Venoarterial Extracorporeal Membrane Oxygenation Cannulation Research Articles

Unloading the left ventricle in VA-ECMO: a comparative analysis of outcomes

Abstract Funding Acknowledgements None. Introduction Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) has radically changed the way we see and treat cardiogenic shock, despite the challenges it presents. The retrograde delivery of oxygenated blood to the aorta via the arterial cannula imposes increased afterload on an already strained left ventricle (LV). Unloading techniques aim to reduce the preload and afterload caused by VA-ECMO on the LV. Purpose Our study aims to compare the clinical outcomes of patients on VA-ECMO where additional invasive techniques were employed to unload the LV, against those without unloading strategies. Methods Patients treated with VA-ECMO in our hospital since 2012 were categorized into two groups: the Venting Group (VG) that received LV unloading interventions and the Non-Venting Group (NVG) without such interventions. We collected comprehensive clinical data, including demographics, baseline characteristics, ECMO-related parameters, in-hospital complications, and patient outcomes. Statistical analyses involved chi-square tests for categorical variables and independent samples t-tests for continuous variables to assess the impact of unloading strategies on patient outcomes. Results Our hospital treated 100 patients with VA-ECMO (mean age 58.4 ± 11.9 years, 60% male). Approximately 39% of patients received LV unloading support. The choice of unloading device was guided by our center's expertise. Most commonly, Intra-Aortic Balloon Pump (IABP) was used (61.5%), followed by Impella CP (23.1%), percutaneous atrial septostomy (2.6%) and surgical LV venting (12.8%). Unloading techniques were implemented either concurrently with VA-ECMO cannulation (58.9%), before (17.9%), or after its insertion (23.2%). Most patients (68%) received inotropic drugs, predominantly dobutamine. The mean duration of venting device use was 4.2 ± 3.8 days. Airway bleeding (3.3% NVG vs. 17.9% VG, p=0.032) and thromboembolic complications (19.7% NVG vs. 41.0% VG, p=0.036) were significantly more prevalent in the VG. There were no significant differences in the others reported ECMO-related complications. No significant differences were observed in the mean duration of support with VA-ECMO (3 days NVG vs. 4 days VG, p=0.147) or in the mean duration of hospitalization (13 days NVG vs. 12 VG, p=0.619) between the two groups. The 30-day survival rates were 42% (95% CI, 0.30-0.59) in NVG and 29% (95% CI, 0.18-0.49) in VG, which did not display statistical significance, p=0.24 [Figure 1]. Conclusions In our cohort, incorporating unloading devices alongside VA-ECMO did not yield major differences in survival rates, yet led to a considerable increase in airway bleeding and thromboembolic complications. The precocity of unloading device implantation occurred either as an initial strategy or to prevent increased afterload in hearts with limited contractile reserve.Characteristics and Clinical OutcomesSurviving Curves VG vs. NVG

An unusual case of relapsing arrhythmia during veno-arterial extracorporeal membrane oxygenation cannulation.

An unusual case of relapsing arrhythmia during veno-arterial extracorporeal membrane oxygenation cannulation.

Association of Sepsis With Neurologic Outcomes of Adult Patients Treated With Venoarterial Extracorporeal Membrane Oxygnenation

