Complications of Extracorporeal Membrane Oxygenation for Treatment of Cardiogenic Shock and Cardiac Arrest: A Meta-Analysis of 1,866 Adult Patients

Risk of acute ischemic stroke with early versus late initiation of mechanical circulatory support in hospitalizations with acute myocardial infarction complicated by cardiogenic shock: a propensity-matched analysis

BACKGROUND

Mechanical circulatory support (MCS) devices have been widely used for managing acute myocardial infarction complicated by cardiogenic shock (AMI-CS). However, their use additionally elevates acute ischemic stroke (AIS) risk. There is insufficient data on the risk of AIS associated with early versus late initiation of MCS in AMI-CS cases. Therefore, this study aimed to assess the timing of MCS initiation associated with the risk of AIS in hospitalizations with AMI-CS.

METHODS

A retrospective data analysis of the National Inpatient Sample (January 2016-December 2020) identified AMI-CS hospitalizations: categorized into early MCS initiation (< 48 h) and late MCS initiation (> 48 h). The primary outcome was AIS; the secondary outcomes included in-hospital mortality, acute kidney injury (AKI), cardiac arrest, major bleeding, and blood transfusion. The outcomes were compared using logistic multivariate regression and 1:1 propensity score matching analyses between the groups.

RESULTS

Among 78,405 weighted hospitalizations with AMI-CS receiving MCS, 82.77% (n = 64,895) and 17.23% (n = 13,510) underwent early and late MCS initiation, respectively. Hospitalizations with late MCS initiation had higher risks of AIS (adjusted odds ratio [aOR], 1.46; 95%confidence interval [CI], 1.19-1.79; p < 0.001), AKI (aOR, 1.41; 95%CI, 1.27-1.55; p < 0.001), and major bleeding (aOR, 1.12; 95%CI, 1.01-1.23; p = 0.028). After propensity score matching, late MCS initiation remained associated with increased risks of AIS (aOR, 1.39; 95%CI, 1.08-1.78; p = 0.010), AKI (aOR, 1.37; 95%CI, 1.23-1.53; p < 0.001), and major bleeding (aOR, 1.14; 95%CI, 1.02-1.28; p = 0.027).

CONCLUSIONS

Late initiation of MCS was associated with increased risks of AIS, AKI, and major bleeding.

Antibiotic-Induced Gut Microbiome Dysbiosis Aggravates Cerebral Injury During Extracorporeal Membrane Oxygenation

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is an effective treatment for cardiopulmonary failure. However, it is associated with severe complications, including cerebral injury, which contribute to elevated mortality and disability rates. The administration of antibiotics may lead to gut microbiome dysbiosis among critically ill patients.

AIMS

This study aims to investigate the association between antibiotic-induced gut microbiome dysbiosis and cerebral injury during ECMO treatment.

METHODS

The compositional changes in the gut microbiome induced by antibiotic (ABX) treatment were analyzed using microbiome analysis techniques. ECMO treatment models were established by using rat. Brain tissue pathology was assessed using H&E and Nissl staining. Serum concentrations of S100β and NSE were quantified using ELISA. Pro-inflammatory factors in the brain and serum were analyzed, and microglial activation was evaluated via immunofluorescence.

RESULTS

Gut microbiome dysbiosis induced by ABX treatment. Compared to the sham group, significant cerebral injury was observed in both the ECMO and ECMO-ABX groups. The expression levels of S100β and NSE were significantly elevated in the ECMO-ABX group. Additionally, parameters of microglial activation, such as cell body area, total branch length, mean length of branches, and number of branch points, were significantly increased in the ECMO-ABX group compared to the ECMO group.

CONCLUSIONS

This study demonstrates that cerebral injury occurs during ECMO treatment, and antibiotic-induced gut microbiome dysbiosis may exacerbate this cerebral injury.

Long-term health-related quality of life in survivors of extracorporeal cardiopulmonary resuscitation compared to conventional cardiopulmonary resuscitation- A cohort study using Australian and New Zealand extracorporeal membrane oxygenation registry and the Victorian Ambulance Cardiac Arrest Registry

AIM

To compare the long-term health-related quality of life (HRQoL) between patients receiving extracorporeal cardiopulmonary resuscitation (ECPR) and conventional cardiopulmonary resuscitation (CCPR) for out-of-hospital cardiac arrest (OHCA).

METHODS AND SETTINGS

A retrospective cohort study using the Australian and New Zealand extracorporeal membrane oxygenation (EXCEL) registry for ECPR cases and the Victorian Ambulance Cardiac Arrest Registry (VACAR) for CCPR cases. All the adult patients with OHCA who had their cardiac arrest and 12-month HRQoL data recorded between July 2019 and July 2023 were eligible for inclusion. The primary outcomes were the 12-month EuroQol five-dimension (EQ-5D-5L) utility score and EuroQol visual analogue score (EQ-VAS).

RESULTS

There were 33/122(28%) ECPR and 1,074/8,990(12%) CCPR OHCA survivors at 12 months. Of these, 24 (73%) ECPR and 754 (70%) CCPR survivors had HRQoL data. The ECPR cohort was younger [mean(SD) 50.4(13.46) vs 60.5(14.01) yrs, p < 0.01] and more likely to have received bystander CPR [19(79%) ECPR vs 397(52%) CCPR, p < 0.001]. Both cohorts had similar proportions of males, witnessed arrests and initial shockable rhythms. Median (IQR) arrest to ROSC/ECMO time was longer in ECPR than CCPR [61(41.5-97) vs 6(2-14) minutes, p < 0.001]. The median (IQR) EQ-5D-5L utility score [0.95 (0.72-1) ECPR vs 0.96 (0.86-1) CCPR, p = 0.64] and median (IQR) EQ-VAS at 12 months [80 (64.5-90) ECPR vs 75 (60-85) CCPR, p = 0.39] were similar. There were no significant differences in the EQ-5D-5L utility scores and EQ-VAS even after adjustment for baseline imbalances.

CONCLUSIONS

Despite significant baseline differences between ECPR and CCPR, there were no differences in HRQoL at 12 months.

Sex-related outcomes during short-term mechanical circulatory support: A systematic review and meta-analysis of propensity-score matched studies

BackgroundThe association between sex and cardiovascular risk and different responses to heart failure therapies is well established. However, sex related outcomes of different types of short-term mechanical circulatory support (MCS) therapy remains controversial.MethodsWe performed a systematic review and meta-analysis of studies comparing outcomes of MCS between sexes. We restricted inclusion to propensity score matched studies to minimize the risk of confounding. We pooled binary and continuous outcomes with odds ratio (OR) and mean differences (MD), respectively, under a random effects model.ResultsWe pooled 6 propensity score matched studies evaluating sex related outcomes during short-term MCS, with 18,720 patients, of whom 9442 (50.5%) were male and 9278 (49.5%) were female. Subgroup analysis showed higher 30-day mortality during ECMO (OR 1.11; 95% CI 1.01-1.22; p = .038; I2 = 0%) in males, but lower 30-day mortality during Impella® therapy than females (OR 0.87; 95% CI 0.80-0.94; p = .001; I2 = 0%). Males had a higher need of myocardial revascularization (OR 3.09; 95% CI 1.56-5.99; p = .001; I2 = 0%), but a higher risk of acute kidney injury (OR 1.20; 95% CI 1.09-1.31; p < .001; I2 = 18%).ConclusionIn-hospital and 30-day mortality were similar between females and males.

The effectiveness of NIRS technology to the early diagnosis of lower limb ischemia in patients on peripheral VA ECMO: A systematic review and meta-analysis

BACKGROUND

Acute lower limb ischemia is a major complication of peripheral venoarterial ECMO, significantly impacting patient outcomes and survival rates. Traditional methods for assessing limb perfusion, such as physical exams and Doppler ultrasound, are often unreliable and do not provide continuous monitoring. Near-infrared spectroscopy (NIRS), a non-invasive technique, shows promise for perfusion monitoring in venoarterial ECMO patients, but its effectiveness in the early detection of limb hypoperfusion remains unreviewed.

AIM

Evaluate the effectiveness of NIRS technology in the early diagnosis of lower limb ischemia in patients undergoing peripheral VA ECMO.

METHODS

The search strategy covered five databases. Inclusion criteria included studies in Portuguese, English, Spanish, or German involving participants aged 18 or older dependent on peripheral VA ECMO. The intervention assessed was limb perfusion monitoring using NIRS in VA ECMO patients. The primary outcome was the effectiveness of NIRS in the early diagnosis of limb ischemia. Exclusion criteria included review articles, book chapters, books, editorials, conference papers, and studies on pediatric patients, central VA ECMO, or venovenous ECMO. Study quality was evaluated using the ROBINS-I tool. Meta-analysis was performed using R package meta. Narrative synthesis was applied when meta-analysis was unfeasible.

RESULTS

Of 180 studies, 164 were excluded after initial screening. Of the remaining 16 studies, eight were removed for irrelevance, high bias risk, or pediatric focus, leaving eight studies. The results revealed a pooled sensitivity of the diagnostic method of 0.71 (95% CI: [0.67, 0.74]) and a pooled specificity of 0.68 (95% CI: [0.61, 0.74]).

CONCLUSIONS

NIRS technology is an effective diagnostic tool for reliably detecting true positive cases of limb ischemia.

IMPLICATIONS FOR CLINICAL PRACTICE

The decrease in NIRS values and the difference between limbs may indicate hypoperfusion, requiring further investigation. NIRS also helps assess distal perfusion catheter functionality, enhancing our ability to provide safe, high-quality care.

