Venoarterial Research Articles

The role of extracorporeal life support in extended lung resections for non-small cell lung cancer: a narrative review.

Extracorporeal membrane oxygenation (ECMO) may be used as a substitute of traditional cardiopulmonary bypass (CPB) in thoracic surgeries. Extended resections for the treatment of non-small cell lung cancer (NSCLC) occasionally require extracorporeal life support. We present a narrative review of the current clinical uses of extracorporeal devices in this setting of patients. We searched Medline database/PubMed for "extra-corporeal membrane oxygenation" and "non-small cell lung carcinoma" in the English language literature between the years 2000 and 2022. As opposed to CPB, ECMO is simple, requires minimal or no anticoagulation and elicits fewer complications. T4 lung cancers are frequently considered for surgery in marginally operable patients. ECMO may provide the means to achieve these resections. There are case series of carinal extended resections safely performed under venovenous (VV) or venoarterial (VA) support. The main advantages are a clear surgical field, certainty of proper oxygenation and avoidance of ventilator induced trauma. Left atrial resections have been described with VA ECMO, but the standard of care is still CPB. Descending thoracic aorta resections can also benefit from extracorporeal support, making sure that abdominal organs and lower limbs are well perfused, the heart is not overloaded, and cross clamping is safe. Surgeons performing extended lung cancer resections should be familiar with ECMO and are encouraged to report their experience.

Extracorporeal membrane oxygenation in the surgical management of large mediastinal masses: a narrative review.

The management of large mediastinal tumors requires a complex multidisciplinary approach, particularly in the perioperative setting due to increased risk of hemodynamic compromise. The utilization of extracorporeal membrane oxygenation (ECMO) provides a useful adjunct in the surgical management for biopsy and resection of these mediastinal masses. The objective of this article is to review indications and implementation of ECMO in the surgical management of mediastinal disease. A literature review of the PubMed database was completed evaluating articles discussing 'extracorporeal circulation', 'cardiopulmonary bypass', 'anesthesia', 'mediastinal disease', and 'mediastinal cancer'. These articles were evaluated for contribution to the discussion of indications and implementation of ECMO in the management of these patients. Large mediastinal tumors place patients at risk of hemodynamic collapse on induction of anesthesia due to compression of vascular structures, tracheobronchial tree and creation of V/Q mismatch. Patients may be stratified regarding their risk of perioperative complications by evaluation of postural symptoms, cross sectional imaging findings and pulmonary function tests. Those patients at elevated perioperative risk may benefit from the utilization of ECMO, most commonly veno-arterial (V-A) ECMO. Guidewires or ECMO cannulas may be placed under local anesthesia prior to induction. Those patients with hemodynamic compromise may receive mechanical circulatory support to allow completion of the operation. The use of a multidisciplinary team consisting of surgeons, anesthesiologists, perfusionists and OR team is critical to the success in the use of ECMO in the resection of mediastinal masses. With diligent preparation, these high-risk patients may be optimally managed at the time of resection.

Extracorporeal membrane oxygenation for the treatment of massive pulmonary embolism. An analysis of the ELSO database

AimExtracorporeal membrane oxygenation (ECMO) may be beneficial in treatment of massive pulmonary embolus (PE), however the current evidence to guide its use is limited. We aimed to compare the incidence, characteristics, treatments, and outcomes of patients with massive PE by mode of ECMO from a large international registry. MethodsRetrospective observational study of the Extracorporeal Life Support Organization (ELSO) database. ResultsA total of 821 patients underwent 833 ECMO episodes for PE. Mean age was 49 (±15) years, 408 (50.1%) were female, and 450 (54.7%) had a cardiac arrest prior to ECMO initiation. Venoarterial (VA) ECMO was the most common mode in 489 (58.7%), followed by extracorporeal cardiopulmonary resuscitation (ECPR) in 229 (27.4%) and venovenous (VV) ECMO in 85 (10.2%). The number of episodes per year increased over the study period, predominantly driven by an increase in ECPR. In-hospital mortality was the highest for ECPR 156/229 (68.1%), followed by VA ECMO 209/498 (42.7%) and VV ECMO 24/85 (28.2%) P < 0.001. After controlling for univariate and clinically significant variables at the time of ECMO initiation, increasing age (OR 1.02 (1.00–1.03), lower pH (OR 0.18 (0.03–0.44), lower diastolic blood pressure (OR 0.99 (0.97–1.00) and ECPR mode (OR 3.67 (1.46–9.230) were independently associated with in-hospital mortality. ConclusionECMO use for massive PE is increasing globally, and overall mortality rates compare favorably with other indications of ECMO. The use of ECPR and worsening metabolic status at initiation were associated with higher in-hospital mortality, suggesting delays in initiating ECMO should be avoided.