OBJECTIVES: Neurologic outcomes of patients under venoarterial extracorporeal membrane oxygenation (VA-ECMO) may be worsened by secondary insults of systemic origin. We aimed to assess whether sepsis, commonly observed during ECMO support, is associated with brain injury and outcomes. DESIGN: Single-center cohort study of the “exposed-non-exposed” type on consecutive adult patients treated by VA-ECMO. SETTING: Medical ICU of a university hospital, France, 2013–2020. PATIENTS: Patients with sepsis at the time of VA-ECMO cannulation (“sepsis” group) were compared with patients without sepsis (“no sepsis” group). The primary outcome measure was poor functional outcome at 90 days, defined by a score greater than or equal to 4 on the modified Rankin scale (mRS), indicating severe disability or death. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 196 patients were included (“sepsis,” n = 128; “no sepsis,” n = 68), of whom 87 (44.4%) had presented cardiac arrest before VA-ECMO cannulation. A poor functional outcome (mRS ≥ 4) was observed in 99 of 128 patients (77.3%) of the “sepsis” group and 46 of 68 patients (67.6%) of the “no sepsis” group (adjusted logistic regression odds ratio (OR) 1.21, 95% CI, 0.58–2.47; inverse probability of treatment weighting (IPTW) OR 1.24; 95% CI, 0.79–1.95). Subsequent analyses performed according to pre-ECMO cardiac arrest status suggested that sepsis was independently associated with poorer functional outcomes in the subgroup of patients who had experienced pre-ECMO cardiac arrest (adjusted logistic regression OR 3.44; 95% CI, 1.06–11.40; IPTW OR 3.52; 95% CI, 1.68–7.73), whereas no such association was observed in patients without pre-ECMO cardiac arrest (adjusted logistic regression OR 0.69; 95% CI, 0.27–1.69; IPTW OR 0.76; 95% CI, 0.42–1.35). Compared with the “no sepsis” group, “sepsis” patients presented a significant increase in S100 calcium-binding protein beta concentrations at day 1 (0.94 μg/L vs. 0.52 μg/L, p = 0.03), and more frequent EEG alterations (i.e., severe slowing, discontinuous background, and a lower prevalence of sleep patterns), suggesting brain injury. CONCLUSION: We observed a detrimental role of sepsis on neurologic outcomes in the subgroup of patients who had experienced pre-ECMO cardiac arrest, but not in other patients.

Use of microaxial flow pumps in adolescents.

The Impella 5.5 has been successfully used in the adult population; however, safety and efficacy data in patients aged less than 18 years are limited. Six pediatric patients, aged 13 to 16years and weighing 45 to 113kg, underwent axillary artery graft placement and attempted placement of the Impella 5.5 device at our institution between August 2020 and March 2023. Indications for implantation were heart failure secondary to myocarditis (2), rejection of prior orthotopic heart transplant, idiopathic dilated cardiomyopathy (2), and heart failure after transposition of the great arteries repair. Placement was unsuccessful in a 13.8-year-old female patient due to prohibitively acute angulation of the right subclavian artery, and venoarterial extracorporeal membrane oxygenation cannulation was performed via the axillary graft. In 5 patients with successful Impella 5.5 placement, median duration of support was 13.5days (range, 7-42days). One experienced cardiac arrest secondary to coagulation-associated device failure, requiring temporary HeartMate3 implantation. Four patients were bridged to transplant; 3 patients received a transplant directly from Impella 5.5, and 1 patient received a transplant after HeartMate3. The final patient received the HeartMate3 on Impella day 42 and is awaiting transplant. Although exact size cutoffs and anatomy are still being determined, our experience provides a framework for use of the Impella 5.5 in adolescents.

Recurrent Myopericarditis and Fulminant Cardiogenic Shock Due to Autoimmune Polyglandular Syndrome 2

A 34-year-old man presented with acute pericarditis and a small pericardial effusion but rapidly decompensated into cardiac tamponade and fulminant cardiogenic shock, requiring venoarterial extracorporeal membrane oxygenation cannulation. He was diagnosed with autoimmune polyglandular syndrome 2 and was treated with stress dose steroids and an interleukin-1 inhibitor, with improvement in his cardiac function.

Practice patterns in extracorporeal life support in tertiary cardiac intensive care units in north america: a survey-based analysis from the critical care cardiology trials network

