Venoarterial Membrane Oxygenation Research Articles

Non-invasive assessment of left ventricular contractility by myocardial work index in veno-arterial membrane oxygenation patients: rationale and design of the MIX-ECMO multicentre observational study.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an increasingly utilized therapeutic choice in patients with cardiogenic shock, however, high complication rate often counteracts with its beneficial cardiopulmonary effects. The assessment of left ventricular (LV) function in key in the management of this population, however, the most commonly used measures of LV performance are substantially load-dependent. Non-invasive myocardial work is a novel LV functional measure which may overcome this limitation and estimate LV function independent of the significantly altered loading conditions of VA-ECMO therapy. The Usefulness of Myocardial Work IndeX in ExtraCorporeal Membrane Oxygenation Patients (MIX-ECMO) study aims to examine the prognostic role of non-invasive myocardial work in VA-ECMO-supported patients. The MIX-ECMO is a multicentric, prospective, observational study. We aim to enroll 110 patients 48-72 h after the initiation of VA-ECMO support. The patients will undergo a detailed echocardiographic examination and a central echocardiography core laboratory will quantify conventional LV functional measures and non-invasive myocardial work parameters. The primary endpoint will be failure to wean at 30 days as a composite of cardiovascular mortality, need for long-term mechanical circulatory support or heart transplantation at 30 days, and besides that other secondary objectives will also be investigated. Detailed clinical data will also be collected to compare LV functional measures to parameters with established prognostic role and also to the Survival After Veno-arterial-ECMO (SAVE) score. The MIX-ECMO study will be the first to determine if non-invasive myocardial work has added prognostic value in patients receiving VA-ECMO support.

Biventricular unloading with Impella on top of veno-arterial membrane oxygenation improves short- and long-term survival in refractory post-cardiac arrest cardiogenic shock

Abstract Background Patients with refractory post-cardiac arrest (CA) cardiogenic shock (RCS) may present with LV-failure, biventricular failure or even combined cardiopulmonary failure. Mechanical circulatory support (MCS) with Impella or veno-arterial membrane oxygenation (vaECMO) have emerged as an alternative strategy in order to stabilize the heart function without the detrimental effects of catecholamines or to bridge these patients in definite therapies. However, the selection of the appropriate MCS device should be tailored according to the underlying pathophysiology and properties of the respective MCS device. Especially vaECMO patients may show signs of LV overloading, causing pulmonary edema, LV distension and thus compromising LV myocardial recovery. Nowadays there is no data concerning the role of biventricular unloading with an Impella on top of a vaECMO in the homogenous group of post-CA RCS. Purpose To report our experience from the combined use of Impella (2.5 and CP) on top of a vaECMO in the homogenous group of patients with post-CA RCS. Methods Single center study of consecutive patients with biventricular unloading with Impella after initial vaECMO support over a 6-year period suffering from post-CA RCS. Propensity scoring matching analysis was used to account for the differences in baseline data between the two groups. Results A total of 91 patients underwent vaECMO support for RCS, whereas in another 32 patients initial vaECMO support was escalated with an Impella (75% CP) (BiVent group). Mean age was 60.88 ± 9.8 and 98 (80%) patients were male. Survival rates were similar in both groups (hospital survival: BiVent 40.6% and vaECMO 33%, p=0.52; 12-month survival BiVent 37.5% and vaECMO 31.9%, p=0.67). After adjustment for baseline difference with propensity scoring matching analysis, survival rates were significantly better in the BiVent group (hospital and 12-month survival: BiVent 50% and vaECMO 17%, p=0.03 (Figure 1). Vasopressor doses and lactate levels decreased significantly more firmly in the BiVent group within 72 h on biventricular support compared to vaECMO (p<0.05). Moreover, the patients in the BiVent group demonstrated a greater functional recovery of the LV at 96 hours after admission compared to vaECMO patients (Figure 2). Conclusions Impella on top of vaECMO improves short- and long-term survival in patients with post-cardiac arrest refractory cardiogenic shock leading to a better restoration of the left ventricle and end organ function.