Plasma Transfusion and Procoagulant Product Administration in Extracorporeal Membrane Oxygenation: A Secondary Analysis of an International Observational Study on Current Practices.

To achieve optimal hemostatic balance in patients on extracorporeal membrane oxygenation (ECMO), a liberal transfusion practice is currently applied despite clear evidence. We aimed to give an overview of the current use of plasma, fibrinogen concentrate, tranexamic acid (TXA), and prothrombin complex concentrate (PCC) in patients on ECMO. A prespecified subanalysis of a multicenter retrospective study. Venovenous (VV)-ECMO and venoarterial (VA)-ECMO are analyzed as separate populations, comparing patients with and without bleeding and with and without thrombotic complications. Sixteen international ICUs. Adult patients on VA-ECMO or VV-ECMO. None. Of 420 VA-ECMO patients, 59% (n = 247) received plasma, 20% (n = 82) received fibrinogen concentrate, 17% (n = 70) received TXA, and 7% of patients (n = 28) received PCC. Fifty percent of patients (n = 208) suffered bleeding complications and 27% (n = 112) suffered thrombotic complications. More patients with bleeding complications than patients without bleeding complications received plasma (77% vs. 41%, p < 0.001), fibrinogen concentrate (28% vs 11%, p < 0.001), and TXA (23% vs 10%, p < 0.001). More patients with than without thrombotic complications received TXA (24% vs 14%, p = 0.02, odds ratio 1.75) in VA-ECMO, where no difference was seen in VV-ECMO. Of 205 VV-ECMO patients, 40% (n = 81) received plasma, 6% (n = 12) fibrinogen concentrate, 7% (n = 14) TXA, and 5% (n = 10) PCC. Thirty-nine percent (n = 80) of VV-ECMO patients suffered bleeding complications and 23% (n = 48) of patients suffered thrombotic complications. More patients with than without bleeding complications received plasma (58% vs 28%, p < 0.001), fibrinogen concentrate (13% vs 2%, p < 0.01), and TXA (11% vs 2%, p < 0.01). The majority of patients on ECMO receive transfusions of plasma, procoagulant products, or antifibrinolytics. In a significant part of the plasma transfused patients, this was in the absence of bleeding or prolonged international normalized ratio. This poses the question if these plasma transfusions were administered for another indication or could have been avoided.

Review of anticoagulation considerations in extracorporeal membrane oxygenation support.

Since its first success in 1975, extracorporeal membrane oxygenation (ECMO) has been used with increasing frequency for pulmonary and cardiopulmonary bypass. Use in adults has increased exponentially since the early 2000s, but despite thousands of international cannulations using both veno-arterial (VA) and veno-venous (VV) ECMO, there are still significant hemocompatibility-related adverse events. Current management of anticoagulation has been based on the Extracorporeal Life Support Organization guidance published in 2014 with recent updates published in 2022. Despite this guidance, there is still limited international consensus on how to manage anticoagulation in ECMO. For this review, we completed a comprehensive search of multiple electronic databases to identify studies pertaining to anticoagulation of adult patients on VV or VA-ECMO. The highest priority was given to sources that were prospective, randomized, controlled studies, but in the absence of such resources, observational studies, retrospective uncontrolled studies, and case series/reports were considered for inclusion. This document serves to provide a comprehensive review of the current understanding of management pertaining to anticoagulation relating to ECMO.

Temperature Outcomes without heater cooler units in adult patients supported with extracorporeal membrane oxygenation: A retrospective cohort study.