Abstract Funding Acknowledgements Type of funding sources: None. Background The use of veno-arterial (VA) and veno-venous (VV) extracorporeal membrane oxygenation (ECMO) has significantly increased in the last decade. However, there is substantial variability in practice patterns between institutions. To date, the optimal ECMO program model is unclear and possible differences between ECMO centers in staffing, organization and team structure have been poorly characterized. Purpose Our aim was to describe contemporary practices of care for patients undergoing ECMO in tertiary cardiac centers in North America. Methods An 11-question anonymous survey was sent to all participating sites in the Critical Care Cardiology Trials Network (CCCTN), a prospective registry of advanced cardiac intensive care units (CICUs) in North America, coordinated by the TIMI Study Group. The survey evaluated ECMO staffing models, decision-making processes, cannulation and longitudinal care. Results The response rate was 100% (39/39) across CCCTN centers. The decision to proceed with VA ECMO was made as a team in 79% of the cases and in 58.3% of the VV ECMO cases, rather than by an individual specialty. An ECMO consult service was used in 67% of the centers, and integrated with the cardiogenic shock team in 58%. The most common specialty participating in the ECMO service was cardiothoracic surgery (CTS) (73.1%), followed by heart failure specialists (38.5%), with critical care cardiology (CCC) in only 23.1% of the centers (Figure 1A). In the majority of centers, VA ECMO cannulation was performed by CTS alone (46.2%), Interventional cardiology (IC) and CTS (38.5%), and IC alone (7.7%, Figure 1B). Cannulation for VA ECMO was not performed by intensivists at any center. VV ECMO cannulations were performed by CTS in 51.3%, intensivists in 17.9% and IC in 2.6% of the centers. VA ECMO patients were admitted to the cardiovascular surgical intensive care unit in 64.1% of centers, with 20.5 % admitted to the CICU (Figure 1C). VV ECMO patients were admitted to the cardiovascular surgical intensive care unit in 36.8% of sites, and the medical intensive care unit in 34.2%. The most common ECMO specialist model was having a perfusionist at the bedside, followed by nurse specialist (Figure 1D). Specialty services consulted within 24-48 hours of cannulation included physical therapy in 48.7%, palliative care in 30.8%, and bioethics in only 2.6% of centers. Simulation-based ECMO training is performed in 59% of the centers. Half (51.3%) of the centers perform ECPR, while 17.9% reported plans of developing a program. Conclusions Although there is significant variability in ECMO cannulation, location of care, staffing practices in advanced CICUs in North America, a multidisciplinary team approach is common in ECMO centers, with early involvement of physical therapy and palliative care specialists. Further research to establish the optimal model for ECMO programs is of high importance.

Central versus Peripheral Postcardiotomy Veno-Arterial Extracorporeal Membrane Oxygenation: Systematic Review and Individual Patient Data Meta-Analysis.

It is unclear whether peripheral arterial cannulation is superior to central arterial cannulation for postcardiotomy veno-arterial extracorporeal membrane oxygenation (VA-ECMO). A systematic review was conducted using PubMed, Scopus, and Google Scholar to identify studies on postcardiotomy VA-ECMO for the present individual patient data (IPD) meta-analysis. Analysis was performed according to the intention-to-treat principle. The investigators of 10 studies agreed to participate in the present IPD meta-analysis. Overall, 1269 patients were included in the analysis. Crude rates of in-hospital mortality after central versus peripheral arterial cannulation for VA-ECMO were 70.7% vs. 63.7%, respectively (adjusted OR 1.38, 95% CI 1.08-1.75). Propensity score matching yielded 538 pairs of patients with balanced baseline characteristics and operative variables. Among these matched cohorts, central arterial cannulation VA-ECMO was associated with significantly higher in-hospital mortality compared to peripheral arterial cannulation VA-ECMO (64.5% vs. 70.8%, p = 0.027). These findings were confirmed by aggregate data meta-analysis, which showed that central arterial cannulation was associated with an increased risk of in-hospital mortality compared to peripheral arterial cannulation (OR 1.35, 95% CI 1.04-1.76, I2 21%). Among patients requiring postcardiotomy VA-ECMO, central arterial cannulation was associated with an increased risk of in-hospital mortality compared to peripheral arterial cannulation. This increased risk is of limited magnitude, and further studies are needed to confirm the present findings and to identify the mechanisms underlying the potential beneficial effects of peripheral VA-ECMO.

Multi-Lobar Atelectasis in Children Receiving Venoarterial Extracorporeal Membrane Oxygenation for Cardiac Indications.

