ABI and the relationships between ABI and near infrared spectroscopy (NIRS). This is a retrospective single-center review of consecutive adult patients placed on femoral VA-ECMO between January 2019 and October 2019. Data were collected on patients with paired ABI and NIRS values. Relationships between NIRS and ABI of the cannulated (E-NIRS and E-ABI) and non-cannulated legs (N-NIRS and N-ABI) along with the difference between legs (d-NIRS and d-ABI) were determined using Pearson correlation. Overall, 22 patients (mean age 56.5 ± 14.0 years, 72.7% male) were assessed with 295 E-ABI and E-NIRS measurements, and 273 N-ABI and N-NIRS measurements. Mean duration of ECMO support was 129.8 ± 78.3 h. ECMO-mortality was 13.6% and in-hospital mortality was 45.5%. N-ABI and N-NIRS were significantly higher than their ECMO counterparts (ABI mean difference 0.16, 95% confidence interval [CI]: 0.13-0.19, p < .0001; NIRS mean difference 2.51, 95% CI: 1.48-3.54, p < .0001). There was no correlation between E-ABI versus E-NIRS (r = .032, p = .59), N-ABI versus N-NIRS (r = .097, p = .11), or d-NIRS versus d-ABI (r = .11, p = .069). ABI is a quantitative metric that may be used to monitor limb perfusion and supplement clinical exams to identify limb ischemia in femorally cannulated VA-ECMO patients. More studies are needed to characterize the significance of ABI in femoral VA-ECMO and its value in identifying limb ischemia in this patient population.

Levosimendan in venoarterial ECMO weaning. Rational and design of a randomized double blind multicentre trial.

AimsVenoarterial extracorporeal membrane oxygenation (VA‐ECMO) is increasingly being used in circulatory failure. The main indications are cardiogenic shock, post‐cardiotomy cardiac failure, and refractory cardiac arrest. However, VA‐ECMO weaning is particularly challenging, and weaning failure is reported to be as high as 50%, with increased related mortality. Levosimendan is a novel long acting effect inodilator used in cardiogenic shock and terminal heart failure decompensation. Levosimendan use in VA‐ECMO patients seems to reduce weaning failure regardless of the initial aetiology and to reduce mortality when administrated early after VA‐ECMO initiation. However, studies are limited to retrospective analyses and reported case series. The aim of the WEANILEVO trial is to evaluate whether administration of levosimendan before VA‐ECMO weaning is associated with a reduced rates of weaning failure and recourse to other temporary circulatory support.Methods and resultsWEANILEVO is a randomized, prospective, multicentre, double‐blind, parallel‐group, controlled trial. One hundred eighty patients will be enrolled if they had acute circulatory heart failure treated with VA‐ECMO and for whom weaning is expected within 48 h. The study drugs are either levosimendan (0.2 μg/kg/min for 24 h) or a placebo. The primary endpoint of the trial is the absence of VA‐ECMO weaning, recourse to another VA‐ECMO, or other temporary circulatory assistance or death within 7 days of VA‐ECMO weaning.ConclusionsLevosimendan use in VA‐ECMO appears to be beneficial for reducing weaning failure and mortality. The results of WEANILEVO should significantly influence decisions regarding the use of levosimendan for VA‐ECMO weaning.

Clinical efficacy of direct or indirect left ventricular unloading during venoarterial extracorporeal membrane oxygenation for primary cardiogenic shock