The Relation Between Obesity and Mortality in Postcardiotomy Venoarterial Membrane Oxygenation

BackgroundObesity is an important health problem in cardiac surgery and among patients requiring postcardiotomy venoarterial extracorporeal membrane oxygenation (V-A ECMO). Still, whether these patients are at risk for unfavorable outcomes after postcardiotomy V-A ECMO remains unclear. The current study evaluated the association between body mass index (BMI) and in-hospital outcomes in this setting. MethodsThe Post-cardiotomy Extracorporeal Life Support (PELS-1) study is an international, multicenter study. Patients requiring postcardiotomy V-A ECMO in 36 centers from 16 countries between 2000 and 2020 were included. Patients were divided in 6 BMI categories (underweight, normal weight, overweight, class I, class II, and class III obesity) according to international recommendations. Primary outcome was in-hospital mortality, and secondary outcomes included major adverse events. Mixed logistic regression models were applied to evaluate associations between BMI and mortality. ResultsThe study cohort included 2046 patients (median age, 65 years; 838 women [41.0%]). In-hospital mortality was 60.3%, without statistically significant differences among BMI classes for in-hospital mortality (P = .225) or major adverse events (P = .126). The crude association between BMI and in-hospital mortality was not statistically significant after adjustment for comorbidities and intraoperative variables (class I: odds ratio [OR], 1.21; 95% CI, 0.88-1.65; class II: OR, 1.45; 95% CI, 0.86-2.45; class III: OR, 1.43; 95% CI, 0.62-3.33), which was confirmed in multiple sensitivity analyses. ConclusionsBMI is not associated to in-hospital outcomes after adjustment for confounders in patients undergoing postcardiotomy V-A ECMO. Therefore, BMI itself should not be incorporated in the risk stratification for postcardiotomy V-A ECMO.

Escalation from intra-aortic balloon pump to axillary impella 5.5 support: Staged removal of the femoral access.

Background: With the growing population of advanced heart failure, the use of Impella 5.5 has been increasing. Here, we report an effective strategy of removing the intra-aortic balloon pump (IABP) in the setting of escalation of support to Impella 5.5.Results: From January 1, 2022 to June 30, 2022, a total of 6 patients have undergone IABP removal during Impella 5.5 insertion. The IABP was subsequently removed over the long wire with manual compression on the femoral artery to control bleeding. An 8 or 9 Fr short sheath is inserted over the wire. Staged hemostasis was successfully performed in 4 patients, and the remaining two patients required escalation of support to veno-arterial membrane oxygenation as EC-PELLA utilizing the femoral arterial sheath.Conclusion: This does not only achieve secured hemostasis but also enables a smooth transition to further escalate support such as extracorporeal membrane oxygenation support, if necessary.

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.

Biventricular unloading with impella and venoarterial extracorporeal membrane oxygenation in severe refractory cardiogenic shock: prognosis and implications from the combined use of the devices

Abstract Background Patients with refractory cardiogenic shock (RCS) may present with left ventricle (LV)-failure, biventricular failure or even combined cardiopulmonary failure. Mechanical support with Impella or veno-arterial membrane oxygenation (VA-ECMO) have emerged as an alternative strategy in order to stabilize the heart function without the detrimental effects of catecholamines or to bridge the patients in definite therapies. However, the selection of the appropriate MCS should be tailored according to the underlying pathophysiology and properties of the respective MCS device. Patients with Impella who initially presented with univentricular LV failure may develop additionally right ventricle (RV) dysfunction or pulmonary failure whereas patients with VA-ECMO may show signs of LV overloading, causing pulmonary edema, LV distension and thus compromising LV myocardial recovery. Purpose To present the main outcomes and predictors of survival and safety in RCS treated with Impella and VA-ECMO. Methods Single center study of consecutive patients with biventricular unloading with Impella and VA-ECMO for RCS admitted to Cardiology department of Philipps University in Marburg, Germany, from February 2013 until December 2019. The selection of the device was based on a standard algorithm (Figure 1). Results A total of 67 patients was included in the study. Mean age was 61.07±10.7 and 54 (80.6%) patients were male. Main cause of RCS was acute myocardial infarction (AMI) (74.6%), while 44 (65.7%) were resuscitated prior to admission. In 28 patients Impella was implanted first, whereas VA-ECMO was the first MCS device in 39 patients. The mean Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment Score (SOFA) score on admission was 73.54±16.03 and 12.25±2.71, respectively, corresponding to an expected mortality of higher than 80%. Vasopressor doses and lactate levels were significantly decreased within 72 h on biventricular support (p<0.05 for both). Overall, 17 (25.4%) patients were discharged to cardiac rehabilitation and 5 patients (7.5%) were bridged successfully to ventricular assist device implantation, leading to a total of 32.8% survival on hospital discharge. The 6-month survival was 31.3%. Lactate >6 mmol/L, vasoactive score >100 and pH <7.26 on initiation of biventricular support, as well as Charlson comorbity index (CCI) >3 and prior resuscitation were independent predictors of survival (Figure 2). Conclusions Biventricular support with Impella and VA-ECMO in patients with RCS is feasible and efficient leading to a better survival than predicted through traditional risk scores, mainly via significant hemodynamic improvement and reduction in lactate levels. Lactate, pH and vasoactive score on initiation of biventricular support, as well as age-adjusted CCI and prior resuscitation are independent risk factors associated with mortality in this group of patients. Funding Acknowledgement Type of funding sources: None.

