2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients

Outcome and complications in postcardiotomy cardiogenic shock treated with extracorporeal life support - a systematic review and meta-analysis

BACKGROUND

Postcardiotomy cardiogenic shock (PCCS) in cardiac surgery is associated with a high rate of morbidity and mortality. Beside other therapeutic measures (e.g. intraaortic balloon pump (IABP)), extracorporeal life support is being increasingly used in this particular form of shock. Objectives of this meta-analysis were to determine mortality and complications of extracorporeal life support treatment (ECLS) in cardiac surgery patients, and if outcomes were influenced by a preexisting cardiovascular risk profile.

METHODS

MEDLINE and EMBASE were searched for studies in English, published between January 1st 2000 and January 16th 2023, reporting mortality and morbidity in patients aged ≥ 18 treated with ECLS for PCCS. Supplementary data were requested from the respective corresponding authors. Outcomes were weaning from extracorporeal life support, hospital survival and complications.

RESULTS

Two thousand, seven hundred seventy-four papers were screened, of which 132 full text articles were assessed for suitability. 70 remaining studies were included for further evaluation and data analysis. Five studies could be included in the final analysis since the corresponding authors provided additional necessary information. Successful weaning from extracorporeal life support was accomplished in 52.8% (30.8%-57.4%) and 31.1% were discharged alive (mortality of 25.0 - 56.2% after weaning). 95.1% of all treated patients suffered from at least one complication. Diabetes mellitus and obesity seem to be independent risk factors for poor outcome.

CONCLUSIONS

Extracorporeal life support for PCCS is associated with a substantial mortality and complication rate. Diabetes mellitus and obesity seem to be independent risk factors. Therefore, until future work has elucidated which patients benefit at all, the risks of ECLS-treatment must be critically weighed up against a possible benefit.

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.

Pharmacokinetic Changes and Influencing Factors of Polymyxin B in Different ECMO Modes

PURPOSE

With the development of extracorporeal membrane oxygenation (ECMO) technology, the duration of ECMO support has gradually increased, leading to an increased risk of ECMO-related bacterial resistance. Polymyxin B (PMB) is used to treat drug-resistant bacterial infections. However, the pharmacokinetic (PK) parameters of antibiotics may change during ECMO, resulting in over- or under-exposure. This study aimed to clarify the changes in PK parameters and identify factors influencing PMB levels in patients receiving venovenous or venoarterial ECMO.

PATIENTS AND METHODS

A prospective PK study was performed in 11 patients receiving ECMO with resistant bacteria. After reaching a steady state, the drug concentrations of PMB pre- and post-oxygenator were measured. Nonlinear mixed-effects modelling was used to construct a population PK model for PMB. Microbial results were assessed using repeated cultures at the end of treatment. Semiquantitative microbial culture results were used to form clearance and uncleared groups.

RESULTS

The PMB concentrations were not significantly different between pre- and post-oxygenator. A two-compartment model best described the PK of PMB. ECMO flow rate was included as a covariate of clearance (CL). Continuous renal replacement therapy (CRRT) were included as covariates on the volume of the central compartment. The PK parameters central compartment, volume of the peripheral compartment, CL, and inter-compartmental clearance or flow rate(Q) were 20.41 L, 9.86 L, 3.75 L/h, and 3.82 L/h. 7 patients (63.64%) had two consecutive negative bacterial cultures at discharge. The Css,avg shows a significant difference between clearance group (2.26±0.72) and uncleared group (1.25±0.24), P<0.05.

CONCLUSION

There were no significant differences in PMB concentrations between pre- and post-oxygenator. The PK of PMB may be altered in patients receiving CRRT-ECMO. The ECMO flow rate is strongly correlated with the CL. The Css,avg is correlated with the bacterial clearance rate. In clinical practice, increasing the incidence of therapeutic drug monitoring may improve the clinical outcomes.

Features and outcomes of female and male patients requiring postcardiotomy extracorporeal life support

OBJECTIVES

Although cardiogenic shock requiring extracorporeal life support after cardiac surgery is associated with high mortality, the impact of sex on outcomes of postcardiotomy extracorporeal life support remains unclear with conflicting results in the literature. We compare patient characteristics, in-hospital outcomes, and overall survival between females and males requiring postcardiotomy extracorporeal life support.

METHODS

This retrospective, multicenter (34 centers), observational study included adults requiring postcardiotomy extracorporeal life support between 2000 and 2020. Preoperative, procedural, and extracorporeal life support characteristics, complications, and survival were compared between females and males. Association between sex and in-hospital survival was investigated through mixed Cox proportional hazard models.

RESULTS

This analysis included 1823 patients (female: 40.8%; median age: 66.0 years [interquartile range, 56.2-73.0 years]). Females underwent more mitral valve surgery (females: 38.4%, males: 33.1%, P = .019) and tricuspid valve surgery (feamales: 18%, males: 12.4%, P < .001), whereas males underwent more coronary artery surgery (females: 45.9%, males: 52.4%, P = .007). Extracorporeal life support implantation was more common intraoperatively in feamales (females: 64.1%, females: 59.1%) and postoperatively in males (females: 35.9%, males: 40.9%, P = .036). Ventricular unloading (females: 25.1%, males: 36.2%, P < .001) and intra-aortic balloon pumps (females: 25.8%, males: 36.8%, P < .001) were most frequently used in males. Females had more postoperative right ventricular failure (females: 24.1%, males: 19.1%, P = .016) and limb ischemia (females: 12.3%, males: 8.8%, P = .23). In-hospital mortality was 64.9% in females and 61.9% in males (P = .199) with no differences in 5-year survival (females: 20%, 95% CI, 17-23; males: 24%, 95% CI, 21-28; P = .069). Crude hazard ratio for in-hospital mortality in females was 1.12 (95% CI, 0.99-1.27; P = .069) and did not change after adjustments.

CONCLUSIONS

This study demonstrates that female and male patients requiring postcardiotomy extracorporeal life support have different preoperative and extracorporeal life support characteristics, as well as complications, without a statistical difference in in-hospital and 5-year survivals.