Flow capabilities of arterial and drainage cannulae during venoarterial extracorporeal membrane oxygenation: A simulation model

BackgroundLarge cannulae can increase cannula-related complications during venoarterial extracorporeal membrane oxygenation (VA ECMO). Conversely, the ability for small cannulae to provide adequate support is poorly understood. Therefore, we aimed to evaluate a range of cannula sizes and VA ECMO flow rates in a simulated patient under various disease states.MethodsArterial cannulae sizes between 13 and 21 Fr and drainage cannula sizes between 21 and 25 Fr were tested in a VA ECMO circuit connected to a mock circulation loop simulating a patient with severe left ventricular failure. Systemic and pulmonary hypertension, physiologically normal, and hypotension were simulated by varying systemic and pulmonary vascular resistances (SVR and PVR, respectively). All cannula combinations were evaluated against all combinations of SVR, PVR, and VA ECMO flow rates.ResultsA 15 Fr arterial cannula combined with a 21 Fr drainage cannula could provide >4 L/min of total flow and a mean arterial pressure of 81.1 mmHg. Changes in SVR produced marked changes to all measured parameters, while changes to PVR had minimal effect. Larger drainage cannulae only increased maximum circuit flow rates when combined with larger arterial cannulae.ConclusionSmaller cannulae and lower flow rates could sufficiently support the simulated patient under various disease states. We found arterial cannula size and SVR to be key factors in determining the flow-delivering capabilities for any given VA ECMO circuit. Overall, our results challenge the notion that larger cannulae and high flows must be used to achieve adequate ECMO support.

Early left ventricular unloading during extracorporeal membrane oxygenation in cardiogenic shock: A systematic review and meta-analysis

BACKGROUND

Left ventricular (LV) unloading is a crucial intervention to decrease the harmful consequences of extracorporeal membrane oxygenation (ECMO) on hemodynamic status in cardiogenic shock (CS) patients. However, a lingering question preoccupies experts: Should we intervene early or wait until clinical deterioration caused by increasing afterload is detected?

METHODS

A systematic review and meta-analysis synthesizing studies, which were retrieved by systematically searching PubMed, Web of Science, SCOPUS, and Cochrane through December 2023. We used R V. 4.3 to pool dichotomous data using risk ratio (RR) and continuous data using mean difference (MD) with a 95% confidence interval (CI).

PROSPERO ID

CRD42024501643.

RESULTS

Eight studies with 2.117 patients were included. Early/prophylactic LV unloading was associated with a lower incidence of all-cause mortality [RR: 0.87 with 95% CI (0.79, 0.95), p < 0.01]. However, there was no significant difference between the two groups regarding cardiac mortality [RR: 1.01 with 95% CI (0.68, 1.48), p = 0.98], non-cardiac mortality [RR: 0.86 with 95% CI (0.46, 1.62), p = 0.64], and in-hospital mortality [RR: 0.95 with 95% CI (0.86, 1.05), p = 0.30]. There was no significant difference between the two groups regarding ECMO weaning, myocardial recovery, ECMO duration, and length of hospitalization.

CONCLUSION

Early/prophylactic LV unloading during ECMO for CS patients was associated with a decreased incidence of all-cause mortality and sepsis or infection, with no effect on ECMO weaning, myocardial recovery, ECMO duration, and hospital length of stay.

AI-powered model for predicting mortality risk in VA-ECMO patients: a multicenter cohort study

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a critical life support technology for severely ill patients. Despite its benefits, patients face high costs and significant mortality risks. To improve clinical decision-making, this study aims to develop a non-invasive, efficient artificial intelligence (AI)-enabled model to predict the risk of mortality within 28 days post-weaning from VA-ECMO. A multicenter, retrospective cohort study was conducted across five hospitals in China, including all the patients who received VA-ECMO support between January 2020 and January 2024. Based on the innovatively selected 25 easily obtainable patient examination features as potentially relevant, this study involved developing ten predictive models using both classical and advanced machine learning techniques. The model's performance is evaluated using various statistical metrics and the optimal predictive model are identified. Feature correlations are analyzed using Pearson correlation coefficients, and SHapley Additive exPlanations (SHAP) are employed to interpret feature importance. Decision curve analysis is used to evaluate the clinical utility of the predictive models. The study included 225 patients, with 66 patients from one hospital forming the training cohort. Three validation cohorts were used: internal validation with 16 patients from the training hospital and external validation with 30 and 60 patients from the other 4 hospitals. The random forest model emerged as the best predictor of 28-day mortality, achieving an AUROC of 1.00 in the training cohort and 1.00, 0.97, and 0.93 in the three validation cohorts, respectively. Despite the limited training data, the developed model, eCMoML, demonstrated high accuracy, generalizability and reliability. The model will be available online for immediate use by clinicians. The eCMoML model, validated in a multicenter cohort study, offers a rapid, stable, and accurate tool for predicting 28-day mortality post-VA-ECMO weaning. It has the potential to significantly enhance clinical decision-making, helping doctors better assess patient prognosis, optimize treatment plans, and improve survival rates.

Flow characteristics of reperfusion sheaths when utilizing large bore mechanical circulatory support devices

BACKGROUND

Reperfusion sheaths are commonly utilized to prevent acute limb ischemia (ALI) when using large bore mechanical circulatory support devices, though little is known about flow characteristics of these sheaths.

METHODS

The purpose of this assessment was to characterize the flow rates of various femoral to femoral (fem-fem) bypass circuits. We devised a test setup that maintains a preset input pressure for test devices to enable an accurate comparison of bypass techniques.

RESULTS

Negligible flow rate increases were observed in active or passive ipsilateral and contralateral circuits when donor or receiver sheaths were sequentially increased in size. When using a contralateral fem-fem bypass circuit, the use of a Merit Prelude Pro 8F sheath paired with a 5F Arrow reperfusion sheath provided 167 ml/min of flow. If the reperfusion sheath was exchanged to a 6F sheath the flow rate was 169 ml/min, 175 ml/min with a 7F sheath and 179 ml/min with an 8F sheath, a total difference of 7 %. When maintaining a 6F reperfusion sheath as a constant, the use an ipsilateral fem-fem bypass circuit using an Abiomed 14F Low profile sheath provided 215 ml/min of flow, a 27 % higher flow than a contralateral 8F circuit. The use of an active pressure bypass system using an 18F ECMO cannula provided 356 ml/min, a 66 % higher flow than a 14F ipsilateral fem-fem bypass and 110 % higher flow than an 8F contralateral fem-fem bypass.

CONCLUSION

Flow rate through a fem-fem bypass circuit is contingent upon the smallest diameter along the pathway which is typically the side port of the sheath. There are negligible changes in flow rate based on increasing donor or receiver sheath sizes. Novel, purpose-built reperfusion sheath taking these flow characteristics into account are needed to improve such systems.

Efficacy, safety, and complications of manta vascular closure device in VA-ECMO decannulation: A systematic review and meta-analysis

BACKGROUND

VenoArterial (VA)-ExtraCorporeal Membrane Oxygenation (ECMO) decannulation was traditionally performed surgically, often resulting in high rates of periprocedural complications such as surgical site infections, bleeding, and elevated patient mobilization costs. The advent of percutaneous techniques, particularly the MANTA® vascular closure device (MVCD), has significantly reduced these risks by enabling faster and safer decannulation. This study aimed to systematically review the success rates and complications associated with the use of percutaneous closure devices for VA-ECMO decannulation.

OBJECTIVE

Therefore, this systematic review with meta-analysis aims to evaluate the success rates and complications associated with the use of MVCD device for VA-ECMO decannulation.

MATERIALS AND METHODS

A systematic search was conducted across Pubmed, Web of Science, and Cochrane databases to identify studies evaluating postoperative outcomes in patients undergoing VA-ECMO decannulation using the MANTA® vascular closure device. The MANTA® efficacy, incidence of emergent open repair, arterial thrombosis, acute limb ischemia, pseudoaneurysms, and major bleeding were pooled by fixed-effects meta-analysis, with sources of heterogeneity being explored by meta-regression. Assessment of studies' quality was performed using the National Heart, Lung, and Blood Institute (NHLBI) Study Quality Assessment Tool for observational cohorts and case-series studies.

RESULTS

Seven observational studies with 235 patients were included in the final analysis. Overall efficacy of MVCD in VA-ECMO decannulation was 94.8% (95% CI 91.8%-97.9%). In 235 patients, the incidence of emergency open repair after MVCD failure was 3.7% (95% CI 1.3%-6.1%), the incidence of arterial thrombosis was 7.1% (95% CI 2.9%-11.3%), the incidence of pseudoaneurysms was 3.2% (95% CI 0.9%-5.5%), the incidence of acute limb ischemia was 5.0% (95% CI 2.3%-7.8%), and the incidence of major arterial bleeding was 4.1% (95% CI 1.6%-6.7%).

CONCLUSION

This systematic review and meta-analysis highlights the safety and efficacy of the MANTA® vascular closure device in achieving hemostasis following VA-ECMO decannulation, demonstrating an acceptable success rate and a low incidence of major complications. Further studies with larger cohorts are necessary to validate these findings and to address the limitations of this preliminary experience.

Comparison of mechanical resuscitation by an LV Impella device to extracorporeal resuscitation using VAECMO in a large animal model

Extracorporeal cardiopulmonary resuscitation (ECPR) is an effective treatment for cardiac arrest (CA). Percutaneous left ventricular (LV) assist devices such as the Impella ECP (intravascular CPR [ICPR]) have been proposed as a less invasive alternative. The aim of this study was to explore the haemodynamic differences between ECPR and ICPR using a large animal model of electrically induced CA. Fourteen juvenile female German landrace pigs (72.4 ± 9.8 kg) were subjected to electrically induced CA for 5 mins followed by either ECPR (veno-arterial extracorporeal membrane oxygenation [VA-ECMO]) or ICPR (Impella ECP). Haemodynamic parameters and echocardiographic ventricular function indicators were monitored. Mechanical circulatory support (MCS) was continued until five hours after the return of spontaneous circulation (ROSC), when the devices were removed. Resuscitation outcomes and the haemodynamic effects of ECPR and ICPR were compared. The cannulation time for ECMO (469 ± 129 s) was significantly longer than the time for Impella device implantation (153 ± 64 s, p < 0.001). ECPR facilitated ROSC in 6/6 animals, whereas ICPR facilitated ROSC in 6/8 animals (p = 0.19). Echocardiography revealed no difference in LV or right ventricular (RV) dysfunction between the ECPR- and ICPR-treated animals after resuscitation (LV-global longitudinal strain [GLS] 3 h post-ROSC: ICPR: - 16.5 ± 5.6% vs. ECPR: - 13.7 ± 5.9%, p = 0.99; RV-GLS 3 h post-ROSC: ICPR: - 15.9 ± 3.3% vs. ECPR: - 17.3 ± 10.6%, p = 0.99). MCS using VA-ECMO and the Impella device both provided effective haemodynamic support during CA and post-ROSC in this large animal model. Despite LV unloading conferring a hypothetical advantage for ICPR, no significant differences in myocardial recovery were observed.

