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Isha S, Narra SA, Batool H, Jonna S, Giri A, Herrmann O, Dyson A, Nichols MD, Hannon R, Pham S, Moreno Franco P, Baz M, Sanghavi D, Kiley S, Waldron N, Pandompatam G, Bohman JKK, Chaudhary S, Rosenbaum DN, Guru PK, Bhattacharyya A. Assessing Right Ventricle Over Time in Patients on Veno-Venous Extracorporeal Membrane Oxygenation: Insights From Serial Echocardiography. ASAIO J 2024:00002480-990000000-00488. [PMID: 38819317 DOI: 10.1097/mat.0000000000002235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is often used in acute respiratory distress syndrome (ARDS) with refractory hypoxemia. There is limited literature highlighting the development of right ventricular (RV) failure while on ECMO. We conducted a retrospective multicenter observational study including 70 patients who were placed on veno-venous (VV)-ECMO for respiratory failure at Mayo Clinic, Jacksonville, and Mayo Clinic, Rochester, between January 2018 and June 2022 and had at least two post-ECMO transthoracic echoes. The primary outcomes were the incidence and progression of RV dysfunction and dilatation. The secondary outcome was in-patient mortality. Among 70 patients in our cohort, 60.6% had a normal RV function at the time of ECMO placement, whereas only 42% had a normal RV function at the second post-ECMO echo. On multinomial regression, a moderate decrease in RV function was associated with ECMO flow (odds ratio [OR] = 2.32, p = 0.001) and ECMO duration (OR = 1.01, p = 0.01). A moderately dilated RV size was also associated with ECMO flow (OR = 2.62, p < 0.001) and ECMO duration (OR = 1.02, p = 0.02). An increasing degree of RV dysfunction was associated with worse outcomes. Our study showed that the increasing duration and flow of VV-ECMO correlated with progressive RV dilatation and dysfunction, which were associated with poor survival.
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Affiliation(s)
- Shahin Isha
- From the Department of Internal Medicine, Ascension Saint Joseph Hospital, Chicago, Illinois
| | - Sai Abhishek Narra
- Department of Internal Medicine, Mercy Fitzgerald Hospital, Philadelphia, Pennsylvania
| | - Humera Batool
- Department of Internal Medicine, Mercy Fitzgerald Hospital, Philadelphia, Pennsylvania
| | - Sadhana Jonna
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Abhishek Giri
- Department of Internal Medicine, Fairview Hospital, Cleveland, Ohio
| | - Olivia Herrmann
- Cope Lab, Department of Biomedical Engineering, Georgia Institute of Technology,, Atlanta, Georgia
| | - Amari Dyson
- Florida State College, Jacksonville, Florida
| | - Mick D Nichols
- Department of Nursing, Mayo Clinic, Jacksonville, Florida
| | - Rachel Hannon
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Si Pham
- Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, Florida
| | | | - Maher Baz
- Department of Transplant, Mayo Clinic, Jacksonville, Florida
| | - Devang Sanghavi
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Sean Kiley
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Nathan Waldron
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Govind Pandompatam
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - J Kyle K Bohman
- Department of Anesthesia, Mayo Clinic, Rochester, Minnesota; and
| | - Sanjay Chaudhary
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Drew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Pramod K Guru
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
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Becker T, Struble RD, Rappaport C. Veno-venous extracorporeal membrane oxygenation (VV ECMO) cannula malposition identified with point-of-care ultrasound. Ultrasound J 2024; 16:27. [PMID: 38717534 PMCID: PMC11078911 DOI: 10.1186/s13089-024-00357-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 01/24/2024] [Indexed: 05/12/2024] Open
Abstract
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.
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Affiliation(s)
- Taylor Becker
- Department of Internal Medicine, University of Iowa, C123 GH, 200 Hawkins Dr., Iowa City, IA, 52242, USA.