Use of Intravascular Micro-Axial Left Ventricular Assist Devices as a Bridging Strategy for Cardiogenic Shock: Mid-Term Outcomes

Objectives: Patients in cardiogenic shock (CS) may be successfully bridged using intravascular micro-axial left ventricular assist devices (M-LVADs) for recovery or determination of definitive therapy. Methods: One hundred and seven CS patients implanted with M-LVADs from January 2020 to May 2024 were divided into four groups; group-1: 34 patients (transplant); group-2: 25 patients (LVAD); group-3: 42 patients (postcardiotomy CS (PCCS)); group-4: 6 patients (decision/recovery but excluded from analysis). Multivariable logistic regression and Multivariable Coxregression models identified predictors of early -hospital and late mortality, and Odds ratios (ORs) and hazard ratios (HRs) with p < 0.05, respectively, were considered statistically significant. SPSS 29.0 and Python 3.11.1. were used for analyses. Results: Complications included device-malfunction (6%), gastrointestinal bleed (9%), long-term hemodialysis (21%), axillary hematoma requiring re-exploration (10%), heparin-induced thrombocytopenia (4%) requiring heparin therapy cessation/initiation of argatroban infusion, and non-fatal stroke (11%). Early hospital mortality included 13 patients: 2 in group-1, 1 in group-2, 10 in group-3 (p = 0.02). In the Logistic-Regression model, category of CS requiring an M-LVAD was significant (OR = 4.7, p = 0.05). Patients were followed for 4.5 years (mean follow-up was 23 ± 17 months), and 23 deaths occurred; group-1: 3 patients, group-2: 5 patients, and group-3: 15 patients (p = 0.019). At 4.5 years, actuarial survival was 90.7 ± 5.1% in group-1, 79.2 ± 8.3% in group-2, 62.8 ± 7.7% in group-3 (p = 0.01). In the Cox-Regression model, M-LVAD category (HR = 3.63, p = 0.04), and long-term postoperative dialysis (HR = 3.9, p = 0.002) emerged as predictors of long-term mortality. Conclusions: In cardiogenic shock, mid-term outcomes demonstrate good survival with M-LVADs as bridge to transplant/durable LVADs and reasonable survival with M-LVADs as a bridge to recovery following cardiotomy, accompanied by reduced ECMO usage, and early ambulation/rehabilitation.

Post-cardiotomy extracorporeal life support: A cohort of cannulation in the general ward

OBJECTIVES

Post-cardiotomy extracorporeal life support (ECLS) cannulation might occur in a general post-operative ward due to emergent conditions. Its characteristics have been poorly reported and investigated This study investigates the characteristics and outcomes of adult patients receiving ECLS cannulation in a general post-operative cardiac ward.

METHODS

The Post-cardiotomy Extracorporeal Life Support (PELS) is a retrospective (2000-2020), multicenter (34 centers), observational study including adult patients who required ECLS for post-cardiotomy shock. This PELS sub-analysis analyzed patients´ characteristics, in-hospital outcomes, and long-term survival in patients cannulated for veno-arterial ECLS in the general ward, and further compared in-hospital survivors and non-survivors.

RESULTS

The PELS study included 2058 patients of whom 39 (1.9%) were cannulated in the general ward. Most patients underwent isolated coronary bypass grafting (CABG, n = 15, 38.5%) or isolated non-CABG operations (n = 20, 51.3%). The main indications to initiate ECLS included cardiac arrest (n = 17, 44.7%) and cardiogenic shock (n = 14, 35.9%). ECLS cannulation occurred after a median time of 4 (2-7) days post-operatively. Most patients' courses were complicated by acute kidney injury (n = 23, 59%), arrhythmias (n = 19, 48.7%), and postoperative bleeding (n = 20, 51.3%). In-hospital mortality was 84.6% (n = 33) with persistent heart failure (n = 11, 28.2%) as the most common cause of death. No peculiar differences were observed between in-hospital survivors and nonsurvivors.

CONCLUSIONS

This study demonstrates that ECLS cannulation due to post-cardiotomy emergent adverse events in the general ward is rare, mainly occurring in preoperative low-risk patients and after a postoperative cardiac arrest. High complication rates and low in-hospital survival require further investigations to identify patients at risk for such a complication, optimize resources, enhance intervention, and improve outcomes.

Venopulmonary extracorporeal membrane oxygenation for right ventricular support as a bridge to lung transplantation: A narrative review

This review evaluates the effectiveness of veno-pulmonary support with an oxygenator using extracorporeal membrane oxygenation as a bridge to lung transplantation strategy in patients undergoing veno-venous extracorporeal membrane oxygenation while awaiting lung transplantation. Examining indications, contraindications, and clinical outcomes, the study highlights potential benefits, drawing insights from successful cases in South Korea and the United States. Despite limited sample sizes, veno-pulmonary support with an oxygenator using extracorporeal membrane oxygenation emerges as a promising approach for further investigation in lung transplantation support. The review emphasizes its role in improving hemodynamic status, preventing complications during extended waiting periods, and presenting a cost-effective alternative to traditional methods, especially in developing countries. While in-hospital mortality rates range from 0% to 10%, comparable to other approaches, cautious optimism surrounds veno-pulmonary support with an oxygenator using extracorporeal membrane oxygenation, urging expanded research to solidify its standing in enhancing patient outcomes, reducing costs, and promoting transplant success.

Different ECLS Pump Configurations for Temporary Right Ventricular Assist Device in LVAD Patients: A Retrospective Case-Control Study

BACKGROUND

Acute right ventricular failure is a critical complication after left ventricular assist device (LVAD) implantation, often managed with a temporary paracorporeal right ventricular assist device (RVAD). This study examined three extracorporeal life support (ECLS) systems regarding mortality, bleeding complications, and intensive care unit (ICU) stay duration.

METHODS

This monocentric, retrospective case-control study included all patients receiving LVAD with paracorporeal RVAD between 2009 and 2020. Three patient groups were formed: CentrimagTM (A), CardiohelpTM (B), and DeltastreamTM (C).

RESULTS

A total of 245 patients were included. Preoperative parameters were similar between the CentrimagTM and DeltastreamTM groups, but CardiohelpTM patients had worse Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) Scores (A: 1.7 ± 0.8, B: 1.36 ± 0.5, C: 1.9 ± 0.9; p < 0.05). In-hospital death rates were A: 61 (41.8%), B: 15 (32.6%), C: 29 (54.7%); p < 0.05, and reoperation due to bleeding rates were A: 32 (21.9%), B: 8 (17.4%), C: 25 (47.2%); p < 0.05, with the DeltastreamTM group showing the highest rates. This group also had increased thrombocyte consumption and prolonged ICU stays.