Survivors of veno-arterial membrane oxygenation have good long-term quality of life.

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is used for the management of acute cardiogenic shock with improving short term survival. However, the long-term quality of life (QOL) of this patient population is not well characterized. We prospectively evaluated the QOL of adult patients who survived VA ECMO support for cardiogenic shock at our institution between October 2011 and January 2018 with the Minnesota Living with Heart Failure Questionnaire (MLWHFQ). We surveyed survivors at 3, 6, and 9 months after discharge, and annually for up to 5 years thereafter. A total of 64 patients were evaluated: mean age 54 ± 13 years, 73% male. There were 178 total surveys completed. MLWHFQ total scores significantly improved over time and this pattern was sustained (51.7 ± 25.3 at 3 months, vs 37.7 ± 23.6 at 6 months, vs 25.4 ± 21.3 at ⩾9 months (p < 0.01, p-trend < 0.01)). Most patients supported with VA ECMO for cardiogenic shock who survive to discharge demonstrate excellent quality of life, 6 months since index hospitalization, which is maintained over subsequent years.

Subclavian versus femoral arterial cannulations during extracorporeal membrane oxygenation: A propensity-matched comparison.

During peripheral extracorporeal veno-arterial membrane oxygenation (VA-ECMO) support, subclavian arterial cannulation provides, in comparison to femoral arterial cannulation, an anterograde flow which may prevent from left ventricular (LV) distention and improve outcomes. We aimed to compare the effectiveness of subclavian cannulation to femoral cannulation in reducing LV overdistension consequences, hemostatic complications and mortality. This retrospective study conducted in two intensive care units of the Lille academic hospitals from January 2013 to December 2019 included 372 non-moribund adult patients supported by VA-ECMO. The primary endpoint was a new onset of pulmonary edema (PO) or LV unloading. Secondary endpoints were myocardial recovery, serious bleeding (according to Extracorporeal Life Support Organization definition), thrombotic complications (a composite of stroke, cannulated limb or mesenteric ischemia, intracardiac or aortic-root thrombosis) and 28 day mortality. Differences in outcomes were analyzed using propensity score matching (PSM) and inverse probability of treatment weighting adjustment (IPTW). As compared to femoral cannulation (n=320 patients), subclavian cannulation (n=52 patients) did not reduce the occurrence of new onset of PO or LV unloading after PSM [HR 0.99 (95% CI 0.51-1.91)]. There was no other difference in outcomes in PSM cohort. In IPTW adjustment cohort, subclavian cannulation was associated with reduced recovery and increased serious bleeding with four accidental decannulations observed. Subclavian artery cannulation was not associated with reduced LV distension related complications, thrombotic complications and 28 day mortality. Rather, it may increase serious bleeding and accidental decannulations, and reduce recovery. Therefore, subclavian cannulation should be limited to vascular accessibility issues.

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

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

Less Invasive Reoperative Ventricular Assist Device Insertion for Patients With Patent Bypass Grafts

We report our technique for left ventricular assist device insertion that is useful in patients with patent coronary artery bypass grafts or mediastinal adhesions from other previous surgeries. An inverted-T upper hemisternotomy is made at the level of the second or third intercostal space, and with the left sternal section retracted, dissection is carried along the chest wall into the left pleural space. The device is implanted in the left ventricular apex via a left thoracotomy in the fifth or sixth intercostal space. The outflow graft is routed through the left pleural space and anastomosed to the ascending aorta.

