Venoarterial Extracorporeal Membrane Oxygenation Cannulation Research Articles

Development, implementation, and refinement of a comprehensive postcardiac arrest care training course in Japan

AimIn Japan, no training course is dedicated to postcardiac arrest care (PCAC), including venoarterial extracorporeal membrane oxygenation (VA‐ECMO); thus, faculty members of the Japanese Circulation Society developed an original, comprehensive PCAC training course. This report reviews the development, implementation, and refinement of this PCAC training course.MethodsWe examined the preserved data from the Japanese Circulation Society PCAC training courses between 2014 and 2020. Data related to the learning content and number of the attendees and instructors were collected and summarized.ResultsSixteen courses were held between August 2014 and February 2020, before the coronavirus disease 2019 (COVID‐19) pandemic. A total of 677 health care providers participated: 351 doctors, 225 nurses, 62 perfusionists, five emergency medical professionals, and two pharmacists. Thirty‐two attendees’ data were missing. The core learning contents of all the courses included a standardized postcardiac arrest algorithm, targeted temperature management, VA‐ECMO cannulation skills, and postcannulation management. Concerning curriculum evolution, extracorporeal cardiopulmonary resuscitation simulation, postarrest neurological examination and monitoring, and ultrasound‐guided Seldinger technique training were added in the 4th, 5th, and 13th courses, respectively.ConclusionThe Japanese Circulation Society PCAC training course has been developed and refined to provide an organized, comprehensive opportunity for health care providers to acquire specific knowledge and skills in PCAC and VA‐ECMO.

Preclosure technique versus arterial cutdown after percutaneous cannulation for venoarterial extracorporeal membrane oxygenation.

BackgroundArteriotomy repair through the preclosure technique during elective arterial access procedures is well documented. Outcomes associated with application of this technique to the removal of arterial access cannulas in patients undergoing urgent venoarterial extracorporeal membrane oxygenation (VA-ECMO) have not previously been reported.MethodsWe reviewed the records of consecutive patients who required VA-ECMO for cardiogenic shock. Patients were compared by use of the preclosure device (Perclose ProGlide Suture-Mediated Closure System; Abbott Vascular, Abbott Park, Ill) at time of VA-ECMO cannulation. The rate of limb complications (composite of limb ischemia, infection, and site necrosis) and secondary end points of bleeding events, pseudoaneurysm, distal part embolization, and intensive care unit length of stay after decannulation were compared between the groups.ResultsNinety-nine consecutive patients managed with VA-ECMO were identified and the preclosure device was utilized in 51 of these patients. Preclosure device failure occurred in 5 instances (9.8%) and was successfully managed with surgical repair in 4 cases and endovascular intervention in another. Use of the preclosure device was associated with both fewer limb complications (odds ratio, 0.19; 95% confidence interval, 0.03-0.78) and bleeding events (odds ratio, 0.21; 95% confidence interval, 0.04-0.89). Pseudoaneurysm (n = 0) and distal part embolization (n = 1) were infrequently encountered in the cohort and no difference in intensive care unit length of stay after decannulation was noted between the groups.ConclusionsIn this cohort, use of the preclosure technique in weaning from VA-ECMO was technically feasible, safe, and associated with an approximate 80% lower likelihood of limb complications and bleeding events compared with surgical removal.

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.

ELSO Interim Guidelines for Venoarterial Extracorporeal Membrane Oxygenation in Adult Cardiac Patients.

ELSO Interim Guidelines for Venoarterial Extracorporeal Membrane Oxygenation in Adult Cardiac Patients.

To Vent or Not to Vent: A Loaded Question During Venoarterial Extracorporeal Membrane Oxygenation Support for Cardiogenic Shock

To Vent or Not to Vent: A Loaded Question During Venoarterial Extracorporeal Membrane Oxygenation Support for Cardiogenic Shock