CONCLUSIONS

Temporary RVADs lead to bleeding complications, affecting patient outcomes. The DeltastreamTM group had significantly higher bleeding complications, likely due to high pump revolution rates and thrombocyte decline. Due to the study's retrospective nature and complex patient profiles, these interesting findings should be validated in future studies.

Definitions of adverse events associated with extracorporeal membrane oxygenation in children: results of an international Delphi process from the ECMO-CENTRAL ARC

Extracorporeal membrane oxygenation (ECMO) is a high-risk and low-volume life support with increasing clinical study. However, heterogenous outcome definitions impede data assimilation into evidence to guide practice. The Academic Research Consortium (ARC), an international collaborative forum committed to facilitating the creation of stakeholder-driven consensus nomenclature and outcomes for clinical trials of medical devices, supported the ECMO Core Elements Needed for Trials Regulation And quality of Life (ECMO-CENTRAL) ARC. The ECMO-CENTRAL ARC was assembled to develop definitions of paediatric ECMO adverse events for use in clinical trials and regulatory device evaluation. An initial candidate list of ECMO adverse events derived from the mechanical circulatory support ARC was supplemented with a review of ECMO-relevant adverse event definitions collated from literature published between Jan 1, 1988, and Feb 20, 2023. Distinct teams of international topic experts drafted separate adverse event definitions that were harmonised to existing literature when appropriate. Draft definitions were revised for paediatric ECMO relevance with input from patients, families, and an international expert panel of trialists, clinicians, statisticians, biomedical engineers, device developers, and regulatory agencies. ECMO-CENTRAL ARC was revised and disseminated across research societies and professional organisations. Up to three rounds of internet-based anonymous surveys were planned as a modified Delphi process. The expert panel defined 13 adverse event definitions: neurological, bleeding, device malfunction, acute kidney injury, haemolysis, infection, vascular access-associated injury, non-CNS thrombosis, hepatic dysfunction, right heart failure, left ventricular overload, lactic acidaemia, and hypoxaemia. Definitional structure varied. Among 165 expert panel members, 114 were eligible to vote and 111 voted. Consensus was achieved for all proposed definitions. Agreement ranged from 82% to 95%. ECMO-CENTRAL ARC paired rigorous development with methodical stakeholder involvement and dissemination to define paediatric ECMO adverse events. These definitions will facilitate new research and the assimilation of data across clinical trials and ECMO device evaluation in children.

Modeling the effect of patient size on cerebral perfusion during veno-arterial extracorporeal membrane oxygenation

INTRODUCTION

A well-known complication of veno-arterial extracorporeal membrane oxygenation (VA ECMO) is differential hypoxia, in which poorly-oxygenated blood ejected from the left ventricle mixes with and displaces well-oxygenated blood from the circuit, thereby causing cerebral hypoxia and ischemia. We sought to characterize the impact of patient size and anatomy on cerebral perfusion under a range of different VA ECMO flow conditions.

METHODS

We use one-dimensional (1D) flow simulations to investigate mixing zone location and cerebral perfusion across 10 different levels of VA ECMO support in eight semi-idealized patient geometries, for a total of 80 scenarios. Measured outcomes included mixing zone location and cerebral blood flow (CBF).

RESULTS

Depending on patient anatomy, we found that a VA ECMO support ranging between 67-97% of a patient's ideal cardiac output was needed to perfuse the brain. In some cases, VA ECMO flows exceeding 90% of the patient's ideal cardiac output are needed for adequate cerebral perfusion.

CONCLUSIONS

Individual patient anatomy markedly affects mixing zone location and cerebral perfusion in VA ECMO. Future fluid simulations of VA ECMO physiology should incorporate varied patient sizes and geometries in order to best provide insights toward reducing neurologic injury and improved outcomes in this patient population.

Central versus peripheral VA ECMO for cardiogenic shock: an 8-year experience of a tertiary cardiac surgery center in Greece

BACKGROUND

Venoarterial extracorporeal membrane oxygenation (VA ECMO) has emerged as an effective rescue therapy in patients with cardiogenic shock refractory to standard treatment protocols, and its use has been rising worldwide in the last decade. Although experience and availability are growing, outcomes remain poor. There is need for evidence to improve clinical practice and outcomes.

METHODS

We retrospectively reviewed the medical records of all patients who were supported with VA ECMO for cardiogenic shock at our institution between January 2015 and January 2023. The study purpose was to compare outcomes between patients who were supported with central versus peripheral configuration.

RESULTS

ECMO was applied in 108 patients, 48 (44%) of whom received central configuration and 60 (56%) peripheral. Patients supported with central VA ECMO were more likely to be supported for post-cardiotomy shock (odds ratio [OR] 4.6 [95% confidence interval (CI) 2.03-10.41]), while patients in the peripheral group were predominantly treated for chronic heart failure decompensation (OR 9.4 [95% CI 1.16-76.3]). Central VA ECMO had lower survival rates during ECMO support (29.2% versus 51.7%, p = 0.018) and at discharge (8% versus 37%, p = 0.001). These patients were at high risk of complications, such as acute kidney injury (AKI) (OR 2.37 [95% CI 1.06-5.3], p = 0.034) and major bleeding (OR 3.08 [95% CI 1.36-6.94], p < 0.001).

CONCLUSIONS

Patients on central VA ECMO were supported mainly for post-cardiotomy shock, presented with more complications such as major bleeding and AKI, and had worse survival to hospital discharge compared with patients on peripheral VA ECMO. Patient selection, timing of implementation, cannulation strategy, and configuration remain the main determinants of clinical outcome.

Neurologic complications in patients receiving aortic versus subclavian versus femoral arterial cannulation for post-cardiotomy extracorporeal life support: results of the PELS observational multicenter study

BACKGROUND

Cerebral perfusion may change depending on arterial cannulation site and may affect the incidence of neurologic adverse events in post-cardiotomy extracorporeal life support (ECLS). The current study compares patients' neurologic outcomes with three commonly used arterial cannulation strategies (aortic vs. subclavian/axillary vs. femoral artery) to evaluate if each ECLS configuration is associated with different rates of neurologic complications.