Transition from VA-ECMO to Durable VAD Systems. Do We Need Cardiopulmonary Bypass Machine? On Behalf of ECMO-VAD Study Group

Many surgeons prefer to use cardiopulmonary bypass (CPB) machine when durable ventricular assist devices (VAD) is implanted in patients on veno-arterial membrane oxygenation (VA-ECMO). The aim of this study was to investigate if omitting CPB machine at the time of surgery negatively influence the outcome. Data of eleven high volume VA-ECMO/VAD centers are collected and evaluated to identify patients who underwent VAD implantation after ECMO support between January 2010 and July 2018. Preoperative parameters and postoperative outcome are analyzed. Propensity score analysis was performed to identify two identical groups; one who were operated on without CPB (no CPB group) and the other group were operated on using CPB (CPB group) RESULTS: A total of 531 patients met the inclusion criteria. Nineteen patients were supported with Cardiowest TAH and are excluded from this analysis. The remaining 512 patients included 306 patients in the CPB group and 206 patients in no CPB group. After 1:1 propensity score matching 207 patients remained in each group and were compared. The total surgery time was significantly longer in the CBP group (288 ± 92 vs. 206 ± 64 min, p= <0.001). The postoperative chest tube output on the day of surgery was comparable between the groups (1580 ± 1271 vs. 1321 ± 1047 ml , p= 0.09). However, resternotomy for bleeding was necessary in 41% vs. 30% of patients with or without CPB respectively (p=0.022) and a significantly higher number of PRBC were given to the patients who were operated with CPB (11 ± 8 Units vs. 9 ± 4 Units, p= 0.009); The number of transufused FFP and platelets were comparable. A temporary postoperative right ventricular assist device implantation was necessary in 48% vs. 40% of the patients with or without CPB respectively (p=0.082). Stroke rate of 20% comparable in both groups (p= 0.922). Postoperative renal failure, liver failure and respiratory failure were also comparable (p= 0.223 - 0.708). No significant difference in the postoperative survival between the two groups was observed (p=0.096). This study shows, omitting CPB at the time of durable VAD implantation for patients on VA-ECMO results in shorter surgery time, lower reexploration rate for bleeding and less blood product requirements. A trend toward lower RVAD use was also observed. Survival remains similar between both Groups.

Implanting Durable VAD Systems in Patients on VA-ECMO: Comparing Less Invasive to Sternotomy Approach. On Behalf of ECMO-VAD Study Group

Patients on veno-arterial membrane oxygenation (VA-ECMO) are high-risk candidates for durable ventricular assist device (VAD) surgery. The aim of this study was to compare the outcome of patients who received durable VAD on VA-ECMO using less invasive (LIS) vs. sternotomy approach. Data of eleven high volume VA-ECMO/VAD centers are collected and evaluated to identify patients who underwent VAD implantation after ECMO support between January 2010 and July 2018. Preoperative parameters and postoperative outcome are analyzed. A total of 531 patients met the inclusion criteria. Nineteen patients were supported with Cardiowest TAH and were excluded from this analysis. The remaining 512 patients were 1:3 propensity score matched and resulted in 99 patients remained in LIS group vs. 293 patients in sternotomy group. The total surgery time was significantly longer in the sternotomy group (270±80 vs. 203±61 min; p<0.001). The postoperative chest tube Output was comparable between the groups (p= 0.476). The number of postoperative PRBC, FFP and platelets given were comparable (p=0.296, 0.081 and 0.111 respectively). A temporary postoperative RVAD was necessary in 37% vs. 43% of the patients in LIS vs. sternotomy, respectively (p=0.353). Surgical re-exploration for bleeding was necessary in 39% vs. 34% of patients in LIS vs. sternotomy (p=0.345). Stroke rate was not statistically different in both groups (25% vs 17%, p = 0.097). Renal and liver failure rates were comparable with 31% vs. 30% and 28% vs 22% (LIS vs. sternotomy, p= 0.762 and 0.173). Comparison of the postoperative outcome between the two groups demonstrated superior short and long-term survival for LIS patients (p=0.015) (Figure 1) CONCLUSION: This study shows that LIS approach may be superior to sternotomy approach for patients on VA-ECMO. The postoperative morbidities were comparable. However, a superior short and long term outcome was observed in LIS Group.