Bedside VA-ECMO Cannulation for a Patient with CTEPH and RV Failure

Introduction Acute pulmonary embolus (PE) in the setting of chronic thromboembolic pulmonary hypertension (CTEPH) with elevated PA pressures and right ventricular (RV) failure is a complex condition associated with increased mortality if left untreated. We demonstrate an alternative bedside veno-arterial extracorporeal membrane oxygenation (VA-ECMO) strategy used to facilitate stabilization and pre-operative optimization. Case Report A 29-year-old female with a history of previous PE (on Lovenox), RV dysfunction with elevated PA pressures, and IVC thrombus requiring VV-ECMO assisted suction embolectomy presented to an outside hospital with shortness of breath, hypoxia and CT demonstrating acute on chronic, bilateral PEs. A transthoracic echocardiogram (TTE) showed worsening RV function. She was normotensive, had a heart rate of 140, and was hypoxic so was placed on BiPAP. She was transferred to our facility for further management. On arrival, the patient was tachypneic and hypoxic. She was started on Epinephrine, Milrinone, and inhaled Epoprostenol but was persistently hypoxic with a rising lactic acid and worsening metabolic acidosis. With evidence of worsening RV failure, the patient was cannulated for VA-ECMO to facilitate optimization for advanced management. Prior to cannulation, bedside ultrasound revealed occlusive thrombus in both femoral and iliac veins. The venous drainage cannula was placed in the right internal jugular vein and the arterial return cannula was placed in the right common femoral artery, with antegrade reperfusion cannula. Bedside TTE was used to aide in cannula placement and cannula position was confirmed with x-ray.The patient was on VA-ECMO for 72 hours. During this time, her acidosis improved, Milrinone was weaned off, and she was diuresed. On ECMO day 3, she was taken to the OR for a pulmonary thromboendarterectomy and decannulated from VA-ECMO. The following day she was extubated and a TTE revealed improved right ventricular function. Summary Stabilization with VA-ECMO in patients with PE can be beneficial. This case illustrates the use of an alternative VA-ECMO cannulation strategy to optimize a patient with CTEPH. Of note, the cannulation occurred at the bedside with the use of ultrasound and without the need for intubation. Though this cannulation strategy is theoretically described in the literature, this case illustrates a concrete example of its use.

Impact of Duration of Veno-Arterial Extra-Corporeal Membrane Oxygenation Cannulation on Post Transplant Survival Following the UNOS Allocation Policy Change

Purpose The 2018 revised UNOS heart allocation policy restructured the prioritization of patients awaiting heart transplantation (HT) based on illness severity. Among the group of patients assigned the highest priority includes candidates cannulated with veno-arterial extracorporeal membrane oxygenation (VA ECMO). Those meeting strict hemodynamic criteria set forth by UNOS are granted a 7-day status 1 window. Beyond this timeframe, transplant programs must apply for extensions with hemodynamic data demonstrating continued dependence on VA-ECMO support and contraindications to a durable device. Herein we report the 6-month survival outcomes for patients bridged to transplant with VA-ECMO based on duration of VA-ECMO support prior to HT. Methods The UNOS registry was queried for all patients on VA-ECMO in the 12-months following the UNOS allocation policy change. A total of 122 patients were bridged to HT with VA-ECMO in this time. Patients were divided into short- (N=105) and long- (N=17) duration groups based on time on VA-ECMO support, while listed as Status 1, using a cutoff of 7-days. Clinical, laboratory, hemodynamic, and ischemic time were compared with standard statistical methods and predictors of post-transplant mortality were assessed with Cox proportional hazards modeling. Results Baseline recipient characteristics and comorbidities were similar between the short- and long-duration groups. Median number (interquartile range) of days on VA-ECMO while listed as status 1 was 3 (2, 4) days versus 9 (7, 13) days with 105/122 (86%) successfully bridged to HT in less than 7-days. The short-duration group spent a total median time on VA-ECMO support of 4 (2, 9) days compared to 24 (17, 50) days in the long-duration group. There were no significant differences in invasive cardiac hemodynamics, serum creatinine, mechanical ventilation or need for dialysis at time of transplantation. Additionally, there were no differences in mean donor age or allograft ischemic times. Finally, there were no significant differences in 6-month post-HT survival outcomes between the two groups (log-rank, p = 0.91). Conclusion Post-transplant survival did not depend on duration of VA-ECMO cannulation based on a cutoff of 7-days. This finding suggests that longer duration of VA-ECMO support may still permit acceptable outcomes.

Central Versus Peripheral Arterial Cannulation for Veno-Arterial Extracorporeal Membrane Oxygenation in Post-Cardiotomy Patients.