Extracorporeal Membrane Oxygenation-Assisted Thoracic Surgery: A Series of 10 Cases

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) is a type of extracorporeal circulation used to divert blood from and deliver blood to peripheral blood vessels. Recently, the use of ECMO has been reported in various non-transplant surgeries. Particularly in tracheal surgeries, ECMO provides an unobstructed surgical field and enables safe induction of general anesthesia in difficult intubation cases. Here, we report on 10 cases of thoracic surgery in which ECMO was employed at our institution.

CASE PRESENTATION

These 10 cases comprise 4 tracheal cancer surgeries, 2 lung cancer surgeries, and 1 case each of surgery for thyroid cancer, mediastinal cancer, tracheomalacia, and tracheobronchial injury. Veno-venous (VV)-ECMO is most often selected, but veno-arterial (VA)-ECMO is chosen when recirculation with VV-ECMO is unacceptable, when pulmonary artery bleeding needs to be controlled, or when cardiac support is necessary. Among the 10 presented cases, VV-ECMO was used in 8, while VA-ECMO was employed in 2. Three of these cases involved ECMO bailout due to dyspnea caused by airway stenosis. Six of the patients did not receive heparin maintenance. Of those, 1 was maintained on nafamostat mesilate, 2 were maintained on nafamostat mesilate after receiving a single dose of heparin, and 3 received only a single dose of heparin. In none of those cases did ECMO fail to maintain flow due to thrombus formation. A postoperative hemothorax occurred as one of the ECMO-related complications in Case 4. There were no perioperative cardiopulmonary complications, in-hospital deaths, or deaths within 30 days after surgery. One patient died from metastatic recurrence of non-small cell lung cancer 5 months after surgery, another from progression of disease in mediastinal anaplastic cancer 4 months after surgery, and the 3rd from upper gastrointestinal bleeding 2 years after surgery. The other 7 patients remain alive.

CONCLUSIONS

ECMO is useful in tracheal surgery and in cases where intubation is difficult or dangerous, because it facilitates safe and accurate surgery. We also believe that individualized anticoagulant strategies can be safely implemented.

A Retrospective Analysis of the Effects of Concomitant Use of Intra-Aortic Balloon Pump (IABP) and Veno-Arterial Extracorporeal Membrane Oxygenation (va-ECMO) Therapy on Procedural Brain Infarction

Background/Objectives: Brain ischemia is a frequent complication in patients undergoing veno-arterial extracorporeal membrane oxygenation (va-ECMO) therapy due to hypoperfusion, low oxygenation, and thromboembolism. While concomitant intra-aortic balloon pump (IABP) therapy may improve the perfusion of the supra-aortic branches, it may also favor thromboembolism. This retrospective study aimed to evaluate the effects of combined va-ECMO and IABP therapy on procedural brain infarction compared to va-ECMO therapy alone, with a specific focus on analyzing the types of infarctions. Methods: Cranial computed tomography (CCT) scans of consecutive patients receiving va-ECMO therapy were analyzed retrospectively. Subgroups were formed for patients with combined therapy (ECMO and IABP) and va-ECMO therapy only. The types of infarctions and the potential impacts of va-ECMO vs. combined therapy with IABP on stroke were investigated. Results: Overall, 146 patients (36 female, 110 male, mean age 61 ± 13.3 years) were included, with 69 undergoing combined therapy and 77 patients receiving va-ECMO therapy alone. In total, 14 stroke events occurred in 11 patients in the ECMO-only group and there were 12 events in 12 patients in the ECMO + IABP-group, showing no significant difference (p = 0.61). The majority of infarctions were of thromboembolic (n = 23; 88%) origin, with 14 stroke-events in 12 patients in the ECMO + IABP-group and 9 stroke events in the ECMO-only group. The survival rate within 30 days of treatment was 29% in the ECMO-only group and 32% in the ECMO + IABP group. Conclusions: The results of this retrospective study show that concomitant IABP therapy appears to be neither protective nor more hazardous in relation to ECMO-related stroke. Thus, the indication for additional IABP therapy should be assessed independently from the procedural risk of brain ischemia. Thromboembolic infarctions seem to represent the most common type of infarction in ECMO, especially within the first 48 h of treatment.

Incidence and risk factors associated with stroke when utilizing peripheral VA-ECMO

BACKGROUND

Mechanical circulatory support with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has brought forward a paradigm shift in the management of cardiogenic shock. Neurological complications associated with VA-ECMO represent a significant source of morbidity and mortality and serve as a limiting factor in its application and duration of use.

METHODS

We performed a single-center retrospective case-control study of patients who developed stroke while managed with peripheral VA-ECMO from January 2018 to September 2022 at a quaternary center. We included consecutive patients above the age of 18 who were admitted to the cardiac intensive care unit and were managed with peripheral VA-ECMO. All patients who developed a stroke while on VA-ECMO were included in the case cohort, and compared to those who did not suffer stroke. Multivariable logistic regression was performed to identify risk factors associated with stroke on VA-ECMO. In-hospital outcomes were assessed out to 30 days.

RESULTS

A total 244 patients were included in the final analysis, 36 (14.7 %) of whom developed stroke on VA-ECMO. Ischemic stroke was seen in 20 patients (55.6 %) whereas hemorrhagic stroke was seen in 16 patients (44.4 %). The use of P2Y12 antagonists (aOR 2.70, p = 0.019), limb ischemia (aOR 4.41, p = 0.002), and blood transfusion requirement (aOR 8.55, p = 0.041) were independently associated with development of stroke on VA-ECMO. Female sex trended towards statistical significance (aOR 2.19, p = 0.053) while age was not independently associated with development of stroke on VA-ECMO. There was no significant association between stroke development and outcomes of VA-ECMO duration, hospital length of stay, and all-cause mortality out to 30-days.

CONCLUSIONS

VA-ECMO carried a considerable risk of neurological complications. Mortality and duration of hemodynamic support was not associated with stroke risk. Awareness regarding stroke risk is imperative in facilitating early identification and management of ischemic and hemorrhagic stroke. Research involving clinical trials and multicenter studies are necessary to empower centers in mitigating this source of significant morbidity and mortality in patients on mechanical circulatory support.

Development and Evaluation of a Novel Drainage Cannula for Venoarterial Extracorporeal Membrane Oxygenation

A critical factor in thrombus formation during venoarterial extracorporeal membrane oxygenation (VA ECMO) is prothrombotic flow dynamics generated by the drainage cannula's design. This study aimed to create and evaluate a novel drainage cannula design which optimized blood flow dynamics to reduce thrombus formation. Computational fluid dynamics (CFD) was used to iteratively vary drainage cannula design parameters such as inner wall shape and side hole shape. The final novel design was then placed in an ex vivo blood circulation loop, and compared against a Bio-Medicus cannula (n = 6, each). Clot volume, hemolysis, and other parameters were measured to assess thrombus formation markers. The novel design consisted of a parabolic inner wall profile with closely spaced side holes angled at 30º to align with flow. When tested in the ex vivo loop, the novel design resulted in lower instances (two vs . four) and volumes of clot in the cannula (360.5 ± 254.8 vs . 1258.0 ± 651.7 µl) when compared to the Bio-Medicus cannula. Results from tests assessing hemolysis, platelet activation, and other thrombotic markers revealed a noninferior relationship between the novel and Bio-Medicus designs. Future work will explore the clinical applicability of these findings.

Age Differences in Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock: Trends in Application and Outcome From the Chinese Extracorporeal Life Support Registry

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used for cardiogenic shock (CS) in adults, with age-influencing outcomes. Data from the Chinese Extracorporeal Life Support (CSECLS) Organization registry (January 2017-July 2023) were analyzed to assess in-hospital mortality in VA-ECMO for CS. Patients ≤65 years were categorized as young, and those >65 as elder. The primary outcome was in-hospital mortality, with secondary outcomes including ECMO weaning, 30 day survival, and complications. Of 5,127 patients, the young group (73.4%) had a median age of 51.0 (40.0-58.0) years, and the elder group (26.6%) had a median age of 71.0 (68.0-75.0) years. The in-hospital mortality was lower in the younger group (45.1%) compared with the elder group (52.6%, p < 0.001). The young group also had higher ECMO weaning rates (79.4% vs. 74.8%, p < 0.001) and 30 day survival (59.1% vs. 51.3%, p < 0.001). Bleeding, renal, and pulmonary complications were more frequent in young patients, though not statistically significant. Young patients undergoing VA-ECMO for CS generally have better outcomes than older patients, though careful selection is crucial to manage complications.

Hemodynamic Effects and Clinical Outcomes of Left Atrial Veno-Arterial Extracorporeal Membrane Oxygenation (LAVA-ECMO) in Cardiogenic Shock

Left atrial veno-arterial extracorporeal membrane oxygenation (LAVA-ECMO) in cardiogenic shock (CS) is a novel mechanical cardiocirculatory support strategy that provides robust cardiocirculatory support and simultaneous left and right atrial venting by way of a multifenestrated transeptal catheter. We performed a single-center retrospective analysis of all patients aged ≥18 years with CS who underwent LAVA-ECMO at a quaternary care institution from 2018 to 2023. Clinical outcomes and prehemodynamics and posthemodynamics were evaluated. A total of 68 patients were analyzed (75% were men, 72% were white, median age of 63 years). The indications for LAVA-ECMO were CS because of myocardial infarction (29.4%), biventricular failure (26.5%), and/or valvular heart disease (26.5%). Trans-septal puncture was guided by intracardiac echocardiography (86.8%) or transesophageal echocardiography (13.2%). Arterial cannulation was performed by way of transcaval access in 25% of the cases. Post-LAVA-ECMO cannulation was associated with substantial improvement in the hemodynamics within 24 hours after cannulation, including reduction in right atrial pressure (absolute mean difference: -5.0 mm Hg, p <0.001), mean pulmonary artery pressure (-9.0 mm Hg, p <0.001), pulmonary capillary wedge pressure (-10.0 mm Hg, p <0.001), and left ventricular end-diastolic pressure (-14.0 mm Hg, p <0.001). Survival to decannulation occurred in 69.1%, whereas the 30-day survival from cannulation was 51.5%. The in-hospital all-cause mortality was 51.5%. Only 5 patients (7.4%) required additional mechanical circulatory support (MCS) (4 Impella, 1 veno-arterio-venous extracorporeal membrane oxygenation). There were no complications related to transeptal placement of the venous ECMO cannula. In conclusion, LAVA-ECMO, an MCS strategy providing biatrial drainage, appears to also provide simultaneous left ventricular venting, as demonstrated by improved invasive hemodynamics. Although the procedure appears safe, with no direct complications to interatrial septal cannulation, postcannulation complications remain high, and further studies are needed to evaluate the full safety profile of LAVA-ECMO compared with alternative MCS strategies.