Respiratory complications are common in patients who require venoarterial (VA) extracorporeal membrane oxygenation (ECMO) for cardiac indications. We aimed to examine the frequency and characteristics of patients who develop multi-lobar atelectasis early in the course of VA ECMO and to identify factors associated with its occurrence. We performed a single-center retrospective review of consecutive pediatric subjects on VA ECMO in the cardiovascular ICU from 2014 to 2019. Chest radiographs before VA ECMO initiation and daily for up to 5 d of VA ECMO support were reviewed. Multi-lobar atelectasis was defined as the collapse of ≥2 lobes of the same lung. Patients with multi-lobar atelectasis before or immediately after VA ECMO cannulation were excluded. Bivariate comparisons and multivariable logistic regression analyses were performed to identify factors independently associated with lung collapse. Results of the multivariable analysis are provided as odds ratio (OR) with 95% CI. We reviewed 119 VA ECMO runs in 101 unique subjects. Multi-lobar atelectasis occurred in 36 runs (30%), with an isolated collapse of the left lung occurring most frequently (no. runs = 20). VA ECMO runs complicated by multi-lobar atelectasis were significantly longer and associated with lower hospital survival (51% vs 77%, survival in subjects without multi-lobar atelectasis; P = .01). Multivariable logistic regression analysis identified a subsequent ECMO run during the same admission to be independently associated with multi-lobar atelectasis (OR 5.4, 95% CI 1.2-21.5). Subanalysis of the subjects with isolated left lung collapse revealed male sex (OR 8.9, 95% CI 1.6-48.2) and subsequent ECMO run during the same admission (OR 4.0, 95% CI 1.2-13.6) to be independently associated with this complication, and mechanical ventilation at least 12 h before ECMO may be protective (OR 0.22, 95% CI 0.07-0.76). Multi-lobar atelectasis commonly occurred in children who were receiving VA ECMO for cardiac failure and was associated with worse outcomes. Male patients, a subsequent VA ECMO run during the same hospitalization, and patients in whom mechanical ventilation was initiated shortly before ECMO cannulation may be at increased risk for this complication.

Initial hospital length of stay and long-term survival of patients successfully resuscitated using extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest.

The long-term outcomes of patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) for refractory ventricular tachycardia/ventricular fibrillation (VT/VF) out-of-hospital cardiac arrest (OHCA) remain poorly defined. The purpose of this study was to describe the hospital length of stay and long-term survival of patients who were successfully rescued with ECPR after refractory VT/VF OHCA. In this retrospective cohort study, the length of index admission and long-term survival of patients treated with ECPR after OHCA at a single centre were evaluated. In a sensitivity analysis, survival of patients managed with left ventricular assist device (LVAD) implantation or heart transplantation during the same period was also evaluated. Between 1 January 2016 and 12 January 2020, 193 patients were transferred for ECPR considerations and 160 underwent peripheral veno-arterial extracorporeal membrane oxygenation cannulation. Of these, 54 (33.7%) survived the index admission. These survivors required a median 16 days of intensive care and 24 days total hospital stay. The median follow-up time of the survivors was 1216 (683, 1461) days. Of all, 79.6 and 72.2% were alive at 1 and 4 years, respectively. Most deaths within the first year occurred among the patients requiring discharge to a long-term acute care facility. Overall survival rates at 4 years were similar in the ECPR and LVAD cohorts (P = 0.30) but were significantly higher for transplant recipients (P < 0.001). This data suggest that the lengthy index hospitalization required to manage OHCA patients with ECPR is rewarded by excellent long-term clinical outcomes in an expert ECPR programme.

Impact factors of POCUS-guided cannulation for peripheral venoarterial extracorporeal membrane oxygenation: One single-center retrospective clinical analysis.