Different arterial cannulation strategies are feasible for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in postcardiotomy shock. We aimed to analyze potential benefits and safety of different arterial cannulation strategies. We identified 158 patients with postcardiotomy cardiogenic shock requiring VA-ECMO between 01/10 and 01/19. Eighty-eight patients were cannulated via axillary or femoral artery (group P), and 70 centrally via the ascending aorta directly or through an 8 mm vascular graft anastomosed to the ascending aorta (group C). Demographics and operative parameters were similar. Change of cannulation site for Harlequin's syndrome or hyperperfusion of an extremity occurred in 13 patients in group P but never in group C (p = 0.001). Surgical revision of cannulation site was also encountered more often in group P than C. The need for left ventricular (LV) unloading was similar between groups, whereas surgical venting was more often implemented in group C (11.4% vs. 2.3, p = 0.023). Stroke rates, renal failure, and peripheral ischemia were similar. Weaning rate from ECMO (52.9% vs. 52.3%, p = NS) was similar. The 30 day mortality was higher in group P (60% vs. 76.1%, p = 0.029). Central cannulation for VA-ECMO provides antegrade flow without Harlequin's syndrome, changes of arterial cannula site, and better 30 day survival. Complication rates regarding need for reexploration and transfusion requirements were similar.

Acquired von Willebrand syndrome in ECMO patients: A 3-year cohort study

BackgroundBleeding is a common but possibly underreported side effect of Extracorporeal Membrane Oxygenation (ECMO). Impairment of primary hemostasis by acquired von Willebrand syndrome (aVWS) and platelet dysfunction as well as activation and consumption of plasmatic coagulation factors contribute to hemorrhage. The aim of the present cohort study of consecutively enrolled patients admitted to our ECMO center was to collect demographic, medical and laboratory data possibly associated with i) development of clinically relevant bleeding and/or ii) death during a 12-months follow-up. ResultsWithin a 3-year period 338 white patients aged 18–89 years (median: 60; male 64.5%) were enrolled. 78 of 338 patients (23%) presented with clinical relevant bleeding symptoms. The overall death rate was 74.6% within a median time of 9 days (1–229) post intervention. Logistic-regression analysis adjusted for age and gender revealed that i) the presence of blood group O versus non-O (Odds ratio (OR)/95%CI: 1.9/1.007–3.41), ECMO duration per day (1.1/1.06–1.14), veno-venous versus veno-arterial ECMO cannulation (2.33/1.2–4.5) and the overall need for blood product administered per unit (1.02/1.016–1.028) was independenly associated with bleeding in patients suffering from aVWS. ii) Older age (increase per year) at ECMO start (1.015/1.012–1.029) and an increasing amount of blood product units were significantly related with death (1.007/1.001–1.013). Patients with veno-venous versus veno-arterial cannulation survived longer (0.48/0.24–0.94). ConclusionIn the present cohort study we found a clinical relevant bleeding rate of 23% in subjects with aVWS associated with blood group O, a longer ECMO duration and veno-venous cannulation.

Abstract 16208: Safety and Efficacy of Arterio-venous Extracorporeal Membrane Oxygenation (SAVE Study) Cannulation by Interventional Cardiologists for Pediatric Population: Results of a Single Center Pilot Study

Introduction: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) cannulations have been successfully performed in adults by interventional cardiologists (IC) for cardiopulmonary resuscitation (CPR) but little data exists in children. Hypothesis: This study aimed to describe the safety and efficacy of ultrasound-guided percutaneous VA-ECMO cannulation performed by IC for cardiopulmonary resuscitation. Methods: VA-ECMO cannulation performed by IC for CPR between January 2018 - June 2020 in a tertiary care children’s hospital were reviewed. Efficacy was defined as successful initiation of VA-ECMO following CPR without a surgical cut-down. Safety was defined as the absence of the need for additional procedures related to the cannulation event. Results: Eight VA-ECMO cannulations were attempted on 7 patients with 100% success; 1 patient was cannulated twice at 2 separate CPR events. Patients had congenital heart disease (n=3), idiopathic pulmonary hypertension (n=1), T-cell lymphoma (n=1) and dilated cardiomyopathy (n=2). Median age was 15 (6-18) years, median weight was 74 (16-109) kg. Uninterrupted CPR occurred during all cannulations. All cannulations were performed from left femoral artery and right femoral vein, 4 (50%) cannulations included additional internal jugular vein access. Reperfusion cannulation for distal limb circulation was also performed percutaneously by IC for 5 cannulations. Median venous cannula size was 22 (15-25) Fr and median arterial cannula size was 17 (15-17) Fr. Median cannulation start time to ECMO flow was 34.5 (18-112) min. Median ECMO duration was 3 (0.3-50) days. Survival at ECMO decannulation was 75% with a 30-day survival of 87.5%. The overall complication rate was 12.5%. One patient developed hematoma at cannulation site that was conservatively managed, and 1 patient (16 kg) developed avulsion of the intima of the left common femoral artery that needed repair. A cardiovascular surgeon was available or present during all ECMO cannulations. Conclusions: Pediatric VA-ECMO cannulation for CPR can be performed safely and efficiently by IC without interruption. Larger studies and further investigations are necessary especially in smaller children before advocating for its routine practice.

