Veno-veno-arterial extracorporeal membrane oxygenation for acute respiratory distress syndrome with septic-induced cardiomyopathy due to severe pulmonary tuberculosis

Extracorporeal membrane oxygenation in acute respiratory distress syndrome caused by elderly tuberculous meningitis: a case report and review of the literature

Diagnosing and clinical management of tuberculous meningitis (TBM) are still challenging for clinicians. Analysis of cerebrospinal fluid (CSF) is an important diagnostic tool for patients with suspected central nervous system (CNS) diseases. Acute respiratory distress syndrome (ARDS), an inflammatory lung injury, can be treated by mechanical ventilation, fluid management, and even extracorporeal membrane oxygenation (ECMO). In addition, metagenomic next-generation sequencing (mNGS) can facilitate the detection of atypical, rare pathogens in clinical specimens. We report a case of a 65-year-old man with ARDS caused by TBM. He was admitted with a fever and shaking. Despite aggressive initial treatment, the patient progressed rapidly and developed ARDS. Without positive results of mNGS and culture, anti-tuberculosis (TB) treatment was started. In order to improve oxygenation levels, he was placed on veno-venous ECMO for 8 days. On day 47, the tracheotomy catheter was pulled out and sealed. The patient was conscious and could communicate with family members as normal.

Extracorporeal Membrane Oxygenation in Septic Cardiomyopathy Caused by Aspergillus Infection: The First Case Report

Septic cardiomyopathy (SCM) is often associated with bacterial infections but also occurs with infections with viruses such as influenza and spirochetes, including syphilis. However, there has been no systematic investigation into whether Aspergillus infections can cause septic cardiomyopathy. We report on such a case for the first time in a patient without immunodeficiency. Therefore, clinicians should be concerned with septic cardiomyopathy caused by some atypical or rare pathogens when admitting such patients.

Extracorporeal membrane oxygenation for tuberculosis pneumonia with empyema

Acute respiratory distress syndrome (ARDS) caused by Mycobacterium Tuberculosis (TB) is a rare entity. Extracorporeal membrane oxygenation (ECMO) therapy had been used as an effective therapy for this cases, but the evidence is scarce. We present a case that took place in the middle of SARS-CoV2 pandemic. A 33-year-old female presented with ARDS due to pulmonary TB infection (pneumonia with empyema and pneumothorax), which required invasive mechanical ventilation with poor response. Long term veno-arterio-venous (VAV) ECMO, overlapped with veno-venous ECMO, was used as a salvage therapy with a good response for a total of 26 days. This is an example of the effectiveness of this therapy in this scenario, never described before. The fact that this therapy was used in the middle of SARS-CoV2 pandemic, with limited resources available, was remarkable, but it was encouraged by previous successful experiences.

Prognostic implication of risk scoring systems in patients with cardiogenic shock supported by ECMO and Impella

We experienced two refractory cardiogenic shock patients receiving veno-arterial extracorporeal membrane oxygenation and Impella percutaneous left ventricular assist device (ECPELLA). TVAD score, which was originally proposed to predict one-year mortality following left ventricular assist device implantation using four objective parameters, was retrospectively calculated using data of day 3 following ECPELLA initiations. One patient with estimated intermediate risk could achieve successful explantation of ECPELLA, whereas another patient with estimated high risk was expired despite explantation of extracorporeal membrane oxygenation. TVAD score might be a useful tool to risk stratify and construct next strategy (i.e., bridge to recovery or bridge to more intensive therapy) for those with ECPELLA, although further studies are warranted to validate this hypothesis.

Practical Management of ECPELLA

Veno-arterial extracorporeal membrane oxygenation (ECMO) is a strong mechanical circulatory device for patients with hemodynamic deterioration due to cardiogenic shock, but its drawback is an increase in left ventricular afterload. The Impella axial-flow transcatheter left ventricular assist device is a recently developed promising device to mechanically unload the left ventricle, although its support flow may not necessarily be sufficient to support shock vital. Recently, ECMO and concomitant Impella support (ECPELLA) is increasingly being used to treat cardiogenic shock by maintaining systemic circulation and unloading the left ventricle. There are several pitfalls to maintaining ECPELLA, and one useful tool is the pulmonary artery pulsatility index. The clinical advantages of ECPELLA compared to conventional ECMO alone should be demonstrated in larger scale studies in the near future.