We aimed to evaluate associated factors for point-of-care ultrasound (POCUS)-guided percutaneous catheterization for venoarterial extracorporeal membrane oxygenation (VA-ECMO). VA-ECMO cases from March 2018 to October 2020 in Department of Intensive Care Unit, Binhaiwan Central Hospital of Dongguan, were enrolled. Clinical data, outcomes, and complications were recorded and summarized. Fifty-nine cases were enrolled, among which 88.1% succeeded in POCUS-guided catheterization via Seldinger technique, whereas 59.3% succeeded at the first puncture. Results showed that artery diameter and times of arterial punctures were independent associated factors for Seldinger puncture (P = .018, odds ratio [OR] = 23.374, 95% confidence interval [CI] = 1.706-320.270; P = .031, OR = 145.098, 95% CI = 1.592-13220.980), and artery diameter and cardiac ejection fraction value (≥30%/<30%) were independent associated factors for first puncture (P = .044, OR = 1.622, 95% CI = 1.014-2.596; P = .013, OR = 5.565, 95% CI = 1.441-21.488). For extracorporeal cardiopulmonary resuscitation patients, artery diameter was independent associated factor for Seldinger puncture (P = .022, OR = 2.070, 95% CI = 1.110-3.858), and cardiac ejection fraction value (≥30%/<30%) was independent associated factor for first puncture (P = .007, OR = 9.533, 95% CI = 1.847-49.204). Thirteen patients (22.0%) had local hemorrhage post puncture, 8 patients (13.6%) presented distal limb arterial ischemia, and 8 patients (13.6%) suffered puncture-related thrombosis. Vasoactive Inotropic Score was found to be independent associated factor for local hemorrhage (P = .039, OR = 0.994, 95% CI = 0.988-1.000), and the Acute Physiology and Chronic Health Evaluation II score was independent associated factor for thrombosis (P = .025, OR = 0.935, 95% CI = 0.882-0.992). Diabetes and cardiopulmonary resuscitation time before catheterization were independent factors for distal limb ischemia (P = .026, OR = 220.774, 95% CI = 1.905-25591.327; P = .017, OR = 1.054, 95% CI = 1.009-1.101). POCUS-guided percutaneous catheterization via Seldinger technique can be the first choice for VA-ECMO cannulation, especially for a team without angiotomy qualifications. Before cannulation, evaluating the target artery and heart function by ultrasound can help predict outcome of catheterization. Assessing risk factors (diabetes, cardiopulmonary resuscitation time before catheterization, Vasoactive Inotropic Score, the Acute Physiology and Chronic Health Evaluation II score) is helpful for prevention and treatment of complications.

Extracorporeal Membrane Oxygenation-First Strategy for Acute Life-Threatening Pulmonary Embolism.

BackgroundBoth venoarterial extracorporeal membrane oxygenation (VA-ECMO) and percutaneous mechanical thrombectomy (PMT) are increasingly used to treat acute life-threatening pulmonary embolism (PE). However, there are little data regarding their effectiveness. This study aimed to present the short-term outcomes after managing nine patients with acute life-threatening massive or submassive PE by VA-ECMO with or without complemented PMT and propose a preliminary treatment algorithm.MethodsThis study was a single-center retrospective review of a prospectively maintained registry. It included nine consecutive patients with massive or submassive pulmonary embolism who underwent VA-ECMO for initial hemodynamic stabilization, with or without PMT, from August 2018 to November 2021.ResultsMean patient age was 54.7 years. Four of nine patients (44.4%) required cardiopulmonary resuscitation before or during VA-ECMO cannulation. All cannulations (100%) were successfully performed percutaneously. Overall survival was 88.9% (8 of 9 patients). One patient died from a hemorrhagic stroke. Of the survivors, the median ECMO duration was 8 days in patients treated with ECMO alone and 4 days in those treated with EMCO and PMT. Five of nine patients (55.6%) required concomitant PMT to address persistent right heart dysfunction, with the remaining survivors (44.4%) receiving VA-ECMO and anticoagulation alone. For survivors receiving VA-ECMO plus PMT, median hospital lengths of stay were 7 and 13 days, respectively.ConclusionsAn ECMO-first strategy complemented with PMT can be performed effectively and safely for acute life-threatening massive or submassive PE. VA-ECMO is feasible for initial stabilization, serving as a bridge to therapy primarily in inoperable patients with massive PE. Further evaluation in a larger cohort of patients is warranted to assess whether VA-ECMO plus PMT may offer an alternative or complementary therapy to thrombolysis or surgical thrombectomy.Type of ResearchSingle-center retrospective review of a prospectively maintained registry.