Heater-cooler units (HCUs) are frequently incorporated into extracorporeal membrane oxygenation (ECMO) circuits to help maintain patient normothermia. However, these devices may be associated with increased cost and infection risk. This study describes our institution's experience managing adult ECMO patients without the routine use of in-circuit HCUs. We performed a retrospective analysis of adult patients treated with veno-venous (VV) or veno-arterial (VA) ECMO at our institution. The primary outcomes were rates of HCU use and the relative duration of the ECMO treatment course in which patients maintained normothermia (36-37.5°C), with and without HCUs. Secondary outcomes of mortality and ECMO-related complications were planned across HCU and non-HCU groups; exploratory analyses were performed across a 75% "ECMO time in normothermia" threshold. Among a cohort of 71 patients, zero (0%) were managed with in-circuit HCUs. A majority of ECMO patient-hours were spent in the normothermic range. Median and mean percentages of ECMO normothermia time were 75% (IQR 49%-81%) and 62% (SD ± 27%). Twenty-nine patients (40%) met the threshold of 75% ECMO normothermia time, as used to evaluate secondary outcomes. At this threshold, mortality risk was significantly higher among the non-normothermic cohort; other ECMO-related complications did not vary significantly. In the absence of HCU use, the majority of ECMO patient-hours were spent in normothermia. However, only a minority of patients achieved normothermia for at least 75% of their ECMO course. In-circuit HCUs may be required to maintain high percentages of normothermic time in adult EMCO patients.

Weaning assessment of veno-arteriovenous (V-AV) extracorporeal membrane oxygenation (ECMO)

Currently, there is a lack of methods for simultaneous assessment of readiness for decannulation of the veno-venous (V-V) and veno-arterial (V-A) components during veno-arteriovenous (V-AV) extracorporal membrane oxygenation (ECMO) support. We describe a novel approach using a simultaneous off-sweep and controlled backflow test to assess readiness for decannulation from V-AV ECMO. This method needs testing in future clinical trials.

Epidemiology and risk factors of infections among patients with extracorporeal membrane oxygenation in a tertiary heart center.

Extracorporeal membrane oxygenation (ECMO) is an important treatment strategy for severe acute respiratory and/or cardiac failure. Despite advancements in device technology and intensive care, mortality rates, and complications remain high. Patients undergoing ECMO are at an increased risk of infection due to factors such as immunosuppression, the presence of cannulas, and variable antibiotic pharmacokinetics. Unfortunately, an acquired infection in these patients can lead to increased morbidity, longer hospital stays, and even mortality. The purpose of this study was to examine the prevalence, profiles, and sites of ECMO-related infections, as well as underlying risk factors associated with these infections. We retrospectively analyzed clinical data from 73 patients who received veno-arterial (VA) and/or venovenous (VV) ECMO support due to severe but potentially reversible cardiac and/or pulmonary failure lasting ≥24 hours. We involved patients with no suspicion of pre-existing infection before ECMO insertion from January 2015 to February 2023, classifying them into either infected or non-infected based on available evidence. The estimated probability for infection according to ECMO-day was established. Significance was set at p<0.05. The primary interesting outcome is the infection probability. Mean age was 52.2±14.8 years in all groups, and 55 (75.3%) were male. Median hospital stay was 6 (2-16) days and duration of ICU was 5 (2-10) days in all groups. The duration of ICU stay was significantly higher in the infected group compared to the non-infected group [10 days (5-15) vs. 3 days (2-7)], p<0.001, respectively. 66 patients (90.4%) received VA ECMO and 18 of them (94.7%) were infected. In all groups, the ECMO wean ratio was 28.8%. Death before 48 hours occurred in 28 patients (38.4%). 26% of patients under ECMO support consisted of the infected group and had 68 episodes per 1,000 ECMO days. Of these, the most frequent infection site was lower respiratory tract infection (47.3%). The most common pathogen among these was K. pneumonia. 39.7% of patients received no antibiotics. The probability of infection was 19% for 1.5 (mean-1SD) ECMO days, approximately 41% for 4 ECMO days, and 52% for (mean+1SD) 6.5 ECMO days. Nosocomial infections, which are commonly observed during ECMO procedures, are considered a significant concern. The respiratory system is frequently affected by such infections. Even though the use of antibiotics for prophylaxis remains debatable, it is predicted that there will be an inclination towards the regular application of prophylactic measures and the development of standardized protocols based on solid evidence obtained from prospective research studies in the future.