Clinical impact of hypermagnesemia in acute kidney injury patients undergoing continuous kidney replacement therapy: A propensity score analysis utilizing real-world data

PURPOSE

While hypomagnesemia is known to be a risk factor for acute kidney injury (AKI), the impact of hypermagnesemia on prognosis in AKI patients undergoing continuous kidney replacement therapy (CKRT) remains unclear. This study investigates the relationship between hypermagnesemia and clinical outcomes in this patient population.

METHODS

A retrospective analysis was conducted using data from a multicenter medical repository spanning from 2001 to 2019, involving patients who underwent CKRT. Patients were categorized into normomagnesemia (<2 mEq/L) and hypermagnesemia groups based (≥2 mEq/L) on their levels at CKRT initiation.

RESULTS

Among the 2625 patients, 1194 (45.5 %) had elevated serum magnesium levels. The hypermagnesemia group exhibited a similar rate of non-recovery of renal function at 90-days compared to the normomagnesemia group (63.1 % vs. 62.8 %, odds ratio [OR] = 1.01, 95 % confidence interval [CI] 0.90-1.14). Furthermore, the high magnesium group demonstrated higher one-year all-cause mortality (hazard ratio [HR] 1.14, 95 % CI 1.07-1.21) and an elevated risk of one-year arrhythmia (HR 4.77, 95 % CI 1.59-14.29). There was no difference of incidence of seizure between hypermagnesemia and normomagnesemia group.

CONCLUSIONS

Our study suggests that hypermagnesemia in AKI patients undergoing CKRT is not associated with improved renal recovery but is linked to worse clinical outcomes, including all-cause mortality and arrhythmia. Close monitoring of serum magnesium levels is recommended in this population for optimizing clinical outcomes.

Perioperative extracorporeal membrane oxygenation in liver transplantation-bridge to transplantation, intraoperative salvage, and postoperative support: outcomes and predictors for survival in a large-volume liver transplant center

Data on perioperative extracorporeal membrane oxygenation (ECMO) in liver transplantation (LT) are scarce. ECMO has been used preoperatively, intraoperatively, and postoperatively for a variety of indications at our center. This retrospective, single-center study of ECMO use peri-LT aimed to describe predictors for successful outcome in this highly select cohort of patients. Demographics, support method, and indication for LT were compared between survivors and nonsurvivors. Twenty-nine patients received venovenous (V-V; n = 20), venoarterial (V-A; n = 8), and venoarteriovenous (n = 1) ECMO. Twelve (41.4%) patients were bridged to emergency LT for acute liver failure, and emergency redo LT. Four (13.3%) patients required intraoperative V-A ECMO salvage, 2 necessitating extracorporeal cardiopulmonary resuscitation. Thirteen (43.3%) patients required ECMO support after LT: V-V ECMO (n = 9); V-A ECMO (n = 1); and extracorporeal cardiopulmonary resuscitation (n = 3) between postoperative days 2 to 30. Overall, 19 patients (65.5%) were successfully weaned off ECMO; 15 (51.7%) survived to intensive care unit discharge. All patients who underwent intraoperative salvage ECMO and all who were bridged to emergency redo LT died. Peri-LT ECMO is feasible. Post-LT ECMO outcomes are encouraging, in particular for V-V ECMO. Intraoperative ECMO salvage, uncontrolled sepsis, and graft failure are associated with poor outcomes.

Acute Limb Ischemia in Patients on Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) Support: A Ten-Year Single-Center Experience

BACKGROUND

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been increasingly utilized as a life-saving modality in patients with cardiopulmonary compromise. Acute limb ischemia (ALI) has been reported when the femoral artery was accessed, and it was associated with higher mortality in patients on extracorporeal membrane oxygenation (ECMO). However, prior studies were limited by small sample size and the lack of long-term follow-up. We aimed to investigate the predictors of ALI in ECMO and the effect of ALI on long-term mortality.

METHODS

Retrospective institutional chart review was performed. Patients who underwent VA-ECMO (Jan/2008-Jan/2018) were identified. Primary outcomes were ALI and 4-year mortality. Logistic regression analysis was used to investigate the predictors of ALI. Survival analysis methods were used to examine 4-year mortality.

RESULTS

A total of 377 patients were included. Vascular complications took place in 149 (39.5%) patients. The majority was ALI (107, 75.4%). Eleven patients had limb loss. ALI patients were younger (mean age: 50.2 ± 15.9 vs. 54.1 ± 15.5; P = 0.03), were more likely to have history of peripheral arterial disease (PAD) (7.6% vs. 3.0%; P = 0.047), were less likely to be on aspirin (40.2% vs. 54.4%; P = 0.013), and were more likely to be on vasopressors (97.1% vs. 88.0%; P = 0.007). Arterial cannula size was not associated with ALI so as the concurrent use of ventricular offloading devices (intra-aortic balloon pump or Impella (Abiomed Inc, Dancers, MA)). The use of distal perfusion catheter (DPC) was not protective against ALI in this cohort. However, DPC was associated with less likelihood to require vascular intervention (20.1% vs. 32.0%; P = 0.009). In adjusted analysis, aspirin use was protective against ALI [adjusted odds ratios (aOR) 95% CI: 0.52(0.30 - 0.90); P = 0.018]. The only predictor of ALI was the use of vasopressors [aOR (95% CI): 6.8 (1.5 - 30.4); P = 0.012]. For those who were successfully decannulated, 4-year survival was 65.1% in patients without ALI versus 46.8% in ALI (P = 0.044). After adjusting for potential risk factors, 4-year mortality hazard was significantly higher in patients with ALI [HR: 1.80(1.04 - 3.12); P = 0.035].

CONCLUSIONS

Patients requiring ECMO are critically ill. The development of ALI is detrimental to this population. This effect extends beyond the acute period. ALI increased 4-year mortality risk by 80%. The use of DPC did not protect against ALI, but it was associated with less vascular interventions.

Fibrinogen levels and bleeding risk in adult extracorporeal cardiopulmonary resuscitation: multicenter observational study subanalysis

•Hypofibrinogenemia frequently occurs in extracorporeal cardiopulmonary resuscitation (ECPR) and may heighten bleeding risk. This subanalysis of a multicenter observational study (SAVE-J II) included 2,100 adult patients receiving ECPR after out-of-hospital cardiac arrest at 36 facilities in Japan.•Overall, 7.5% of patients experienced non-cannulation hemorrhagic complications, and those with fibrinogen levels below 140 mg/dL at ECPR initiation faced significantly higher bleeding risk. These findings underscore the importance of monitoring and managing fibrinogen levels in ECPR to mitigate hemorrhagic events and improve patient outcomes.

Dexmedetomidine alleviates acute kidney injury in a rat model of veno-arterial extracorporeal membrane oxygenation

BACKGROUND

Although extracorporeal membrane oxygenation (ECMO) is an effective technique for life support, the incidence of acute kidney injury (AKI) during ECMO support remains high. Dexmedetomidine (DEX), which has been widely used for sedation during ECMO, possesses several properties that help reduce the occurrence of AKI. This study aimed to investigate the protective effect of DEX on kidney function during ECMO.

METHODS

A total of 18 male Sprague-Dawley (SD) rats were randomly divided into three groups: Sham, ECMO, and ECMO + DEX groups. ECMO was established through the right jugular vein for venous drainage and right femoral artery for arterial infusion and lasts for four hours. Hematoxylin and eosin staining was used to evaluate the kidney Paller score for the rats in each group. Enzyme-linked immunosorbent assay was used to measure the levels of kidney injury biomarkers and cytokines in the serum. Reagent kits were used to measure the blood urea nitrogen (BUN) and creatinine (Cr) levels, which helped determine kidney function. Immunohistochemical staining was used to evaluate neutrophil infiltration in the kidney.

RESULTS

The pathological Paller score was substantially lower in the ECMO + DEX group. The levels of Kidney Injury Molecule-1 (KIM-1) and N-acetyl-β-D-glucosaminidase (NAG) were also significantly reduced. The kidney functionality, as indicated by BUN and Cr, was significantly improved compared with the ECMO group. The levels of cytokines IL-6, IL-1β, and TNF-α, were also significantly decreased in the ECMO + DEX group.

CONCLUSION

This study demonstrated that dexmedetomidine could reduce inflammatory response and alleviate AKI during ECMO support.

Current and novel biomarkers in cardiogenic shock

Cardiogenic shock (CS) carries a 30-50% in-hospital mortality rate, with little improvement in outcomes in the last decade. Challenges in improving outcomes are closely linked to the frequent late presentation or diagnosis of CS where the 'point of no return' has often passed, leading to haemodynamic dysregulation, progressive myocardial depression, hypotension, and a downward spiral of hypoperfusion, organ dysfunction and decreasing myocardial function, driven by inflammation and metabolic derangements. Novel therapeutic interventions may have varying efficacy depending on the type and stage of shock in which they are applied. Biomarkers that aid prediction and early detection of CS, provide early signs of organ dysfunction and define prognosis could help optimize management. Temporal change in such biomarkers, particularly in response to pharmacological interventions and/or mechanical circulatory support, can guide management and predict outcome. Several novel biomarkers enhance the prediction of mortality in CS, compared to conventional parameters such as lactate, with some, such as adrenomedullin and circulating dipeptidyl peptidase 3, also able to predict the development of CS. Some biomarkers reflect systemic inflammation (e.g. interleukin-6, angiopoietin 2, fibroblast growth factor 23 and suppressor of tumorigenicity 2) and are not specific to CS, yet inform on the activation of important pathways involved in the downward shock spiral. Other biomarkers signal end-organ hypoperfusion and could guide targeted interventions, while some may serve as novel therapeutic targets. We critically review current and novel biomarkers that guide prediction, detection, and prognostication in CS. Future use of biomarkers may help improve management in these high-risk patients.