B-38 | Decannulation of Percutaneously Placed Veno-Arterial ECMO Cannulas in Children by the Pediatric Interventional Cardiologist

Decannulation from veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in the pediatric population has historically been performed by surgeons. We have previously described techniques for successful percutaneous VA-ECMO cannulation at our institution by pediatric interventional cardiologists (PIC) in children. The goal of this study is to describe the safety and feasibility for VA-ECMO decannulation by PIC.

A Real Circuit Breaker: Hyperhemolysis Syndrome Related to the VA-ECMO Circuit?

<h3>Introduction</h3> Myocarditis is an inflammatory disease of cardiac muscle caused by a variety of infectious and non-infectious conditions. Viral infection is the most frequent cause of myocarditis; however, herpes simplex virus 1 (HSV-1) infection causing myocarditis has been rarely described. We present a case of a young woman with HSV-1 viremia and fulminant myocarditis presenting with cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO), complicated by hyperhemolysis. <h3>Case Report</h3> A 35 year-old immunocompetent woman with moderate alcohol consumption presented to hospital with a 4-day history of fever and flu-like symptoms. She was fully vaccinated for COVID-19 two months prior to symptom onset. Her COVID-19 testing was negative and she was discharged home. She returned to hospital 4 days later in cardiogenic shock. Transthoracic echocardiogram demonstrated LVEF of 30% with a small pericardial effusion. Coronary angiogram revealed normal coronaries. She was placed on peripheral VA-ECMO for worsening cardiogenic shock. Due to inadequate LV unloading, she underwent atrial septostomy. Five days after VA-ECMO cannulation, HSV-1 was detected in the blood and she was started on intravenous acyclovir. Her ECMO course was complicated by acute kidney injury requiring dialysis, and hyperhemolysis with a peak LDH of 12,000 U/L. The mechanism of hemolysis was attributed to an intravascular process (plasma free hemoglobin 7487 mg/L, normal < 150 mg/L) likely from a combination cold agglutinins and the mechanical circuit. Interestingly the membrane pressure gradient was within normal. The patient received treatment with plasmapheresis (Table 1), and was eventually decannulated after 12 days following hemodynamic improvement. <h3>Summary</h3> This case report highlights a rare viral cause of fulminant myocarditis and emphasizes the need for collaboration among various specialists in the management of complex cases.

Percutaneous Pulmonary Artery Cannulation to Treat Acute Secondary Right Heart Failure While on Veno-venous Extracorporeal Membrane Oxygenation.

Right heart failure (RHF) is a common, yet difficult to manage, complication of severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation (ECMO) that is associated with increased mortality. Reports of the use of percutaneous mechanical circulatory support devices for concurrent right heart and respiratory failure are limited. This series describes the percutaneous cannulation of the pulmonary artery for conversion from veno-venous to veno-pulmonary artery return ECMO in 21 patients who developed secondary RHF. All patients cannulated between May 2019 and September 2021 were included. Either a 19 or 21 French venous cannula was placed percutaneously into the pulmonary artery via the internal jugular or subclavian vein, providing a total of 821 days of support (median 23 [4-71] days per patient) with flows up to 6 L/min. Five patients underwent cannulation at the bedside, with the remainder performed in the cardiac catheterization laboratory. Pulmonary artery cannulation occurred after 12 [8.5-23.5] days of ECMO support. Vasoactive infusion requirements decreased significantly within 24 hours of pulmonary artery cannula placement (p = 0.0004). Nonetheless, 75% of these patients expired after a median of 12 [4-63] days of support, with three patients found to have had significant pericardial effusions peri-arrest. This cannulation technique may be an effective alternative to veno-arterial ECMO cannulation or the placement of a dual-lumen cannula for the treatment of RHF.

Mild hypothermia and neurologic outcomes in patients undergoing venoarterial extracorporeal membrane oxygenation.

