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Frere C, Mazzeffi M, Maier CL, Helms J, Steiner ME, Sullenger BA, Tanaka KA, Connors JM, Levy JH. Acquired von Willebrand syndrome during extracorporeal membrane oxygenation support: a comprehensive review of current evidence: communication from the ISTH SSC on perioperative and critical care thrombosis and hemostasis. J Thromb Haemost 2024; 22:2608-2628. [PMID: 38925492 DOI: 10.1016/j.jtha.2024.06.007] [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: 04/28/2024] [Revised: 06/11/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024]
Abstract
During extracorporeal membrane oxygenation (ECMO) support, the high shear stress in the ECMO circuit results in increased proteolysis of von Willebrand factor (VWF), loss of VWF high-molecular-weight multimers, and impaired ability to bind to platelets and collagen. These structural changes in VWF are consistent with acquired von Willebrand syndrome (AVWS) type 2A and may contribute to the bleeding diathesis frequently observed in ECMO patients. We performed a systematic review of all clinical studies evaluating the prevalence and associated outcomes of AVWS in ECMO patients. Our findings suggest that almost all ECMO patients develop partial or complete loss of VWF high-molecular-weight multimers within a few hours of device implantation. The AVWS persists as long as the patient is supported by ECMO. Weaning from ECMO rapidly and completely resolves the AVWS. Nevertheless, few studies have reported bleeding outcomes in ECMO patients with AVWS, and the extent to which AVWS contributes to the bleeding diathesis during ECMO support cannot be determined by current evidence. Data supporting the use of VWF concentrates to prevent bleeding complications in ECMO patients remain limited.
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Affiliation(s)
- Corinne Frere
- Department of Hematology, Sorbonne Université, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
| | - Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Julie Helms
- Department of Medical Intensive Care, Strasbourg University (UNISTRA), Strasbourg University Hospital, Strasbourg, France; INSERM (French National Institute of Health and Medical Research), UMR (Unité mixte de recherche) 1260, Regenerative Nanomedicine (RNM), Strasbourg, France
| | - Marie E Steiner
- Department of Pediatrics, Divisions of Hematology/Oncology and Critical Care, University of Minnesota, Minneapolis, Minnesota, USA
| | - Bruce A Sullenger
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Jean M Connors
- Hematology Division Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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Augustin KJ, Wieruszewski PM, McLean L, Leiendecker E, Ramakrishna H. Analysis of the 2023 European Multidisciplinary Consensus Statement on the Management of Short-term Mechanical Circulatory Support of Cardiogenic Shock in Adults in the Intensive Cardiac Care Unit. J Cardiothorac Vasc Anesth 2024; 38:1786-1801. [PMID: 38862282 DOI: 10.1053/j.jvca.2024.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 04/21/2024] [Indexed: 06/13/2024]
Affiliation(s)
- Katrina Joy Augustin
- Division of Anesthesia and Critical Care Medicine, Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, MN; Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | - Patrick M Wieruszewski
- Department of Pharmacy, Mayo Clinic, Rochester, MN; Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | - Lewis McLean
- Intensive Care Unit, John Hunter Hospital, Newcastle, Australia
| | | | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Garaj M, Francesconi A, Durila M, Vajter J, Holubová G, Hrachovinová I. ECMO produces very rapid changes in primary hemostasis detected by PFA-200 during lung transplantation: An observational study. J Heart Lung Transplant 2024:S1053-2498(24)01745-5. [PMID: 39038564 DOI: 10.1016/j.healun.2024.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 06/13/2024] [Accepted: 07/12/2024] [Indexed: 07/24/2024] Open
Abstract
BACKGROUND The pathology of primary hemostasis is a common complication of extracorporeal membrane oxygenation (ECMO) support. Scientific data describing its changes in patients on short-term ECMO support and the ability and speed of the restoration of its functions are limited. AIMS The aim of this study was to describe the pathology of primary hemostasis induced by short-term ECMO support and its development over time using PFA-200, ROTEM platelet, and von Willebrand factor (vWF) analyses. METHODS In patients undergoing lung transplantation surgery using intraoperative veno-arterial ECMO support, blood samples were analyzed using the following tests: PFA-200, ROTEM platelet tests, vWF antigen, ristocetin cofactor (RCo), and collagen-binding protein (CB) before, during, and after ECMO support. RESULTS Blood samples from 32 patients were analyzed. All 3 PFA-200 tests (COL/EPI, COL/ADP, and COL/P2Y) showed significant deterioration during ECMO support with rapid restoration after ECMO cessation (p < 0.05), suggesting an ECMO-induced primary hemostasis disorder. A significant increase of vWF antigen after ECMO cessation (p < 0.05) was found with an increase of RCo and CB levels, although it was not significant (p > 0.05). CONCLUSIONS Short-term ECMO support induces primary hemostasis pathology. It occurs immediately after initiation but is rapidly restored after ECMO cessation, which is detectable by PFA-200. Despite there being persistent platelet dysfunction after ECMO cessation, as seen with the ROTEM platelet results, the increased levels of vWF antigen might explain the normal results of primary hemostasis detected by PFA-200.