Extracorporeal Cardiopulmonary Resuscitation-Where Do We Currently Stand?

Extracorporeal cardiopulmonary resuscitation (eCPR) is a method of acute resuscitation for patients who have suffered a cardiac arrest through the utilization of an extracorporeal membrane oxygenation (ECMO) pump. The use and efficacy of eCPR is an active area of investigation with ongoing clinical investigation across the world. Since its inception, ECMO has been utilized for several conditions, but more recently, its efficacy in maintaining cerebrovascular perfusion in eCPR has generated interest in more widespread utilization, particularly in cases of out-of-hospital cardiac arrest. However, successful implementation of eCPR can be technically challenging and resource intensive and has been countered with ethical challenges beyond the scope of conventional in-hospital ECMO care. The aim of this review is to summarize the status of eCPR in the current era.

Left atrial appendage cannulation for left ventricular unloading in a patient with ventricular thrombus on extracorporeal life support

BACKGROUND

Left ventricular unloading is needed in patients on extracorporeal life support (ECLS) with severely impaired left ventricular contractility to avoid stasis and pulmonary congestion, and to promote LV recovery. The presence of thrombi in the LV precludes the use of conventional active unloading methods such as transaortic microaxial pumps or apical LV vents. We describe placement of a vent cannula via the left atrial appendage (LAA) as a useful bailout option.

CASE PRESENTATION

A 61-year-old patient presenting with normotensive cardiogenic shock (SCAI C) after subacute anterior wall myocardial infarction deteriorated with pulmonary edema and ventricular fibrillation, requiring veno-arterial extracorporeal life support under ongoing CPR (SCAI E). An Impella CP was placed for LV unloading, but was unable to generate flow and was thus removed. A large left ventricular thrombus was detected as the cause for insufficient Impella flow. For urgent LV unloading, we placed a vent cannula via the LAA through a thoracotomy to bridge our patient to total artificial heart implantation. However, intraoperative TEE showed resolution of the LV thrombus, enabling to change the strategy to left ventricular assist device implantation only, which was performed successfully. Our patient made a full recovery and is now doing well in regular outpatient follow ups.

CONCLUSIONS

ECLS provides excellent circulatory support at the price of a high complication burden and considerable LV afterload increase. ECLS complications often require individualized solutions not represented in current heart failure guidelines. This patient has developed a dreaded and nearly always fatal ECLS complication, which was successfully managed with vent placement via the LAA.

Routine Versus Selective Distal Perfusion Catheter Use in Venoarterial Extracorporeal Membrane Oxygenation

Although current studies support the use of prophylactic distal perfusion catheters (DPCs) to decrease limb ischemia in patients on venoarterial extracorporeal membrane oxygenation (VA ECMO), methods for monitoring limb ischemia differ between studies. We evaluated the safety of a selective rather than prophylactic DPC strategy at a single center with a well-established protocol for limb ischemia monitoring. Distal perfusion catheters were placed selectively if there was evidence of hypoperfusion at any point until decannulation. All patients were followed daily by vascular surgery with continuous regional saturation monitoring. Of 188 patients supported with VA ECMO, there were no significant differences in baseline characteristics between patients with upfront, delayed, and no DPC. Thirty day mortality was highest in patients with an upfront DPC (56% in the upfront DPC group, 19% in the delayed DPC group, and 22% in the no-DPC group, p < 0.001). The incidence of major bleeding, fasciotomy, and amputation in the entire cohort was 3.7%, 3.7%, and 0%, respectively. With strict adherence to a protocol for limb ischemia monitoring, a selective rather than prophylactic DPC strategy is safe and may obviate the risks of an additional arterial catheter.

A randomized embedded multifactorial adaptive platform for extra corporeal membrane oxygenation (REMAP ECMO) - design and rationale of the left ventricular unloading trial domain

BACKGROUND

The use of Extracorporeal Membrane Oxygenation (ECMO) remains associated with high rates of complications, weaning failure and mortality which can be partly explained by a knowledge gap on how to properly manage patients on ECMO support. To address relevant patient management issues, we designed a "Randomized Embedded Multifactorial Adaptive Platform (REMAP)" in the setting of ECMO (REMAP ECMO) and a first embedded randomized controlled trial (RCT) investigating the effects of routine early left ventricular (LV) unloading through intra-aortic balloon pumping (IABP).

METHODS

REMAP ECMO describes a registry-based platform allowing for the embedding of multiple response adaptive RCTs (trial domains) which can perpetually address the effect of relevant patient management issues on ECMO weaning success. A first trial domain studies the effects of LV unloading by means of an IABP as an adjunct to veno-arterial (V-A) ECMO versus V-A ECMO alone on ECMO weaning success at 30 days in adult cardiogenic shock patients admitted to the Intensive Care Unit (ICU). The primary outcome of this trial is "successful weaning from ECMO" being defined as a composite of survival without the need for mechanical circulatory support, heart transplantation, or left ventricular assist device (LVAD) at 30 days after initiation of ECMO. Secondary outcomes include the need for interventional escalation of LV unloading strategy, mechanistic endpoints, survival characteristics until 1 year after ECMO initiation, and quality of life. Trial data will be analysed using a Bayesian statistical framework. The adaptive design allows for a high degree of flexibility, such as response adaptive randomization and early stopping of the trial for efficacy or futility. The REMAP ECMO LV unloading study is approved by the Medical Ethical Committee of the Erasmus Medical Center and is publicly registered.

CONCLUSION

This REMAP ECMO trial platform enables the efficient roll-out of multiple RCTs on relevant patient management issues. A first embedded trial domain will compare routine LV unloading by means of an IABP as an adjunct to V-A ECMO versus V-A ECMO alone.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05913622.

Vascular Complications After Venoarterial Extracorporeal Membrane Oxygenation Support: A CT Study

OBJECTIVES

Vascular complications after venoarterial extracorporeal membrane oxygenation (ECMO) remains poorly studied, although they may highly impact patient management after ECMO removal. Our aim was to assess their frequency, predictors, and management.

DESIGN

Retrospective, observational cohort study.

SETTING

Two ICUs from a tertiary referral academic hospital.

PATIENTS

Adult patients who were successfully weaned from venoarterial ECMO between January 2021 and January 2022.

INTERVENTIONS

None.

PRIMARY OUTCOME

Vascular complications frequency related to ECMO cannula.

MEASUREMENTS AND MAIN RESULTS

A total of 288 patients were implanted with venoarterial ECMO during the inclusion period. One hundred ninety-four patients were successfully weaned, and 109 underwent a CT examination to assess for vascular complications until 4 days after the weaning procedure. The median age of the cohort was 58 years (interquartile range [IQR], 46-64 yr), with a median duration of ECMO support of 7 days (IQR, 5-12 d). Vascular complications were observed in 88 patients (81%). The most frequent complication was thrombosis, either cannula-associated deep vein thrombosis (CaDVT) ( n = 63, 58%) or arterial thrombosis ( n = 36, 33%). Nonthrombotic arterial complications were observed in 48 patients (44%), with 35 (31%) presenting with bleeding. The most common site of CaDVT was the inferior vena cava, occurring in 33 (50%) of cases, with 20% of patients presenting with pulmonary embolism. There was no association between thrombotic complications and ECMO duration, anticoagulation level, or ECMO rotation flow. CT scans influenced management in 83% of patients. In-hospital mortality was 17% regardless of vascular complications.

CONCLUSIONS

Vascular complications related to venoarterial ECMO cannula are common after ECMO implantation. CT allows early detection of complications after weaning and impacts patient management. Patients should be routinely screened for vascular complications by CT after decannulation.

Acute Vascular Complications of VA-ECMO in COVID-19 Patients. Does COVID-19 Affect the Outcome?

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) through the femoral artery and vein can lead to significant vascular complications. We retrospectively studied the acute vascular complications of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) in COVID-19 patients compared to non-COVID patients during the period from January 2020 to July 2023.

RESULTS

Seventy-eight patients underwent VA-ECMO for various indications from January 2020 to July 2023. The studied patients had a mean age of 59.6 ± 6.9 years for non-COVID patients (38 patients), and 62.2 ± 7.6 years for COVID patients (40 patients), with a P = 0.268. In non-COVID patients, The baseline characteristics were similar in both groups. The primary indications for ECMO were cardiac diseases, followed by respiratory failure (78.9% vs 10.5%). Conversely, in COVID patients, respiratory failure due to COVID-19 infection was the main indication (45% vs 40%). The overall incidence of general complications, including cerebrovascular stroke, acute kidney injury, intracardiac thrombi, and wound infection, was comparable in both groups (31.6% vs 45%). The overall incidence of vascular complications in both groups was 33.3%. Ipsilateral acute lower limb ischemia occurred in 5.3% vs 10% of non-COVID and COVID patients, respectively. Thrombosis of the distal perfusion catheter (DPC) occurred in 10.5% vs 15%, respectively.

CONCLUSION

During the COVID-19 pandemic, an increasing number of patients required VA-ECMO due to associated respiratory failure. Patients undergoing VA-ECMO are at high risk of developing various vascular complications. COVID-19 significantly increases the risk of acute limb ischemia and distal perfusion catheter thrombosis in both upper and lower limbs. However, other VA-ECMO-related vascular complications are comparable between COVID-19 and non-COVID patients.

The early and mid-term outcomes of acute type A aortic dissection patients with ECMO

Background

Acute type A aortic dissection (ATAAD) poses significant challenges in cardiovascular management due to its high morbidity and mortality rates. Postcardiotomy cardiogenic shock (PCS) is a severe complication following ATAAD repair that complicates postoperative recovery. Extracorporeal membrane oxygenation (ECMO) has emerged as a potential life-saving intervention in this context, yet the specific outcomes related to ECMO in ATAAD patients remain insufficiently studied.