Neonatal venoarterial and venovenous ECMO

ECMO remains an important support tool in the treatment of neonates with reversible congenital cardiopulmonary diseases. There are specific circumstances that call for either venoarterial (VA) or venovenous (VV) ECMO in neonates. While limited by the infant's the size and gestational age, ECMO can confer exceptional survival rates to a number of neonates who can often develop without devastating complications. However, it remains a labor and time intensive endeavor, which may be impractical or unattainable in resource-limited environments. While adult and pediatric ECMO indications and equipment options have expanded in recent years, neonatal ECMO continues to be a niche subspecialty requiring specific expertise and technical skill, especially considering the ever-changing neonatal physiology in the setting of cardiopulmonary support.It is critical to recognize the unique approaches to cannulation options, imaging, vessel management, anticoagulation, and monitoring protocols to achieve optimal outcomes. Thus, it becomes nearly impossible to separate the role of pediatric surgeons from the continuous involvement with and management of neonatal ECMO patients. This necessitates that pediatric surgeons in ECMO centers continue to hone their expertise and remain heavily involved in neonatal ECMO. This section reviews the most critical current approaches and unresolved controversies in neonatal ECMO with special attention to the practical aspects and decisions a surgeon faces in initiation and termination of neonatal ECMO.

A Systematic Review of Clinical Outcomes After Carotid Artery Ligation Versus Carotid Artery Reconstruction Following Venoarterial Extracorporeal Membrane Oxygenation in Infants and Children

IntroductionIn pediatric and neonatal populations, the carotid artery is commonly cannulated for venoarterial (VA) extracorporeal membrane oxygenation (ECMO). The decision to ligate (carotid artery ligation [CAL]) versus reconstruct (carotid artery reconstruction [CAR]) the artery at decannulation remains controversial as long-term neurologic outcomes remain unknown. The objective of this study was to summarize current literature on clinical outcomes following CAL and CAR after Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO). MethodsPubMed (MEDLINE), Embase, Web of Science, and Cochrane databases were searched using keywords from January 1950 to October 2020. Studies examining clinical outcomes following CAL and CAR for VA-ECMO in patients <18 y of age were included. Prospective and retrospective cohort studies, case series, case-control studies, and case reports were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were performed independently by two reviewers. Assessment of risk of bias was performed. ResultsEighty studies were included and classified into four categories: noncomparative clinical outcomes after CAL (n = 23, 28.8%), noncomparative clinical outcomes after CAR (n = 12, 15.0%), comparative clinical outcomes after CAL and/or CAR (n = 28, 35.0%), and case reports of clinical outcomes after CAL and/or CAR (n = 17, 21.3%). Follow-up ranged from 0 to 11 y. CAR patency rates ranged from 44 to 100%. There was no substantial evidence supporting an association between CAL versus CAR and short-term neurologic outcomes. ConclusionsStudies evaluating outcomes after CAL versus CAR for VA-ECMO are heterogeneous with limited generalizability. Further studies are needed to evaluate long-term consequences of CAL versus CAR, especially as the first survivors of pediatric/neonatal ECMO approach an age of increased risk of carotid stenosis and stroke.

Evaluation of Bivalirudin During Adult Extracorporeal Membrane Oxygenation: A Retrospective Characterization of Dosing, Efficacy and Bleeding.

