[Percutaneous extracorporeal life support in acute severe hemodynamic collapses: single centre experience in 100 consecutive patients]

Percutaneous circulatory assistance in an interventional cardiology centre without on-site cardiac surgery

BACKGROUND

Percutaneous extracorporeal membrane oxygenation (ECMO) has been developed thanks to the progress in the field of cannulation, but still justifies the presence of an on-site cardiac resuscitation department. Corsica is a French island without an on-site cardiac surgery department.

AIM

To evaluate the percutaneous ECMO programme in Corsica.

METHODS

All patients who received ECMO at the Bastia Hospital Centre between 01 January 2016 and 30 April 2022 were included.

RESULTS

ECMO was implanted in 39 patients. The mean age was 52.7years, with male predominance (84.6%). The majority of veno-arterial ECMOs were placed in the coronary angiography laboratory, whereas venovenous ECMOs were preferentially placed in the medical intensive care unit. Twenty patients (51.3%) were medically transferred to other referral centres after canulation. Percutaneous vascular cannulation was performed with ultrasound guidance in all cases (100%), and was successfully performed without immediate complications in all patients except two (who presented an immediate complication during cannulation), which is similar to large trials, despite the absence of on-site cardiac surgery. The use of ultrasound guidance (and sometimes fluoroscopy guidance) during cannulation and the experience of the medical team facilitated control over correct positioning of the cannulas and decreased implantation failure, without the need for a surgical approach.

CONCLUSIONS

Percutaneous ECMO by trained interventional cardiologists without a surgical approach appears to be safe. Widespread use of percutaneous cannulation without cardiac surgery would increase survival for some patients who are far from these centres.

Vascular Complications of Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Regression Analysis

OBJECTIVES

Perform a systematic review and meta-analysis of vascular complications associated with extracorporeal membrane oxygenation and identify prognostic and predictive factors.

DATA SOURCES

Systematic search for publications reporting vascular complications on extracorporeal membrane oxygenation, published from 1972 to January 31, 2020, was conducted via PubMed, Scopus, and Embase.

STUDY SELECTION

Of 4,076 references screened, 47 studies with 6,583 patients were included in final analyses. Studies with fewer than 10 patients were excluded.

DATA EXTRACTION

Relevant data, including demographics, comorbidities, extracorporeal membrane oxygenation and cannulation characteristics, occurrence rates of early and late vascular complications, patient outcomes, and use of distal perfusion cannula, were extracted from selected articles into an excel sheet specifically designed for this review.

DATA SYNTHESIS

Random-effects meta-analyses and meta-regression analyses were undertaken. Overall pooled estimate of vascular complications in our meta-analysis was 29.5% (95% CI, 23.6-35.9%). Two-thousand three-hundred forty-seven vascular complications in 6,124 venoarterial extracorporeal membrane oxygenation patients compared with 95 in 459 venovenous extracorporeal membrane oxygenation patients (odds ratio, 2.35; 95% CI, 1.87-2.96; p < 0.0001) were analyzed. Successful weaning off extracorporeal membrane oxygenation occurred in 60.6% of pooled patients; 46.2% were eventually discharged. Pooled prevalences of vascular complications like significant bleeding, limb ischemia, and cannula site bleeding were 15.4% (95% CI, 8.6-23.7%), 12.6% (95% CI, 10.0-15.5%), and 12.6% (95% CI, 9.6-18.5%), respectively. Meta-analysis showed that the use of distal perfusion cannula was associated with lower odds of limb ischemia (odds ratio, 1.93; 95% CI, 1.17-2.47; p = 0.03) Meta-regression showed that male sex, smoking, advanced age, and comorbidities contributed to higher in-hospital mortality, while distal perfusion cannula was protective.

CONCLUSIONS

Nearly a third of patients on extracorporeal membrane oxygenation develop vascular complications; elderly males with comorbidities appear vulnerable. The use of distal perfusion cannulas caused significant reduction in limb ischemia and mortality.

The Crashing Toxicology Patient

This article examines, using an organ-systems based approach, rapid diagnosis, resuscitation, and critical care management of the crashing poisoned patient in the emergency department. The topics discussed in this article include seizures and status epilepticus, respiratory failure, cardiovascular collapse and mechanical circulatory support, antidotes and drug-specific therapies, acute liver failure, and extracorporeal toxin removal.

Acute chloroquine and hydroxychloroquine toxicity: A review for emergency clinicians

Background

Acute chloroquine and hydroxychloroquine toxicity is characterized by a combination of direct cardiovascular effects and electrolyte derangements with resultant dysrhythmias and is associated with significant morbidity and mortality.

Objective

This review describes acute chloroquine and hydroxychloroquine toxicity, outlines the complex pathophysiologic derangements, and addresses the emergency department (ED) management of this patient population.