Methods

This retrospective single-center study reviewed the medical records of 479 patients who underwent ATAAD surgery from September 2017 to June 2021. Patients were stratified into those requiring postoperative ECMO support and those who did not. Data collected included demographics, operative details, and postoperative outcomes.

Results

Of the cohort, 19 patients (4.0%) required ECMO support. The ECMO group exhibited significantly higher mortality rates (57.9% vs. 5.4%, p < 0.001) and increased complications, including a higher rate of continuous renal replacement therapy (84.2% vs. 24.3%, p < 0.001) and prolonged ICU stays (14.5 days vs. 7.6 days, p = 0.009). Survival analysis demonstrated a stark contrast in 3-year survival rates, with 36.8% for the ECMO group vs. 92.8% for non-ECMO patients (p < 0.001).

Conclusions

ECMO can be a crucial intervention for ATAAD patients suffering from PCS; however, it is associated with significantly higher mortality and complications. Despite lower long-term survival rates compared to non-ECMO patients, ECMO may offer a survival benefit as a salvage therapy. Interpretation is limited by the retrospective single-center design, small ECMO cohort size, and lack of post-discharge quality-of-life data.

Imaging in acute percutaneous mechanical circulatory support in adults: a clinical consensus statement of the Association for Acute CardioVascular Care (ACVC) of the ESC, the European Association of Cardiovascular Imaging (EACVI) of the ESC and the European branch of the Extracorporeal Life Support Organization (EuroELSO)

The use of temporary mechanical circulatory support (tMCS) in cardiogenic shock patients has increased during the last decades with most management strategies relying on observational studies and expert opinion, including hemodynamic monitoring, device selection, and timing of support institution/duration. In this context, imaging has a pivotal role throughout the patient pathway, from identification to initiation, monitoring, and weaning. This manuscript summarizes the consensus of an expert panel from the European Society of Cardiology Association for Acute CardioVascular Care, the European Association of CardioVascular Imaging, and the European Extracorporeal Life Support Organization, providing the rationale for and practical guidance of imaging to tMCS based on existing evidence and consensus on best current practice.

Arterial Complications Assessed by Duplex Ultrasound After Decannulation of Peripheral Venoarterial Extracorporeal Membrane Oxygenation

BACKGROUND

Vascular complications are common and can be fatal even after successful decannulation in patients with peripherally cannulated veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Therefore, we aimed to accurately determine the incidence of arterial complications assessed by Duplex ultrasound following peripheral VA-ECMO decannulation. In addition, we investigated the predictors of severe complications requiring intervention.

METHODS AND RESULTS

We retrospectively reviewed 1,350 adult patients who underwent ECMO between January 2012 and April 2023. Of 839 patients treated with peripherally cannulated VA-ECMO, 596 were successfully weaned off and 212 underwent Duplex ultrasound for final analysis. The primary outcome was arterial complications requiring vascular intervention. Thirty-three (15.6%) patients experienced such complications after decannulation. Acute limb ischemia due to thrombotic occlusion was the most common complication, occurring in 23 (10.8%) patients, followed by stenosis (3.8%), pseudoaneurysm (3.8%), arteriovenous fistula (0.9%), and dissection (0.9%). No significant differences in complication rates were found between the percutaneous and surgical decannulation groups in the propensity score-matched population (12.7% vs. 15.9%, respectively; P=0.799). Multivariable analysis revealed disseminated intravascular coagulation (DIC; odds ratio 2.6; 95% confidence interval 1.17-5.69; P=0.019) as the only predictor of arterial complications after decannulation.

CONCLUSIONS

Arterial complications requiring vascular intervention frequently occur following successful weaning from VA-ECMO regardless of the decannulation strategy. In this setting, DIC appears to be associated with an increased rate of arterial complications.

Factors associated with acute limb ischemia in cardiogenic shock and downstream clinical outcomes: Insights from the Cardiogenic Shock Working Group

BACKGROUND

There are limited data depicting the prevalence and ramifications of acute limb ischemia (ALI) among cardiogenic shock (CS) patients.

METHODS

We employed data from the Cardiogenic Shock Working Group (CSWG), a consortium including 33 sites. We constructed a multi-variable logistic regression to examine the association between clinical factors and ALI, we generated another logistic regression model to ascertain the association of ALI with mortality.

RESULTS

There were 7,070 patients with CS and 399 (5.6%) developed ALI. Patients with ALI were more likely to be female (40.4% vs 29.4%) and have peripheral arterial disease (13.8% vs 8.3%). Stratified by maximum society for cardiovascular angiography & intervention (SCAI) shock stage, the rates of ALI were stage B 0.0%, stage C 1.8%, stage D 4.1%, and stage E 10.3%. Factors associated with higher risk for ALI included: peripheral vascular disease OR 2.24 (95% CI: 1.53-3.23; p < 0.01) and ≥2 mechanical circulatory support (MCS) devices OR 1.66 (95% CI: 1.24-2.21, p < 0.01). ALI was highest for venous-arterial extracorporeal membrane oxygenation (VA-ECMO) patients (11.6%) or VA-ECMO+ intra-aortic balloon pump (IABP)/Impella CP (16.6%) yet use of distal perfusion catheters was less than 50%. Mortality was 38.0% for CS patients without ALI but 57.4% for CS patients with ALI. ALI was significantly associated with mortality, adjusted OR 1.40 (95% CI 1.01-1.95, p < 0.01).

CONCLUSIONS

The rate of ALI was 6% among CS patients. Factors most associated with ALI include peripheral vascular disease and multiple MCS devices. The downstream ramifications of ALI were dire with a considerably higher risk of mortality.

Anticoagulation Monitoring Using Activated Clotting Time in Patients Receiving Extracorporeal Membrane Oxygenation: A Meta-Analysis of Correlation Coefficients

OBJECTIVE

Extracorporeal membrane oxygenation (ECMO) requires systemic anticoagulation to maintain the circuit patency. However, the use of anticoagulation carries a risk of severe hemorrhage, necessitating rigorous monitoring. Activated clotting time (ACT) is a widely used monitoring tool; however, the evidence of its correlation with unfractionated heparin (UFH) infusion dose is limited. Here we aimed to analyze the correlation between ACT and UFH infusion during ECMO.

DESIGN

Systematic literature review and meta-analysis of correlation coefficients (Scopus and PubMed, up to July 13, 2024).

PROSPERO

CRD42023448888 SETTING: All retrospective and prospective studies PARTICIPANTS: Patients receiving ECMO support INTERVENTION: Anticoagulation monitoring during ECMO support MEASUREMENTS AND MAIN RESULTS: Nineteen studies were included in the analysis, and the meta-analysis encompassed 16 studies. The vast majority of studies (n = 15) found a weak correlation, and no study reported a strong correlation between ACT and UFH infusion dose. The meta-analysis (n = 12,625 samples) identified a weak correlation, with a pooled estimate of correlation coefficients of 0.132 (95% confidence interval 0.03-0.23). The most common adverse events were hemorrhage (pooled incidence, 45%) and thrombosis (30%), and 47% of the patients died during their hospital stay.

CONCLUSIONS

Even though ACT is a widely used UFH monitoring tool in ECMO patients, our meta-analysis found a weak correlation between ACT and UFH infusion dose. New trials are needed to investigate the role of emerging tools and to clarify the most appropriate monitoring strategy for patients receiving ECMO support.

ISHLT consensus statement on the perioperative use of ECLS in lung transplantation: Part II: Intraoperative considerations

The use of extracorporeal life support (ECLS) throughout the perioperative phase of lung transplantation requires nuanced planning and execution by an integrated team of multidisciplinary experts. To date, no multidisciplinary consensus document has examined the perioperative considerations of how to best manage these patients. To address this challenge, this perioperative utilization of ECLS in lung transplantation consensus statement was approved for development by the International Society for Heart and Lung Transplantation Standards and Guidelines Committee. International experts across multiple disciplines, including cardiothoracic surgery, anesthesiology, critical care, pediatric pulmonology, adult pulmonology, pharmacy, psychology, physical therapy, nursing, and perfusion, were selected based on expertise and divided into subgroups examining the preoperative, intraoperative, and postoperative periods. Following a comprehensive literature review, each subgroup developed recommendations to examine via a structured Delphi methodology. Following 2 rounds of Delphi consensus, a total of 39 recommendations regarding intraoperative considerations for ECLS in lung transplantation met consensus criteria. These recommendations focus on the planning, implementation, management, and monitoring of ECLS throughout the entire intraoperative period.

The Effect of Extracorporeal Membrane Oxygenation in Patients With Multiple Orthopaedic Injuries

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) plays a vital role in providing life support for patients with reversible cardiac or respiratory failure. Given the high rate of complications and difficulties associated with caring for ECMO patients, the goal of this study was to compare outcomes of orthopaedic surgery in polytrauma patients who received ECMO with similar patients who have not. This will help elucidate the timing and type of fixation that should be considered in patients on ECMO.

METHODS

A retrospective cohort was collected from the electronic medical record of two level I trauma centers over an 8-year period (2015 to 2022) using Current Procedural Terminology codes. Patients were matched with a similar counterpart not requiring ECMO based on sex, age, American Society of Anesthesiologists score, body mass index, injury severity score, and fracture characteristics. Outcomes measured included length of stay, number of revisions, time to definitive fixation, infection, amputation, revision surgery to promote bone healing, implant failure, bleeding requiring return to the operating room, and mortality.

RESULTS

Thirty-two patients comprised our ECMO cohort with a patient-matched control group. The ECMO cohort had an increased length of stay (40 versus 17.5 days, P = 0.001), number of amputations (7 versus 0, P = 0.011), and mortality rate (19% versus 0%, P = 0.024). When comparing patients placed on ECMO before definitive fixation and after definitive fixation, the group placed on ECMO before definitive fixation had significantly longer time to definitive fixation than the group placed on ECMO after fixation (14 versus 2.0 days, P < 0.001).

CONCLUSION

ECMO is a lifesaving measure for trauma patients with cardiopulmonary issues but can complicate fracture care. Although it is not associated with an increase in revision surgery rates, ECMO was associated with prolonged hospital stay and delays in definitive fracture surgery when initiated before definitive fixation.