Current indication and practical management of percutaneous left ventricular assist device support therapy in Japan

Impella (Abiomed, Danvers, MA, USA) is a recently-innovated (commercially available from 2017 in Japan) percutaneous left ventricular assist device which is inserted percutaneously and transfers blood from the left ventricle to the ascending aorta, improving systemic circulation and end-organ dysfunction as well as unloading left ventricle in patients with cardiogenic shock. Impella has not yet shown a significant survival benefit in patients with cardiogenic shock compared to intra-aortic balloon pump in randomized control trials, but gives powerful circulatory support immediately with minimally invasive manner when used in appropriate patients at optimal timing with adequate management. In this review article, we will introduce and discuss optimal and practical management of Impella therapy in Japan.

Sepsis induced cardiomyopathy: Pathophysiology and use of mechanical circulatory support for refractory shock

Sepsis remains a major cause of morbidity and mortality, and sepsis-induced cardiomyopathy (SCM) has been recognized as a relevant complication. In this article, the pathophysiology of SCM and the literature regarding the clinical care with a focus on the use of mechanical circulatory support for the rescue of patients with severe SCM are reviewed. Lastly, a pragmatic approach to the care of this complex patient population is provided using a representative case example.

Tuberculosis-induced acute respiratory distress syndrome treated with veno-venous extracorporeal membrane oxygenation

Tuberculosis (TB) is a rare but known cause of acute respiratory distress syndrome (ARDS) with a high mortality. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) may be an alternative option for treating TB-induced ARDS. However, the literature on TB-induced ARDS treated with VV-ECMO is limited and the most of them were prolonged therapy. We report on a-48-year-old man with TB-induced ARDS who was successfully treated by short-term use of VV-ECMO (5 days). He was developed symptoms and hospitalized with severe dyspnea in a local hospital for 3 days before admission to our hospital. At the time when he was transferred to our hospital, his chest computed tomography showed bilateral, diffuse and consolidative shadows all over the lungs, the ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO₂/FiO₂) was 50 mmHg, and respiratory system compliance was 12.5 mL/cmH₂O. Two days after admission, Mycobacterium tuberculosis was detected by a sputum smear examination and he was diagnosed with TB-induced ARDS. VV-ECMO support was then initiated with administration of anti-TB drugs and systemic corticosteroid treatment. On the 4^thday of ECMO support, his PaO₂/FiO₂ increased to 400 mmHg and lung compliance increased to 45 mL/cmH₂O. He was weaned from ECMO on the 5th day of ECMO support and was extubated at the 8th day. He was discharged from hospital on the 47th hospitalized day and continued anti-TB medication at home. VV-ECMO is effective for TB-induced ARDS even in short-term administration if progression of ARDS is rapid.

Veno-arterio-venous ECMO for septic cardiomyopathy: a single-centre experience

INTRODUCTION

The role of extracorporeal support for patients with septic shock remains unclear.

METHODS

We conducted a retrospective analysis of our single-centre experience with veno-arterio-venous extracorporeal membrane oxygenation (VAV ECMO) in adult patients with severe respiratory failure and septic cardiomyopathy. Clinical data was extracted from electronic medical records including a dedicated ECMO referral and follow-up database.

RESULTS

Twelve patients were commenced on VAV ECMO for septic cardiomyopathy for a median of four days (IQR 3.0 to 5.3) between 01/2014 and 12/2017. Five patients (41.7%) had a cardiac arrest prior to initiation of ECMO support. At baseline, median left ventricular ejection fraction was 16.25% (IQR 13.13 to 17.5) and median PaO₂/FiO₂ ratio was 9 kPa (IQR 6.5 to 12.0) [67.50 mmHg (IQR 48.75 to 90.00)]. The survival rate to hospital discharge for VAV ECMO was 75% in this cohort. None of the surviving patients died within the follow-up period (median six month).

CONCLUSION

VAV ECMO is a feasible rescue strategy for a small proportion of patients with combined respiratory and cardiac failure secondary to septic shock with septic cardiomyopathy. We provide a detailed report of our experience with this technique. Further research is required comparing the different extracorporeal strategies directly to conventional resuscitation and against each other.