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Affiliation(s)
- Michal Garaj
- Department of Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic.
| | | | - Miroslav Durila
- Department of Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Jaromir Vajter
- Department of Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Gabriela Holubová
- Department of Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Ingrid Hrachovinová
- Laboratory for Disorders in Hemostasis, Institute of Hematology and Blood Transfusion, Prague, Czech Republic
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de Roux Q, Disli Y, Bougouin W, Renaudier M, Jendoubi A, Merle JC, Delage M, Picard L, Sayagh F, Cherait C, Folliguet T, Quesnel C, Becq A, Mongardon N. Upper gastrointestinal bleeding on veno-arterial extracorporeal membrane oxygenation support. Ann Intensive Care 2024; 14:104. [PMID: 38958791 PMCID: PMC11222359 DOI: 10.1186/s13613-024-01326-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 05/29/2024] [Indexed: 07/04/2024] Open
Abstract
INTRODUCTION Patients on veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support are at a high risk of hemorrhagic complications, including upper gastrointestinal bleeding (UGIB). The objective of this study was to evaluate the incidence and impact of this complication in V-A ECMO patients. MATERIALS AND METHODS A retrospective single-center study (2013-2017) was conducted on V-A ECMO patients, excluding those who died within 24 h. All patients with suspected UGIB underwent esophagogastroduodenoscopy (EGD) and were analyzed and compared to the remainder of the cohort, from the initiation of ECMO until 5 days after explantation. RESULTS A total of 150 V-A ECMO cases (65 after cardiac surgery and 85 due to medical etiology) were included. 90% of the patients received prophylactic proton pump inhibitor therapy and enteral nutrition. Thirty-one patients underwent EGD for suspected UGIB, with 16 confirmed cases of UGIB. The incidence was 10.7%, with a median occurrence at 10 [7-17] days. There were no significant differences in clinical or biological characteristics on the day of EGD. However, patients with UGIB had significant increases in packed red blood cells and fresh frozen plasma needs, mechanical ventilation duration and V-A ECMO duration, as well as in length of intensive care unit and hospital stays. There was no significant difference in mortality. The only independent risk factor of UGIB was a history of peptic ulcer (OR = 7.32; 95% CI [1.07-50.01], p = 0.042). CONCLUSION UGIB occurred in at least 1 out of 10 cases of V-A ECMO patients, with significant consequences on healthcare resources. Enteral nutrition and proton pump inhibitor prophylaxis did not appear to protect V-A ECMO patients. Further studies should assess their real benefits in these patients with high risk of hemorrhage.
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Affiliation(s)
- Quentin de Roux
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France.
- U955-IMRB, Equipe 03 "Stratégies pharmacologiques et thérapeutiques expérimentales des insuffisances cardiaques et coronaires", Inserm, UPEC, Ecole Nationale Vétérinaire d'Alfort, Maisons-Alfort, France.