METHODS

This retrospective, multicenter (34 centers), observational study included adults requiring post-cardiotomy ECLS between January 2000 and December 2020 present in the Post-Cardiotomy Extracorporeal Life Support (PELS) Study database. Patients with Aortic, Subclavian/Axillary and Femoral cannulation were compared on the incidence of a composite neurological end-point (ischemic stroke, cerebral hemorrhage, brain edema). Secondary outcomes were overall in-hospital mortality, neurologic complications as cause of in-hospital death, and post-operative minor neurologic complications (seizures). Association between cannulation and neurological outcomes were investigated through linear mixed-effects models.

RESULTS

This study included 1897 patients comprising 26.5% Aortic (n = 503), 20.9% Subclavian/Axillary (n = 397) and 52.6% Femoral (n = 997) cannulations. The Subclavian/Axillary group featured a more frequent history of hypertension, smoking, diabetes, previous myocardial infarction, dialysis, peripheral artery disease and previous stroke. Neuro-monitoring was used infrequently in all groups. Major neurologic complications were more frequent in Subclavian/Axillary (Aortic: n = 79, 15.8%; Subclavian/Axillary: n = 78, 19.6%; Femoral: n = 118, 11.9%; p < 0.001) also after mixed-effects model adjustment (OR 1.53 [95% CI 1.02-2.31], p = 0.041). Seizures were more common in Subclavian/Axillary (n = 13, 3.4%) than Aortic (n = 9, 1.8%) and Femoral cannulation (n = 12, 1.3%, p = 0.036). In-hospital mortality was higher after Aortic cannulation (Aortic: n = 344, 68.4%, Subclavian/Axillary: n = 223, 56.2%, Femoral: n = 587, 58.9%, p < 0.001), as shown by Kaplan-Meier curves. Anyhow, neurologic cause of death (Aortic: n = 12, 3.9%, Subclavian/Axillary: n = 14, 6.6%, Femoral: n = 28, 5.0%, p = 0.433) was similar.

CONCLUSIONS

In this analysis of the PELS Study, Subclavian/Axillary cannulation was associated with higher rates of major neurologic complications and seizures. In-hospital mortality was higher after Aortic cannulation, despite no significant differences in incidence of neurological cause of death in these patients. These results encourage vigilance for neurologic complications and neuromonitoring use in patients on ECLS, especially with Subclavian/Axillary cannulation.

Hyperlactatemia and poor outcome After postcardiotomy veno-arterial extracorporeal membrane oxygenation: An individual patient data meta-Analysis

INTRODUCTION

Postcardiotomy veno-arterial extracorporeal membrane oxygenation (V-A-ECMO) is associated with significant mortality. Identification of patients at very high risk for death is elusive and the decision to initiate V-A-ECMO is based on clinical judgment. The prognostic impact of pre-V-A-ECMO arterial lactate level in these critically ill patients has been herein evaluated.

METHODS

A systematic review was conducted to identify studies on postcardiotomy VA-ECMO for the present individual patient data meta-analysis.

RESULTS

Overall, 1269 patients selected from 10 studies were included in this analysis. Arterial lactate level at V-A-ECMO initiation was increased in patients who died during the index hospitalization compared to those who survived (9.3 vs 6.6 mmol/L, p < 0.0001). Accordingly, in hospital mortality increased along quintiles of pre-V-A-ECMO arterial lactate level (quintiles: 1, 54.9%; 2, 54.9%; 3, 67.3%; 4, 74.2%; 5, 82.2%, p < 0.0001). The best cut-off for arterial lactate was 6.8 mmol/L (in-hospital mortality, 76.7% vs. 55.7%, p < 0.0001). Multivariable multilevel mixed-effect logistic regression model including arterial lactate level significantly increased the area under the receiver operating characteristics curve (0.731, 95% CI 0.702-0.760 vs 0.679, 95% CI 0.648-0.711, DeLong test p < 0.0001). Classification and regression tree analysis showed the in-hospital mortality was 85.2% in patients aged more than 70 years with pre-V-A-ECMO arterial lactate level ≥6.8 mmol/L.

CONCLUSIONS

Among patients requiring postcardiotomy V-A-ECMO, hyperlactatemia was associated with a marked increase of in-hospital mortality. Arterial lactate may be useful in guiding the decision-making process and the timing of initiation of postcardiotomy V-A-ECMO.

Comparing Outcomes of Post-Cardiotomy Cardiogenic Shock Patients: On-Site Cannulation vs. Retrieval for V-A ECMO Support

Background: Post-cardiotomy cardiogenic shock (PCCS) remains a life-threatening complication after cardiac surgery. Extracorporeal membrane oxygenation (ECMO) represents the mainstay of mechanical circulatory support for PCCS; however, its availability is limited to larger experienced centers, leading to a mismatch between centers performing cardiac surgery and hospitals offering ECMO management beyond cannulation. We sought to evaluate the outcomes and complications of PCCS patients requiring veno-arterial (V-A) ECMO cannulated at our hospital compared to those cannulated at referral hospitals. Methods: A retrospective analysis of PCCS patients requiring V-A ECMO was conducted between October 2014 to December 2022. Results: A total of 121 PCCS patients required V-A ECMO support, of which 62 (51%) patients were cannulated at the referring institutions and retrieved (retrieved group), and 59 (49%) were cannulated at our hospital (on-site group). The baseline demographics and pre-ECMO variables were similar between groups, except retrieved patients had higher lactic acid levels (retrieved group: 8.5 mmol/L ± 5.8 vs. on-site group: 6.6 ± 5; p = 0.04). Coronary artery bypass graft was the most common surgical intervention (51% in the retrieved group vs. 47% in the on-site group). There was no difference in survival-to-discharge rates between the groups (45% in the retrieved group vs. 51% in the on-site group; p = 0.53) or in the rate of patient-related complications. Conclusions: PCCS patients retrieved on V-A ECMO can achieve similar outcomes as those cannulated at experienced centers. An established network in a hub-and-spoke model is critical for the PCCS patients managed at hospitals without ECMO abilities to improve outcomes.

Veno-venous extracorporeal membrane oxygenation (VV ECMO) cannula malposition identified with point-of-care ultrasound

BACKGROUND

Point-of-care ultrasound (POCUS) has become a mainstay in the evaluation of critically ill patients in the intensive care unit (ICU). ECMO patients are susceptible to complications during prolonged ICU stay, including cannula malposition, which has deleterious consequences. Although the literature surrounding utility of ultrasound on ECMO patients is expansive, direct comparison between radiographic imaging versus ultrasound for identification of cannula malposition is lacking.