Neuron-Specific Enolase Levels in Adults Under Venoarterial Extracorporeal Membrane Oxygenation

We aimed to determine if elevations in serum neuron-specific enolase are associated with brain injury and outcomes in adults who require venoarterial extracorporeal membrane oxygenation. Prospective observational study. Two ICUs of a university hospital, Paris, France. Consecutive adult patients treated with venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock or in-hospital refractory cardiac arrest. None. Serum sampled 1, 3, and 7 days after venoarterial extracorporeal membrane oxygenation cannulation was stored at -80°C and neuron-specific enolase concentrations were measured in batches at the end of the study. The association between neuron-specific enolase concentrations and outcomes (28-d mortality and poor outcome, defined by a score of 4-6 on the modified Rankin scale at 90 d) were explored by multivariable logistic regression, with neuron-specific enolase concentrations dichotomized according to median values. One-hundred three patients were included, of whom 26 (25%) received preextracorporeal membrane oxygenation cardiopulmonary resuscitation. Median (interquartile range) day-1, day-3, and day-7 neuron-specific enolase serum concentrations were 37 μg/L (26-51 μg/L), 25 μg/L (19-37) μg/L, and 22 μg/L (17-31 μg/L). After adjustment for Simplified Acute Physiology Score II, preextracorporeal membrane oxygenation cardiopulmonary resuscitation, and Sepsis Organ Failure Assessment score at time of cannulation, a day-3 neuron-specific enolase greater than 25 μg/L remained independently associated with 28-day mortality (adjusted odds ratio, 4.98; 95% CI, 1.86-13.32) and poor outcome at 90 days (adjusted odds ratio, 4.63; 95% CI, 1.81-11.84). A day-3 neuron-specific enolase threshold greater than 80 μg/L had a 100% specificity for prediction of both mortality (95% CI, 92-100%) and poor functional outcome (95% CI, 89-100%). In a subset of patients who underwent brain CT, neuron-specific enolase concentrations were significantly higher in patients diagnosed with stroke, as compared with those without stroke. In adult patients under venoarterial extracorporeal membrane oxygenation, day-3 serum neuron-specific enolase concentrations are independently associated with short-term mortality and poor functional outcomes. These findings deserve validation in a multicenter setting.

Venoarterial extracorporeal membrane oxygenation is an effective management strategy for massive pulmonary embolism patients

ObjectiveTreatment of massive pulmonary embolism (MPE) is controversial, with mortality rates ranging from 25% to 65%. Patients commonly present with profound shock or cardiac arrest. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used as a form of acute cardiopulmonary support in critically ill patients. We reviewed our institution's pulmonary embolism response team experience using VA-ECMO for patients presenting with advanced shock and/or cardiac arrest from MPE. MethodsFrom March 2017 to July 2019 we retrospectively reviewed 17 consecutive patients at our institution with MPE who were placed on VA-ECMO for initial hemodynamic stabilization. ResultsThe mean patient age and body mass index was 55.8 years and 31.8, respectively. Ten of 17 patients (59%) required cardiopulmonary resuscitation before or during VA-ECMO cannulation. All patients had evidence of profound shock with a mean initial lactate of 8.95 mmol/L, a mean pH of 7.10, and a mean serum creatinine of 1.78 mg/dL. Seventeen of 17 cannulations (100%) were performed percutaneously, with 41% (n = 7) of patients placed on VA-ECMO while awake and using local analgesia. Five of 17 patients (29%) required reperfusion cannulas, with 0% incidence of limb loss. Overall survival was 13 of 17 patients (76%), with causes of death resulting from anoxic brain injury (n = 2), septic shock (n = 1), and cardiopulmonary resuscitation-induced hemorrhage from liver laceration (n = 1). In survivors, 12 of 13 patients (92%) were discharged without evidence of neurologic insult. The median duration of the VA-ECMO run for survivors was 86 hours (range, 45-218 hours). In survivors, the median length of time from ECMO cannulation to lactate clearance (<2.0 mmol/L) was 10 hours and the median length of time from ECMO cannulation to freedom from vasopressors was 6 hours. Three of 13 patients (23%) required concomitant percutaneous thrombectomy and catheter-directed thrombolysis to address persistent right heart dysfunction, with the remaining survivors (77%) receiving VA-ECMO and anticoagulation alone as definitive therapy for their MPE. The median intensive care and hospital length of stay for survivors was 9 and 13 days, respectively. ConclusionsVA-ECMO was effective at salvaging highly unstable patients with MPE. Survivors had rapid reversal of multiple organ failure with ECMO as their primary therapy. The majority of survivors required ECMO and anticoagulation alone for definitive therapy of their MPE.