| | - Roger D Struble
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City, USA
| | - Charles Rappaport
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City, USA
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Douflé G, Dragoi L, Morales Castro D, Sato K, Donker DW, Aissaoui N, Fan E, Schaubroeck H, Price S, Fraser JF, Combes A. Head-to-toe bedside ultrasound for adult patients on extracorporeal membrane oxygenation. Intensive Care Med 2024; 50:632-645. [PMID: 38598123 DOI: 10.1007/s00134-024-07333-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/20/2024] [Indexed: 04/11/2024]
Abstract
Bedside ultrasound represents a well-suited diagnostic and monitoring tool for patients on extracorporeal membrane oxygenation (ECMO) who may be too unstable for transport to other hospital areas for diagnostic tests. The role of ultrasound, however, starts even before ECMO initiation. Every patient considered for ECMO should have a thorough ultrasonographic assessment of cardiac and valvular function, as well as vascular anatomy without delaying ECMO cannulation. The role of pre-ECMO ultrasound is to confirm the indication for ECMO, identify clinical situations for which ECMO is not indicated, rule out contraindications, and inform the choice of ECMO configuration. During ECMO cannulation, the use of vascular and cardiac ultrasound reduces the risk of complications and ensures adequate cannula positioning. Ultrasound remains key for monitoring during ECMO support and troubleshooting ECMO complications. For instance, ultrasound is helpful in the assessment of drainage insufficiency, hemodynamic instability, biventricular function, persistent hypoxemia, and recirculation on venovenous (VV) ECMO. Lung ultrasound can be used to monitor signs of recovery on VV ECMO. Brain ultrasound provides valuable diagnostic and prognostic information on ECMO. Echocardiography is essential in the assessment of readiness for liberation from venoarterial (VA) ECMO. Lastly, post decannulation ultrasound mainly aims at identifying post decannulation thrombosis and vascular complications. This review will cover the role of head-to-toe ultrasound for the management of adult ECMO patients from decision to initiate ECMO to the post decannulation phase.
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Affiliation(s)
- Ghislaine Douflé
- Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada.
- Department of Anesthesia and Pain Management, Toronto General Hospital, 585 University Avenue, Toronto, ON, M5G 2N2, Canada.
| | - Laura Dragoi
- Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada
| | - Diana Morales Castro
- Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada
| | - Kei Sato
- Critical Care Research Group, The Prince Charles Hospital, Level 3 Clinical Sciences Building, Chermside, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Dirk W Donker
- Intensive Care Center, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
- Cardiovascular and Respiratory Physiology, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Nadia Aissaoui
- Service de Médecine intensive-réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Cité, Paris, France
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada
| | - Hannah Schaubroeck
- Department of Intensive Care Medicine, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Susanna Price
- Departments of Cardiology and Intensive Care, Royal Brompton & Harefield NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Level 3 Clinical Sciences Building, Chermside, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Alain Combes
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université, Hôpital Pitié Salpêtrière, Paris, France
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
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Walczak AB, Bigelow AM, Schneider B, Deitemyer M, Duffy V, Lloyd EA, Frazier WJ, Seabrook RB, Halaweish IF, McConnell PI. Experience With the Crescent• Right Atrial Jugular Dual Lumen Catheter for Pediatric Venovenous Extracorporeal Membrane Oxygenation: A Case Series. ASAIO J 2023; 69:e526-e530. [PMID: 37678262 DOI: 10.1097/mat.0000000000002004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023] Open
Abstract
The Crescent dual lumen right atrial (RA) cannula has recently been introduced for the support of pediatric patients in need of venovenous extracorporeal membrane oxygenation (VV ECMO) support. We present the first pediatric case series illustrating utility of the Crescent RA cannula in the pediatric patient population at a single institution over a 10 month period. From December 2021 to August 2022, six pediatric patients were adequately supported on seven VV ECMO runs at our institution with the Crescent RA cannula. ECMO cannulation, circuit design, anticoagulation management, ECMO circuit pressures, flow rates, and recirculation were similar to our standard of care for VV ECMO. The Crescent RA cannula can be used safely and effectively to provide adequate support for pediatric patients requiring VV ECMO.