- Service d'Anesthésie-Réanimation et Médecine Péri-Opératoire, CHU Henri Mondor, 1 rue Gustave Eiffel, Créteil, 94000, France.
| | - Yekcan Disli
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Wulfran Bougouin
- Réanimation polyvalente, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, Massy, France
- AfterROSC research group, Paris, France
| | - Marie Renaudier
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Ali Jendoubi
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Jean-Claude Merle
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Mathilde Delage
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Lucile Picard
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Faiza Sayagh
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Chamsedine Cherait
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Thierry Folliguet
- Service de chirurgie cardiaque, Assistance Publique-Hôpitaux de Paris, DMU CARE, Hôpitaux Universitaires Henri Mondor, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France
| | - Christophe Quesnel
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France
| | - Aymeric Becq
- Service de gastro-entérologie, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France
| | - Nicolas Mongardon
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France
- U955-IMRB, Equipe 03 "Stratégies pharmacologiques et thérapeutiques expérimentales des insuffisances cardiaques et coronaires", Inserm, UPEC, Ecole Nationale Vétérinaire d'Alfort, Maisons-Alfort, France
- AfterROSC research group, Paris, France
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Aljeaidi M, Fiorilla XM, Mammana B, Anstey M. Mucosal bleeding while on venovenous extracorporeal membrane oxygenation in the setting of vitamin C deficiency. BMJ Case Rep 2024; 17:e259185. [PMID: 38926124 DOI: 10.1136/bcr-2023-259185] [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: 06/28/2024] Open
Abstract
A major complication with extracorporeal membrane oxygenation (ECMO) is bleeding which can occur in up to 40% of cases and can be life-threatening. Minor bleeding may be overlooked and under-reported. While some of the underlying mechanisms such as platelet injury and anticoagulation therapy have been identified, several other factors are still under-researched. Here, we describe a unique case of a subtle mucosal membrane bleeding that is found to be associated with vitamin C deficiency while on treatment with ECMO. Investigating vitamin C levels may be useful in understanding causes of bleeding in some patients on ECMO therapy, particularly if there are risk factors for malnutrition.
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Affiliation(s)
- Muhamad Aljeaidi
- The University of Western Australia Medical School, Perth, Western Australia, Australia
- Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | | | - Bianca Mammana
- Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Matthew Anstey
- Intensive Care, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
- The University of Western Australia Medical School, Nedlands, Western Australia, Australia
- School of Public Health, Curtin University, Perth, Western Australia, Australia
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6
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Moussa MD, Soquet J, Robin E, Labreuche J, Rousse N, Rauch A, Loobuyck V, Leroy G, Duburcq T, Gantois G, Leroy X, Ait-Ouarab S, Lamer A, Thellier L, Lukowiak O, Schurtz G, Muller C, Juthier F, Susen S, Vincentelli A. Definitions of major bleeding for predicting mortality in critically ill adult patients who survived 24 hours while supported with peripheral veno-arterial extracorporeal membrane oxygenation for cardiogenic shock: a comparative historical cohort study. Can J Anaesth 2024; 71:523-534. [PMID: 38438682 DOI: 10.1007/s12630-024-02704-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 03/06/2024] Open
Abstract
PURPOSE The severity of bleeding events is heterogeneously defined during peripheral veno-arterial extracorporeal membrane oxygenation (pVA-ECMO). We studied three bleeding definitions in pVA-ECMO: the Extracorporeal Life Support Organization (ELSO)-serious bleeding, the Bleeding Academic Research Consortium (BARC), and the universal definition of postoperative bleeding (UPDB) classifications. METHODS We included consecutive adult patients supported by pVA-ECMO for refractory cardiogenic shock admitted to Lille academic hospitals between January 2013 and December 2019. We assessed the association of bleeding definitions with the primary endpoint of 28-day all-cause mortality with the use of multivariate models accounting for time-dependent and competing variables. We compared models' performances using the Harrell's C-Index and the Akaike information criteria. RESULTS Twenty-eight-day mortality occurred in 128/308 (42%) 308 patients. The ELSO-serious bleeding (hazard ratio [HR], 1.67; 95% confidence interval [CI], 1.09 to 2.56) and BARC ≥ type 2 (HR, 1.55; 95% CI, 1.01 to 2.37) were associated with 28-day mortality (Harrell's C-index, 0.69; 95% CI, 0.63 to 0.74 for both). Predictors of ELSO-serious bleeding were postcardiotomy, body mass index, baseline platelets count, fibrinogen, and hemoglobin levels. CONCLUSION Extracorporeal Life Support Organization-serious bleeding and BARC ≥ type 2 are relevant definitions of major bleeding regarding their association with mortality in critically ill patients who survived the first 24 hr while supported with pVA-ECMO for cardiogenic shock. STUDY REGISTRATION CERAR (IRB 00010254-2022-050, Paris, France); first submitted on 18 April 2022.
