Occurrence, predictors, and management of late vascular complications following extracorporeal membrane oxygenation

OBJECTIVE

Vascular complications (VCs) associated with extracorporeal membrane oxygenation (ECMO) during index hospitalization are prevalent and associated with increased mortality. Few studies have evaluated late VCs following ECMO; this study aims to assess occurrence and management practices of late VCs following discharge.

METHODS

A retrospective single-institution review was performed of all patients surviving initial hospitalization after being cannulated for central or peripheral veno-venous (VV) or veno-arterial (VA) ECMO between January 1, 2019, and December 31, 2020. Primary outcomes were to categorize and determine the rate of late VCs. Late VCs were defined as any cannulated vessel injury resulting from ECMO cannulation presenting after discharge from index hospitalization. Analysis was conducted by cannulated vessel and stratified by VV or VA ECMO configurations.

RESULTS

A total of 229 patients were identified, of which 50.6% (n = 116) survived until discharge. Late VCs occurred in 7.8% of the surviving cohort (n = 9/116); with a median time until presentation of 150 days (interquartile range, 83-251 days). The most common late VC was infection (n = 5; 55.6%) followed by progression to limb-threatening ischemia (n = 4; 44.4%). Urgent procedures were required in 55.6% of patients (n = 5), whereas 44.4% (n = 4) were elective interventions. Interventions performed for management of late VCs included lower extremity arterial revascularization (n = 6; 66.7%), major (n = 1; 11.1%) or minor amputation (n = 1; 11.1%), and wound debridement (n = 1; 11.1%). The majority of patients presenting with late VCs had initially been cannulated for peripheral VA ECMO (n = 8; 88.9%), and one patient (11.1%) was cannulated for peripheral VV ECMO. VCs during index hospitalization were seen in 77.8% of patients (n = 7) returning with late VCs. Odds for late VCs were significantly increased in patients that had been cannulated for ECMO as part of extracorporeal cardiopulmonary resuscitation (odds ratio, 8.4; P = .016) and in cases where patients had experienced an index VC during index hospitalization (odds ratio, 19.3; P = .001).

CONCLUSIONS

Late vascular complications after peripheral ECMO cannulation are not rare, particularly after arterial cannulation. Patients should be followed closely early after surviving ECMO with wound evaluation and formal assessment of perfusion with ankle-branchial indices in the cannulated limb.

Percutaneous debulking of tricuspid valve endocarditis in severe COVID-19 pneumonia after prolonged venovenous extracorporeal membrane oxygenation with right-ventricular support: a case series

Background

Over the past 2 years, the utilization of venovenous extracorporeal membrane oxygenation (VV-ECMO) for the treatment of coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) has increased. While supporting respiratory function, VV-ECMO requires large-bore indwelling venous cannulas, which risk bleeding and infections, including endocarditis.

Case summary

We describe two adults hospitalized for COVID-19 pneumonia who developed ARDS and right-ventricular failure, requiring VV-ECMO and ProtekDuo cannulation. After over 100 days with these devices, both patients developed tricuspid valve vegetations. Our first patient was decannulated from ECMO and discharged, but re-presented with a segmental pulmonary embolism and tricuspid mass. The Inari FlowTriver system was chosen to percutaneously remove both the tricuspid mass and pulmonary thromboembolism. Pathological examination of the mass demonstrated Candida albicans endocarditis in the setting of Candida fungemia. Our second patient developed a tricuspid valve vegetation which was also removed with the FlowTriever system. Pathological examination demonstrated endocarditis consistent with Pseudomonas aeruginosa in the setting of Pseudomonas bacteremia. Both patients experienced resolution of fungemia and bacteremia after percutaneous vegetation removal. After ECMO decannulation and percutaneous debulking, both patients experienced prolonged hospital stays for ventilator weaning and were eventually discharged with supplemental oxygen.