Objective: Although heparin is the current standard anticoagulant during venoarterial (VA) and venovenous (VV) extracorporeal membrane oxygenation (ECMO), factors including heparin-induced thrombocytopenia, heparin resistance and drug shortages necessitate alternative anticoagulants such as direct thrombin inhibitors. The aim was to characterize dosing, safety, and efficacy of bivalirudin during ECMO support. Methods: This retrospective single-center study included 24 adults on ECMO support who received ≥6 hours of bivalirudin. The primary endpoint was dose to first therapeutic activated partial thromboplastin time (aPTT). Secondary endpoints included evaluating dosing between ECMO modes, incidence of bleeding and thrombotic events, and time in therapeutic range (TTR). Results: The dose at time of first therapeutic aPTT was bivalirudin 0.05 [0.05-0.1] mg/kg/hour. Bivalirudin dosing requirements were lower in VAECMO compared to VV-ECMO patients and were not impacted by continuous venovenous hemofiltration. Time to therapeutic aPTT was 5.5 [2-13] hours for VA-ECMO and 4.5 [2-8.6] hours for VV-ECMO patients. During any mode of ECMO TTR was 58.3% [39.6-73.1]. Thrombotic events occurred in 3 (13%) patients and major bleeding occurred in 12 (50%) patients. Conclusions: Our findings demonstrated variable bivalirudin dosing requirements based on mode of ECMO and dosing modifications may not be required during CVVH. Factors including mode of ECMO, indication for bivalirudin and concomitant antiplatelet therapy may impact hematologic events. Application of this data can assist with developing a bivalirudin ECMO protocol which provides less variability in initial dosing and TTR.

Management of primary graft dysfunction after lung transplantation with extracorporeal life support: an evidence-based review.

Primary graft dysfunction (PGD) is a complex inflammatory syndrome that can lead to respiratory failure after lung transplantation (LTx). The pathogenesis of PGD is multifactorial and can be driven by attributes of both the donor and recipient, perioperative characteristics, and technical handling of the graft. Despite significant advancements in patient and donor selection, perioperative management and surgical technique, PGD is still a major contributor to morbidity and mortality after lung transplant. Although there are no known durable treatment options for PGD after LTx, an increasing body of evidence and experience in high-volume lung transplant centers show that extracorporeal life support (ECLS) is a reliable option for both preventing PGD and supporting critically ill patients with PGD. Both veno-venous (V-V) ECLS and veno-arterial (V-A) ECLS are proven and feasible strategies for mitigating the morbidity and mortality associated with post-LTx PGD. In this evidence-based review, we provide an overview of the epidemiology and physiology of PGD as well as a growing body of data that supports ECLS as a major tool to manage PGD. We describe the role of ECMO in PGD prevention and management, worldwide outcomes of LTx with ECLS support, and outline our step-wise approach to managing this complex respiratory syndrome leading up to institution of ECLS.

Current use of extracorporeal life support in airway surgery: a narrative review.

Extracorporeal life support (ECLS) is widely used in patients with severe respiratory or cardiocirculatory failure. The most commonly used extracorporeal membrane oxygenation (ECMO) modes are veno-venous (V-V) and veno-arterial (V-A) ECMO, which can both be achieved by various types of vascular cannulation. Within the scope of tracheobronchial surgery, intraoperative ECLS may occasionally be necessary to provide sufficient oxygenation to a patient throughout a procedure, especially when conventional ventilation strategies are limited. Additionally, V-A ECMO can provide cardiopulmonary support in emergencies and in cases where hemodynamic instability can occur. This narrative literature review was carried out to identify the use and the specifics of ECLS in airway surgery over the last years. Data from 168 cases were summarized according to the indication for surgery and the mode of ECLS (V-V, V-A). The most common tracheobronchial pathologies in which support was needed were: primary malignant disease of the airways, malignant infiltration, tracheal stenosis, injury of the airway, and congenital airway disease. With increasing experience in ECLS, the number of reported cases performed with intraoperative ECLS increased steadily over the last decade. A trend favoring the use of V-V ECMO over V-A ECMO was identified. These approaches should now be considered indispensable tools for managing challenging surgical cases.