CASE PRESENTATION

The authors identified four patients with cannula malposition discovered through POCUS that was missed on routine radiographic imaging. Identification and correction of malposition changed their ECMO course.

CONCLUSION

This case series is the first in literature demonstrating that ultrasound may be superior to radiographic images for ECMO cannula malposition. Further investigation into this subject is warranted.

Cardiac Extracorporeal Membrane Oxygenation in Community Cardiac Surgery Program: Are the Results Comparable?

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) outcomes in small centers are commonly considered less favorable than in large-volume centers. New ECMO protocols and procedures were established in our regional community hospital system as part of a cardiogenic shock initiative. This retrospective study aims to evaluate the outcomes of veno-arterial extracorporeal membrane oxygenation (VA ECMO) and extracorporeal cardiopulmonary resuscitation (ECPR) in a community hospital system with cardiac surgery capability and assess whether protocol optimization and cannulation standards result in comparable outcomes to larger centers whether the outcomes of this new ECMO program at the community hospital setting were comparable to the United States averages.

METHODS

Our regional system comprises five hospitals with 1500 beds covering southwestern New Jersey, with only one of these hospitals having cardiac surgery and ECMO capability. In May 2021, the new ECMO program was initiated. Patients were screened by a multidisciplinary call, cannulated by our ECMO team, and subsequently treated by the designated team. We reviewed our cardiac ECMO outcomes over two years, from May 2021 to April 2023, in patients who required ECMO due to cardiogenic shock or as a part of extracorporeal cardiopulmonary resuscitation (ECPR).

RESULTS

A total of 60 patients underwent cardiac ECMO, and all were VA ECMO, including 18 (30%) patients who required ECPR for cardiac arrest. The overall survival rate for our cardiac ECMO program turned out to be 48% (29/60), with 50% (22/42) in VA ECMO excluding ECPR and 39% (7/18) in the ECPR group. The hospital survival rate for the VA ECMO and ECPR groups was 36% (15/42) and 28% (5/18), respectively. The ELSO-reported national average for hospital survival is 48% for VA ECMO and 30% for ECPR. Considering these benchmarks, the hospital survival rate of our program did not significantly lag behind the national average.

CONCLUSIONS

With protocol, cannulation standards, and ECMO management optimized, the VA ECMO results of a community hospital system with cardiac surgery capability were not inferior to those of larger centers.

Scrutinizing the Role of Venoarterial Extracorporeal Membrane Oxygenation: Has Clinical Practice Outpaced the Evidence?

The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for temporary mechanical circulatory support in various clinical scenarios has been increasing consistently, despite the lack of sufficient evidence regarding its benefit and safety from adequately powered randomized controlled trials. Although the ARREST trial (Advanced Reperfusion Strategies for Patients with Out-of-Hospital Cardiac Arrest and Refractory Ventricular Fibrillation) and a secondary analysis of the PRAGUE OHCA trial (Prague Out-of-Hospital Cardiac Arrest) provided some evidence in favor of VA-ECMO in the setting of out-of-hospital cardiac arrest, the INCEPTION trial (Early Initiation of Extracorporeal Life Support in Refractory Out-of-Hospital Cardiac Arrest) has not found a relevant improvement of short-term mortality with extracorporeal cardiopulmonary resuscitation. In addition, the results of the recently published ECLS-SHOCK trial (Extracorporeal Life Support in Cardiogenic Shock) and ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock) discourage the routine use of VA-ECMO in patients with infarct-related cardiogenic shock. Ongoing clinical trials (ANCHOR [Assessment of ECMO in Acute Myocardial Infarction Cardiogenic Shock, NCT04184635], REVERSE [Impella CP With VA ECMO for Cardiogenic Shock, NCT03431467], UNLOAD ECMO [Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO, NCT05577195], PIONEER [Hemodynamic Support With ECMO and IABP in Elective Complex High-risk PCI, NCT04045873]) may clarify the usefulness of VA-ECMO in specific patient subpopulations and the efficacy of combined mechanical circulatory support strategies. Pending further data to refine patient selection and management recommendations for VA-ECMO, it remains uncertain whether the present usage of this device improves outcomes.

The importance of timing in postcardiotomy venoarterial extracorporeal membrane oxygenation: A descriptive multicenter observational study

OBJECTIVES

Postcardiotomy extracorporeal membrane oxygenation (ECMO) can be initiated intraoperatively or postoperatively based on indications, settings, patient profile, and conditions. The topic of implantation timing only recently gained attention from the clinical community. We compare patient characteristics as well as in-hospital and long-term survival between intraoperative and postoperative ECMO.

METHODS

The retrospective, multicenter, observational Postcardiotomy Extracorporeal Life Support (PELS-1) study includes adults who required ECMO due to postcardiotomy shock between 2000 and 2020. We compared patients who received ECMO in the operating theater (intraoperative) with those in the intensive care unit (postoperative) on in-hospital and postdischarge outcomes.

RESULTS

We studied 2003 patients (women: 41.1%; median age: 65 years; interquartile range [IQR], 55.0-72.0). Intraoperative ECMO patients (n = 1287) compared with postoperative ECMO patients (n = 716) had worse preoperative risk profiles. Cardiogenic shock (45.3%), right ventricular failure (15.9%), and cardiac arrest (14.3%) were the main indications for postoperative ECMO initiation, with cannulation occurring after (median) 1 day (IQR, 1-3 days). Compared with intraoperative application, patients who received postoperative ECMO showed more complications, cardiac reoperations (intraoperative: 19.7%; postoperative: 24.8%, P = .011), percutaneous coronary interventions (intraoperative: 1.8%; postoperative: 3.6%, P = .026), and had greater in-hospital mortality (intraoperative: 57.5%; postoperative: 64.5%, P = .002). Among hospital survivors, ECMO duration was shorter after intraoperative ECMO (median, 104; IQR, 67.8-164.2 hours) compared with postoperative ECMO (median, 139.7; IQR, 95.8-192 hours, P < .001), whereas postdischarge long-term survival was similar between the 2 groups (P = .86).

CONCLUSIONS

Intraoperative and postoperative ECMO implantations are associated with different patient characteristics and outcomes, with greater complications and in-hospital mortality after postoperative ECMO. Strategies to identify the optimal location and timing of postcardiotomy ECMO in relation to specific patient characteristics are warranted to optimize in-hospital outcomes.