Discussion

VV-ECMO and right-ventricular support devices are invasive and create various risks, including bloodstream infection and infective endocarditis. Percutaneous debulking of valvular vegetations associated with these right-sided indwelling devices may be an effective means of infection source control. It is unclear whether prolonged use of VV-ECMO provides a mortality benefit in COVID-19 ARDS.

Atrial arrhythmia related outcomes in critically ill COVID-19 patients

Rationale

Coronavirus disease 2019 (COVID‐19) is associated with many clinical manifestations including respiratory failure and cardiovascular compromise.

Objectives

We examine outcomes in critically ill individuals with COVID‐19 who develop atrial tachyarrhythmias.

Methods

We collected data from electrocardiograms and the electronic medical record of COVID‐19 positive (COVID⁺) and negative (COVID⁻) individuals admitted to our medical intensive care unit between February 29 and June 28, 2020. We compared clinical and demographic characteristics, new onset atrial tachyarrhythmia, hemodynamic compromise following atrial tachyarrhythmia, and in‐hospital mortality in COVID⁺ versus COVID⁻. Hemodynamic compromise was defined as having a new or increased vasopressor requirement or the need for direct current cardioversion for hemodynamic instability within 1 hour of atrial tachyarrhythmia onset.

Results

Of 300 individuals included, 200 were COVID⁺ and 100 were COVID⁻. Mean age was 60 ± 16 years, 180 (60%) were males, and 170 (57%) were African American. New onset atrial tachyarrhythmia occurred in 16% of COVID⁺ and 19% of COVID⁻ individuals (P = .51). When compared to COVID⁻ participants without atrial tachyarrhythmia, COVID⁺ individuals with new onset atrial tachyarrhythmia had higher mortality after multivariable adjustment (OR 5.0, 95% CI 1.9–13.5). New onset atrial tachyarrhythmia was followed by hemodynamic compromise in 18 COVID⁺ but no COVID⁻ participants (P = .0001). COVID⁺ individuals with hemodynamic compromise after atrial tachyarrhythmia required increased ventilatory support at the time of atrial tachyarrhythmia onset.

Conclusions

Atrial tachyarrhythmia is associated with increased mortality in critically ill individuals with COVID‐19, especially those mechanically ventilated. Recognition of this could assist with clinical care for individuals with COVID‐19.

Ischemic Evaluation in Patients Presenting with Hypertensive Emergency / Urgency and Acute Systolic Heart Failure: Is Coronary Angiography Required for all?

BACKGROUND

Patients presenting with hypertensive urgency / emergency (HUE) often have systolic heart failure(SHF). Coronary angiography is routinely done for these patients to rule out obstructive coronary artery disease (Obs-CAD). We performed a retrospective study to investigate predictors of ObsCAD in this population.

METHODS

Patients who underwent angiography to investigate SHF and had hospital admission(s) for HUE in the preceding 6 months were included in the study. Chart review was performed to obtain demographic, clinical and imaging / angiographic data. A risk score was formulated based on multivariable logistic regression analysis.

RESULTS

205 patients [age 58.9 ± 14.4 years; 62.4% male; 39.5% diabetic; median EF 25% (Inter Quartile Range: 11)] were included in the study. 33.1% patients (n = 68) had obs-CAD. Patients with obs-CAD were older, diabetic, more likely to have a history of stroke, echocardiographic regional wall motion abnormalities (RWMA) while African Americans were less likely to have obs-CAD. On multivariable analysis, only non-African American race (OR: 2.18; CI: 1.08-4.4) and RWMA (OR: 5.62; CI: 2.47-12.81) remained significant predictors of obs-CAD. A risk score (RANDS) from 0 to 9 was formulated which had a c-statistic of 0.75 with a sensitivity and specificity of 84% and 53% for predicting obsCAD respectively.

CONCLUSION

Our results suggest that only a minority of patients with HUE and SHF have obs-CAD. A simple risk score may be used to stratify this population and lower risk individuals may be screened with non-invasive testing instead of invasive catheterization. These results should be validated in large registry populations.