LEVEL OF EVIDENCE

III.

Effect of intra-aortic balloon pump with veno-arterial extracorporeal membrane oxygenation in acute myocardial infarction with cardiogenic shock: A meta-analysis

BACKGROUND

The effectiveness of a concomitant intra-aortic balloon pump (IABP) with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) intervention in acute myocardial infarction with cardiogenic shock (AMICS) patients is contested in the literature. This study sought to compare short-term mortality weaning rate from VA-ECMOin AMICS cases.

METHODS

We conducted a literature review and compared the primary and secondary endpoints in the following treatment groups of AMICS patients: (1) VA-ECMO plus IABP vs. IABP alone and (2) VA-ECMO plus IABP vs. VA-ECMO alone. The primary endpoint was in-hospital all-cause mortality; while 30-days mortality, weaning from VA-ECMO, and vascular complications comprised secondary endpoints.

RESULTS

VA-ECMO concomitant with IABP was administered to 3,580 (76.4%) patients, while IABP alone and VA-ECMO alone treatments accounted for 1.7% and 21.9% of the patients, respectively. We found that in-hospital mortality was significantly lower in patients treated with VA-ECMO plus IABP vs. VA-ECMO alone (odds ratio (OR) = 0.52; 95% Confidence Interval (CI) = 0.21-1.31; I-squared statistic (I2 = 30%) or IABP alone (OR = 0.20; 95% CI = 0.08-0.55; I2 = 0%). Additionally, 30-days mortality was significantly lower in patients treated with VA-ECMO plus IABP vs. VA-ECMO alone (OR = 0.31; 95% CI = 0.25-0.40; I2 = 0%) or IABP alone (OR = 0.24; 95% CI = 0.11-0.50; I2 = 0%). A significant difference was observed in weaning from VA-ECMO in patients treated with VA-ECMO plus IABP vs. VA-ECMO alone (OR = 1.91; 95% CI = 1.09-3.33; I2 = 0%).

CONCLUSION

In-hospital and 30-days mortality were significantly lower in AMICS patients treated with VA-ECMO plus IABP vs. VA-ECMO alone or IABP alone. VA-ECMO with concomitant IABP could increase the proportion of patients weaned from VA-ECMO, significantly reducing in-hospital mortality, without increasing complications.

Trends and outcomes of different mechanical circulatory support modalities for acute myocardial infarction associated cardiogenic shock in patients undergoing early revascularization

Background

The use of Mechanical Circulatory Support (MCS) devices in cardiogenic shock (CS) is growing. However, the recent trends in using different MCS modalities and their outcomes in acute myocardial infarction associated CS (AMI-CS) are unknown.

Methods

The national readmission database (2016-2020) was used to identify AMI-CS requiring MCS. Cohorts were stratified as ECMO compared to Impella. Propensity score matching (PSM) was used to remove confounding factors. Pearson's x2 test was applied to matched cohorts to compare outcomes. We used multivariate regression and reported predictive margins for adjusted trend analysis.

Results

Among 20,950 AMI-CS hospitalizations requiring MCS, 19,628 (93.7 %) received Impella vs 1322 (6.3 %) were placed only on ECMO. ECMO group was younger (median age: 61 vs. 68 years, p < 0.001) and had a lower comorbidity burden. On propensity-matched cohorts (N 742), the ECMO cohort had higher adverse events, including mortality (51.6 % vs. 41.5 %), sudden cardiac arrest (SCA) (40.9 % vs. 31.8 %), acute stroke (9.2 % vs. 4.6 %) and major bleeding (16 % vs 12.2 %) [p < 0.05]. However, comparing ECPELLA (ECMO + Impella) to Impella alone, mortality (46.2 % vs. 39.4 %) and SCA (44 % vs. 36.4 %) rates were similar, though major bleeding was higher (18.2 % vs. 9.8 %). From 2016 to 2020, mortality trends for AMI-CS in the U.S. showed no significant change (p-trend: 0.071).

Conclusion

Despite advances in MCS modalities, the overall mortality rate for AMI-CS remains unchanged. ECMO use without LV unloading showed higher mortality and adverse events compared to Impella. Prospective studies are needed to verify these findings.

Efficacy of venoarterial extracorporeal membrane oxygenation with and without intra-aortic balloon pump in adult cardiogenic shock

Introduction

Intra-aortic balloon pump (IABP) is sometimes coupled with Venoarterial extracorporeal membrane oxygenation (VA-ECMO) to treat patients with cardiogenic shock. In this study, we attempted to evaluate the association of the IABP approach on survival and vascular complication rates in adults with cardiogenic shock undergoing VA-ECMO.

Methods

We performed a systematic search of original studies on VA-ECMO with and without IABP in PubMed, EMBASE, and the Cochrane Library.

Results

A total of 42 studies with 8,759 patients were included. The pooled in-hospital deaths of patients on VA-ECMO with and without IABP were 2,962/4,807 (61.61%) versus 2,666/3,952 (67.45%). VA-ECMO with IABP presents lower in-hospital mortality (risk ratio, 0.88; 95% CI, 0.86-0.91; P < 0.00001). In addition, IABP was associated with lower in-hospital mortality of patients with postcardiotomy cardiogenic shock and ischaemic heart disease. (risk ratio, 0.93; 95% CI, 0.87-0.98; P = 0.01; risk ratio, 0.85; 95% CI, 0.82-0.89; P < 0.00001). There was no significant difference in in-hospital morbidity in neurological, gastrointestinal, limb-related, bleeding, and infection complications between patients on VA-ECMO with and without IABP.

Discussion

In these observational studies, concomitant use of IABP and VA-ECMO in adult patients with cardiogenic shock was associated with reduced in-hospital mortality.

Systematic Review Registration

PROSPERO [CRD42017069259].

Sex-Related Differences in Utilization and Outcomes of Extracorporeal Cardio-Pulmonary Resuscitation for Refractory Cardiac Arrest

Sparse data exist on sex-related differences in extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest (rCA). We explored the role of sex on the utilization and outcomes of ECPR for rCA by retrospective analysis of the Extracorporeal Life Support Organization (ELSO) International Registry. The primary outcome was in-hospital mortality. Exploratory outcomes were discharge disposition and occurrence of any specific extracorporeal membrane oxygenation (ECMO) complications. From 1992 to 2020, a total of 7,460 adults with ECPR were identified: 30.5% women; 69.5% men; 55.9% Whites, 23.7% Asians, 8.9% Blacks, and 3.8% Hispanics. Women's age was 50.4 ± 16.9 years (mean ± standard deviation) and men's 54.7 ± 14.1 ( p < 0.001). Ischemic heart disease occurred in 14.6% women vs. 18.5% men ( p < 0.001). Overall, 28.5% survived at discharge, 30% women vs. 27.8% men ( p = 0.138). In the adjusted analysis, sex was not associated with in-hospital mortality (odds ratio [OR] = 0.93 [confidence interval {CI} = 0.80-1.08]; p = 0.374). Female sex was associated with decreased odds of neurologic, cardiovascular, and renal complications. Despite being younger and having fewer complications during ECMO, women had in-hospital mortality similar to men. Whether these findings are driven by biologic factors or disparities in health care warrants further investigation.

Ultrasound vector flow imaging during veno-arterial extracorporeal membrane oxygenation in a thoracic aorta model

In veno-arterial extracorporeal membrane oxygenation (VA-ECMO) treatment, the mixing zone is a key hemodynamic factor that determines the efficacy of the treatment. This study aimed to evaluate the applicability of a novel ultrasound technique called vector flow imaging (VFI) for visualizing complex flow patterns in an aorta phantom under VA-ECMO settings. VFI experiments were performed to image aortic hemodynamics under VA-ECMO treatment simulated in an anthropomorphic thoracic aorta phantom using a pulsatile pump (cardiac output: 2.7 L/min) and an ECMO pump with two different flow rates, 0.35 L/min and 1.0 L/min. The cardiac cycle of hemodynamics in the ascending aorta, aortic arch, and descending aorta was visualized, and the spatio-temporal dynamics of flow vectors were analyzed. VFI successfully visualized dynamic flow patterns in the aorta phantom. When the flow rate of the ECMO pump increased, ECMO flow was more dominant than cardiac output in the diastole phase, and the speed of cardiac output was suppressed in the systole phase. Vortex flow patterns were also detected in the ascending aorta and the arch under both ECMO flow rate conditions. The VFI technique may provide new insights into aortic hemodynamics and facilitates effective and safe VA-ECMO treatment.

Vascular Complications in Extracorporeal Membrane Oxygenation-A Narrative Review

The establishment of a peripheral ECMO circuit can lead to significant arterial and venous complications in 10-30% of patients. Vascular complications, particularly acute limb ischemia, are associated with worsening overall outcomes. Limb ischemia occurs significantly more frequently in the early stages of VA ECMO than in VV ECMO. Mechanisms of limb ischemia include arterial obstruction, cannulation injury, loss of pulsatile flow, thromboembolism, venous stasis from compressive obstruction with large venous cannulas, and systemic vasoconstriction due to shock and pharmacologic vasoconstriction. The care team may use several mitigation strategies to prevent limb ischemia. Arterial and venous complications can be mitigated by careful access site selection, minimizing cannula size, placement of distal perfusion and/or outflow catheter(s), and continuous NIRS monitoring. Rapid intervention, when ischemia or compartment syndrome occurs, can reduce limb loss but may not affect the mortality and morbidity of the ECMO patient in the long term due to their underlying conditions and the etiology of the ECMO need.