Cannulation strategies for extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation (ECMO) is a type of extracorporeal life support (ECLS) in which the function of the heart and/or lungs is partially or completely replaced by a portable system that provides prolonged support to critically ill patients with respiratory or cardiac failure. There are two major variants of ECMO: veno-venous (VV) ECMO and veno-arterial (VA) ECMO. VV ECMO replaces the function of the lung in which it uses a cannula to remove venous blood and oxygenates it using the extracorporeal system, and returns the blood to the right atrium to be pumped to the body. VA ECMO is slightly different in that it replaces the function of the heart and lungs by returning oxygenated blood to the aorta. As a therapy for respiratory failure, ECMO minimizes hypoxia, diminishes lung stress and strain, and allows lung protective mechanical ventilation. As a support for acute and terminal heart failure, ECMO reduces preload, increases aortic flow, and allows for end-organ perfusion. Due to its physiological support and advantages, it is used for a variety of chronic and acute support purposes such as bridge therapy for heart/lung transplant, durable ventricular assist devices, and intermediate-term mechanical support postoperatively. Our review gives a broad overview of the two main types of ECMO strategies and their clinical indications, cannulation strategies, unique clinical utility, and their limitations.

TOP6: Ambulatory Extra Corporeal Membrane Oxygenation as a Bridge to Lung Transplant

Background: Mechanical circulatory support, including both veno-venous (VV) and veno-arterial (VA) extra corporeal membrane oxygenation (ECMO), is being used more frequently to bridge critically ill patients to lung transplant (LTX). This study evaluates post LTX survival outcomes of patients bridged by ECMO. Methods: The United Network for Organ Sharing (UNOS) thoracic organ transplant database was queried for patients aged >/= 18 years between year 2016 and 2021 to identify pre-transplant patients supported by ECMO. Patients supported by both VA and VV-ECMO were excluded. The patients initially classified in VA-ECMO and VV-ECMO cohorts and further classified as ambulatory (AMB) and non-ambulatory (nAMB) within their respective ECMO cohorts. Each cohort was controlled against the non-ECMO patients. Univariate statistical tests as well as Kaplan-Meier survival curves were used for analysis. Results: Of total 14,369 LTX patients, 13,470 were non-ECMO, 702 were VV-ECMO (44% AMB, 56% nAMB) and 197 were VA-ECMO (47% AMB, 53% nAMB). Table 1A (non-ECMO v. AMB VV-ECMO v. nAMB VV-ECMO at time of LTX) and 1B (non-ECMO v. AMB VA-ECMO v. nAMB VA-ECMO at time of LTX) shows higher age (62 v. 52 v. 50) lower O2 requirement (4 v. 15 v. 10), LAS (44 v. 88 v. 89) and lesser likelihood of COVID etiology (1% v. 22% v. 6%) in non-ECMO group compared to VV-ECMO and VA-ECMO. Within the ECMO groups AMB and nAMB patients were comparable except idiopathic fibrosis was more common in nAMB. The 1-year post LTX survival between non-ECMO and AMB VV-ECMO was comparable (88% v. 88%, p=0.66) which was better than nAMB VV-ECMO patients (88% v. 88% v. 81% (nAMB VV-ECMO), p<.01, F1A). The 1-year (71% v. 78% v. 88%) survival was better for AMB VA-ECMO patients than nAMB VA-ECMO patients, and better for non-ECMO patients than AMB VA-ECMO patients (p<.01, F1B). A Cox proportional hazard model showed that compared to non-ECMO patients, the nAMB VV-ECMO patients (HR = 1.25, p=0.02) had higher risk of post LTX mortality whereas post LTX risk for AMB VV-ECMO patients (HR = 0.95, p=0.71) was similar. Conclusion: Although ambulatory VV-ECMO patients have higher LAS and O2 requirements at time of transplant, their post LTX survival is comparable to the non-ECMO patients. Survival amongst the VA-ECMO patients continued to be poor compared to the non-ECMO patients irrespective of their ambulatory status. Strategies to ambulate ECMO patients could be associated better post LTX outcomes. Figure 1. Survival by ECMO ambulationTable 1. Patient Characteristics at time of LTX

Non-elective thoracic surgery in patients supported by veno-venous (VV) or veno-arterial (VA) extracorporeal membrane oxygenation (ECMO)

Non-elective thoracic surgery in patients supported by veno-venous (VV) or veno-arterial (VA) extracorporeal membrane oxygenation (ECMO)

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.