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Affiliation(s)
- Mouhamed D Moussa
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France.
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France.
- Service d'Anesthésie-Réanimation Cardiovasculaire et thoracique, Institut Cœur - Poumon, CHU Lille, 2 avenue Oscar Lambret, 59 037, Lille, France.
| | - Jérôme Soquet
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
| | - Emmanuel Robin
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France
| | | | - Natacha Rousse
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
| | - Antoine Rauch
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
| | - Valentin Loobuyck
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
| | | | | | | | - Xavier Leroy
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France
| | | | - Antoine Lamer
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France
| | - Lise Thellier
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France
| | | | - Guillaume Schurtz
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiology, CHU Lille, Lille, France
| | | | - Francis Juthier
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
| | - Sophie Susen
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
| | - André Vincentelli
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
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Nishimura T, Toda K, Ako J, Hirayama A, Kinugawa K, Kobayashi Y, Ono M, Sato N, Shindo T, Shiose A, Takayama M, Yasukochi S, Sawa Y. Prevalence of bleeding events in real-world Japanese registry for Percutaneous Ventricular Assist Device. J Artif Organs 2024:10.1007/s10047-023-01429-5. [PMID: 38396197 DOI: 10.1007/s10047-023-01429-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 12/14/2023] [Indexed: 02/25/2024]
Abstract
PURPOSE Bleeding complication is a critical risk factor for outcomes of acute heart failure patients requiring mechanical circulatory support (MCS), including percutaneous catheter-type heart pumps (Impella). The Japanese registry for Percutaneous Ventricular Assist Device (J-PVAD) is an ongoing, large-scale, real-world registry to characterize Japanese patients requiring Impella. Here we analyzed bleeding complication profiles in patients who received Impella. METHODS All consecutive Japanese patients who received Impella from October 2017 to January 2020 were enrolled. The 30-day survival and bleeding complications were analyzed. RESULTS A total of 1344 patients were included: 653 patients received Impella alone, 685 patients received a combination of veno-arterial extracorporeal membrane oxygenation and Impella (ECPELLA), and 6 patients had failed Impella delivery. Overall 30-day survival was 67.0%, with Impella alone at 81.9% and ECPELLA at 52.7%. Overall bleeding/hematoma adverse events with a relation or not-excluded relation to Impella was 6.92%. Among them, the rates of hematoma and bleeding from medical device access sites were 1.41% and 4.09%, respectively. There was no difference between etiologies for these events. CONCLUSION This study represents the first 3-year survival and the safety profile focused on bleeding adverse events from the J-PVAD registry. The results show that the real-world frequency of bleeding adverse events for patients who received Impella was an expected range from previous reports, and future real-world studies should aim to expand this data set to improve outcomes and adverse events.
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Affiliation(s)
- Takashi Nishimura
- Department of Cardiovascular and Thoracic Surgery, Graduate School of Medicine, Ehime University, Ehime, Japan.