Abstract P136: Ischemic Evaluation in Patients With Hypertensive Emergency / Urgency and Acute Systolic Heart Failure: Is Coronary Angiography Required for All?

Aim: Patients presenting with hypertensive urgency / emergency (HU/E) often have systolic heart failure(S-HF). Coronary angiography is routinely done for these patients to rule out obstructive coronary artery disease (O-CAD). We performed a retrospective study to investigate predictors of O-CAD in this population.

Methods: Consecutive patients who underwent angiography to investigate S-HF and had hospital admissions for HU/E in the preceding 6 months were included in the study. Chart review was performed to obtain demographic, clinical and imaging / angiographic data. Statistical analysis was performed using SAS 9.4 software.

Results: 205 patients [age 58.9 ± 14.4 years; 62.4 % male; 39.5% diabetic; median EF 25% (Inter Quartile Range: 11)] were included in the study. 33.1% patients (n=68) had O-CAD. Age > 60 years (Odds Ratio: 2.3; 95% Confidence intervals: 1.3-4.3) , Diabetes (OR: 2.1; 95% CI: 1.2-3.8), history of stroke (OR: 2.7; 95% CI: 1.1-7.0) and presence of regional wall motion abnormalities (RWMA; OR: 7.4; 95% CI: 3.4-16.1) and abnormal perfusion study (OR: 7.6; 95% CI: 1.5-39.6) were significantly associated with O-CAD while African American (AA) race was a protective factor (OR: 0.4; 95% CI: 0.2-0.8). ROC curves constructed using an age cut off of 60 years along with non AA race, diabetes and RWMA yielded a good fit with a c statistic of 0.75.

Conclusions: Our results suggest that only a minority of patients with HU/E and S-HF have obstructive CAD. It may be possible to stratify patients using demographic and non-invasive tests to direct only those with high likelihood of O-CAD for coronary angiography. These results should be validated in large registry populations.

Mechanisms of sudden cardiac death

Sudden cardiac death (SCD) continues to be a major public health problem and is thought to account for almost half of all cardiac deaths. Cardiac arrest and SCD are most commonly due to ventricular arrhythmias. Most patients who suffer cardiac arrest have underlying structural heart disease, with coronary artery disease (CAD) being the most common. In the setting of CAD, ventricular arrhythmias can result due to acute ischemia in the absence of preexisting myocardial scarring or in the presence of established scar from prior infarction without clinically significant ischemia. LV systolic dysfunction is an important predictor of risk for SCD in ischemic heart disease and in most nonischemic disorders, although other factors such as ventricular hypertrophy also play a role. Cardiac arrest and SCD can also occur due to primary electrical disorders in the absence of major structural abnormalities.

Polarization of Charge-Transfer Bands and Rectification in Hexadecylquinolinium 7,7,8-Tricyanoquinodimethanide and Its Tetrafluoro Analog

A Langmuir-Blodgett (LB) multilayer film of the unimolecular rectifier hexadecyl-gamma-quinolinium-7,7,8-tricyanoquinodimethanide (C(16)H(33)gammaQ-3CNQ) has two distinct polarized charge-transfer bands, one at lower film pressures (28 mN m(-1)) with a peak at 530 nm, due to an intramolecular charge transfer or intervalence transfer (IVT); past the collapse point (32 to 35 mN m(-1)), this band disappears, and a new intermolecular charge-transfer band appears with peak at 570 nm. An LB multilayer film of the tetrafluoro analogue, hexadecyl-gamma-quinolinium-2,3,5,6-tetrafluoro-7,7,8-tricyanoquinodimethanide (C(16)H(33)gammaQ-3CNQF(4)) shows, for all film pressures, only one IVT band with a peak at 504 nm; when sandwiched between gold electrodes, (C(16)H(33)gammaQ-3CNQF(4) is also an LB monolayer electrical rectifier.