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Affiliation(s)
- Ashley B Walczak
- From the Department of Cardiothoracic Surgery, The Heart Center, Nationwide Children's Hospital, Columbus, OH
| | - Amee M Bigelow
- From the Department of Cardiothoracic Surgery, The Heart Center, Nationwide Children's Hospital, Columbus, OH
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Brian Schneider
- From the Department of Cardiothoracic Surgery, The Heart Center, Nationwide Children's Hospital, Columbus, OH
| | - Matthew Deitemyer
- From the Department of Cardiothoracic Surgery, The Heart Center, Nationwide Children's Hospital, Columbus, OH
| | - Vicky Duffy
- From the Department of Cardiothoracic Surgery, The Heart Center, Nationwide Children's Hospital, Columbus, OH
| | - Eric A Lloyd
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
- Department of Critical Care, Nationwide Children's Hospital, OH
| | - W Joshua Frazier
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
- Department of Critical Care, Nationwide Children's Hospital, OH
| | - Ruth B Seabrook
- Division of Neonatology, Nationwide Children's Hospital, Department of Pediatrics, The Ohio State University, Columbus, OH
| | - Ihab F Halaweish
- Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
- Department of Clinical Surgery, The Ohio State University, Columbus, OH
| | - Patrick I McConnell
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, OH
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Wang Q, Zhu J, Chen L, He Y, Li H, Lan Y, Huang C, Peng L. Successful treatment of severe ARDS caused by accidental inhalation of nitric acid fumes with veno-venous ECMO: A case report and literature review. Medicine (Baltimore) 2022; 101:e29447. [PMID: 35905254 PMCID: PMC9333490 DOI: 10.1097/md.0000000000029447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
RATIONALE The treatment of severe acute respiratory distress syndrome caused by accidental inhalation of nitric acid fumes is challenging. Few successful cases have been reported in literature. Owing to the development of extracorporeal life support, extracorporeal membrane oxygenation (ECMO) may play an important role in treatment. PATIENT CONCERNS A 40-year-old man was accidentally exposed to nitric acid fumes for 10 minutes in a factory. Mild throat irritation and dyspnea occurred 3.5 hours after exposure. Severe dyspnea recurred approximately two hours later. Chest computed tomography revealed bilateral interstitial edema. Tracheal intubation and mechanical ventilation were provided when the non-invasive ventilator failed to support the patient. However, his vital signs, respiratory function, and circulation were aggravated. DIAGNOSIS Aspiration pneumonia (inhalation of nitric acid fumes), acute respiratory distress syndrome, and hypertension. INTERVENTIONS Veno-venous ECMO (VV-ECMO) was started 6 hours after exposure at the intensive care unit. During VV-ECMO, hypoxia improved. However, chest radiography revealed aggravated pulmonary edema. Prone positioning under ultrasound monitoring and high-dose methylprednisolone were administered on the first day. Nebulization and fiberoptic bronchoscopy for airway management were performed on the second day after the exposure. Pulmonary secretions were significantly reduced 48 hours later. OUTCOMES The patient was weaned off V-V ECMO after 6 days, achieved the standard of extubation after 9 days, and was discharged without serious pulmonary or infectious complications after 12 days of hospitalization. Three weeks after discharge, the patient's lung function showed a slight decline in the diffusion function. Two months after discharge, the patient's lung function returned to normal. LESSON Early ECMO combined with prone positioning and visualized management through ultrasonography can better improve the prognoses of patients and promote lung function recovery.
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Affiliation(s)
- Qian Wang
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, China
| | - Junchen Zhu
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, China
| | - Lvlin Chen
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, China
- *Correspondence: Lvlin Chen, Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, No.82, North Section 2, 2nd Ring Road, Jinniu District, Chengdu, Sichuan 610081, China (e-mail: , Junchen Zhu: )
| | - Yan He
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, China
| | - Hui Li
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, China
| | - Ying Lan
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, China
| | - Chao Huang
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, China
| | - Liyuan Peng
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, China
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Hussey PT, von Mering G, Nanda NC, Ahmed MI, Addis DR. Echocardiography for extracorporeal membrane oxygenation. Echocardiography 2022; 39:339-370. [PMID: 34997645 PMCID: PMC9195253 DOI: 10.1111/echo.15266] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/16/2021] [Accepted: 11/06/2021] [Indexed: 02/03/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) provides advanced cardiopulmonary life support for patients in cardiac and/or respiratory failure. Echocardiography provides essential diagnostic and anatomic information prior to ECMO initiation, allows for safe and efficient ECMO cannula positioning, guides optimization of flow, provides a modality for rapid troubleshooting and patient evaluation, and facilitates decision-making for eventual weaning of ECMO support. Currently, guidelines for echocardiographic assessment in this clinical context are lacking. In this review, we provide an overview of echocardiographic considerations for advanced imagers involved in the care of these complex patients. We focus predominately on new cannulas and complex cannulation techniques, including a special focus on double lumen cannulas and a section discussing indirect left ventricular venting. Echocardiography is tremendously valuable in providing optimal care in these challenging clinical situations. It is imperative for imaging physicians to understand the pertinent anatomic considerations, the often complicated physiological and hemodynamic context, and the limitations of the imaging modality.