Transition from Short-Term to Durable Mechanical Circulatory Support Systems. Outcome and Patient Selection. On Behalf of ECMO-VAD Study Group

Purpose The implantation of durable ventricular assist devices (VAD) in patients on veno-arterial membrane oxygenation (VA-ECMO) is controversial. Available studies in this field are limited to anecdotal case reports. In this study, data of ten high volume VA-ECMO/VAD centers are collected and analysed. Methods Following approval from corresponding ethic committees, data of patients undergoing durable mechanical circulatory support implantations at ten institutions between 01.2010 - 07.2018 were reviewed. Inclusion criteria are patients with prior VA-ECMO support. Several parameters including patient´s characteristics, results of blood gas analysis, blood chemistry, and catecholamine doses prior to the assist device surgery are collected and analysed. The primary endopint was survival or cardiac transplantation at one year. Results A total of 494 patients met the inclusion criteria. The average age was 53 ± 12 yrs. The majority of the patients (82%) were male and 33% of the patients had cardiopulmonary resuscitaion prior to the VA-ECMO implantation. The mean VA-ECMO support duration prior to durable device implantation was 7 ± 8 days. Up to 34 % of the patients were on renal dialysis. Cardiopulmonary bypass was used in 63% of the patients at the time of durable device surgery. Less invasive VAD implantation was performed in 19% of the patients. Type of implanted pump included HeartWare HVAD (70%), HeartMate II (17%), HeartMate III (8%), CardioWest TAH (3.6%) and other pumps in (1.4%). The 30 day, 1 year and 2 year survival was 75 and 50% and 40% respectively. Postoperative complications included right heart failure requiring right VAD in 41% of patients, bleeding requiring resternotomy in 38%, respiratory failure in 65%, renal failure in 68% and hepatic failure in 35% of the patients. Stroke rate was 21%. Heart transplantation was performed in 33% of the patients. Conclusion In this largest ever reported series of durable assist device patients with prior VA-ECMO support, higher rate of postoperative right ventricular failure and bleeding /end organ function complications are observed compared to elective VAD implantations. Nevertheless, considering preoperative characteristics of these patients, acceptable outcome of 50% 1 year success was achieved.

Impact of Veno-Arterial Membrane Oxygenation on Outcome of “Crash and Burn” Patients Transitioned to Durable Left Ventricular Assist Device

Purpose To investigate the outcome of patients in refractory cardiogenic shock who required VA ECMO as a bridge to durable LVAD Methods This is a retrospective review of all adult INTERMACS profile 1 patients who underwent LVAD implantation at our institution between 01/01/2015 and 12/31/2017. The outcomes of patients who were bridged with VA ECMO (ECMO group) were compared with those without bridging (non-ECMO group). Results Out of 27 patients, 16 were bridged with VA ECMO. Basic characteristics are presented in Table 1. After the LVAD implantation, patients in the ECMO group experienced more right ventricular failure requiring temporary RVAD (75% vs. 27%, P = 0.014) and more postoperative surgical bleeding (75% vs. 36%, P = 0.045). Hospital mortality was 25% in ECMO and 18% in non-ECMO group (P = 0.675). Of the hospital survivors, 8 were transplanted, 4 recovered, one patient underwent pump exchange and three are still on support. One-year survival for ECMO group was 56 ±18% versus 47 ±20% in non-ECMO group (Figure 1A). Freedom from infection (Figure 1B), neurologic dysfunction (Figure 1C) and device malfunction (Figure 1D) was 47 ±13%, 65 ±20% and 79 ±11% in ECMO group and 44 ±18%, 37 ±22% and 78 ±14% in non-ECMO group. Conclusion Patients in refractory cardiogenic shock have acceptable post LVAD outcome when bridged with percutaneous VA ECMO. Despite significantly higher rate of postoperative surgical bleeding and the need for biventricular support, both overall survival and LVAD-associated complications are comparable to non-ECMO bridged INTERMACS profile 1 LVAD recipients.

Anticoagulation Levels and Bleeding After Emergency Department Extracorporeal Cardiopulmonary Resuscitation

We aimed to describe bleeding events associated with extracorporeal cardiopulmonary resuscitation (eCPR) using two institutional heparin protocols. In addition, we discuss current barriers to optimal anticoagulation in this critical population. Patients initiated on venoarterial membrane oxygenation (VA-ECMO) are at risk of bleeding and thrombosis; both conditions can lead to severe morbidity or mortality. Intravenous heparin is the preferred form of anticoagulation for VA-ECMO. Prior studies have found elevated activated partial thromboplastin time (aPTT) may be an independent risk factor for bleeding; however, many studies lack standardization of bleeding scores and optimal anticoagulation targets. All six patients initiated on VA-ECMO experienced at least one bleeding event. Of 71 aPTT levels collected, 44% were within therapeutic range, 18% were subtherapeutic, and 38% were supratherapeutic. There were no obvious correlation between aPTT levels and bleeding. Future studies are needed to evaluate anticoagulation strategies in this population.

