ECMO Used in a Refractory Ventricular Tachycardia and Ventricular Fibrillation Patient: A National Case-Control Study

Veno-arterial extracorporeal membrane oxygenation without allogeneic blood transfusion: An observational cohort study

INTRODUCTION

It remains unclear whether patients who will not accept allogeneic blood transfusion can be managed successfully with veno-arterial (V-A) extracorporeal membrane oxygenation (ECMO). The objective of our study was to determine what percentage of V-A ECMO patients were managed without allogeneic blood transfusion.

METHODS

This was a retrospective, observational cohort study of patients with cardiogenic shock requiring V-A ECMO between January 2016 and January 2019. The primary outcome was avoidance of any allogeneic blood transfusion.

RESULTS

Of the 206 patients included, 23 (11.2%) were managed without any allogeneic blood transfusion. Fourteen (60.9%) avoided allogeneic blood transfusion during their entire hospitalization. "No-transfusion" patients were younger, more commonly men, were less likely to have a prior diagnosis of hypertension or coronary artery disease, had higher baseline hemoglobin, had higher SAVE scores, and were less likely to have received aspirin before ECMO. No patients in the "no-transfusion" group had major bleeding compared to 35% of patients in the blood transfusion group (p < 0.001). In-hospital mortality was 17.4% for those who avoided blood transfusion and 41.5% for those who received blood transfusion (p = 0.04). ECMO duration was significantly shorter in patients who avoided blood transfusion compared to those who received blood transfusion (median 3.5 vs 7 days, p < 0.001).

CONCLUSIONS

Select patients can be successfully managed on V-A ECMO without allogeneic blood transfusion. Jehovah's Witnesses and other patients with objections to allogeneic transfusion might be offered V-A ECMO if its anticipated duration is short (e.g. <7 days) and baseline hemoglobin concentration is high (e.g. ≥10 mg/dL).

Impaired Pharmacokinetics of Amiodarone under Veno-Venous Extracorporeal Membrane Oxygenation: From Bench to Bedside

BACKGROUND

Adjusting drug therapy under veno-venous extracorporeal membrane oxygenation (VV ECMO) is challenging. Although impaired pharmacokinetics (PK) under VV ECMO have been reported for sedative drugs and antibiotics, data about amiodarone are lacking. We evaluated the pharmacokinetics of amiodarone under VV ECMO both in vitro and in vivo.

METHODS

In vitro: Amiodarone concentration decays were compared between closed-loop ECMO and control stirring containers over a 24 h period. In vivo: Potassium-induced cardiac arrest in 10 pigs with ARDS, assigned to either control or VV ECMO groups, was treated with 300 mg amiodarone injection under continuous cardiopulmonary resuscitation. Pharmacokinetic parameters Cmax, Tmax AUC and F were determined from both direct amiodarone plasma concentrations observation and non-linear mixed effects modeling estimation.

RESULTS

An in vitro study revealed a rapid and significant decrease in amiodarone concentrations in the closed-loop ECMO circuitry whereas it remained stable in control experiment. In vivo study revealed a 32% decrease in the AUC and a significant 42% drop of Cmax in the VV ECMO group as compared to controls. No difference in Tmax was observed. VV ECMO significantly modified both central distribution volume and amiodarone clearance. Monte Carlo simulations predicted that a 600 mg bolus of amiodarone under VV ECMO would achieve the amiodarone bioavailability observed in the control group.

CONCLUSIONS

This is the first study to report decreased amiodarone bioavailability under VV ECMO. Higher doses of amiodarone should be considered for effective amiodarone exposure under VV ECMO.

A case report about successful treatment of refractory ventricular tachycardia with ablation under prolonged haemodynamic support with extracorporeal membrane oxygenation

Background

In patients with severe left ventricular dysfunction, recurrent ventricular tachycardia (VT) non-responsive to antiarrhythmic therapies may cause further deterioration of cardiac function and haemodynamic instability. The use of extracorporeal membrane oxygenation (ECMO) in the setting of haemodynamically unstable VT may allow rhythm stabilization and can be effective in providing haemodynamic stability during VT ablation procedures.