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Affiliation(s)
- Patrick T. Hussey
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesiology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Gregory von Mering
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Navin C. Nanda
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Mustafa I. Ahmed
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Dylan R. Addis
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesiology, Division of Molecular and Translational Biomedicine, and the UAB Comprehensive Cardiovascular Center, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
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Severity of acute respiratory distress syndrome and echocardiographic findings in clinical practice-an echocardiographic pilot study. Heart Lung 2020; 49:622-625. [PMID: 32220394 DOI: 10.1016/j.hrtlng.2020.02.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 02/14/2020] [Accepted: 02/25/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUNDS The still high poor outcome of ARDS may be more consequence of circulatory failure than hypoxemia per se. For patients with circulatory failure and ARDS, hemodynamic instability is directly related to ARDS following pulmonary circulation dysfunction and its consequence - right ventricular (RV) dysfunction. OBJECTIVES We hypothesize that in the era of protective ventilation, echocardiographic abnormalities did not parallel ARDS severity, defined by the degree of hypoxemia. METHODS We included 63 consecutively identified mechanically ventilated ARDS patients (1st January 2015 to 31th December 2016). All had echocardiography performed routinely within the first 12 h after ICU admission. RESULTS The analysis included 110 exams. Twenty-eight patients had severe ARDS (28/63, 44.4%), 27 had moderate ARDS (27/63, 42.1%) and 8 mild ARDS (8/63, 12.7%).There was no difference in echocardiographic findings between mild-moderate and severe ARDS. At Pearson's linear regression analysis, TAPSE was directly correlated with LVEF (r = 0.22, p = 0.021) and inversely with sPAP (r = -0.37, p < 0.001). Systolic pulmonary arterial pressure (sPAP) showed a direct correlation with pCO2 (r = 0.30, p = 0.002) and an inverse one with pH (r = -0.35, p < 0.001) and TAPSE (r =-0.35, p < 0.001). CONCLUSIONS Among patients with ARDS, the severity of disease (as indicated by pO2) does not translate into specific cardiac abnormalities, detected by echocardiography. However, RV function (as indicated by TAPSE) is inversely related to pCO2 and to sPAP (which therefore may be underestimated in presence ofRV dysfunction). Our data strongly suggest that in mechanically ventilated ARDS, the interpretation of echo findings should consider also pCO2 values.
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Duhachek-Stapelman AL, Roberts EK, Schulte TE, Shillcutt SK. The Cardiothoracic Anesthesiologist as a Perioperative Consultant—Echocardiography and Beyond. J Cardiothorac Vasc Anesth 2019; 33:744-754. [DOI: 10.1053/j.jvca.2018.06.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Indexed: 11/11/2022]
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Lazzeri C, Bonizzoli M, Cianchi G, Batacchi S, Guetti C, Cozzolino M, Bernardo P, Peris A. Right ventricular dysfunction and Pre Implantation Vasopressors in Refractory ARDS Supported by VV-ECMO. Heart Lung Circ 2018; 27:1483-1488. [DOI: 10.1016/j.hlc.2017.10.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 09/26/2017] [Accepted: 10/14/2017] [Indexed: 01/28/2023]
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Bautista-Rodriguez C, Sanchez-de-Toledo J, Da Cruz EM. The Role of Echocardiography in Neonates and Pediatric Patients on Extracorporeal Membrane Oxygenation. Front Pediatr 2018; 6:297. [PMID: 30416991 PMCID: PMC6212474 DOI: 10.3389/fped.2018.00297] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 09/21/2018] [Indexed: 11/13/2022] Open
Abstract
Indications for extracorporeal membrane oxygenation (ECMO) and extracorporeal cardiopulmonary resuscitation (ECPR) are expanding, and echocardiography is a tool of utmost importance to assess safety, effectiveness and readiness for circuit initiation and separation. Echocardiography is key to anticipating complications and improving outcomes. Understanding the patient's as well as the ECMO circuit's anatomy and physiology is crucial prior to any ECMO echocardiographic evaluation. It is also vital to acknowledge that the utility of echocardiography in ECMO patients is not limited to the evaluation of cardiac function, and that clinical decisions should not be made exclusively upon echocardiographic findings. Though echocardiography has specific indications and applications, it also has limitations, characterized as: prior to and during cannulation, throughout the ECMO run, upon separation and after separation from the circuit. The use of specific and consistent echocardiographic protocols for patients on ECMO is recommended.
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Affiliation(s)
- Carles Bautista-Rodriguez
- Pediatric Cardiology Department, Hospital Sant Joan de Deu Barcelona, Universitat de Barcelona, Barcelona, Spain
- Department of Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Joan Sanchez-de-Toledo
- Pediatric Cardiology Department, Hospital Sant Joan de Deu Barcelona, Universitat de Barcelona, Barcelona, Spain
- Division of Cardiac Intensive Care, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Eduardo M. Da Cruz
- Department of Pediatrics, Heart Institute, Children's Hospital Colorado, School of Medicine, University of Colorado Denver, Aurora, CO, United States
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Abstract
PURPOSE OF REVIEW An increasing number of patients are placed on extracorporeal membrane oxygenation (ECMO) for respiratory or cardiac failure. Sound understanding of physiology and configuration of ECMO is essential for proper management. This review covers different monitoring parameters and tools for patients supported with different types of ECMO. RECENT FINDINGS Emphasis is placed on monitoring saturations at different sites depending on type of ECMO support. The main monitoring tools detailed in this review are echocardiography and pulmonary artery catheters. SUMMARY The review will help physicians better assess adequate ECMO support by using the appropriate parameters for each type of configuration.