Patients with venoarterial extracorporeal membrane oxygenation (VA-ECMO) are at risk of cerebral reperfusion injury after prolonged hypoperfusion and immediate restoration of systemic blood flow. We aimed to examine the impact of mild hypothermia during the first 24 h post-ECMO on neurological outcomes in VA-ECMO patients. This was a retrospective study of adult VA-ECMO patients from a tertiary care center. Mild hypothermia was defined as 32-36°C during the first 24 h post-ECMO. The primary outcome was a good neurological function at discharge measured by a modified Rankin Scale ≤3. Multivariable logistic regression analysis was performed for primary outcome adjusting for pre-specified covariates. Overall, 128 consecutive patients with VA-ECMO support (median age: 60 years and 63% males) were included. Within the first 24 h of VA-ECMO cannulation, we found a median of 71 readings per patient (interquartile range 45-88). Eighty-eight patients (68.8%) experienced mild hypothermia within the first 24 h while 18 of those 88 patients (14.2%) had a mean temperature <36°C. ECMO indications included post-cardiotomy shock (39.8%), cardiac arrest (29.7%), and cardiogenic shock (26.6%). Duration of mild hypothermia, but not mean temperature, was independently associated with increased odds of good neurological outcome at discharge (odds ratio [OR] = 1.16, 95% confidence interval [CI] = 1.04-1.31, p = .01) after adjusting for age, the severity of illness, post-ECMO systemic hemorrhage, post-cardiotomy shock, acute brain injury, and mean 24-h PaO2 . Neither duration of mild hypothermia (OR = 0.93, CI = 0.84-1.03, p = .17) nor mean temperature (OR = 0.78, CI = 0.29-2.08, p = .62) was significantly associated with mortality. Similarly, duration of mild hypothermia (p = .47) and mean 24-h temperature (p = .76) were not significantly associated with the frequency of systemic hemorrhages. In this single-center study, a longer duration of mild hypothermia during the first 24 h of ECMO support was significantly associated with improved neurological outcomes. Mild hypothermia was not associated with an increased risk of systemic hemorrhage or improved survival.

Percutaneous versus surgical cannulation for femoro-femoral VA-ECMO in patients with cardiogenic shock: Results from the Extracorporeal Life Support Organization Registry

Percutaneous cannulation is increasingly used for veno-arterial extracorporeal membrane oxygenation (VA-ECMO). However, there is limited evidence about the benefit of this approach compared with conventional surgical cannulation. By using a large international database, this study was designed to compare in-hospital outcomes in cardiac shock patients who received femoro-femoral VA-ECMO with percutaneous versus surgical cannulation. Adults with refractory cardiogenic shock treated with percutaneous (percutaneous group) or surgical (surgical group) femoro-femoral VA-ECMO between January 2008 and December 2019 were extracted from the international Extracorporeal Life Support Organization registry. The primary outcome was in-hospital mortality. Multivariable logistic regression analyses were performed to assess the association between percutaneous cannulation and in-hospital outcomes. Among 12,592 patients meeting study inclusion, 9,249 (73%) underwent percutaneous cannulation. The proportion of patients undergoing percutaneous cannulation increased from 32% to 84% over the study period (p < 0.01 for trend). In-hospital mortality (53% vs 58%; p < 0.01), cannulation site bleeding (19% vs 22%; p < 0.01), and systemic infection (8% vs 15%; p < 0.01) occurred less frequently in the percutaneous group compared to the surgical group. In adjusted analyses, percutaneous cannulation was independently associated with lower rates of in-hospital mortality (odds ratio [OR] 0.76; 95% CI 0.70-0.84; p < 0.01), cannulation site bleeding (OR 0.70; 95% CI 0.60-0.80; p < 0.01) and systemic infection (OR, 0.63; 95% CI 0.54-0.74; p < 0.01). Severe limb ischemia was more frequently observed in the percutaneous group (5% vs 3%; p < 0.01). However, this association was not significant in adjusted analysis (OR 1.28; 95% CI 0.93-1.62; p=0.15). Compared with surgical cannulation, percutaneous cannulation was independently associated with lower in-hospital mortality and fewer complications.

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.