Aggressive placement of distal limb perfusion catheter in venoarterial extracorporeal membrane oxygenation.

The aim of this study is to review the impacts of aggressive placement of a distal perfusion catheter on the outcomes in patients supported with venoarterial extracorporeal membrane oxygenation via femoral cannulation. Analysis was performed with 143 consecutive femoral venoarterial extracorporeal membrane oxygenation cannulation. Patients were divided into two groups: the early period (October 2010 to December 2012, N = 47) where placement of a distal perfusion catheter was attempted percutaneously but not surgically and the late period (January 2013 to November 2018, N = 96) in which placement of distal perfusion catheter was aggressively utilized both percutaneously and surgically. The modification of venoarterial extracorporeal membrane oxygenation cannulation protocol for the late period involved (1) an immediate insertion of a distal perfusion catheter regardless of the size of femoral arterial cannula, (2) an open insertion of a distal perfusion catheter if percutaneous approach failed, and (3) when venoarterial extracorporeal membrane oxygenation cannulation was completed at a non-extracorporeal membrane oxygenation cannulation center, it was encouraged that they attempt insertion of a distal perfusion catheter at the time of cannulation. In the late period, a distal perfusion catheter was placed in 96% (92/96) which was significantly increased from 66% (31/47) in the early period. Of these 92 patients in late period, nine patients (9.8%) required open direct insertion of a distal perfusion catheter. The incidence of lower limb ischemia (early vs. late period 26% vs 12%, P = 0.031) was significantly decreased in the late period. Logistic regression analyses showed that distal perfusion catheter placement was the only factor for preventing lower limb ischemia. Aggressive insertion of a distal perfusion catheter even utilizing surgical cut-down technique was shown to decrease the incidence of distal limb complications.

Neuropathological findings in comatose patients with venoarterial extracorporeal membrane oxygenation.

We sought to describe the relation between neuropathology and clinical information including neurological examination and electroencephalogram findings in extracorporeal membrane oxygenation. We reviewed the patients who had undergone brain autopsy from November 2017 through December 2018. Four patients with neuromonitoring had post mortem examination with brain autopsy. The median age was 56, and all had venoarterial extracorporeal membrane oxygenation cannulation. There was no known acute neurologic injury prior to extracorporeal membrane oxygenation. While on extracorporeal membrane oxygenation, all were persistently comatose off sedation. Continuous encephalogram was done on all four, all of which showed delta frequency with absent reactivity. In Case 1, the pathological evaluation demonstrated small infarcts in cerebral cortices. In Case 2, it showed cortical microhemorrhages and chronic microinfarcts in basal ganglia. In Cases 3 and 4, the neuropathological assessment demonstrated diffuse hypoxic-ischemic brain injury. The clinical presentation was consistent with the widespread neuropathologic injury in two cases (Cases 3 and 4) but not in the other two (Cases 1 and 2). While "poor neurological status" was provided in the end-of-life discussion in all four, only two had significant brain injuries. There is limited understanding about brain injury in extracorporeal membrane oxygenation. Extrapolations related to prognostication from experience in other brain injury needs to be approached cautiously.