Postcardiotomy Shock Syndrome: A Narrative Review of Perioperative Diagnosis and Management

Postcardiotomy shock (PCS) is generally described as the inability to separate from cardiopulmonary bypass due to ineffective cardiac output after cardiotomy, which is caused by a primary cardiac disorder, resulting in inadequate tissue perfusion. Postcardiotomy shock occurs in 0.5% to 1.5% of contemporary cardiac surgery cases, and is accompanied by an in-hospital mortality of approximately 67%. In the last 2 decades, the incidence of PCS has increased, likely due to the increased age and baseline morbidity of patients requiring cardiac surgery. In this narrative review, the authors discuss the epidemiology and pathophysiology of PCS, the rationale and evidence behind the initiation, continuation, escalation, and discontinuation of mechanical support devices in PCS, and the anesthetic implications.

On-Support and Postweaning Mortality in Postcardiotomy Extracorporeal Membrane Oxygenation

BACKGROUND

Postcardiotomy venoarterial extracorporeal membrane oxygenation (VA ECMO) is characterized by discrepancies between weaning and survival-to-discharge rates. This study analyzes the differences between postcardiotomy VA ECMO patients who survived, died on ECMO, or died after ECMO weaning. Causes of death and variables associated with mortality at different time points are investigated.

METHODS

The retrospective, multicenter, observational Postcardiotomy Extracorporeal Life Support Study (PELS) includes adults requiring postcardiotomy VA ECMO between 2000 and 2020. Variables associated with on-ECMO mortality and postweaning mortality were modeled using mixed Cox proportional hazards, including random effects for center and year.

RESULTS

In 2058 patients (men, 59%; median age, 65 years; interquartile range [IQR], 55-72 years), weaning rate was 62.7%, and survival to discharge was 39.6%. Patients who died (n = 1244) included 754 on-ECMO deaths (36.6%; median support time, 79 hours; IQR, 24-192 hours), and 476 postweaning deaths (23.1%; median support time, 146 hours; IQR, 96-235.5 hours). Multiorgan (n = 431 of 1158 [37.2%]) and persistent heart failure (n = 423 of 1158 [36.5%]) were the main causes of death, followed by bleeding (n = 56 of 754 [7.4%]) for on-ECMO mortality and sepsis (n = 61 of 401 [15.4%]) for postweaning mortality. On-ECMO death was associated with emergency surgery, preoperative cardiac arrest, cardiogenic shock, right ventricular failure, cardiopulmonary bypass time, and ECMO implantation timing. Diabetes, postoperative bleeding, cardiac arrest, bowel ischemia, acute kidney injury, and septic shock were associated with postweaning mortality.

CONCLUSIONS

A discrepancy exists between weaning and discharge rate in postcardiotomy ECMO. Deaths occurred during ECMO support in 36.6% of patients, mostly associated with unstable preoperative hemodynamics. Another 23.1% of patients died after weaning in association with severe complications. This underscores the importance of postweaning care for postcardiotomy VA ECMO patients.

Proarrhythmic changes in human cardiomyocytes during hypothermia by milrinone and isoprenaline, but not levosimendan: an experimental in vitro study

BACKGROUND

Accidental hypothermia, recognized by core temperature below 35 °C, is a lethal condition with a mortality rate up to 25%. Hypothermia-induced cardiac dysfunction causing increased total peripheral resistance and reduced cardiac output contributes to the high mortality rate in this patient group. Recent studies, in vivo and in vitro, have suggested levosimendan, milrinone and isoprenaline as inotropic treatment strategies in this patient group. However, these drugs may pose increased risk of ventricular arrhythmias during hypothermia. Our aim was therefore to describe the effects of levosimendan, milrinone and isoprenaline on the action potential in human cardiomyocytes during hypothermia.

METHODS

Using an experimental in vitro-design, levosimendan, milrinone and isoprenaline were incubated with iCell2 hiPSC-derived cardiomyocytes and cellular action potential waveforms and contraction were recorded from monolayers of cultured cells. Experiments were conducted at temperatures from 37 °C down to 26 °C. One-way repeated measures ANOVA was performed to evaluate differences from baseline recordings and one-way ANOVA was performed to evaluate differences between drugs, untreated control and between drug concentrations at the specific temperatures.

RESULTS

Milrinone and isoprenaline both significantly increases action potential triangulation during hypothermia, and thereby the risk of ventricular arrhythmias. Levosimendan, however, does not increase triangulation and the contractile properties also remain preserved during hypothermia down to 26 °C.

CONCLUSIONS

Levosimendan remains a promising candidate drug for inotropic treatment of hypothermic patients as it possesses ability to treat hypothermia-induced cardiac dysfunction and no increased risk of ventricular arrhythmias is detected. Milrinone and isoprenaline, on the other hand, appears more dangerous in the hypothermic setting.

Temporary Mechanical Circulatory Support in Cardiogenic Shock Patients after Cardiac Procedures: Selection Algorithm and Weaning Strategies

Mechanical circulatory support has proven effective in managing postcardiotomy cardiogenic shock by stabilizing patients' hemodynamics and ensuring adequate organ perfusion. Among the available device modalities, the combination of extracorporeal life support and a microaxial flow pump for left ventricular unloading has emerged as a valuable tool in the surgical armamentarium. In this publication, we provide recommendations for the application and weaning of temporary mechanical circulatory support in cardiogenic shock patients, derived from a consensus among leading cardiac centers in German-speaking countries.

Mortality and cost of post-cardiotomy extracorporeal support in the United States

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) has been used increasingly for cardiopulmonary rescue. Despite recent advances however, post-cardiotomy shock (PCS)-ECMO survival remains comparatively poor. We sought to evaluate outcomes and define factors that predict in-hospital mortality.

METHODS

We used the Nationwide Inpatient Sample (NIS) to evaluate adult hospitalizations with a primary procedure code for coronary artery bypass grafting (CABG), and/or valve procedures performed between 2013 and 2018, which also required post cardiotomy ECMO support. Patient-related factors and hospital costs were evaluated to identify those associated with in-hospital mortality.

