Transesophageal echocardiography identification of aortic dissection during cardiac arrest and cessation of ECMO initiation

An Intensivist-Led Extracorporeal Membrane Oxygenation Program: Design, Implementation, and Outcomes of the First Five Years

We describe the development, implementation, and outcomes of an intensivist-led adult extracorporeal life support (ECLS) program using intensivists both to perform venovenous (V-V), venoarterial (V-A), and extracorporeal cardiopulmonary resuscitation (ECPR) cannulations, and to manage patients on ECLS throughout their ICU course. All adults supported with ECLS at the University of New Mexico Hospital (UNMH) from February 1, 2017 to December 31, 2021 were retrospectively analyzed. A total of 203 ECLS cannulations were performed in 198 patients, including 116 V-A cannulations (including 65 during ECPR) and 87 V-V cannulations (including 38 in patients with COVID-19). UNMH intensivists performed 195 cannulations, with 9 cannulation complications. Cardiothoracic surgeons performed 8 cannulations. Overall survival to hospital discharge or transfer was 46.5%. Survival was 32.3% in the ECPR group and 56% in the non-ECPR V-A group. In the V-V cohort, survival was 66.7% in the COVID-19-negative patients and 34.2% in the COVID-19-positive patients. This large series of intensivist-performed ECLS cannulations-including V-A, V-V, and ECPR modalities-demonstrates the successful implementation of a comprehensive intensivist-led ECLS program. With outcomes comparable to those in the literature, our program serves as a model for the initiation and development of ECLS programs in settings with limited access to local subspecialty cardiothoracic surgical services.

Indications, Clinical Impact, and Complications of Critical Care Transesophageal Echocardiography: A Scoping Review

BACKGROUND

Critical care transesophageal echocardiography (ccTEE) is an increasingly popular tool used by intensivists to characterize and manage hemodynamics at the bedside. Its usage appears to be driven by expanded diagnostic scope as well as the limitations of transthoracic echocardiography (TTE) - lack of acoustic windows, patient positioning, and competing clinical interests (eg, the need to perform chest compressions). The objectives of this scoping review were to determine the indications, clinical impact, and complications of ccTEE.

METHODS

MEDLINE, EMBASE, Cochrane, and six major conferences were searched without a time or language restriction on March 31^st, 2021. Studies were included if they assessed TEE performed for adult critically ill patients by intensivists, emergency physicians, or anesthesiologists. Intraoperative or post-cardiac surgical TEE studies were excluded. Study demographics, indication for TEE, main results, and complications were extracted in duplicate.

RESULTS

Of the 4403 abstracts screened, 289 studies underwent full-text review, with 108 studies (6739 patients) included. Most studies were retrospective (66%), performed in academic centers (84%), in the intensive care unit (73%), and were observational (55%). The most common indications for ccTEE were hemodynamic instability, trauma, cardiac arrest, respiratory failure, and procedural guidance. Across multiple indications, ccTEE was reported to change the diagnosis in 52% to 78% of patients and change management in 32% to79% patients. During cardiac arrest, ccTEE identified the cause of arrest in 25% to 35% of cases. Complications of ccTEE included two cases of significant gastrointestinal bleeding requiring intervention, but no other major complications (death or esophageal perforation) reported.

CONCLUSIONS

The use of ccTEE has been described for the diagnosis and management of a broad range of clinical problems. Overall, ccTEE was commonly reported to offer additional diagnostic yield beyond TTE with a low observed complication rate. Additional high quality ccTEE studies will permit stronger conclusions and a more precise understanding of the trends observed in this scoping review.

Extracorporeal Life Support for Cardiac Arrest and Cardiogenic Shock

The rising incidence and recognition of cardiogenic shock has led to an increase in the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). As clinical experience with this therapy has increased, there has also been a rapid growth in the body of observational and randomized data describing the clinical and logistical considerations required to institute a VA-ECMO program with successful clinical outcomes. The aim of this review is to summarize this contemporary data in the context of four key themes that pertain to VA-ECMO programs: the principles of patient selection; basic hemodynamic and technical principles underlying VA-ECMO; contraindications to VA-ECMO therapy; and common complications and intensive care considerations that are encountered in the setting of VA-ECMO therapy.

Salvage extracorporeal membrane oxygenation for acute type A aortic dissection with coronary malperfusion

Perioperative use of extracorporeal membrane oxygenation (ECMO) in type A aortic dissection is a topic of contention with limited available data. We report the case of a patient presenting in severe cardiogenic shock due to coronary malperfusion and severe aortic insufficiency who was resucitated with ECMO as a bridge to recovery.

Extracorporeal cardiopulmonary resuscitation for acute aortic dissection during cardiac arrest: A nationwide retrospective observational study

AIM

Acute aortic dissection (AAD) has been considered a contraindication for extracorporeal cardiopulmonary resuscitation (ECPR). However, studies are lacking regarding the epidemiology and effectiveness of ECPR for AAD. We aimed to examine whether ECPR for AAD during refractory cardiac arrest is effective.

METHODS

Using the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2018, we identified all emergently hospitalized adults who received ECPR on the day of admission and all AAD patients who received cardiopulmonary resuscitation on the day of admission. ECPR was defined as receiving both cardiopulmonary resuscitation and percutaneous extracorporeal membrane oxygenation. Outcomes were in-hospital mortality and neurological outcomes. We calculated the incremental cost-effectiveness ratio of ECPR for AAD.

RESULTS

We identified 398 AAD patients with ECPR, 9840 non-AAD patients with ECPR, and 9709 AAD patients with cardiopulmonary resuscitation but not ECPR. The incidence of AAD among the patients with ECPR on the day of admission was 3.9%. In-hospital mortality was 98% in AAD patients with ECPR, 79% in non-AAD patients with ECPR, and 98% in AAD patients with cardiopulmonary resuscitation but not ECPR. Seven AAD patients survived to discharge after ECPR; of these, six patients had good neurological outcomes at discharge. The incremental cost-effectiveness ratio of ECPR for AAD was estimated at 161,504 US dollars per quality-adjusted life year gained.

CONCLUSION

ECPR successfully improved outcomes and/or facilitated surgery for a small number of AAD patients with refractory cardiac arrest; however, the cost burden of ECPR for AAD patients may be unacceptably high.