Yellow Means Caution: Correlations Between Liver Injury and Mortality with the Use of VA-ECMO

Abnormalities in markers of liver injury after venoarterial extracorporeal membrane oxygenation (VA-ECMO) initiation are of unclear distribution and clinical significance. This study included all consecutive adult patients from a single institution who underwent VA-ECMO cannulation between May 2012 and September 2016 and had liver function panels drawn during their admission (n = 223). Data points include: age, sex, body mass index, diagnosis, duration of ECMO cannulation, duration of hospitalization, pre-ECMO cardiac arrest, central nervous system (CNS) injury, the presence of chronic kidney disease or acute renal failure, renal replacement therapy utilization, lactate levels, duration of pre-ECMO intubation, admission and peak bilirubin/aspartate aminotransferase (AST)/alanine aminotransferase (ALT)/alkaline phosphatase (ALP) levels, and time to peak bilirubin/AST/ALT/ALP in relation to cannulation. Multivariate Poisson regression analyses were performed to determine associations with mortality. In-hospital mortality was 66%. Serum bilirubin elevation appeared to significantly correlate continuously with mortality. Other markers of liver injury were not significant in final multivariate models. As a univariate factor, no patient survived with a total serum bilirubin greater than 30 mg/dl, and specificity for 90% mortality was crossed at 11 mg/dl. Mortality was also significantly associated with the presence of CNS injury and elevation of lactic acid levels. Postcannulation liver injury is significantly associated with increased mortality and total serum bilirubin appears to be a biomarker of considerable clinical significance.

Peripheral versus central extracorporeal membrane oxygenation for postcardiotomy shock: Multicenter registry, systematic review, and meta-analysis

BackgroundWe hypothesized that cannulation strategy in venoarterial extracorporeal membrane oxygenation (VA-ECMO) could play a crucial role in the perioperative survival of patients affected by postcardiotomy shock. MethodsBetween January 2010 and March 2018, 781 adult patients receiving VA-ECMO for postcardiotomy shock at 19 cardiac surgical centers were retrieved from the Postcardiotomy Veno-arterial Extracorporeal Membrane Oxygenation study registry. A parallel systematic review and meta-analysis (PubMed/MEDLINE, Embase, and Cochrane Library) through December 2018 was also accomplished. ResultsCentral and peripheral VA-ECMO cannulation were performed in 245 (31.4%) and 536 (68.6%) patients, respectively. Main indications for the institution VA-ECMO were failure to wean from cardiopulmonary bypass (38%) and heart failure following cardiopulmonary bypass weaning (48%). The doubly robust analysis after inverse probability treatment weighting by propensity score demonstrated that central VA-ECMO was associated with greater hospital mortality (odds ratio 1.54; 95% confidence interval, 1.09-2.18), reoperation for bleeding/tamponade (odds ratio, 1.96; 95% confidence interval, 1.37-2.81), and transfusion of more than 9 RBC units (odds ratio, 2.42; 95% confidence interval, 1.59-3.67). The systematic review provided a total of 2491 individuals with postcardiotomy shock treated with VA-ECMO. Pooled prevalence of in-hospital/30-day mortality in overall patient population was 66.6% (95% confidence interval, 64.7-68.4%), and pooled unadjusted risk ratio analysis confirmed that patients undergoing peripheral VA-ECMO had a lower in-hospital/30-day mortality than patients undergoing central cannulation (risk ratio, 0.92; 95% confidence interval, 0.87-0.98). Adjustments for important confounders did not alter our results. ConclusionsIn patients with postcardiotomy shock treated with VA-ECMO, central cannulation was associated with greater in-hospital mortality than peripheral cannulation.

Clinical utility of venoarterial-extracorporeal membrane oxygenation (VA-ECMO) in patients with drug-induced cardiogenic shock: a retrospective study of the Extracorporeal Life Support Organizations’ ECMO case registry