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12
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Perioperative Management of the Adult Patient on Venovenous Extracorporeal Membrane Oxygenation Requiring Noncardiac Surgery. Anesthesiology 2018; 128:181-201. [DOI: 10.1097/aln.0000000000001887] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Abstract
The use of venovenous extracorporeal membrane oxygenation is increasing worldwide. These patients often require noncardiac surgery. In the perioperative period, preoperative assessment, patient transport, choice of anesthetic type, drug dosing, patient monitoring, and intraoperative and postoperative management of common patient problems will be impacted. Furthermore, common monitoring techniques will have unique limitations. Importantly, patients on venovenous extracorporeal membrane oxygenation remain subject to hypoxemia, hypercarbia, and acidemia in the perioperative setting despite extracorporeal support. Treatments of these conditions often require both manipulation of extracorporeal membrane oxygenation settings and physiologic interventions. Perioperative management of anticoagulation, as well as thresholds to transfuse blood products, remain highly controversial and must take into account the specific procedure, extracorporeal membrane oxygenation circuit function, and patient comorbidities. We will review the physiologic management of the patient requiring surgery while on venovenous extracorporeal membrane oxygenation.
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Lazzeri C, Cianchi G, Mauri T, Pesenti A, Bonizzoli M, Batacchi S, Chiostri M, Socci F, Peris A. A novel risk score for severe ARDS patients undergoing ECMO after retrieval from peripheral hospitals. Acta Anaesthesiol Scand 2018; 62:38-48. [PMID: 29058310 DOI: 10.1111/aas.13022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 09/10/2017] [Accepted: 10/04/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Extracorporeal Membrane Oxygenation in severe ARDS unresponsive to conventional protective ventilation is associated with elevated costs, resource and complications, and appropriate risk stratification of candidate patients could be useful to recognize those more likely to benefit from ECMO. We aimed to derive a new outcome prediction score for patients retrieved by our ECMO team from peripheral centers, including systematic echocardiographic evaluation before ECMO start. METHODS Sixty-nine consecutive patients with refractory ARDS requiring ECMO transferred from peripheral centers to our ICU (a tertiary ECMO referral center), from 1 October 2009 to 31 December 2015, were assessed. RESULTS All patients were transported on ECMO (distance, median 77, range 4-456 km) The mortality rate was 41% (28/69). Our new risk score included age ≥ 42 years, BMI < 31 kg/m2 , RV dilatation, and pH < 7.35. The proposed cut off (Youden's index method) of nine had a sensitivity of 96% and a specificity of 30% (AUC-ROC: 0.85, 95% CI: 0.76-0.94, P < 0.001). When assessing the discriminatory ability of our risk score in the population of local patients, survivors had a mean value of 15.4 ± 8.6, whereas non-survivors showed a mean value of 20.1 ± 7.4 (P < 0.001). CONCLUSIONS Our new risk score shows good discriminatory ability both in patients retrieved from peripheral centers and in those implanted at our center. This score includes variables easily available at bedside, and, for the first time, a pathophysiologic element, RV dilatation.