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, School of Medicine, Kitasato University, Kanagawa, Japan
| | | | - Koichiro Kinugawa
- The Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Naoki Sato
- Department of Cardiology, Kawaguchi Cardiovascular and Respiratory Hospital, Saitama, Japan
| | - Takahiro Shindo
- Division of Cardiology, National Center for Child Health and Development, Tokyo, Japan
| | - Akira Shiose
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medicine, Fukuoka, Japan
| | - Morimasa Takayama
- Department of Cardiovascular Internal Medicine, Sakakibara Heart Institute, Tokyo, Japan
| | - Satoshi Yasukochi
- Department of Pediatric Cardiology, Nagano Children's Hospital, Nagano, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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Ledergerber K, Hollinger A, Zimmermann S, Todorov A, Trutmann M, Gallachi L, Gschwandtner LA, Ryser LA, Gebhard CE, Bolliger D, Buser A, Tsakiris DA, Siegemund M. Impact of Additional Administration of von Willebrand Factor Concentrates to Thrombocyte Transfusion in Perioperative Bleeding in Cardiac Surgery. Transfus Med Hemother 2024; 51:22-31. [PMID: 38314243 PMCID: PMC10836859 DOI: 10.1159/000530810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 04/16/2023] [Indexed: 02/06/2024] Open
Abstract
Background Von Willebrand factor (vWF) is an important part of blood coagulation since it binds platelets to each other and to endothelial cells. In traumatic and surgical haemorrhage, both blood cells and plasmatic factors are consumed, leading to consumption coagulopathy and fluid resuscitation. This often results in large amounts of crystalloids and blood products being infused. Additional administration of vWF complex and platelets might mitigate this problem. We hypothesize that administration of vWF concentrate additionally to platelet concentrates reduces blood loss and the amount of blood products (platelets, red blood cells [RBC], fresh frozen plasma [FFP]) administered. Methods We conducted a monocentric 6-year retrospective data analysis of cardiac surgery patients. Included were all patients receiving platelet concentrates within 48 h postoperatively. Patients who additionally received vWF concentrates were allocated to the intervention group and all others to the control group. Groups were compared in mixed regression models correcting for known confounders, based on nearest neighbour propensity score matching. Primary endpoints were loss of blood (day one and two) and amount of needed blood products on day one and two (platelets, RBC, FFP). Secondary endpoints were intensive care unit (ICU) and in-hospital length of stay, ICU and in-hospital mortality, and absolute difference of platelet counts before and after treatment. Results Of 497 patients analysed, 168 (34%) received vWF concentrates. 121 patients in both groups were considered for nearest neighbour matching. Patients receiving additional vWF were more likely to receive more blood products (RBC, FFP, platelets) in the first 24 h after surgery and had around 200 mL more blood loss at the same time. Conclusion In this retrospective analysis, no benefit in additional administration of vWF to platelet concentrates on perioperative blood loss, transfusion requirement (platelets, RBC, FFP), length of stay, and mortality could be found. These findings should be verified in a prospective randomized controlled clinical trial (www.clinicaltrials.gov identifier NCT04555785).