Continuous near-infrared reflectance spectroscopy monitoring to guide distal perfusion can minimize limb ischemia surgery for patients requiring femoral venoarterial extracorporeal life support

Background: Patients requiring femoral venoarterial (VA) extracorporeal life support (ECLS) are at risk of distal lower limb hypoperfusion and ischemia of the cannulated leg. In the present study, we evaluated the effect of using continuous noninvasive lower limb oximetry with near-infrared reflectance spectroscopy (NIRS) to detect tissue hypoxia and guide distal perfusion catheter (DPC) placement on the rates of leg ischemia requiring surgical intervention.

Brief Overview of the Use of Extracorporeal Membrane Oxygenation (ECMO) in COVID-19 Patients with Severe Acute Respiratory Distress Syndrome (ARDS)

Background A serious complication of coronavirus disease 2019 (COVID-19) is acute respiratory distress syndrome (ARDS). Hypoxemia refractory to traditional management, including invasive positive pressure ventilation, is not uncommon with COVID-19. It can lead to circulatory failure necessitating the use of mechanical circulatory support devices, specifically extracorporeal membrane oxygenation (ECMO). Aim This paper provides a brief update on the use and indications of ECMO for adult patients with COVID-19 around the world. Methods We conducted a rapid umbrella review on the use of ECMO in treating COVID-19-related ARDS (CARDS), as well as current indications and contraindications for the initiation of ECMO. We reviewed the use of venovenous (V-V) ECMO and veno-arterial (V-A) ECMO in CARDS. Findings V-V ECMO is the primary ECMO mode employed in the majority of the patients who required ECMO support for CARDS. Although the duration of V-V ECMO in COVID-19 was longer than the V-V ECMO in non-COVID-19 patients with ARDS, the mortality rate appears similar. Meta-analyses reviewed reported an in-hospital mortality rate ranging from 37% to 49% for COVID-19 patients who required V-V ECMO. Conclusion The survival benefit of ECMO in COVID-19 patients with severe cardiopulmonary failure is not clearly established, but V-V ECMO may be considered in adults with COVID-19 and severe cardiopulmonary compromise when resources are available. V-A ECMO may be considered in COVID-19 patients with severe cardiac failure, but limited data are available on survival benefits.

Hypoalbuminemia and Albumin Replacement during Extracorporeal Membrane Oxygenation in Patients with Cardiogenic Shock.

Extracorporeal membrane oxygenation (ECMO) has been widely used in patients with cardiorespiratory failure. The serum albumin level is an important prognostic marker in critically ill patients. We evaluated the efficacy of using pre-ECMO serum albumin levels to predict 30-day mortality in patients with cardiogenic shock (CS) who underwent venoarterial (VA) ECMO. We reviewed the medical records of 114 adult patients who underwent VA-ECMO between March 2021 and September 2022. The patients were divided into survivors and non-survivors. Clinical data before and during ECMO were compared. Patients' mean age was 67.8±13.6 years, and 36 (31.6%) were female. The proportion of survival to discharge was 48.6% (n=56). Cox regression analysis showed that the pre-ECMO albumin level independently predicted 30-day mortality (hazard ratio, 0.25; 95% confidence interval [CI], 0.11-0.59; p=0.002). The area under the receiver operating characteristic curve of albumin levels (pre-ECMO) was 0.73 (standard error [SE], 0.05; 95% CI, 0.63-0.81; p<0.001; cut-off value=3.4 g/dL). Kaplan-Meier survival analysis showed that the cumulative 30-day mortality was significantly higher in patients with a pre-ECMO albumin level ≤3.4 g/dL than in those with a level >3.4 g/dL (68.9% vs. 23.8%, p<0.001). As the adjusted amount of albumin infused increased, the possibility of 30-day mortality also increased (coefficient=0.140; SE, 0.037; p<0.001). Hypoalbuminemia during ECMO was associated with higher mortality, even with higher amounts of albumin replacement, in patients with CS who underwent VA-ECMO. Further studies are needed to predict the timing of albumin replacement during ECMO.