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Affiliation(s)
- C. Lazzeri
- Intensive Care Unit and Regional ECMO Referral centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - G. Cianchi
- Intensive Care Unit and Regional ECMO Referral centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - T. Mauri
- Department of Anesthesia, Critical Care and Emergency; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; Milan Italy
| | - A. Pesenti
- Department of Anesthesia, Critical Care and Emergency; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; Milan Italy
| | - M. Bonizzoli
- Intensive Care Unit and Regional ECMO Referral centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - S. Batacchi
- Intensive Care Unit and Regional ECMO Referral centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - M. Chiostri
- Intensive Care Unit and Regional ECMO Referral centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - F. Socci
- Intensive Care Unit and Regional ECMO Referral centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - A. Peris
- Intensive Care Unit and Regional ECMO Referral centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
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14
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Lazzeri C, Bonizzoli M, Cianchi G, Batacchi S, Chiostri M, Fulceri GE, Buoninsegni LT, Peris A. Bilirubin in the early course of venovenous extracorporeal membrane oxygenation support for refractory ARDS. J Artif Organs 2017; 21:61-67. [DOI: 10.1007/s10047-017-0979-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 08/01/2017] [Indexed: 11/29/2022]
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Betancor J, Xu B, Rehman KA, Rivas CG, Patel K, Tong MZ, Rodriguez LL. Transesophageal Echocardiographic Guidance of Venovenous Extracorporeal Membrane Oxygenation Cannula (Avalon Cannula) Repositioning. ACTA ACUST UNITED AC 2017; 1:150-154. [PMID: 30062269 PMCID: PMC6058252 DOI: 10.1016/j.case.2017.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jorge Betancor
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bo Xu
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Kunal Patel
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael Z Tong
- Department of Cardiothoracic Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - L Leonardo Rodriguez
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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16
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Lazzeri C, Bonizzoli M, Cianchi G, Batacchi S, Terenzi P, Cozzolino M, Bernardo P, Peris A. Lactate and Echocardiography Before Veno-Venous Extracorporeal Membrane Oxygenation Support. Heart Lung Circ 2017; 27:99-103. [PMID: 28343949 DOI: 10.1016/j.hlc.2017.02.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 02/01/2017] [Accepted: 02/06/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Lactate has been recognised as a prognostic factor in several critical conditions. Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) is a well-established therapy in patients with Acute Respiratory Disease Syndrome (ARDS) unresponsive to conventional therapy and echocardiography pre ECMO initiation has been recently reported to help in risk stratifying these patients. METHODS We assessed whether the detection of hyperlactataemia could be associated with the presence of left ventricle (LV) or right ventricle (RV) dysfunction in 121 consecutive patients with refractory ARDS. RESULTS The mortality rate was 42.9% (52/121). Higher dosages of norepinephrine and dobutamine were administered to non survivors (p=0.023 and p=0.047, respectively) who showed significantly higher levels of lactate (p=0.002). At echocardiography, non survivors showed higher values of systolic pulmonary artery pressure (sPAP) (p=0.05) and a higher incidence of RV dysfunction (as indicated by lower Tricuspid Annular Plane Excursion (TAPSE)) and RV dilatation (p=0.001). At multivariate logistic regression analysis, the following variables were independent predictors of death: body mass index (BMI) (OR: 0.914, 95%CI 0.857-0.975, p=0.006), RV dilatation (OR: 0.239, 95%CI 0.101-0.561, p=0.001) and lactate (OR: 1.292, 95%CI 1.015-1.645, p=0.038). Lactate values were directly correlated with the simplified acute physiology score (SAPS) II (r=0.38, p<0.001), while they showed an indirect correlation with left ventricular ejection fraction (LVEF) (r=-0.24, p=0.009) and TAPSE (r=-0.21, p=0.024). CONCLUSIONS In refractory ARDS, hyperlactataemia before VVV-ECMO identified a subset of patients at higher risk of death, being an independent predictor of in-Intensive Care Unit (ICU) mortality. Lactate values are mainly related to disease severity (as indicated by SAPS II) and haemodynamic impairment (as inferred by LVEF) and RV failure, as (indicated by TAPSE).
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Affiliation(s)
- Chiara Lazzeri
- Intensive Care Unit of Heart and Vessels Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Manuela Bonizzoli
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giovanni Cianchi
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Stefano Batacchi
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Paolo Terenzi
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Morena Cozzolino
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Pasquale Bernardo
- Intensive Care Unit of Heart and Vessels Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Adriano Peris
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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17
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Body mass index and echocardiography in refractory ARDS treated with veno-venous extracorporeal membrane oxygenation. J Artif Organs 2016; 20:50-56. [DOI: 10.1007/s10047-016-0931-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 10/16/2016] [Indexed: 12/12/2022]
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18
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Lazzeri C, Cianchi G, Bonizzoli M, Batacchi S, Terenzi P, Bernardo P, Valente S, Gensini GF, Peris A. Pulmonary vascular dysfunction in refractory acute respiratory distress syndrome before veno-venous extracorporeal membrane oxygenation. Acta Anaesthesiol Scand 2016; 60:485-91. [PMID: 26482659 DOI: 10.1111/aas.12643] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 07/16/2015] [Accepted: 09/09/2015] [Indexed: 01/25/2023]
Abstract
BACKGROUND Pulmonary vascular dysfunction has been described in patients with acute respiratory distress syndrome (ARDS). Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a well-established treatment for these patients. We hypothesized that severe pulmonary vascular dysfunction and cor pulmonale identified by echocardiography before cannulation in these patients were associated with worse survival. METHODS Echocardiography was used to identify pulmonary hypertension in 21 patients with refractory ARDS just before ECMO implantation. Survival was compared for those with and without cor pulmonale. RESULTS In our series, the overall mortality rate was 57.1% (12/21). Echocardiographic exams were transthoracic in 5 patients (23.8%), transesophageal in 4 patients (19%), and both (transthoracic and transesophageal) in the remaining 12 patients (57.1%). In our series, six patients (28.5%) showed LV dysfunction. Acute cor pulmonale was detectable in 2 patients (9.5%), while the remaining 19 patients showed moderate pulmonary dysfunction. Survivors had a higher pre-cannulation LV ejection fraction (EF) (P = 0.02) and tricuspid annular plane excursion (P = 0.04), and lower peak systolic pulmonary artery pressures (P = 0.02). CONCLUSIONS In patients with refractory ARDS immediately before ECMO implantation, the prevalence of acute cor pulmonale is low (9.5%). Survival is associated with higher LVEF and lower systolic pulmonary arterial pressure. These findings support the idea that echocardiographic assessment of pulmonary artery pressure in patients with refractory ARDS before VV-ECMO implantation may have value for risk-stratification.