Vascular Complications in Patients with ECMO Support after Cardiac Surgery

Background: This study assessed vascular complications in patients who received extracorporeal membrane support following cardiac surgery. Methods: We included 84 post-cardiotomy patients who underwent extracorporeal membrane oxygenation (ECMO) from July 2018 to May 2022. Only patients connected to VA-ECMO (Veno-Arterial) via peripheral cannulation were included in this study. Vascular complications were compared between those who had ECMO placed using the percutaneous technique (n = 52) and those who had it placed via femoral incision (n = 32). Results: The incidence of vascular thromboembolism was significantly higher in the percutaneous technique group compared with the open technique group (p < 0.05). Hematomas were also more frequent in the percutaneous technique group (p = 0.04). Conversely, bleeding and leakage were significantly more frequent in the open technique group (p = 0.04). There were no significant differences between the two groups in terms of wound infections or revisions in the inguinal area following ECMO removal. The mortality rate associated with vascular ischemia was 81.2%, while the overall in-hospital mortality rate was 60.7%. Conclusions: The open technique for ECMO placement may reduce the risk of thromboembolic events and hematomas compared to the percutaneous technique. However, it may be associated with a higher incidence of bleeding and leakage. Both techniques show similar outcomes in terms of overall mortality and wound infections.

Extracorporal Membrane Oxygenation in Massive Pulmonary Embolism

BACKGROUND

Massive pulmonary embolism (MPE) carries significant 30-day mortality risk, and a change in societal guidelines has promoted the increasing use of extracorporeal membrane oxygenation (ECMO) in the immediate management of MPE-associated cardiovascular shock. This narrative review examines the current status of ECMO in MPE.

METHODS

A literature review was performed from 1982 to 2022 searching for the terms "Pulmonary embolism" and "ECMO," and the search was refined by examining those publications that covered MPE.

RESULTS

In the patient with MPE, veno-arterial ECMO is now recommended as a bridge to interventional therapy. It can reliably decrease right ventricular overload, improve RV function, and allow hemodynamic stability and restoration of tissue oxygenation. The use of ECMO in MPE has been associated with lower mortality in registry reviews, but there has been no significant difference in outcomes between patients treated with and without ECMO in meta-analyses. Applying ECMO is also associated with substantial multisystem morbidity due to systemic inflammatory response, bleeding with coagulopathy, hemorrhagic stroke, renal dysfunction, and acute limb ischemia, which must be factored into the outcomes.

CONCLUSIONS

The application of ECMO in MPE should be combined with an aggressive interventional pulmonary interventional program and should strictly adhere to the current selection criteria.

Perioperative cardiovascular and cerebrovascular outcomes in recipients of ECMO bridge to lung transplant

Background

The use of extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (BTT) has increased over time. While 1-year and overall survival have been reported to be similar with non-ECMO transplant recipients, there are limited data on major adverse cardiovascular and cerebrovascular events (MACCE) and clinically relevant bleeding (CRB) events. In this study, we sought to evaluate the incidence of perioperative MACCE and CRB in lung transplant recipients who underwent ECMO BTT.

Methods

Using the National Inpatient Sample from 2008-2019, we identified 5,254 lung transplant recipients who either received or did not require pretransplant ECMO. Perioperative MACCE and CRB were compared between the 2 cohorts.

Results

Patients with ECMO BTT had a higher incidence of MACCE compared to non-ECMO patients (35% vs 13.3%, p < 0.0001) and CRB (34.5% vs 12.9%, p < 0.0001). Recipients of pretransplant ECMO for double lung transplant (n = 158) were more likely to have perioperative MACCE and CRB as opposed to patients without pretransplant ECMO (n = 3,584) (adjusted odds ratio 2.69, p < 0.0001; 95% confidence interval 1.86-3.80). The ECMO BTT cohort was notably younger with less cardiac comorbidities and higher diagnoses of cystic fibrosis and interstitial lung disease.

Conclusions

Our data indicate that lung transplant recipients who required ECMO BTT are at significantly higher risk of MACCE and bleeding events despite being younger with less comorbidities as opposed to those who did not require ECMO.

Haemodynamic support with percutaneous devices in patients with cardiogenic shock: the current evidence of mechanical circulatory support

INTRODUCTION

Cardiogenic shock (CS) is a complex life-threatening condition that results from primary cardiac dysfunction, leading to persistent hypotension and systemic hypoperfusion. Among the therapeutic options for CS are various percutaneous mechanical circulatory support (MCS) devices that have emerged as an increasingly effective hemodynamic support option. Percutaneous therapies can act as short-term mechanical circulatory assistance and can be split into intra-aortic balloon pump (IABP) and non-IABP percutaneous mechanical devices.

AREAS COVERED

This review will evaluate the MCS value while considering the mortality rate improvements. We also aim to outline the function of pharmacotherapies and percutaneous hemodynamic MCS devices in managing CS patients to avoid the onset of end-organ dysfunction and improve both early and late outcomes.

EXPERT OPINION

Given the complexity, acuity and high mortality associated with CS, and despite the availability and efficacy of pharmacological management, MCS is required to achieve hemodynamic stability and improve survival. Various percutaneous MCS devices are available with varying indications and clinical outcomes. The rates of early mortality and complications were found to be comparable between the four devices, yet, IABP seemed to show the most optimal clinical profile whilst ECMO demonstrated its more long-term efficacy.

Feasibility of veno-arterial extracorporeal life support in awake patients with cardiogenic shock

OBJECTIVES

This study sought to demonstrate outcomes of veno-arterial extracorporeal life support (VA-ECLS) in non-intubated ('awake') patients with cardiogenic shock, as very few studies have investigated safety and feasibility in this population.

METHODS

This was a retrospective review of 394 consecutive VA-ECLS patients at our institution from 2017 to 2021. We excluded patients cannulated for indications definitively associated with intubation. Patients were stratified by intubation status at time of cannulation and baseline differences were balanced by inverse probability of treatment weighting. The primary outcome was in-hospital mortality while secondary outcomes included adverse events during ECLS and destination at discharge.

RESULTS

Out of 135 patients in the final cohort, 79 were intubated and 56 were awake at time of cannulation. All awake patients underwent percutaneous femoral cannulation with technical success of 100% without intubation. Indications for VA-ECLS in awake patients included acute decompensated heart failure (64.3%), pulmonary hypertension or massive pulmonary embolism (12.5%), myocarditis (8.9%) and acute myocardial infarction (5.4%). After adjustment, awake and intubated patients had similar ECLS duration (7 vs 6 days, P = 0.19), in-hospital mortality (39.6% vs 51.7%, P = 0.28), and rates of various adverse events. Intubation status was not a significant risk factor for 90-day mortality (hazard ratio [95% confidence interval]: 1.26 [0.64, 2.45], P = 0.51) in multivariable analysis. Heart transplantation (15.1% vs 4.9%) and ventricular assist device (17.4% vs 2.2%) were more common destinations at discharge in awake patients than intubated patients (P = 0.02).

CONCLUSIONS

Awake VA-ECLS is safe and feasible with comparable outcomes as intubated counterparts in select cardiogenic shock patients.

Upper gastrointestinal bleeding on veno-arterial extracorporeal membrane oxygenation support

INTRODUCTION

Patients on veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support are at a high risk of hemorrhagic complications, including upper gastrointestinal bleeding (UGIB). The objective of this study was to evaluate the incidence and impact of this complication in V-A ECMO patients.

MATERIALS AND METHODS

A retrospective single-center study (2013-2017) was conducted on V-A ECMO patients, excluding those who died within 24 h. All patients with suspected UGIB underwent esophagogastroduodenoscopy (EGD) and were analyzed and compared to the remainder of the cohort, from the initiation of ECMO until 5 days after explantation.

RESULTS

A total of 150 V-A ECMO cases (65 after cardiac surgery and 85 due to medical etiology) were included. 90% of the patients received prophylactic proton pump inhibitor therapy and enteral nutrition. Thirty-one patients underwent EGD for suspected UGIB, with 16 confirmed cases of UGIB. The incidence was 10.7%, with a median occurrence at 10 [7-17] days. There were no significant differences in clinical or biological characteristics on the day of EGD. However, patients with UGIB had significant increases in packed red blood cells and fresh frozen plasma needs, mechanical ventilation duration and V-A ECMO duration, as well as in length of intensive care unit and hospital stays. There was no significant difference in mortality. The only independent risk factor of UGIB was a history of peptic ulcer (OR = 7.32; 95% CI [1.07-50.01], p = 0.042).

CONCLUSION

UGIB occurred in at least 1 out of 10 cases of V-A ECMO patients, with significant consequences on healthcare resources. Enteral nutrition and proton pump inhibitor prophylaxis did not appear to protect V-A ECMO patients. Further studies should assess their real benefits in these patients with high risk of hemorrhage.

Red blood cell distribution width predicts mortality of adult patients receiving veno-arterial extracorporeal membrane oxygenation

BACKGROUND

Red blood cell distribution width (RDW) is a numerical measure of the variation in the size of circulating red blood cells. Recently, there is increasing interest in the role of RDW as a biomarker for inflammatory states and as a prognostication tool for a wide range of clinical manifestations. The predictive power of RDW on mortality among patients receiving mechanical circulatory support remains largely unknown.

METHODS

A retrospective analysis of 281 VA-ECMO patients at a tertiary referral academic hospital from 2009 to 2019 was performed. RDW was dichotomized with RDW-Low <14.5% and RDW-High ≥14.5%. The primary outcome was all-cause mortality at 30 days and 1 year. Cox proportional hazards models were used to examine the association between RDW and the clinical outcomes after adjusting for additional confounders.

RESULTS

281 patients were included in the analysis. There were 121 patients (43%) in the RDW-Low group and 160 patients (57%) in the RDW-High group. Survival to ECMO decannulation [RDW-H: 58% versus RDW-L: 67%, p = 0.07] were similar between the two groups. Patients in RDW-H group had higher 30-days mortality (RDW-H: 67.5% vs RDW-L: 39.7%, p < 0.001) and 1 year mortality (RDW-H: 79.4% vs RDW-L: 52.9%, p < 0.001) compared to patients in the RDW-L group. After adjusting for confounders, Cox proportional hazards model demonstrated that patients with high RDW had increased odds of mortality at 30 days (hazard ratio 1.9, 95% CI 1.2-3.0, p < 0.01) and 1 year (hazard ratio 1.9, 95% CI 1.3-2.8, p < 0.01) compared to patients with low RDW.

CONCLUSIONS

Among patients receiving mechanical circulatory support with VA-ECMO, a higher RDW was independently associated with increased 30-days and 1-year mortality. RDW may serve as a simple biomarker that can be quickly obtained to help provide risk stratification and predict survival for patients receiving VA-ECMO.