ObjectiveLeft ventricular (LV) distention is a feared complication in patients receiving venoarterial (VA) extracorporeal membrane oxygenation (ECMO). LV unloading can be achieved indirectly with intra-aortic balloon pump (IABP) or directly with an Impella device (Abiomed, Danvers, Mass). We sought to assess the clinical and hemodynamic effects of IABP and Impella devices on patients supported with VA ECMO. MethodsWe conducted a retrospective review of VA ECMO patients at our institution from January 2015 to June 2020. Patients were categorized as either ECMO alone or ECMO with LV unloading. LV unloading was characterized as either ECMO with IABP or ECMO with Impella. We recorded baseline characteristics, survival, complications, and hemodynamic changes associated with device initiation. ResultsDuring the study, 143 patients received ECMO alone whereas 140 received ECMO with LV unloading (68 ECMO with IABP, 72 ECMO with Impella). ECMO with Impella patients had a higher incidence of bleeding events compared with ECMO alone or ECMO with IABP (52.8% vs 37.1% vs 17.7%; P < .0001). Compared with ECMO alone, ECMO with IABP patients had better survival at 180 days (log rank P = .005) whereas survival in ECMO with Impella patients was not different (log rank P = .66). In a multivariable Cox hazard analysis, age (hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.00-1.03; P = .015), male sex (HR, 0.54; 95% CI, 0.38-0.80; P = .002), baseline lactate (HR, 1.06; 95% CI, 1.02-1.11; P = .004), baseline creatinine (HR, 1.06; 95% CI, 1.00-1.11; P = .032), need for extracorporeal membrane oxygenation-cardiopulmonary resuscitation (HR, 2.09; 95% CI, 1.40-3.39; P = .001), and presence of pre-ECMO IABP (HR, 0.45; 95% CI, 0.25-0.83; P = .010) were associated with reduced mortality. There was no significant difference in hemodynamic changes in the ECMO with IABP versus ECMO with Impella cohorts. ConclusionsConcomitant support with IABP might help reduce morbidity and improve 180-day survival in patients receiving VA ECMO for cardiogenic shock.

Ultrasound-assisted catheter directed thrombolysis for pulmonary embolus during extracorporeal membrane oxygenation.

Acute pulmonary embolism (PE) is the third most common cause of cardiovascular death. For patients who are hemodynamically unstable, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support has been shown to provide hemodynamic stability, and allow time for definitive treatment and recovery. Ultrasound-assisted catheter directed thrombolysis (USAT) has the potential to be a safe adjunct and expedite right ventricular (RV) recovery for patients requiring VA-ECMO for PE. A review of all VA-ECMO patients from January 2017 to September 2019 was performed. A total of 49 of these patients were cannulated due to a PE. USAT therapy was used as an adjunct in 6 (12%) of these patients. These 6 patients were given standardized USAT therapy with EKOs catheters at 1 mg/h of tissue plasminogen activator with an unfractionated heparin infusion for additional systemic anticoagulation. Outcomes, including in-hospital death, 90-day survival, RV recovery, and complications, were examined in the cohort of patients that received USAT as an adjunct to ECMO. Median age was 54 years old. Five of the six patients presented with a massive PE and had a PE severity score of Class V. One patient presented with a submassive PE with a Bova score of 2, but was cannulated to VA-ECMO in the setting of worsening RV function. All patients demonstrated recovery of RV function, were free from in-hospital death, and were alive at 90-day follow-up. Ekosonic endovascular system therapy may be a safe and feasible adjunct for patients on VA-ECMO for PE, and allow for survival with RV recovery with minimal complications.

Epinephrine administration in venoarterial extracorporeal membrane oxygenation patients is associated with mortality: a retrospective cohort study.

AimsKnowledge about the impact of epinephrine on the outcome in venoarterial (VA) extracorporeal membrane oxygenation (ECMO) patients is limited, and existing data are conflicting.Methods and resultsWe conducted a retrospective cohort study in a 1500 bed tertiary university hospital. Five hundred and eighty‐nine VA‐ECMO patients were analysed. The median age was 57 years [47–65], 68% of male. The major indications for ECMO were post‐cardiotomy cardiogenic shock (CS) (38%) and medical CS (36%). Two hundred and sixty‐two (44.5%) patients received epinephrine alone or associated with another catecholamine while on ECMO. Baseline factors significantly associated with epinephrine administration were younger age, higher sequential organ failure assessment score, cardiac arrest at implantation, and intra‐aortic balloon pump support at implantation, whereas medical CS and dobutamine administration were significantly associated with a lower risk of epinephrine administration. Epinephrine administration was independently associated with death [hazard ratio = 1.68 (1.44–2.23); P < 0.01]. A sensitivity analysis with propensity score inverse probability weighting in complete cases confirmed a significant association of epinephrine administration with death [hazard ratio = 1.69 (1.43–2.00); P < 0.001].ConclusionsAmong patients who required VA‐ECMO, epinephrine administration was associated with an increased risk for death.

Duration of Hyperoxia and Neurologic Outcomes in Patients Undergoing Extracorporeal Membrane Oxygenation.