Background: Venoarterial-extracorporeal membrane oxygenation (VA-ECMO) is increasingly utilized to treat severe or refractory drug-induced cardiovascular shock. There is limited evidence regarding VA-ECMO’s clinical utility in poisoning. Therefore, we investigated the clinical benefit of VA-ECMO use in drug-induced cardiovascular shock using the Extracorporeal Life Support Organization (ELSO)’s ECMO case registry.Methods: The ELSO registry was systematically searched retrospectively, using ICD-9/10 codes for poisoning-related cases from January 1, 2003 to July 30, 2018. All adult cases (age ≥ 18 years) that received VA-ECMO for cardiac support were included. Cardiogenic shock was defined as systolic blood pressure (SBP) <90 mmHg, mean arterial pressure (MAP) <65 mmHg, or requiring infusion of ≥2 vasopressor agents. Study outcomes included survival to discharge (i.e., from the ECMO center), changes in metabolic (acid/base), hemodynamic and ventilatory status, and complications related to ECMO support. Demographic and clinical characteristics of pre-ECMO and 24-h after VA-ECMO cannulation were compared between survivors vs. non-survivors.Results: A total of 113 cases were identified from the ELSO registry; 9 cases were excluded because cardiogenic shock was not related to poisoning, leaving 104 cases for analysis. The median age was 34 years and 53.5% (n = 54) were male. Cardiovascular agents were involved in 47.1% (n = 49) of the cases followed by opioids (n = 9, 6.7%); 34 cases experienced pre-ECMO cardiac arrest. About 92.4% of the cases (n = 85) received vasopressor infusion for hemodynamic support, most frequently norepinephrine (83.7%). Median duration of VA-ECMO was 68 h (interquartile range [IQR]: 48, 113 h); 52.9% (n = 55) of the cases survived to discharge. VA-ECMO significantly improved hemodynamics (MAP, SBP, and DBP), acidemia/acidosis (pH, HCO3 level) and ventilatory parameters (pO2, SpO2, and SvO2). Non-survivors showed persistent acidemia/acidosis at 24-h after VA-ECMO cannulation compared to survivors. Renal replacement therapy (50.9%) and arrhythmia (26.3%) were the most frequently reported complications.Conclusions: VA-ECMO improved hemodynamic and metabolic parameters in patients with drug-induced cardiogenic shock (DCS).

Cardiac Arrest Prior to Venoarterial Extracorporeal Membrane Oxygenation: Risk Factors for Mortality

Mortality after cardiac arrest remains high despite initiation of venoarterial extracorporeal membrane oxygenation. We aimed to identify pre-venoarterial extracorporeal membrane oxygenation risk factors of 90-day mortality in patients with witnessed cardiac arrest and with greater than or equal to 1 minute of cardiopulmonary resuscitation before venoarterial extracorporeal membrane oxygenation. The association between preimplant variables and all-cause mortality at 90 days was analyzed with multivariable logistic regression. Retrospective observational cohort study. Tertiary medical center. Seventy-two consecutive patients with cardiac arrest prior to venoarterial extracorporeal membrane oxygenation cannulation. None. Median age was 56 years (interquartile range, 43-56 yr), 75% (n = 54) were men. Out-of-hospital cardiac arrest occurred in 12% (n = 9) of the patients. Initial cardiac rhythm was nonshockable in 57% (n = 41) and shockable in 43% (n = 31) of patients. Median cardiopulmonary resuscitation duration was 21 minutes (interquartile range, 10-73 min; range, 1-197 min]. No return of spontaneous circulation was present in 64% (n = 46) and postarrest cardiogenic shock in 36% (n = 26) of the patients at venoarterial extracorporeal membrane oxygenation cannulation. Median duration of venoarterial extracorporeal membrane oxygenation was 5 days (interquartile range, 2-12 d). The 90-day overall mortality and in-hospital mortality were 57% (n = 41), 53% (n = 38) died during venoarterial extracorporeal membrane oxygenation, and 43% (n = 31) were successfully weaned. All survivors had Cerebral Performance Category score 1-2 at discharge to home. Multivariable logistic regression analysis identified initial nonshockable cardiac arrest rhythm (odds ratio, 12.2; 95% CI, 2.83-52.7; p = 0.001), arterial lactate (odds ratio per unit, 1.15; 95% CI, 1.01-1.31; p = 0.041), and ischemic heart disease (7.39; 95% CI, 1.57-34.7; p = 0.011) as independent risk factors of 90-day mortality, whereas low-flow duration, return of spontaneous circulation, and age were not. In 72 patients with cardiac arrest before venoarterial extracorporeal membrane oxygenation initiation, nonshockable rhythm, arterial lactate, and ischemic heart disease were identified as independent pre-venoarterial extracorporeal membrane oxygenation risk factors of 90-day mortality. The novelty of this study is that the metabolic state, expressed as level of lactate just before venoarterial extracorporeal membrane oxygenation initiation seems more predictive of outcome than cardiopulmonary resuscitation duration or absence of return of spontaneous circulation.