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Affiliation(s)
- C. Lazzeri
- Intensive Care Unit of Heart and Vessels Department; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - G. Cianchi
- Intensive Care Unit and Regional ECMO Referral centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - M. Bonizzoli
- Intensive Care Unit and Regional ECMO Referral centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - S. Batacchi
- Intensive Care Unit and Regional ECMO Referral centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - P. Terenzi
- Intensive Care Unit and Regional ECMO Referral centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - P. Bernardo
- Intensive Care Unit of Heart and Vessels Department; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - S. Valente
- Intensive Care Unit of Heart and Vessels Department; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - G. F. Gensini
- Intensive Care Unit of Heart and Vessels Department; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
- Department of Experimental and Clinical Medicine; University of Florence; AOU Careggi; Fondazione Don Carlo Gnocchi IRCCS; Florence Italy
| | - A. Peris
- Intensive Care Unit and Regional ECMO Referral centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
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Lazzeri C, Bonizzoli M, Cozzolino M, Verdi C, Cianchi G, Batacchi S, Franci A, Gensini GF, Peris A. Serial measurements of troponin and echocardiography in patients with moderate-to-severe acute respiratory distress syndrome. J Crit Care 2016; 33:132-6. [PMID: 26851140 DOI: 10.1016/j.jcrc.2016.01.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 12/24/2015] [Accepted: 01/05/2016] [Indexed: 12/21/2022]
Abstract
PURPOSE To assess the clinical significance of serial troponin I levels (measured in the first 72 hours from admission) in 42 consecutive patients with moderate-to-severe acute respiratory distress syndrome (ARDS). Echocardiography and electrocardiogram testings were serially performed in the time window. MATERIALS AND METHODS Troponin I was measured every 12 hours in the first 72 hours from intensive care unit (ICU) admission. Echocardiography and electrocardiogram testings were serially performed in the same time window to clinically interpret Tn I levels. RESULTS Patients with admission positive Tn I (38.1%) showed higher values of systolic pulmonary hypertension (P = .013) associated with significantly lower values of tricuspid annular plane excursion (P = .011). Twenty-five patients (25/42, 59.5%) exhibited positive peak Tn I and at second echocardiographic assessment exhibited significant lower tricuspid annular plane excursion values (P = .005). At stepwise regression analysis the following variables were an independent predictor for in-ICU mortality: Pco2 (OR 1.08, 95% CI 1.011-1.161, P = .023), systolic pulmonary arterial hypertension (OR 0.83, 95% CI 0.701-0.977, P = .002), log peak Tn I (OR 3.56, 95% CI 1.045-12.132, P = .042). CONCLUSIONS In moderate-to-severe ARDS, serial troponin I assessment together with echocardiography evaluation helped to identify a subgroup at higher risk for in-ICU death. Moreover, troponin release can be related to right ventricular dysfunction, thus highlighting the clinical role of echocardiography in ARDS patients.