Discussion

Chloroquine and hydroxychloroquine are aminoquinoline derivatives widely used in the treatment of rheumatologic diseases including systemic lupus erythematosus and rheumatoid arthritis as well as for malaria prophylaxis. In early 2020, anecdotal reports and preliminary data suggested utility of hydroxychloroquine in attenuating viral loads and symptoms in patients with SARS-CoV-2 infection. Aminoquinoline drugs pose unique and significant toxicological risks, both during their intended use as well as in unsupervised settings by laypersons. The therapeutic range for chloroquine is narrow. Acute severe toxicity is associated with 10–30% mortality owing to a combination of direct cardiovascular effects and electrolyte derangements with resultant dysrhythmias. Treatment in the ED is focused on decontamination, stabilization of cardiac dysrhythmias, hemodynamic support, electrolyte correction, and seizure prevention.

Conclusions

An understanding of the pathophysiology of acute chloroquine and hydroxychloroquine toxicity and available emergency treatments can assist emergency clinicians in reducing the immediate morbidity and mortality associated with this disease.

Venoarterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock: Lifeline of Modern Day CICU

Cardiogenic shock (CS) portends an extremely high mortality of nearly 50% during index hospitalization. Prompt diagnoses of CS, its underlying etiology, and efficient implementation of treatment modalities, including mechanical circulatory support (MCS), are critical especially in light of such high predicted mortality. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides the most comprehensive cardiopulmonary support in critically ill patients and hence has seen a steady increase in its utilization over the past decade. Hence, a good understanding of VA-ECMO, its role in treatment of CS, especially when compared with other temporary MCS devices, and its complications are vital for any critical care cardiologist. Our review of VA-ECMO aims to provide the same.

Indications and perioperative outcomes of extracorporeal life support in clermont-ferrand

Objectives

To report the epidemiological profile of the patients who underwent extracorporeal life support (ECLS) and then analyze the indications and outcomes of this procedure.

Methods

It consisted of a retrospective and descriptive study based on the database from the department of cardiovascular surgery.

Setting

University hospital clinic.

Patients

One hundred and sixty-one patients have participated in the study. Included were all patients who presented with left-sided heart or biventricular failure. Those who were suffering from either isolate respiratory failure or isolate right ventricle failure were excluded.

Interventions

Participants underwent ECLS: central ECLS or peripheral ECLS.

Results

: The mean age of the patients was 54 years; there were 73% of male patients and the mean duration of ECLS was 5.3 days. There were two types of ECLS: central (71%) and peripheral (29%). Indications for support were dominated by cardiogenic shock in 69%. Bleeding was the most frequent complication (23.5%). The overall in-hospital mortality of patients who underwent ECLS was 60%.

Conclusion

The number of ECLS performed increases in proportion to mastery of surgical technique. There is a high rate of mortality and morbidity with ECLS. However, it remains a lifesaving therapy for many clinically urgent situations.

Veno-arterial-ECMO in the intensive care unit: From technical aspects to clinical practice

The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as a salvage therapy in cardiogenic shock is becoming of current practice. While VA-ECMO is potentially a life-saving technique, results are sometimes mitigated, emphasising the need for selecting the right indication in the right patient. This relies upon a clear definition of the individual therapeutic project, including the potential for recovery as well as the possible complications associated with VA-ECMO. To maximise the benefits of VA-ECMO, the basics of extracorporeal circulation should be perfectly understood since VA-ECMO can sometimes be detrimental. Hence, to be successful, VA-ECMO should be used by teams with sufficient experience and initiated after a thorough multidisciplinary discussion considering patient's medical history, pathology as well the anticipated evolution of the disease.

Treatment of bronchial foreign body aspiration with extracorporeal life support in a child: A case report and literature review

We present a case in which extracorporeal life support treatment of a 6-year-old girl asphyxiated by aspiration of an elliptic plastic ball is described. The attempts for extraction of the foreign body by conventional bronchoscopy under critically ill conditions had failed. Thus, a skin incision was made in the midline, and an emergency open-chest cardiopulmonary bypass (CPB) with aortic, superior vena cava and inferior vena cava cannulation was performed for circulatory support. Following tracheal extubation, a video-assisted rigid bronchoscope was inserted to clear the airway and remove the foreign body. The CPB lasted for 68 min, and the endotracheal tube was pulled out 6 h after the surgery. On the 10th day, the patient was discharged and followed up for 3 months when no neurological symptoms or other complications were documented. The removal of the aspirated bronchial foreign body under extracorporeal life support has been rarely reported. Here, we review the indication, cannulation method, support mode, surgical procedure, and patient outcome in the 8 papers retrieved from the PubMed database and compare their clinical characteristics with those of our case to justify the safe and effective use of CPB for critically ill patients with bronchial foreign body aspiration.