RESULTS

There were 1,247,835 admissions for cardiac surgical procedures during the study period. Post-cardiotomy shock-ECMO support was provided in 4475 (0.3%) within the study cohort. A total of 2000 (44.7%) hospitalizations involved isolated valvular procedures, 1700 (38.0%) isolated CABG, and 775 (17.3%) involved a combination of both. Overall, in-hospital mortality was 42.1% (n = 1880). Factors significantly associated with in-hospital mortality included patients with multiple comorbidities (> 7) and those undergoing combination of valve and CABG procedures. Only 26.6% of those who survived to discharge, were discharged home independently.

CONCLUSION

Survival to independent home discharge is rare following PCS-ECMO. Its high mortality is associated with multiple comorbidities and combination of CABG and valve surgery.

Left ventricular venting during extracorporeal membrane oxygenation; the effects on cardiac performance in a porcine model of critical post-cardiotomy failure

INTRODUCTION

Left ventricular distension is a major concern with postcardiotomy veno-arterial extracorporeal membrane oxygenation (VA-ECMO) supporting a critical heart failure after cardiac surgery. This porcine study evaluates the effects of left ventricular venting on cardiac function during ECMO-supported circulation and after weaning from ECMO.

METHODS

Twenty anaesthetised open-chest pigs were put on cardiopulmonary bypass with aortic cross-clamping and suboptimal cardioplegic arrest for 40 min. After declamping and defibrillation, the animals were supported by VA-ECMO for 180 min either with or without additional left ventricular venting. Continuous haemodynamic evaluations were performed at baseline and at cardiac arrest, during VA-ECMO and for 120 min after weaning from circulatory support. Left ventricular perfusion and function were evaluated with microspheres, pressure-volume loops and epicardial echocardiography at baseline and after 1 and 2 h with unsupported circulation.

RESULTS

In vented animals both mean aortic and left ventricular peak systolic pressure increased at the end of the ECMO-supported period compared to those not vented and remained increased also after weaning. Both at 60 min and 120 min after weaning from circulatory support, left ventricular stroke work and pressure-volume area were increased in vented compared to not vented animals. At 120 min left ventricular stroke volume was increased in vented compared to not vented animals, myocardial perfusion did not differ. The left ventricular mechanical efficiency, defined as the ratio between pressure volume area and myocardial perfusion, was increased (53.2 ± 5 vs 36.2 ± 2.1 J/mL/g, p = 0.011) in vented- compared to not vented hearts.

CONCLUSION

This experimental study demonstrate that left ventricular venting during post-cardiotomy veno-arterial ECMO for 3 h attenuates deterioration of left ventricular function and haemodynamics early after weaning from circulatory support.

Patient and Management Variables Associated With Survival After Postcardiotomy Extracorporeal Membrane Oxygenation in Adults: The PELS-1 Multicenter Cohort Study

Background Extracorporeal membrane oxygenation (ECMO) has been increasingly used for postcardiotomy cardiogenic shock, but without a concomitant reduction in observed in-hospital mortality. Long-term outcomes are unknown. This study describes patients' characteristics, in-hospital outcome, and 10-year survival after postcardiotomy ECMO. Variables associated with in-hospital and postdischarge mortality are investigated and reported. Methods and Results The retrospective international multicenter observational PELS-1 (Postcardiotomy Extracorporeal Life Support) study includes data on adults requiring ECMO for postcardiotomy cardiogenic shock between 2000 and 2020 from 34 centers. Variables associated with mortality were estimated preoperatively, intraoperatively, during ECMO, and after the occurrence of any complications, and then analyzed at different time points during a patient's clinical course, through mixed Cox proportional hazards models containing fixed and random effects. Follow-up was established by institutional chart review or contacting patients. This analysis included 2058 patients (59% were men; median [interquartile range] age, 65.0 [55.0-72.0] years). In-hospital mortality was 60.5%. Independent variables associated with in-hospital mortality were age (hazard ratio [HR], 1.02 [95% CI, 1.01-1.02]) and preoperative cardiac arrest (HR, 1.41 [95% CI, 1.15-1.73]). In the subgroup of hospital survivors, the overall 1-, 2-, 5-, and 10-year survival rates were 89.5% (95% CI, 87.0%-92.0%), 85.4% (95% CI, 82.5%-88.3%), 76.4% (95% CI, 72.5%-80.5%), and 65.9% (95% CI, 60.3%-72.0%), respectively. Variables associated with postdischarge mortality included older age, atrial fibrillation, emergency surgery, type of surgery, postoperative acute kidney injury, and postoperative septic shock. Conclusions In adults, in-hospital mortality after postcardiotomy ECMO remains high; however, two-thirds of those who are discharged from hospital survive up to 10 years. Patient selection, intraoperative decisions, and ECMO management remain key variables associated with survival in this cohort. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03857217.

Variables associated with in-hospital and postdischarge outcomes after postcardiotomy extracorporeal membrane oxygenation: Netherlands Heart Registration Cohort

OBJECTIVES

Extracorporeal membrane oxygenation (ECMO) for postcardiotomy cardiogenic shock has been increasingly used without concomitant mortality reduction. This study aims to investigate determinants of in-hospital and postdischarge mortality in patients requiring postcardiotomy ECMO in the Netherlands.

METHODS

The Netherlands Heart Registration collects nationwide prospective data from cardiac surgery units. Adults receiving intraoperative or postoperative ECMO included in the register from January 2013 to December 2019 were studied. Survival status was established through the national Personal Records Database. Multivariable logistic regression analyses were used to investigate determinants of in-hospital (3 models) and 12-month postdischarge mortality (4 models). Each model was developed to target specific time points during a patient's clinical course.

RESULTS

Overall, 406 patients (67.2% men, median age, 66.0 years [interquartile range, 55.0-72.0 years]) were included. In-hospital mortality was 51.7%, with death occurring in a median of 5 days (interquartile range, 2-14 days) after surgery. Hospital survivors (n = 196) experienced considerable rates of pulmonary infections, respiratory failure, arrhythmias, and deep sternal wound infections during a hospitalization of median 29 days (interquartile range, 17-51 days). Older age (odds ratio [OR], 1.02; 95% CI, 1.0-1.04) and preoperative higher body mass index (OR, 1.08; 95% CI, 1.02-1.14) were associated with in-hospital death. Within 12 months after discharge, 35.1% of hospital survivors (n = 63) died. Postoperative renal failure (OR, 2.3; 95% CI, 1.6-4.9), respiratory failure (OR, 3.6; 95% CI, 1.3-9.9), and re-thoracotomy (OR, 2.9; 95% CI, 1.3-6.5) were associated with 12-month postdischarge mortality.