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Affiliation(s)
| | - Alexa Hollinger
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | | | - Atanas Todorov
- Cardiovascular Gender Medicine, University Hospital Zürich, Zürich, Switzerland
| | - Maren Trutmann
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Laura Gallachi
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | | | | | - Caroline Eva Gebhard
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Daniel Bolliger
- Medical Faculty, University of Basel, Basel, Switzerland
- Department of Anesthesiology, University Hospital Basel, Basel, Switzerland
| | - Andreas Buser
- Medical Faculty, University of Basel, Basel, Switzerland
- Department of Anesthesiology, University Hospital Basel, Basel, Switzerland
- Regional Blood Transfusion Service of the Swiss Red Cross, Basel, Switzerland
| | - Dimitrios Athanasios Tsakiris
- Medical Faculty, University of Basel, Basel, Switzerland
- Department of Transfusion Medicine and Hematology, Basel University Hospital, Basel, Switzerland
| | - Martin Siegemund
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
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Drop JG, Wildschut ED, de Maat MPM, van Rosmalen J, de Boode WP, de Hoog M, Heleen van Ommen C. Acquired von Willebrand disease in children undergoing extracorporeal membrane oxygenation: a prospective observational study. J Thromb Haemost 2023; 21:3383-3392. [PMID: 37579879 DOI: 10.1016/j.jtha.2023.08.007] [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: 02/28/2023] [Revised: 07/20/2023] [Accepted: 08/02/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) provides cardiopulmonary support for children with severe cardiac and/or pulmonary failure. The incidence of bleeding complications during ECMO support is high. Acquired von Willebrand disease (AVWD) might contribute to the development of bleeding complications. OBJECTIVE To study the incidence and longitudinal profile of AVWD during the first 14 days of ECMO support in children and to investigate the association between AVWD and bleeding complications. METHODS This prospective observational study included pediatric patients (0-17 years) receiving ECMO. Blood was sampled prior to and after ECMO start, daily and 12 to 24 hours after stopping ECMO. von Willebrand factor (VWF) parameters and multimer patterns were determined. Clinical data were collected for each patient. AVWD was defined as loss of high-molecular weight multimers (ie, decreased compared with baseline) or a VWF:collagen binding/VWF: antigen (Ag) ratio or VWF:activity/VWF:Ag ratio below 0.7. RESULTS All of 50 (100%) patients developed AVWD during ECMO. The VWF:collagen binding /VWF:Ag ratio, VWF:activity/VWF:Ag ratio, and high-molecular weight multimers decreased during the initial days and recovered to baseline level within 24 hours after stopping ECMO. The incidence and longitudinal profile of AVWD were similar in patients with and without major bleeding complications. CONCLUSION Children receiving ECMO support commonly develop AVWD. AVWD develops rapidly after ECMO initiation and recovers quickly after ECMO cessation. Importantly, AVWD appears to be independent of major bleeding.
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Affiliation(s)
- Joppe G Drop
- Department of Paediatrics, Division of Paediatric Hematology, Erasmus Medical Center Rotterdam - Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Paediatrics, Division of Pediatric Intensive care and Pediatric surgery, Erasmus Medical Center Rotterdam - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Enno D Wildschut
- Department of Paediatrics, Division of Pediatric Intensive care and Pediatric surgery, Erasmus Medical Center Rotterdam - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Moniek P M de Maat
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Epidemiology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Willem P de Boode
- Division of Neonatology, Dept. of Perinatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Matthijs de Hoog
- Department of Paediatrics, Division of Pediatric Intensive care and Pediatric surgery, Erasmus Medical Center Rotterdam - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - C Heleen van Ommen
- Department of Paediatrics, Division of Paediatric Hematology, Erasmus Medical Center Rotterdam - Sophia Children's Hospital, Rotterdam, the Netherlands.
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10
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Sun GH, Ortoleva JP, Lu SY, Vanneman MW, Tanaka K, Mazzeffi M, Dalia AA. ABO Blood Group and Bleeding and Survival in VA-ECMO Patients. J Intensive Care Med 2023; 38:1015-1022. [PMID: 37291851 DOI: 10.1177/08850666231178759] [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: 06/10/2023]
Abstract
ABO blood group has been shown to be a major determinant of plasma von Willebrand factor (vWF) levels. O blood group is associated with the lowest vWF levels and confers an increased risk of hemorrhagic events, while AB blood group has the highest levels and is associated with thromboembolic events. We hypothesized in extracorporeal membrane oxygenation (ECMO) patients that O blood type would have the highest and AB blood type would have the lowest transfusions, with an inverse relationship to survival. A retrospective analysis of 307 VA-ECMO patients at a major quaternary referral hospital was performed. The distribution of blood groups included 124 group O (40%), 122 group A (40%), 44 group B (14%), and 17 group AB (6%) patients. Regarding usage of packed red blood cells, fresh frozen plasma, and platelets, there was a non-statistically significant difference in transfusions, with group O having the least and group AB having the most requirements. However, there was a statistically significant difference in cryoprecipitate usage when comparing to group O: group A (1.77, 95% CI: 1.05-2.97, P < .05), group B (2.05, 95% CI: 1.16-3.63, P < .05), and group AB (3.43, 95% CI: 1.71-6.90, P < .001). Furthermore, a 20% increase in length of days on ECMO was associated with a 2-12% increase in blood product usage. The cumulative 30-day mortality rate for groups O and A was 60%, group B was 50%, and group AB was 40%; the 1-year mortality rate for groups O and A was 65%, group B was 57%, and group AB was 41%; however, the mortality differences were not statistically significant.