To evaluate the impact of duration of hyperoxia on neurologic outcome and mortality in patients undergoing venoarterial extracorporeal membrane oxygenation. A retrospective analysis of venoarterial extracorporeal membrane oxygenation patients admitted to the Johns Hopkins Hospital. The primary outcome was neurologic function at discharge defined by modified Rankin Scale, with a score of 0-3 defined as a good neurologic outcome, and a score of 4-6 defined as a poor neurologic outcome. Multivariable logistic regression analysis was performed to evaluate the association between hyperoxia and neurologic outcomes. The Johns Hopkins Hospital Cardiovascular ICU and Cardiac Critical Care Unit. None. We measured first and maximum Pao2 values, area under the curve per minute over the first 24 hours, and duration of mild, moderate, and severe hyperoxia. Of 132 patients on venoarterial extracorporeal membrane oxygenation, 127 (96.5%) were exposed to mild hyperoxia in the first 24 hours. Poor neurologic outcomes were observed in 105 patients (79.6%) (102 with vs 3 without hyperoxia; p = 0.14). Patients with poor neurologic outcomes had longer exposure to mild (19.1 vs 15.2 hr; p = 0.01), moderate (14.6 vs 9.2 hr; p = 0.003), and severe hyperoxia (9.1 vs 4.0 hr; p = 0.003). In a multivariable analysis, patients with worse neurologic outcome experienced longer durations of mild (adjusted odds ratio, 1.10; 95% CI, 1.01-1.19; p = 0.02), moderate (adjusted odds ratio, 1.12; 95% CI, 1.04-1.22; p = 0.002), and severe (adjusted odds ratio, 1.19; 95% CI, 1.06-1.35; p = 0.003) hyperoxia. Additionally, duration of severe hyperoxia was independently associated with inhospital mortality (adjusted odds ratio, 1.18; 95% CI, 1.08-1.29; p < 0.001). In patients undergoing venoarterial extracorporeal membrane oxygenation, duration and severity of early hyperoxia were independently associated with poor neurologic outcomes at discharge and mortality.

Intracranial hemorrhage in adult patients on venoarterial extracorporeal membrane oxygenation

Abstract Funding Acknowledgements Type of funding sources: None. Purpose Intracranial hemorrhage (ICH) is one of the most serious complications of adult patients treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) and is associated with increased morbidity and mortality. However, the prevalence and risk factors of ICH in this cohort are still insufficiently understood. Therefore, the purpose of this study was to further investigate prevalence, associated mortality and predictors of ICH in VAECMO patients. Methods We conducted a retrospective multicenter study including adult patients (≥18 years) treated with VA-ECMO in cardiac intensive care units (ICUs) at five clinical sites between January 2016 and March 2020, excluding patients with ICH upon admission. Differences in baseline characteristics and clinical outcome between VA-ECMO patients with and without ICH were analysed. Predictors of ICH were identified by uni- and multivariable regression models. Results Among 598 patients included, 70 (12%) developed ICH during VA-ECMO treatment with mean duration of 82 ± 84h between ECMO initiation and ICH diagnosis. Out of these ICH, 23% were intraparenchymal, 20% subarachnoid, 10% subdural, 3% intraventricular and 44% combined hemorrhage. In-hospital mortality in the ICH cohort was 81% and 1-month mortality 86%, compared to 63% (p = 0.002) and 64% (p &amp;lt; 0.001), respectively, in the non-ICH cohort. In a multivariable regression model, ICH was independently associated with diabetes mellitus (Odds Ratio [OR] 1.952, 95% confidence interval [CI] [1.082, 3.492], p = 0.025), platelet count (OR 0.990, 95% CI [0.982, 0.996], p = 0.003) and fibrinogen (OR 0.996, 95% CI [0.993, 0.998], p = 0.002). Conclusion ICH occurred frequently in VA-ECMO patients and was associated with a significantly higher mortality rate. Diabetes mellitus, low platelet count and low fibrinogen level are independent predictors of ICH. These findings may help to develop effective strategies to prevent and treat ICH and build the basis for further investigations to optimize clinical outcome in patients on VA-ECMO.

Survival of patients with acute pulmonary embolism treated with venoarterial extracorporeal membrane oxygenation: A systematic review and meta-analysis.