CONCLUSIONS

In-hospital and postdischarge mortality after postcardiotomy ECMO in adults remains high in the Netherlands. ECMO support in patients with higher age and body mass index, which drive associations with higher in-hospital mortality, should be carefully considered. Further observations suggest that prevention of re-thoracotomies, renal failure, and respiratory failure are targets that may improve postdischarge outcomes.

Perioperative extracorporeal membrane oxygenation in pediatric congenital heart disease: Chinese expert consensus

BACKGROUND

Congenital heart disease (CHD) is one of the main supportive diseases of extracorporeal membrane oxygenation in children. The management of extracorporeal membrane oxygenation (ECMO) for pediatric CHD faces more severe challenges due to the complex anatomical structure of the heart, special pathophysiology, perioperative complications and various concomitant malformations. The survival rate of ECMO for CHD was significantly lower than other classifications of diseases according to the Extracorporeal Life Support Organization database. This expert consensus aims to improve the survival rate and reduce the morbidity of this patient population by standardizing the clinical strategy.

METHODS

The editing group of this consensus gathered 11 well-known experts in pediatric cardiac surgery and ECMO field in China to develop clinical recommendations formulated on the basis of existing evidences and expert opinions.

RESULTS

The primary concern of ECMO management in the perioperative period of CHD are patient selection, cannulation strategy, pump flow/ventilator parameters/vasoactive drug dosage setting, anticoagulation management, residual lesion screening, fluid and wound management and weaning or transition strategy. Prevention and treatment of complications of bleeding, thromboembolism and brain injury are emphatically discussed here. Special conditions of ECMO management related to the cardiovascular anatomy, haemodynamics and the surgical procedures of common complex CHD should be considered.

CONCLUSIONS

The consensus could provide a reference for patient selection, management and risk identification of perioperative ECMO in children with CHD. Video abstract (MP4 104726 kb).

Successful Rescue of Life-threatening Hemoptysis Caused by Pulmonary Tuberculosis Bridging with Extracorporeal Membrane Oxygenation

Massive hemoptysis is a fatal complication associated with pulmonary tuberculosis (TB). It can lead to severe respiratory failure. Extracorporeal membrane oxygenation (ECMO) is a life-saving technology that is rarely indicated for bleeding disorders. We herein report a 26-year-old man who presented with severe respiratory failure caused by massive hemoptysis with pulmonary TB. Transcatheter artery embolization was successfully performed with venovenous ECMO support. The hemostatic procedure allowed concomitant anticoagulant use, and neither bleeding nor thrombotic complications occurred throughout the clinical course. Administering the appropriate hemostatic procedure with subsequent management, including anticoagulant therapy, supported ECMO application in a case of bleeding.

Case report: Total percutaneous post-closure of femoral arterial access sites after veno-arterial extracorporeal membrane oxygenation

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) which is a form of circulatory and gas exchange support. Following VA-ECMO, total percutaneous closure of the site of femoral arterial puncture with perclose Proglide (PP) has become widespread, enhancing patient comfort and lessening the incidence of wound infections and lymphatic fistulas in a short closure time. The preclose technique with perclose Proglide provides numerous benefits, however, it prolongs extra time during the VA-ECMO procedure, adds additional post-operative care to workloads, and increases the potential for Proglide stitch infection. The modified technique-percutaneous post-closure, described here by a case of a 65-year-old man with heart attack who underwent VA-ECMO, is a simple, rapidly applied technique to wean VA-ECMO also suitable for emergency cannulation. The patient was administered mechanically ventilated and sedated and the femoral artery access site and evaluated by ultrasound for precise positioning, then the VA-ECMO arterial cannula was withdrawn, and a 0.035-in guidewire was left in the artery. The first set of sutures was deployed after the Proglide device was inserted over the guidewire. The second sutures were then replaced in the same way but at a different angle. After hemostasis was achieved, the guidewire was removed, and additional manual compression was used to control any residual blood seeping. No hematoma, pseudoaneurysm, major bleeding, minor bleeding, acute arterial thrombosis, arteriovenous fistula, groin infection, lymphocele, or arterial dissection and stenosis occurred during the periprocedural period or during the 30-day post-procedural follow-up. In conclusion, the standardized algorithm we established, total percutaneous post-closure of femoral arteriotomies utilizing Perclose ProGlide device is feasible and safe with a low incidence of access site complications.

The efficiency of the preoperative extracorporeal membrane oxygenation in the setting of postinfarction ventricular septal defect and how to optimize outcomes: A single center case series

The mortality rate after the development of postinfarction ventricular septal defect remains high despite progress in pharmacologic therapy, invasive cardiology, and surgical techniques. We present a case series of six patients with preoperative venoarterial extracorporeal membrane oxygenation as a bridge to reparative surgical repair. Venoarterial extracorporeal membrane oxygenation allows to hemodynamically stabilize the patient, and safely delay the surgery. Delayed surgery might facilitate successful repair by allowing friable tissue to organize, strengthen, and become well-differentiated from surrounding healthy tissue; thus, definite repair can be performed safely. All patients were in cardiogenic shock and would otherwise require emergent cardiac surgery with associated risk. Three patients were discharged, with one hospital mortality of a patient who had a successful bridge to corrective surgery and died due to pulmonary artery rupture after a right ventricular assist device implantation. Two patients died before surgery while they were supported by venoarterial extracorporeal membrane oxygenation due to vascular complications. We discuss strategies how to optimize the management and function of the venoarterial extracorporeal membrane oxygenation to decrease the rate of adverse effects and optimize the outcomes of these patients.

Left Ventricular Unloading during Extracorporeal Life Support: Current Practice

Veno-arterial extracorporeal life support (VA-ECLS) is a powerful tool that can provide complete cardiopulmonary support for patients with refractory cardiogenic shock. However, VA-ECLS increases left ventricular afterload resulting in greater myocardial oxygen demand, which can impair myocardial recovery and worsen pulmonary edema. These complications can be ameliorated by various LV venting strategies to unload the LV. Evidence suggests that LV venting improves outcomes in VA-ECLS, but there is a paucity of randomized trials to help guide optimal strategy and the timing of venting. In this review, we discuss the available evidence regarding LV venting in VA-ECLS, explain important hemodynamic principles involved, and propose a practical approach to LV venting in VA-ECLS.