Case summary

We describe the clinical course of a patient with ischaemic cardiomyopathy and recurrent VTs in the early post-myocardial infarction (MI) period. Nineteen days after MI, the patient started to experience recurrent attacks of VT, which became more frequent and non-responsive to medical treatment including amiodarone and lidocaine. The patient developed cardiogenic shock and a decision was made to institute ECMO. The patient was supported with ECMO for 32 days because of heart failure, refractory VT, and recurrent infections. An electrophysiological study was performed 4 days after ECMO initiation, which revealed a large scar area in the left ventricle. Radiofrequency energy was applied 69 times, rendering the VT non-inducible. Subsequently, VT attacks disappeared and the patient was weaned from ECMO after 32 days. The patient received a left ventricular assist device 5 days post-ECMO weaning and was then transplanted.

Discussion

There is still no evidence or guidelines regarding patients with refractory VT; however, ECMO support has been successfully used during VT ablation procedures. In this case report, VT ablation had a crucial role in treating the culprit arrhythmia while the implementation of ECMO allowed a complex ablation procedure to be completed safely.

The use of extracorporeal membrane oxygenation in trauma patients: A national case-control study

Extracorporeal membrane oxygenation (ECMO) has been increasingly applied for the treatment of patients with trauma. Because a common complication of ECMO is bleeding, the use of ECMO support for patients with trauma was limited in the past. Studies have demonstrated a survival benefit from ECMO support in cases of traumatic lung injury, and it is likely that patients with other types of trauma would also benefit from ECMO support. However, the effect of ECMO in patients with other types of trauma is unknown.Using the national insurance data of Taiwan, we identified 810 patients with trauma who received ECMO support from 2000 to 2010. Patients who died or who withdrew from the program within 7 days after discharge were defined as deceased. Logistic regression was used to estimate the odds ratio (OR) of death and 95% confidence intervals (CIs).The overall mortality was 32.8% (266/810). A total of 417 patients received surgery during hospitalization, with an overall mortality of 39.0% (163/417). Patients who underwent thoracic surgery had an OR of 2.23 (95% CI: 1.49-3.34) compared with those who did not. Patients who underwent brain surgery had an OR of 2.86 (95% CI: 1.37-5.98) compared with patients who did not. Patients who received abdominal surgery had an OR of 4.47 (95% CI: 2.63-7.61) compared with patients who did not. All types of surgery had odds of mortality except orthopedic surgery; the use of ECMO with orthopedic surgery had an OR of 1.06 (95% CI: 0.69-1.62) compared with patients who did not receive orthopedic surgery.Except for orthopedic surgery, patients with trauma who received ECMO support and required further surgery during hospitalization exhibited a relatively high mortality rate.

Periprocedural Cardiopulmonary Bypass or Venoarterial Extracorporeal Membrane Oxygenation During Transcatheter Aortic Valve Replacement: A Systematic Review

BACKGROUND

There are limited data on the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) or cardiopulmonary bypass (CPB) to provide hemodynamic support periprocedurally during transcatheter aortic valve replacement. This study sought to evaluate patients receiving transcatheter aortic valve replacement with concomitant use of CPB/VA-ECMO.

METHODS AND RESULTS

We systematically reviewed the published literature from 2000 to 2018 for studies evaluating adult patients requiring CPB/VA-ECMO periprocedurally during transcatheter aortic valve replacement. Studies reporting short-term and long-term mortality were included. Given the significant methodological and statistical differences between published studies, meta-analysis of the association of CPB/VA-ECMO with mortality was not performed. Of the 537 studies identified, 9 studies representing 5191 patients met our inclusion criteria. Median ages were between 75 and 87 years with 33% to 75% male patients. Where reported, the Edwards SAPIEN™ transcatheter heart valve was the most frequently used. A total of 203 (3.9%) patients received periprocedural hemodynamic support with CPB/VA-ECMO. Common indications for CPB/VA-ECMO included left ventricular or aortic annular rupture, rapid hemodynamic deterioration, aortic regurgitation, cardiac arrest, and left main coronary artery obstruction. The use of CPB/VA-ECMO was predominantly an emergent strategy and was used for durations of 1 to 2 hours. Short-term mortality (in-hospital and 30-day) was 29.8%, and 1-year mortality was 52.4%. Major complications such as bleeding, vascular injury, tamponade, stroke, and renal failure were noted in 10% to 50% of patients.