2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care (Endorsed by the American Heart Association, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; Affirmation of Value by the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d'intervention)

Although historically the intra-aortic balloon pump has been the only mechanical circulatory support device available to clinicians, a number of new devices have become commercially available and have entered clinical practice. These include axial flow pumps, such as Impella(®); left atrial to femoral artery bypass pumps, specifically the TandemHeart; and new devices for institution of extracorporeal membrane oxygenation. These devices differ significantly in their hemodynamic effects, insertion, monitoring, and clinical applicability. This document reviews the physiologic impact on the circulation of these devices and their use in specific clinical situations. These situations include patients undergoing high-risk percutaneous coronary intervention, those presenting with cardiogenic shock, and acute decompensated heart failure. Specialized uses for right-sided support and in pediatric populations are discussed and the clinical utility of mechanical circulatory support devices is reviewed, as are the American College of Cardiology/American Heart Association clinical practice guidelines.

Arterial vascular complications in peripheral extracorporeal membrane oxygenation support: a review of techniques and outcomes

Peripheral venoarterial extracorporeal membrane oxygenation support provides prolonged support in the event of acute or acute-on-chronic cardiac and/or respiratory failure. This support serves as a bridge to recovery, decision-making, heart transplantation or ventricular-assist device implantation. It can be implanted either through a percutaneous approach using Seldinger's technique or via an open approach via the common femoral artery or the axillary artery. Early and late arterial vascular complications remain an important issue, with rates of up to 28% with femoral and axillary cannulation sites. Among them, limb ischemia requires prompt diagnosis and management to avoid limb amputation. In the case of peripheral artery cannulation, ipsilateral distal limb perfusion to prevent acute limb ischemia can be performed via a single lumen catheter through the artery or via the 'chimney graft' technique during extracorporeal membrane oxygenation implantation.

Mechanical circulatory support for cardiogenic shock

Cardiogenic shock (CS) is a syndrome of progressive depression of myocardial function with systemic hypoperfusion. It occurs due to various aetiologies such as acute myocardial infarction, myocarditis, acute decompensated heart failure and postcardiotomy. Cardiogenic shock carries poor prognosis, and medical therapy alone is not effective. Mechanical circulatory support is required to unload the ventricles, decrease the myocardial demand, prevent further injury, improve the coronary perfusion, stabilise the haemodynamics and maintain the end-organ perfusion before definitive interventions such as coronary reperfusion can take place. Currently, there are several methods of mechanical circulatory support. These include extracorporeal life support, paracorporeal or extracorporeal ventricular-assist devices, percutaneous ventricular assist devices, intra-aortic balloon counterpulsation and total artificial heart. In this review, we discuss the role of each of these circulatory support devices in the management of acute cardiac failure.

Extracorporeal life support as a bridge to high-urgency heart transplantation

Extracorporeal life support (ECLS) represents an effective, emergent therapy for patients with end-stage heart failure or cardiac arrest. However, ECLS is typically not used as a bridge to heart transplantation because of the limited duration of ECLS. In France, high-urgency priority heart transplantation remains a possibility for transplant patients who are on ECLS. In this article, we present our experience with high-urgency priority heart transplantation after ECLS. From July 2004 to December 2009, 242 patients underwent emergent ECLS. Heart transplantation was performed in eight of these patients. Time of ECLS was 6.3 ± 4.6 d. Before heart transplantation, all patients on ECLS had decreased organ dysfunctions and four were conscious. Despite frequent post-operative complications, no death occurred during the first year after transplantation. In our experience, ECLS is a valid method of supporting patients awaiting high-urgency heart transplantation and can be used as a short-term bridge to heart transplantation.

Interprovincial spoke-to-hub transport using the Impella Recover LP 5.0 left ventricular assist device as a bridge to long-term circulatory support

Current hospital administrative practices categorize health care centres in a network of&nbsp; 'spokes' (primary care centres) and 'hubs' (tertiary care centres). For the treatment of cardiogenic shock, long-term left ventricular assist devices (LVADs) and transplant therapies are only used at a few hub centres nationwide and are, thus, only available to patients living in close proximity to these centres. The relatively lower technical requirements of the Impella Recover LP 5.0 LVAD (ABIOMED Inc, USA) translate into greater use by spoke centres for the short-term treatment of cardiogenic shock, and facilitate appropriate stabilization and subsequent transportation to a suitable hub centre. Based on a review of the literature, the present report describes the first case demonstrating successful use of the Impella Recover LP 5.0 LVAD, implanted under local anesthetic, for the purposes of interprovincial spoke-to-hub transport in a bridge-to-bridge-to-transplant procedure. By providing an economical and technically straightforward alternative to traditional extracorporeal membrane oxygenation, the present case demonstrates that less invasive LVADs are valuable to the spoke-and-hub model for delivery of specialized cardiac care.