An urgent open surgical approach for left ventricle venting during peripheral veno-arterial extracorporeal membrane oxygenation for refractory cardiac arrest: case report

The objective of the study is to describe an emergency procedure for left ventricle venting during veno-arterial extracorporeal life support for refractory cardiac arrest. Veno-arterial extracorporeal membrane oxygenation is widely used in refractory cardiac arrest but is characterized by an increase in left ventricle afterload, which may impair cardiac contractility improvement. Different left ventricle venting techniques are available. We report the use of a surgical approach with sternotomy for left ventricle venting in a 21-year-old patient who was placed under veno-arterial extracorporeal membrane oxygenation for refractory cardiac arrest with severe pulmonary edema, respiratory failure, and left ventricle stasis. A 21-year-old woman was admitted for laparoscopic sleeve gastrectomy. In the recovery room, she developed a refractory circulatory shock. Transthoracic echocardiography revealed a dilated cardiomyopathy with severe left ventricle systolic dysfunction (left ventricle ejection fraction at 20%). Coronary angiogram was normal. On day 2, she underwent laparotomy for sepsis and she presented cardiac arrest secondary to ventricular tachycardia. We proceeded to peripheral veno-arterial extracorporeal membrane oxygenation as the cardiac arrest was refractory. A miniaturized veno-arterial extracorporeal membrane oxygenation system was implanted into the right femoral vessels onsite .The low flow duration was 40 minutes. Veno-arterial extracorporeal membrane oxygenation blood flow was set to 3 L min-1, resulting in a closed aortic valve and a massive pulmonary edema. Transesophageal echocardiography showed left ventricular ejection fraction at 5% without aortic valve opening. We first implanted an intra-aortic balloon pump without clinical improvement. Transesophageal echocardiography revealed massive thrombus formation into the aortic root. We decided to perform an open surgical approach for left ventricle unload using a transmitral cannula (22 Fr) via the right superior pulmonary vein connected to the inflow tube of the veno-arterial extracorporeal membrane oxygenation with Y connection. Transesophageal echocardiography showed a full opening of aortic valve and elimination of valve aortic thrombus. Chest radiography showed a significant decrease of pulmonary congestion. We were able to withdraw extracorporeal life support organization on day 10 and discharged on day 54. Clinical explorations reveal a fulminant rocuronium-related hypersensitivity myocarditis. This salvage surgical technique using a modified central veno-arterial extracorporeal membrane oxygenation cannulation technique has efficiently decreased blood stasis and permitted rapid recovery.

Transcranial Doppler is an effective method in assessing cerebral blood flow patterns during peripheral venoarterial extracorporeal membrane oxygenation.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) can be life-saving in refractory cardiogenic shock but carries a risk of neurologic complications such as stroke and hemorrhage. As little is known about the effects of different peripheral VA-ECMO cannulation sites on cerebral blood flow (CBF), transcranial Doppler (TCD) was used to determine whether the cannulation site affects CBF. Thirty-seven patients receiving VA-ECMO for cardiogenic shock via axillary or femoral artery cannulation were prospectively enrolled. Measured bilateral middle cerebral artery (MCA), mean flow velocities (MFV), and pulsatility indices (PI) were the primary outcomes and adverse neurologic events were secondary outcomes. The median age was 58 years (IQR 51-66) with 26 (70%) males. Median VA-ECMO flow was 3.8 L/min (IQR 3.2-4.9) with mean arterial pressures of 80 mm Hg (IQR 75-86). Nineteen patients received right axillary artery cannulation while 18 underwent femoral cannulation. Compared with the femoral group, MFV was higher in the axillary group in the right MCA (46 cm/s [IQR 26-57] vs 27 [17-36], P = 0.03) and left (43 [IQR 35-60] vs 29 cm/s [16-48], P = 0.05). Axillary PI was significantly lower compared with the femoral group (right: 0.48 cm/s [0.25-0.65] vs 0.83 [0.66-0.93], P = 0.02; left: 0.41 cm/s [0.29-0.63] vs 1.02 [0.7-1.3], P = 0.004). One axillary patient experienced a stroke with deficits. TCD appears to be an effective tool for indirect monitoring of CBF in patients withECMO with limited pulsatility. Axillary artery cannulation seems to provide higher cerebral flow rates without any difference in neurologic outcomes. Future studies may incorporate TCD into regulating ECMO flows to achieve physiologic CBF.