CONCLUSIONS

CPB/VA-ECMO was used in 4% in the early experience of patients undergoing transcatheter aortic valve replacement, most commonly for periprocedural complications. There are limited data on preprocedural planned use of VA-ECMO, and the characteristics of this population remain poorly defined.

Postcardiotomy refractory ventricular fibrillation: rescue using veno-arterial extracorporeal membrane oxygenation

We present a case of 7-hour ventricular fibrillation with successful use of veno-arterial extracorporeal membrane oxygenation as a bridge to recovery in a 30-year-old patient with grown-up congenital heart disease who underwent pulmonary valve replacement.

Ventricular Tachycardia with ICD Shocks: When to Medicate and When to Ablate

PURPOSE OF REVIEW

Ventricular tachycardia occurrence in implantable cardioverter defibrillator (ICD) patients may result in shock delivery and is associated with increased morbidity and mortality. In addition, shocks may have deleterious mechanical and psychological effects. Prevention of ventricular tachycardia (VT) recurrence with the use of antiarrhythmic drugs or catheter ablation may be warranted. Antiarrhythmic drugs are limited by incomplete efficacy and an unfavorable adverse effect profile. Catheter ablation can be effective but acute complications and long-term VT recurrence risk necessitating repeat ablation should be recognized. A shared clinical decision process accounting for patients' cardiac status, comorbidities, and goals of care is often required.

RECENT FINDINGS

There are four published randomized trials of catheter ablation for sustained monomorphic VT (SMVT) in the setting of ischemic heart disease; there are no randomized studies for non-ischemic ventricular substrates. The most recent trial is the VANISH trial which randomly allocated patients with ICD, prior infarction, and SMVT despite first-line antiarrhythmic drug therapy to catheter ablation or more aggressive antiarrhythmic drug therapy. During 28 months of follow-up, catheter ablation resulted in a 28% relative risk reduction in the composite endpoint of death, VT storm, and appropriate ICD shock (p = 0.04). In a subgroup analysis, patients having VT despite amiodarone had better outcomes with ablation as compared to increasing amiodarone dose or adding mexiletine. There is evidence for the effectiveness of both catheter ablation and antiarrhythmic drug therapy for patients with myocardial infarction, an implantable defibrillator, and VT. If sotalol is ineffective in suppressing VT, either catheter ablation or initiation of amiodarone is a reasonable option. If VT occurs despite amiodarone therapy, there is evidence that catheter ablation is superior to administration of more aggressive antiarrhythmic drug therapy. Early catheter ablation may be appropriate in some clinical situations such as patients presenting with relatively slow VT below ICD detection, electrical storms, hemodynamically stable VT, or in very selected patients with left ventricular assist devices. The optimal first-line suppressive therapy for VT, after ICD implantation and appropriate programming, remains to be determined. Thus far, there has not been a randomized controlled trial to compare catheter ablation to antiarrhythmic drug therapy as a first-line treatment; the VANISH-2 study has been initiated as a pilot to examine this question.

Extracorporeal Membrane Oxygenation (ECMO) and the Critical Cardiac Patient

PURPOSE OF REVIEW

This review is to summarize the basics of veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) as it is utilized for critically ill cardiac patients.

RECENT FINDINGS

ECMO may be instituted in a variety of health care settings, from the emergency room to the operating room. The types of patients who may benefit from ECMO are reviewed in detail. The complications of ECMO are reviewed, including access-related issues and hematologic and neurologic problems. The principles of weaning of ECMO are described.

CONCLUSION

Due to its versatility and relatively low cost, VA ECMO use is sharply increasing worldwide. It is important to select patients carefully for this mode of therapy as it can keep patients alive even in states of severe neurologic impairment or multiorgan failure. Short courses of ECMO may allow critically ill patients to be salvaged, but ultimately survival depends on resolution of the underlying problem or ability to transition to another more durable mode of cardiac support.