OC31 HOW TO IDENTIFY THE APPROPRIATE LEFT VENTRICULAR ASSIST DEVICE CANDIDATE AMONG PATIENTS ON EXTRACORPOREAL MEMBRANE OXYGENATION SUPPORT

Background and Aim: Implantation of long-term left ventricular assist devices (LVADs) in patients on veno-arterial membrane oxygenation (VA-ECMO) support is controversial. Aim of this study has been to report the experience of seven LVAD centers. Methods: Data of LVAD patients (2010–2017) at seven European institutions were reviewed. The only inclusion criteria was VA-ECMO before LVAD placement. Patients’ characteristics, intraoperative variables and postoperative course were analyzed thus eventually identifying predictors of mortality. Results: A total of 154 continuous flow LVAD patients (mean age 53.1 ± 12 years; 84% male) were identified. The VA-ECMO cannulation was peripheral in 92% of patients and 37% had received cardiopulmonary resuscitation prior to VA-ECMO implantation. Mean VA-ECMO duration prior to LVAD implantation was 7.1 ± 7 days. Cardiopulmonary bypass was adopted in 64% of patients for LVAD implantation. Major postoperative complications included right heart failure requiring temporary right ventricular device (RVAD) support (47%), bleeding requiring rethoracotomy (20%), respiratory failure (54%), renal failure (50%) and hepatic failure (31%). Thirty-day and 1-year survival was 84 and 62%, respectively. At univariate analysis age, lactate level, pH, white blood cells (WBC) count, pre-LVAD dialysis and Model for End-stage Liver Disease eXcluding INR (MELD-XI) score before implant were significant. Multivariate regression analysis identified pre-LVAD MELD-XI (OR 1,250, 95% CI 1,038–1,505; p = 0.019) as the only significant predictor of mortality. Conclusions: The outcome of LVAD patients on VA-ECMO support is limited by the high rate of major adverse events. Preoperative LVAD MELD-XI score seems to identify patients that will clearly not benefit from LVAD implantation.

Selecting Ideal VAD Candidates in Patients on Venoarterial Membrane Oxygenation: Can We Identify the “Point of No Return”?

Selecting Ideal VAD Candidates in Patients on Venoarterial Membrane Oxygenation: Can We Identify the “Point of No Return”?

Haemodynamic Assessment of Patients Supported on Veno-Arterial Membrane Oxygenation with Concurrent Evaluation of Echocardiographic Findings

Introduction: Intrinsic cardiac output is not accurately assessed with thermo-dilution or pulse contour analysis in veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Pulse pressure (PP) is thought to be a surrogate marker for intrinsic cardiac output. We compare invasive haemodynamic parameters with echocardiography (EC) findings.

Implementing an Innovative Cardiac Assist System in a Nonuniversity Hospital--Feasibility, Complications, and First Results.

To evaluate the feasibility of implementing a cardiac assist system in a nonuniversity hospital we analyzed 18 consecutive patients treated with venoarterial membrane oxygenation. The system was used electively in 5/18 (27.8%) patients during high-risk interventions. Thirteen patients (72.2%) were treated in emergency situations. The extracorporal system could be initiated successfully in all patients. Periprocedural complications were hemolysis in 3/18 (16.7%), disseminated intravascular coagulation in 2/18 (11.1%), cerebral ischemia in 1/18 (5.6%), and local infection in 2/18 (11.1%) patients. None of these led to a discontinuation of the therapy. All electively treated patients were successfully weaned from the extracorporeal system. In 9/13 (69.2%) emergency patients the system was removed successfully. The 60-day survival rate of the emergency patients was 53.8% (7/13). Our experience confirms that an innovative extracorporeal circulatory support system can be implemented in a nonuniversity hospital at a tolerable risk and a low complication and high procedural success rate.

Relapse of giant cell myocarditis supported with veno-arterial extracorporeal membrane oxygenation

Giant cell myocarditis (GCM) is a fatal form of myocarditis that often presents with acute heart failure. An inflammatory infiltrate with giant cells and myocardial necrosis is characteristic. During the acute presentation, mechanical circulatory support may be necessary for hemodynamic support while immunosuppression is initiated. We report a case of GCM relapse which was supported with veno-arterial membrane oxygenation until recovery. The patient is doing well one year after explantation.