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Affiliation(s)
- Gina H Sun
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jamel P Ortoleva
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA, USA
| | - Shu Y Lu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Matthew W Vanneman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Hospital, Palo Alto, CA, USA
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Virginia Health University Hospital, Charlottesville, VA, USA
| | - Adam A Dalia
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
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11
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Wang H, Li D, Chen Y, Liu Z, Liu Y, Meng X, Fan H, Hou S. Shear-induced acquired von Willebrand syndrome: an accomplice of bleeding events in adults on extracorporeal membrane oxygenation support. Front Cardiovasc Med 2023; 10:1159894. [PMID: 37485275 PMCID: PMC10357042 DOI: 10.3389/fcvm.2023.1159894] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/21/2023] [Indexed: 07/25/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is an increasingly acceptable life-saving mechanical assistance system that provides cardiac and/or respiratory support for several reversible or treatable diseases. Despite important advances in technology and clinical management, bleeding remains a significant and common complication associated with increased morbidity and mortality. Some studies suggest that acquired von Willebrand syndrome (AVWS) is one of the etiologies of bleeding. It is caused by shear-induced deficiency of von Willebrand factor (VWF). VWF is an important glycoprotein for hemostasis that acts as a linker at sites of vascular injury for platelet adhesion and aggregation under high shear stress. AVWS can usually be diagnosed within 24 h after initiation of ECMO and is always reversible after explantation. Nonetheless, the main mechanism for the defect in the VWF multimers under ECMO support and the association between AVWS and bleeding complications remains unknown. In this review, we specifically discuss the loss of VWF caused by shear induction in the context of ECMO support as well as the current diagnostic and management strategies for AVWS.
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Affiliation(s)
- Haiwang Wang
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Duo Li
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Yuansen Chen
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Ziquan Liu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Yanqing Liu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Xiangyan Meng
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Haojun Fan
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Shike Hou
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
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12
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Noitz M, Brooks R, Szasz J, Jenner D, Böck C, Krenner N, Dünser MW, Meier J. Acquired Factor XIII Deficiency Is Common during ECMO Therapy and Associated with Major Bleeding Events and Transfusion Requirements. J Clin Med 2023; 12:4115. [PMID: 37373805 DOI: 10.3390/jcm12124115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 06/06/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Bleeding events are frequent complications during extracorporeal membrane oxygenation therapy (ECMO). OBJECTIVE To determine the rate of acquired factor XIII deficiency and its association with major bleeding events and transfusion requirements in adults undergoing ECMO therapy. MATERIALS AND METHODS A retrospective single centre cohort study. Adult patients receiving veno-venous or veno-arterial ECMO therapy during a 2-year period were analysed and screened for factor XIII activity measurements. Factor XIII deficiency was defined based on the lowest factor XIII activity measured during ECMO therapy. RESULTS Among 84 subjects included into the analysis, factor XIII deficiency occurred in 69% during ECMO therapy. There were more major bleeding events (OR, 3.37; 95% CI, 1.16-10.56; p = 0.02) and higher transfusion requirements (red blood cells, 20 vs. 12, p < 0.001; platelets, 4 vs. 2, p = 0.006) in patients with factor XIII deficiency compared to patients with normal factor XIII activity. In a multivariate regression model, factor XIII deficiency was independently associated with bleeding severity (p = 0.03). CONCLUSIONS In this retrospective single centre study, acquired factor XIII deficiency was observed in 69% of adult ECMO patients with a high bleeding risk. Factor XIII deficiency was associated with higher rates of major bleeding events and transfusion requirements.
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Affiliation(s)
- Matthias Noitz
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstraße 9, 4020 Linz and Altenberger Strasse 69, 4040 Linz, Austria
| | - Roxane Brooks
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstraße 9, 4020 Linz and Altenberger Strasse 69, 4040 Linz, Austria
| | - Johannes Szasz
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstraße 9, 4020 Linz and Altenberger Strasse 69, 4040 Linz, Austria
| | - Dennis Jenner
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstraße 9, 4020 Linz and Altenberger Strasse 69, 4040 Linz, Austria
| | - Carl Böck
- Institute of Signal Processing, Johannes Kepler University Linz, Altenberger Strasse 69, 4040 Linz, Austria
| | - Niklas Krenner
- Department of Cardiac, Vascular and Thoracic Surgery, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstraße 9, 4020 Linz and Altenberger Strasse 69, 4020 Linz, Austria
| | - Martin W Dünser
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstraße 9, 4020 Linz and Altenberger Strasse 69, 4040 Linz, Austria
| | - Jens Meier
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstraße 9, 4020 Linz and Altenberger Strasse 69, 4040 Linz, Austria
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13
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Mazzeffi M, Gonzalez-Almada A, Wargowsky R, Ting L, Moskowitz K, Hockstein M, Davison D, Levy JH, Tanaka KA. In Vitro Treatment of Extracorporeal Membrane Oxygenation Coagulopathy with Recombinant von Willebrand Factor or Lyophilized Platelets. J Cardiothorac Vasc Anesth 2023; 37:522-527. [PMID: 36690556 DOI: 10.1053/j.jvca.2022.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 12/23/2022] [Accepted: 12/25/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The objective was to compare primary hemostasis between adult ECMO patients and cardiac surgical patients before heparinization and cardiopulmonary bypass. Furthermore, the authors explored whether in vitro treatment of ECMO patient blood samples with recombinant von Willebrand Factor (vWF) or lyophilized platelets improved primary hemostasis in vitro. DESIGN Prospective cohort study. SETTING Single academic medical center. PARTICIPANTS Ten cardiac surgical patients and 8 adult ECMO patients. INTERVENTIONS Cardiac surgical patients and ECMO patients had blood samples collected, and in vitro platelet thrombus formation was assessed using the ATLAS PST device. The ECMO patients had platelet thrombus formation evaluated at baseline and after in vitro treatment with recombinant vWF or lyophilized platelets, whereas cardiac surgical patients had a single blood sample obtained before heparinization and cardiopulmonary bypass run. MEASUREMENTS AND MAIN RESULTS Median maximum force (39.7 v 260.2 nN) and thrombus area (0.05 v 0.11) at 5 minutes were lower in untreated ECMO patient samples compared with cardiac surgical patients (p = 0.008 and p < 0.001, respectively). The ECMO patient samples treated with recombinant vWF demonstrated an increase in both platelet maximum force (median value of 222.1 v 39.7 nN) (p = 0.01) and platelet thrombus area (median value of 0.16 v 0.05; p = 0.001). The ECMO patient samples treated with lyophilized platelets demonstrated no increase in platelet maximum force (median value of 193.3 v 39.7 nN; p = 0.18); however, there was a significant increase in platelet thrombus area (median value of 0.13 v 0.05; p = 0.04). CONCLUSIONS Recombinant vWF and lyophilized platelets may help to restore primary hemostasis in ECMO patients. Future studies should further evaluate the safety and efficacy of these potential therapeutics in ECMO patients.
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Affiliation(s)
- Michael Mazzeffi
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA.
| | - Alberto Gonzalez-Almada
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Richard Wargowsky
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | | | - Max Hockstein
- Department of Critical Care Medicine, