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Heinsar S, Sato K, Obonyo N, Farah SM, Bouquet M, Passmore MR, Liu K, Ijunin S, Ainola C, Bassi GL, Suen JY, Fraser JF. Improved Microcirculation with Pulsatile Venoarterial Extracorporeal Membrane Oxygenation: An Ovine Model of Cardiogenic Shock. Am J Respir Crit Care Med 2024; 209:1396-1399. [PMID: 38498867 DOI: 10.1164/rccm.202402-0419le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 03/18/2024] [Indexed: 03/20/2024] Open
Affiliation(s)
- Silver Heinsar
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- St. Andrews War Memorial Hospital, Spring Hill, Queensland, Australia
- Department of Intensive Care, North Estonia Medical Centre, Tallinn, Estonia
| | - Kei Sato
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Nchafatso Obonyo
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Samia M Farah
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Mahe Bouquet
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Margaret R Passmore
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Keibun Liu
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Shinichi Ijunin
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Carmen Ainola
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Department of Intensive Care, North Estonia Medical Centre, Tallinn, Estonia
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- St. Andrews War Memorial Hospital, Spring Hill, Queensland, Australia
- Intensive Care Unit, The Wesley Hospital, Auchenflower, Queensland, Australia
- Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- Queensland University of Technology, Brisbane, Queensland, Australia; and
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- School of Pharmacy and Medical Sciences, Griffith University, Gold Coast Campus, Southport, Queensland, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- St. Andrews War Memorial Hospital, Spring Hill, Queensland, Australia
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Zhang A, Takeda K. Reply: Defining successful decannulation from extracorporeal life support (ECLS). J Thorac Cardiovasc Surg 2024:S0022-5223(24)00289-7. [PMID: 38678472 DOI: 10.1016/j.jtcvs.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 04/02/2024] [Indexed: 05/01/2024]
Affiliation(s)
- Ashley Zhang
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, NY
| | - Koji Takeda
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, NY
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Mariani S, Makhoul M, Schaefer AK, Wiedemann D, Lorusso R. The knowledge gap on the ECMO gap: The importance of speaking the same language. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00243-5. [PMID: 38597858 DOI: 10.1016/j.jtcvs.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 03/10/2024] [Indexed: 04/11/2024]
Affiliation(s)
- Silvia Mariani
- Cardiovascular Research Institute Maastricht, University of Maastricht, Maastricht, The Netherlands; Cardiac Surgery Unit, Cardio-Thoracic and Vascular Department, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Maged Makhoul
- Cardiovascular Research Institute Maastricht, University of Maastricht, Maastricht, The Netherlands; Department of Cardiac Surgery, Rambam Medical Center, Haifa, Israel
| | | | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria; Department of Cardiac Surgery, Karl Landsteiner University, University Clinic St Pölten, St Pölten, Austria
| | - Roberto Lorusso
- Cardiovascular Research Institute Maastricht, University of Maastricht, Maastricht, The Netherlands
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Hermens JAJ, van Til JA, Meuwese CL, van Dijk D, Donker DW. Clinical decision making for VA ECMO weaning in patients with cardiogenic shock A formative qualitative study. Perfusion 2024; 39:39S-48S. [PMID: 38651581 DOI: 10.1177/02676591241236643] [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] [Indexed: 04/25/2024]
Abstract
Weaning and liberation from VA ECMO in cardiogenic shock patients comprises a complex process requiring a continuous trade off between multiple clinical parameters. In the absence of dedicated international guidelines, we hypothesized a great heterogeneity in weaning practices among ECMO centers due to a variety in local preferences, logistics, case load and individual professional experience. This qualitative study focused on the appraisal of clinicians' preferences in decision processes towards liberation from VA ECMO after cardiogenic shock while using focus group interviews in 4 large hospitals. The goal was to provide novel and unique insights in daily clinical weaning practices. As expected, we found we a great heterogeneity of weaning strategies among centers and professionals, although participants appeared to find common ground in a clinically straightforward approach to assess the feasibility of ECMO liberation at the bedside. This was shown in a preference for robust, easily accessible parameters such as arterial pulse pressure, stable cardiac index ≥2.1 L/min, VTI LVOT and 'eyeballing' LVEF.
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Affiliation(s)
- J A J Hermens
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - J A van Til
- Department of Health Technology and Services Research, University of Twente, Enschede, The Netherlands
| | - C L Meuwese
- Department of Intensive Care Medicine and Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - D van Dijk
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - D W Donker
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Cardiovascular and Respiratory Physiology, TechMed Centre, University of Twente, Enschede, The Netherlands
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5
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Mariani S, Schaefer AK, van Bussel BCT, Di Mauro M, Conci L, Szalkiewicz P, De Piero ME, Heuts S, Ravaux J, van der Horst ICC, Saeed D, Pozzi M, Loforte A, Boeken U, Samalavicius R, Bounader K, Hou X, Bunge JJH, Buscher H, Salazar L, Meyns B, Herr D, Matteucci S, Sponga S, MacLaren G, Russo C, Formica F, Sakiyalak P, Fiore A, Camboni D, Raffa GM, Diaz R, Wang IW, Jung JS, Belohlavek J, Pellegrino V, Bianchi G, Pettinari M, Barbone A, Garcia JP, Whitman G, Shekar K, Wiedemann D, Lorusso R. On-Support and Postweaning Mortality in Postcardiotomy Extracorporeal Membrane Oxygenation. Ann Thorac Surg 2023; 116:1079-1089. [PMID: 37414384 DOI: 10.1016/j.athoracsur.2023.05.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/24/2023] [Accepted: 05/30/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Postcardiotomy venoarterial extracorporeal membrane oxygenation (VA ECMO) is characterized by discrepancies between weaning and survival-to-discharge rates. This study analyzes the differences between postcardiotomy VA ECMO patients who survived, died on ECMO, or died after ECMO weaning. Causes of death and variables associated with mortality at different time points are investigated. METHODS The retrospective, multicenter, observational Postcardiotomy Extracorporeal Life Support Study (PELS) includes adults requiring postcardiotomy VA ECMO between 2000 and 2020. Variables associated with on-ECMO mortality and postweaning mortality were modeled using mixed Cox proportional hazards, including random effects for center and year. RESULTS In 2058 patients (men, 59%; median age, 65 years; interquartile range [IQR], 55-72 years), weaning rate was 62.7%, and survival to discharge was 39.6%. Patients who died (n = 1244) included 754 on-ECMO deaths (36.6%; median support time, 79 hours; IQR, 24-192 hours), and 476 postweaning deaths (23.1%; median support time, 146 hours; IQR, 96-235.5 hours). Multiorgan (n = 431 of 1158 [37.2%]) and persistent heart failure (n = 423 of 1158 [36.5%]) were the main causes of death, followed by bleeding (n = 56 of 754 [7.4%]) for on-ECMO mortality and sepsis (n = 61 of 401 [15.4%]) for postweaning mortality. On-ECMO death was associated with emergency surgery, preoperative cardiac arrest, cardiogenic shock, right ventricular failure, cardiopulmonary bypass time, and ECMO implantation timing. Diabetes, postoperative bleeding, cardiac arrest, bowel ischemia, acute kidney injury, and septic shock were associated with postweaning mortality. CONCLUSIONS A discrepancy exists between weaning and discharge rate in postcardiotomy ECMO. Deaths occurred during ECMO support in 36.6% of patients, mostly associated with unstable preoperative hemodynamics. Another 23.1% of patients died after weaning in association with severe complications. This underscores the importance of postweaning care for postcardiotomy VA ECMO patients.
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Affiliation(s)
- Silvia Mariani
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands.
| | | | - Bas C T van Bussel
- Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands; Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Michele Di Mauro
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Luca Conci
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Philipp Szalkiewicz
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Maria Elena De Piero
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Samuel Heuts
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Justine Ravaux
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Iwan C C van der Horst
- Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands; Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Diyar Saeed
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Matteo Pozzi
- Department of Cardiac Surgery, Louis Pradel Cardiologic Hospital, Lyon, France
| | - Antonio Loforte
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Duesseldorf, Germany
| | - Robertas Samalavicius
- II Department of Anesthesiology, Centre of Anesthesia, Intensive Care and Pain Management, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jeroen J H Bunge
- Department of Intensive Care Adults, Erasmus MC, Rotterdam, the Netherlands; Department of Cardiology, Erasmus MC, Rotterdam, the Netherlands
| | - Hergen Buscher
- Department of Intensive Care Medicine, Center of Applied Medical Research, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Leonardo Salazar
- Department of Cardiology, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Daniel Herr
- Department of Medicine, University of Maryland, Baltimore, Maryland; Department of Surgery, University of Maryland, Baltimore, Maryland
| | - Sacha Matteucci
- Struttura Organizzativa Dipartimentale Cardiochirurgia, Ospedali Riuniti 'Umberto I - Lancisi - Salesi' Università Politecnica delle Marche, Ancona, Italy
| | - Sandro Sponga
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Claudio Russo
- Cardiac Surgery Unit, Cardiac Thoracic and Vascular Department, Niguarda Hospital, Milan, Italy
| | - Francesco Formica
- Cardiac Surgery Unit, San Gerardo Hospital, Monza, Italy; Cardiac Surgery Unit, Department of Medicine and Surgery, University Hospital of Parma, University of Parma, Parma, Italy
| | - Pranya Sakiyalak
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Antonio Fiore
- Department of Cardio-Thoracic Surgery, University Hospital Henri-Mondor, Créteil, Paris, France
| | - Daniele Camboni
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Rodrigo Diaz
- ECMO Unit, Departamento de Anestesia, Clínica Las Condes, Las Condes, Santiago, Chile
| | - I-Wen Wang
- Division of Cardiac Surgery, Memorial Healthcare System, Hollywood, Florida
| | - Jae-Seung Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Jan Belohlavek
- Second Department of Internal Medicine, Cardiovascular Medicine General Teaching Hospital, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Vin Pellegrino
- Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Giacomo Bianchi
- Ospedale del Cuore, Fondazione Toscana "G. Monasterio," Massa, Italy
| | - Matteo Pettinari
- Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Alessandro Barbone
- Cardiac Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - José P Garcia
- IU Health Advanced Heart & Lung Care, Indiana University Methodist Hospital, Indianapolis, Indiana
| | - Glenn Whitman
- Cardiac Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Maryland
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
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Hermens JA, Meuwese CL, Szymanski MK, Gianoli M, van Dijk D, Donker DW. Patient-centered weaning from venoarterial extracorporeal membrane oxygenation: "A practice-oriented narrative review of literature". Perfusion 2023; 38:1349-1359. [PMID: 35939761 DOI: 10.1177/02676591221115938] [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] [Indexed: 11/15/2022]
Abstract
Venoarterial extracorporeal membrane oxygenation (V-A ECMO) is increasingly used in cardiogenic shock for rapid stabilization and bridging towards recovery, long-term mechanical circulatory support or transplant. Although technological advances have instigated its widespread use, the complex, long-lasting ECMO care creates a significant strain on hospital staff and resources. Therefore, optimal clinical management including timely decisions on ECMO removal and further therapy are pivotal, yet require a well-structured weaning approach. Although dedicated guidelines are lacking, a variety of weaning protocols have distillated echocardiographic and hemodynamic predictors for successful weaning. Nevertheless, a strikingly high mortality up to 70% after initial successful weaning raises concerns about the validity of current weaning strategies. Here, we plead for a patient-tailored approach including a bailout strategy when weaning fails. This should account not only for left- but also right ventricular function and interdependence, as well as the temporal course of cardiac recovery in function of extracorporeal support. Patients with a high risk of weaning failure should be identified early, enabling timely transportation to an advanced heart failure center. This review summarizes predictors of successful weaning and discusses all relevant elements for a structured weaning approach with a central role for patient-specific clinical considerations and echocardiography.
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Affiliation(s)
- Jeannine Aj Hermens
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Christiaan L Meuwese
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Mariusz K Szymanski
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Monica Gianoli
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Diederik van Dijk
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Dirk W Donker
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Cardiovascular and Respiratory Physiology, TechMed Centre, University of Twente, Enschede, The Netherlands
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Rali AS, Tran LE, Auvil B, Xu M, Huang S, Labrada L, Schlendorf KH, Bacchetta MD, Shah AS, Hernandez A, Lindenfeld J. Modifiable Mechanical Ventilation Targets Are Associated With Improved Survival in Ventilated VA-ECLS Patients. JACC. HEART FAILURE 2023; 11:961-968. [PMID: 37178085 PMCID: PMC10171237 DOI: 10.1016/j.jchf.2023.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/29/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND In acute respiratory distress syndrome (ARDS), lung protective ventilation (LPV) improves patient outcomes by minimizing ventilator-induced lung injury. The value of LPV in ventilated patients with cardiogenic shock (CS) requiring venoarterial extracorporeal life support (VA-ECLS) is not known, but the extracorporeal circuit provides a unique opportunity to modify ventilatory parameters to improve outcomes. OBJECTIVES The authors hypothesized that CS patients on VA-ECLS who require mechanical ventilation (MV) may benefit from low intrapulmonary pressure ventilation (LPPV), which has the same end goals as LPV. METHODS The authors queried the ELSO (Extracorporeal Life Support Organization) registry for hospital admissions between 2009 and 2019 for CS patients on VA-ECLS and MV. They defined LPPV as peak inspiratory pressure at 24 hours on ECLS of <30 cm H2O. Positive end-expiration pressure and dynamic driving pressure (DDP) at 24 hours were also studied as continuous variables. Their primary outcome was survival to discharge. Multivariable analyses were performed that adjusted for baseline Survival After Venoarterial Extracorporeal Membrane Oxygenation score, chronic lung conditions, and center extracorporeal membrane oxygenation volume. RESULTS A total of 2,226 CS patients on VA-ECLS were included: 1,904 received LPPV. The primary outcome was higher in the LPPV group vs the no-LPPV group (47.4% vs 32.6%; P < 0.001). Median peak inspiratory pressure (22 vs 24 cm H2O; P < 0.001) as well as DDP (14.5 vs 16 cm H2O; P < 0.001) were also significantly lower in those surviving to discharge. The adjusted OR for the primary outcome with LPPV was 1.69 (95% CI: 1.21-2.37; P = 0.0021). CONCLUSIONS LPPV is associated with improved outcomes in CS patients on VA-ECLS requiring MV.
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Affiliation(s)
- Aniket S Rali
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | - Lena E Tran
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bryan Auvil
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Meng Xu
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - Shi Huang
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - Lyana Labrada
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelly H Schlendorf
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew D Bacchetta
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - JoAnn Lindenfeld
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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8
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Mariani S, van Bussel BCT, Ravaux JM, Roefs MM, De Piero ME, Di Mauro M, Willers A, Segers P, Delnoij T, van der Horst ICC, Maessen J, Lorusso R. Variables associated with in-hospital and postdischarge outcomes after postcardiotomy extracorporeal membrane oxygenation: Netherlands Heart Registration Cohort. J Thorac Cardiovasc Surg 2023; 165:1127-1137.e14. [PMID: 36229294 DOI: 10.1016/j.jtcvs.2022.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/25/2022] [Accepted: 08/30/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Extracorporeal membrane oxygenation (ECMO) for postcardiotomy cardiogenic shock has been increasingly used without concomitant mortality reduction. This study aims to investigate determinants of in-hospital and postdischarge mortality in patients requiring postcardiotomy ECMO in the Netherlands. METHODS The Netherlands Heart Registration collects nationwide prospective data from cardiac surgery units. Adults receiving intraoperative or postoperative ECMO included in the register from January 2013 to December 2019 were studied. Survival status was established through the national Personal Records Database. Multivariable logistic regression analyses were used to investigate determinants of in-hospital (3 models) and 12-month postdischarge mortality (4 models). Each model was developed to target specific time points during a patient's clinical course. RESULTS Overall, 406 patients (67.2% men, median age, 66.0 years [interquartile range, 55.0-72.0 years]) were included. In-hospital mortality was 51.7%, with death occurring in a median of 5 days (interquartile range, 2-14 days) after surgery. Hospital survivors (n = 196) experienced considerable rates of pulmonary infections, respiratory failure, arrhythmias, and deep sternal wound infections during a hospitalization of median 29 days (interquartile range, 17-51 days). Older age (odds ratio [OR], 1.02; 95% CI, 1.0-1.04) and preoperative higher body mass index (OR, 1.08; 95% CI, 1.02-1.14) were associated with in-hospital death. Within 12 months after discharge, 35.1% of hospital survivors (n = 63) died. Postoperative renal failure (OR, 2.3; 95% CI, 1.6-4.9), respiratory failure (OR, 3.6; 95% CI, 1.3-9.9), and re-thoracotomy (OR, 2.9; 95% CI, 1.3-6.5) were associated with 12-month postdischarge mortality. CONCLUSIONS In-hospital and postdischarge mortality after postcardiotomy ECMO in adults remains high in the Netherlands. ECMO support in patients with higher age and body mass index, which drive associations with higher in-hospital mortality, should be carefully considered. Further observations suggest that prevention of re-thoracotomies, renal failure, and respiratory failure are targets that may improve postdischarge outcomes.
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Affiliation(s)
- Silvia Mariani
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.
| | - Bas C T van Bussel
- Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands; Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Justine M Ravaux
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Maaike M Roefs
- Netherlands Heart Registration, Utrecht, The Netherlands
| | - Maria Elena De Piero
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Michele Di Mauro
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Anne Willers
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Patrique Segers
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Thijs Delnoij
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Iwan C C van der Horst
- Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands; Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jos Maessen
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands; Netherlands Heart Registration, Utrecht, The Netherlands
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
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ECMO Retrieval Program: What Have We Learned So Far. Life (Basel) 2023; 13:life13010157. [PMID: 36676106 PMCID: PMC9865097 DOI: 10.3390/life13010157] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/29/2022] [Accepted: 01/03/2023] [Indexed: 01/06/2023] Open
Abstract
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used for patients with cardiogenic shock or cardiac arrest. However, survival rates remain low. It is unclear to what extent ECMO patients benefit from the ECMO team learning curve. Therefore, we aimed to analyze our mobile ECMO program patients from the past seven years to evaluate if a learning curve benefits patients’ outcomes. We analyzed 111 patients from our databank who were supported with a VA-ECMO and brought to our hospital from January 2015 to December 2021. Patients were divided into two groups: survival (n = 70) and non-survival (n = 41). As expected, complications after ECMO implantation were more severe in the non-survivor group. The incidence of thromboembolic events (p = 0.002), hepatic failure (p < 0.001), renal failure (p = 0.002), dialysis (p = 0.002) and systemic inflammatory response syndrome (SIRS, p = 0.044) occurred significantly more often compared with the survivor group. We were able to show that despite our extensive experience in terms of ECMO retrieval program the high mortality and morbidity rates stay fairly the same over the years. This displays that we have to focus even more on patient selection and ECMO indication.
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Meuwese CL, Brodie D, Donker DW. The ABCDE approach to difficult weaning from venoarterial extracorporeal membrane oxygenation. Crit Care 2022; 26:216. [PMID: 35841052 PMCID: PMC9284848 DOI: 10.1186/s13054-022-04089-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/05/2022] [Indexed: 11/10/2022] Open
Abstract
AbstractVenoarterial extracorporeal membrane oxygenation (VA ECMO) has been increasingly applied in patients with cardiogenic shock in recent years. Nevertheless, many patients cannot be successfully weaned from VA ECMO support and 1-year mortality remains high. A systematic approach could help to optimize clinical management in favor of weaning by identifying important factors in individual patients. Here, we provide an overview of pivotal factors that potentially prevent successful weaning of VA ECMO. We present this through a rigorous approach following the relatable acronym ABCDE, in order to facilitate widespread use in daily practice.
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A Murine Model of Veno-Arterial Extracorporeal Membrane Oxygenation. ASAIO J 2022; 68:e243-e250. [PMID: 36229020 DOI: 10.1097/mat.0000000000001828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The mechanisms driving the pathologic state created by extracorporeal membrane oxygenation (ECMO) remain poorly defined. We developed the first complete blood-primed murine model of veno-arterial ECMO capable of maintaining oxygenation and perfusion, allowing molecular studies that are unavailable in larger animal models. Fifteen C57BL/6 mice underwent ECMO by cannulating the left common carotid artery and the right external jugular vein. The mean arterial pressure was measured through cannulation of the femoral artery. The blood-primed circuit functioned well. Hemodynamic parameters remained stable and blood gas analyses showed adequate oxygenation of the animals during ECMO over a 1-hour timeframe. A significant increase in plasma-free hemoglobin was observed following ECMO, likely secondary to hemolysis within the miniaturized circuit components. Paralleling clinical data, ECMO resulted in a significant increase in plasma levels of multiple proinflammatory cytokines as well as evidence of early signs of kidney and liver dysfunction. These results demonstrate that this novel, miniature blood-primed ECMO circuit represents a functional murine model of ECMO that will provide unique opportunities for further studies to expand our knowledge of ECMO-related pathologies using the wealth of available genetic, pharmacological, and biochemical murine reagents not available for other species.
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Lorusso R, Kowalewski M, Di Mauro M, Mariani S. After the storm comes a calm: the (rather good) post-discharge survival of adults undergoing post-cardiotomy extracorporeal life support. Eur J Cardiothorac Surg 2022; 61:1186-1187. [PMID: 35165705 DOI: 10.1093/ejcts/ezac094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 01/28/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
| | - Mariusz Kowalewski
- Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland.,Thoracic Research Centre, Collegium Medicum, Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Michele Di Mauro
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Silvia Mariani
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 61:1178-1185. [DOI: 10.1093/ejcts/ezac035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 12/07/2021] [Accepted: 01/15/2022] [Indexed: 11/14/2022] Open
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Roeleveld PP, Blom NA, Hazekamp MG. Invited Commentary: Residual Lesions and ECMO: Seek and You Shall Find Ways to Narrow the ECMO Gap. World J Pediatr Congenit Heart Surg 2021; 12:614-615. [PMID: 34597208 DOI: 10.1177/21501351211035785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Nicolaas A Blom
- 4501Leiden University Medical Center, Leiden, The Netherlands
| | - Mark G Hazekamp
- 4501Leiden University Medical Center, Leiden, The Netherlands
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