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Affiliation(s)
- Chiara Lazzeri
- Intensive Care Unit of Heart and Vessels Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Manuela Bonizzoli
- Intensive Care Unit and Regional ECMO Referral centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Morena Cozzolino
- Intensive Care Unit and Regional ECMO Referral centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Camilla Verdi
- Intensive Care Unit and Regional ECMO Referral centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giovanni Cianchi
- Intensive Care Unit and Regional ECMO Referral centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Stefano Batacchi
- Intensive Care Unit and Regional ECMO Referral centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Andrea Franci
- Intensive Care Unit and Regional ECMO Referral centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Gian Franco Gensini
- Intensive Care Unit of Heart and Vessels Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, AOU Careggi, Fondazione Don Carlo Gnocchi IRCCS, Florence, Italy
| | - Adriano Peris
- Intensive Care Unit and Regional ECMO Referral centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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20
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Lazzeri C, Cianchi G, Bonizzoli M, Batacchi S, Peris A, Gensini GF. The potential role and limitations of echocardiography in acute respiratory distress syndrome. Ther Adv Respir Dis 2015; 10:136-48. [PMID: 26660667 DOI: 10.1177/1753465815621251] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Bedside use of Doppler echocardiography is being featured as a promising, clinically useful tool in assessing the pulmonary circulation in patients with acute respiratory distress syndrome (ARDS). The present review is aimed at summarizing the available evidence obtained with echocardiography on right ventricle (RV) function and pulmonary circulation in ARDS and to highlight the potential of this technique in clinical practice (only articles in English language were considered). According to the available evidence on echocardiographic findings, the following conclusions can be drawn: (a) echocardiography (transthoracic and transesophageal) has a growing role in the management ARDS patients mainly because of the strict interactions between the lung (and ventilation) and the RV and pulmonary circulation; (b) there may be a continuum of alterations in RV size and function and pulmonary circulation which may end in the development of acute cor pulmonale, probably paralleling ARDS disease severity; and (c) the detection of acute cor pulmonale should prompt intensivists to tailor their ventilatory strategy to the individual patient depending on the echocardiography findings. Bearing in mind the clinical role and growing importance of echocardiography in ARDS and the available evidence on this topic, we present a flow chart including the parameters to be measured and the timing of echo exams in ARDS patients. Despite the important progress that echocardiography has gained in the evaluation of patients with ARDS, several open questions remain and echocardiography still appears to be underused in these patients. A more systematic use of echocardiography (mainly through shared protocols) in ARDS could help intensivists to tailor the optimal treatment in individual patients as well as highlighting the limits and potential of this methodology in patients with ALI.
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Affiliation(s)
- Chiara Lazzeri
- Intensive Care Unit of Heart and Vessels Department, University of Florence, AOU Careggi, Fondazione Don Carlo Gnocchi IRCCS, viale Morgagni 8550134, Florence, Italy
| | - Giovanni Cianchi
- Intensive Care Unit and Regional ECMO Referral Center, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Manuela Bonizzoli
- Intensive Care Unit and Regional ECMO Referral Center, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Stefano Batacchi
- Intensive Care Unit and Regional ECMO Referral Center, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Adriano Peris
- Intensive Care Unit and Regional ECMO Referral Center, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Gian Franco Gensini
- Intensive Care Unit of Heart and Vessels Department, University of Florence, AOU Careggi, Fondazione Don Carlo Gnocchi IRCCS, Florence, Italy
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21
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Douflé G, Roscoe A, Billia F, Fan E. Echocardiography for adult patients supported with extracorporeal membrane oxygenation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:326. [PMID: 26428448 PMCID: PMC4591622 DOI: 10.1186/s13054-015-1042-2] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Venoarterial (VA) and venovenous (VV) extracorporeal membrane oxygenation (ECMO) support is increasingly being used in recent years in the adult population. Owing to the underlying disease precipitating severe respiratory or cardiac failure, echocardiography plays an important role in the management of these patients. Nevertheless, there are currently no guidelines on the use of echocardiography in the setting of ECMO support. This review describes the current state of application of echocardiography for patients supported with both VA and VV ECMO.
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Affiliation(s)
- Ghislaine Douflé
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, M5G 2N2, Canada. .,Extracorporeal Life Support (ECLS) Program, Toronto General Hospital, Toronto, ON, M5G 2N2, Canada.
| | - Andrew Roscoe
- Department of Anaesthesia & ICU, Papworth Hospital, Cambridge, CB23 3RE, UK
| | - Filio Billia
- Extracorporeal Life Support (ECLS) Program, Toronto General Hospital, Toronto, ON, M5G 2N2, Canada.,Peter Munk Cardiac Centre, University Health Network, Toronto, ON, M5G 2N2, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, M5G 2N2, Canada.,Extracorporeal Life Support (ECLS) Program, Toronto General Hospital, Toronto, ON, M5G 2N2, Canada
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