To examine whether venoarterial extracorporeal membrane oxygenation (VA-ECMO) improves survival of patients with acute pulmonary embolism (PE). Following the PRISMA guidelines, a systematic search was conducted up to August 2019 of the databases: PubMed/MEDLINE, EMBASE and Cochrane. All studies reporting the survival of adult patients with acute PE treated with VA-ECMO and including four patients or more were included. Exclusion criteria were: correspondences, reviews and studies in absence of a full text, written in other languages than English or Dutch, or dating before 1980. Short-term (hospital or 30-day) survival data were pooled and presented with relative risks (RR) and 95% confidence intervals (95% CI). Also, the following pre-defined factors were evaluated for their association with survival in VA-ECMO treated patients: age > 60 years, male sex, pre-ECMO cardiac arrest, surgical embolectomy, catheter directed therapy, systemic thrombolysis, and VA-ECMO as single therapy. A total of 29 observational studies were included (N = 1947 patients: VA-ECMO N = 1138 and control N = 809). There was no difference in short-term survival between VA-ECMO treated patients and control patients (RR 0.91, 95% CI 0.71-1.16). In acute PE patients undergoing VA-ECMO, age > 60 years was associated with lower survival (RR 0.72, 95% CI 0.52-0.99), surgical embolectomy was associated with higher survival (RR 1.96, 95% CI 1.39-2.76) and pre-ECMO cardiac arrest showed a trend toward lower survival (RR 0.88, 95% CI 0.77-1.01). The other evaluated factors were not associated with a difference in survival. At present, there is insufficient evidence that VA-ECMO treatment improves short-term survival of acute PE patients. Low quality evidence suggest that VA-ECMO patients aged ≤60 years or who received SE have higher survival rates. Considering the limited evidence derived from the present data, this study emphasizes the need for prospective studies. PROSPERO CRD42019120370.

Early and Long-Term Outcomes after Direct Bridge-to-Transplantation with Extracorporeal Membrane Oxygenation

Purpose Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as direct bridge-to-transplantation (dBTT) remains controversial. We compared the short- and long-term outcomes of adult patients undergoing urgent HT with (dBTT) and without (non-BTT) VA-ECMO support at the time of heart transplantation (HT). Methods Adults who underwent urgent HT in two institutions were assessed (n=133; dBTT: n=34 and non-BTT: n=99). Patient characteristics, donor characteristics, in-hospital outcomes, and overall survival were compared. Mean follow-up was 77±38 months and was 100% complete. Mortality predictors were identified using univariate and multivariate analyses. Results Before HT, patients with dBTT had higher rates of ischemic cardiomyopathy, acute kidney injury, liver failure, respiratory failure, and longer graft ischemia times. More patients in the dBTT group required VA-ECMO postoperatively (dBTT=50% vs. non-BTT= 20%, p Conclusion Long-term outcomes were not significantly different between patients undergoing dBTT on VA-ECMO support and patients undergoing urgent HT without VA-ECMO, especially dBTT recipients without any preoperative associated organ failure and a low preoperative MELD-XI score (≤10.5).

Tissue Factor Pathway Inhibitor Levels During Veno-Arterial Extracorporeal Membrane Oxygenation in Adults.

Tissue factor pathway inhibitor (TFPI) has multiple anticoagulant properties. To our knowledge, no studies have measured TFPI levels in adult veno-arterial (VA) extracorporeal membrane oxygenation patients. We hypothesized that adult VA ECMO patients would have increased TFPI levels and slowed tissue factor triggered thrombin generation. Twenty VA ECMO patients had TFPI levels and thrombin generation lag time measured on ECMO day 1 or 2, day 3, and day 5. TFPI levels and thrombin generation lag time were compared against healthy control plasma samples. Mean TFPI levels were significantly higher in ECMO patients on ECMO day 1 or 2 = 81,877 ± 19,481 pg/mL, day 3 = 73,907 ± 26,690 pg/mL, and day 5 = 77,812 ± 23,484 pg/mL compared with control plasma = 38,958 ± 9,225 pg/mL (P < 0.001 for all comparisons). Median thrombin generation lag time was significantly longer in ECMO patients on ECMO day 1 or 2 = 10.0 minutes [7.5, 13.8], day 3 = 9.0 minutes [6.8, 12.1], and day 5 = 10.7 minutes [8.3, 15.2] compared with control plasma = 3.6 minutes [2.9, 4.2] (P < 0.001 for all comparisons). TFPI is increased in VA ECMO patients and tissue factor triggered thrombin generation is slowed. Increased TFPI levels could contribute to the multifactorial coagulopathy that occurs during ECMO.

IMPELLA® or Extracorporeal Membrane Oxygenation for Left Ventricular Dominant Refractory Cardiogenic Shock.

Mechanical circulatory support (MCS) devices are effective tools in managing refractory cardiogenic shock (CS). Data comparing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and IMPELLA® are however scarce. We aimed to assess outcomes of patients implanted with these two devices and eligible to both systems. From 2004 to 2020, we retrospectively analyzed 128 patients who underwent VA-ECMO or IMPELLA® in our institution for refractory left ventricle (LV) dominant CS. All patients were eligible to both systems: 97 patients were first implanted with VA-ECMO and 31 with IMPELLA®. The primary endpoint was 30-day all-cause death. VA-ECMO patients were younger (52 vs. 59.4, p = 0.006) and had a higher lactate level at baseline than those in the IMPELLA® group (6.84 vs. 3.03 mmol/L, p < 0.001). Duration of MCS was similar between groups (9.4 days vs. 6 days in the VA-ECMO and IMPELLA® groups respectively, p = 0.077). In unadjusted analysis, no significant difference was observed between groups in 30-day mortality: 43.3% vs. 58.1% in the VA-ECMO and IMPELLA® groups, respectively (p = 0.152). After adjustment, VA-ECMO was associated with a significant reduction in 30-day mortality (HR = 0.25, p = 0.004). A higher rate of MCS escalation was observed in the IMPELLA® group: 32.3% vs. 10.3% (p = 0.003). In patients eligible to either VA-ECMO or IMPELLA® for LV dominant refractory CS, VA-ECMO was associated with improved survival rate and a lower need for escalation.

Long-term renal function after venoarterial extracorporeal membrane oxygenation.

The utilization of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a life-supporting therapy has increased exponentially over the last decade. As more patients receive and survive ECMO, there are a number of unanswered clinical questions about their long-term prognosis and organ function including the need for long-term dialysis. We aimed to utilize over 208 patient-years of follow-up data from our large institutional cohort of VA-ECMO patients to determine the incidence of requiring VA-ECMO support on the need for renal replacement therapy after discharge (LT-dialysis). This retrospective review included all adult VA-ECMO patients at our institution from January 2014 to October 2018 (N = 283). Out of the 99 (35%) survivors, 88 (89%) did not require LT-dialysis of any duration after discharge from the index hospitalization. Patients who required VA-ECMO for decompensated cardiogenic shock were more likely to need LT-dialysis (p = .034), and those who required renal replacement therapy during VA-ECMO (N = 27) also had a higher incidence of LT-dialysis (33%). Overall, these data suggest there is a low incidence of long-term dialysis dependence among survivors of VA-ECMO support. Worries about the potential long-term detrimental effect of VA-ECMO should not preclude patients from receiving this life-saving support.

Multiscale modeling of blood flow to assess neurological complications in patients supported by venoarterial extracorporeal membrane oxygenation

Computational blood flow models in large arteries elucidate valuable relationships between cardiovascular diseases and hemodynamics, leading to improvements in treatment planning and clinical decision making. One such application with potential to benefit from simulation is venoarterial extracorporeal membrane oxygenation (VA-ECMO), a support system for patients with cardiopulmonary failure. VA-ECMO patients develop high rates of neurological complications, partially due to abnormal blood flow throughout the vasculature from the VA-ECMO system. To better understand these hemodynamic changes, it is important to resolve complex local flow parameters derived from three-dimensional (3D) fluid dynamics while also capturing the impact of VA-ECMO support throughout the systemic arterial system. As high-resolution 3D simulations of the arterial network remain computationally expensive and intractable for large studies, a validated, multiscale model is needed to compute both global effects and high-fidelity local hemodynamics. In this work, we developed and demonstrated a framework to model hemodynamics in VA-ECMO patients using coupled 3D and one-dimensional (1D) models (1D→3D). We demonstrated the ability of these multiscale models to simulate complex flow patterns in specific regions of interest while capturing bulk flow throughout the systemic arterial system. We compared 1D, 3D, and 1D→3D coupled models and found that multiscale models were able to sufficiently capture both global and local hemodynamics in the cerebral arteries and aorta in VA-ECMO patients. This study is the first to develop and compare 1D, 3D, and 1D→ 3D coupled models on the larger arterial system scale in VA-ECMO patients, with potential use for other large scale applications.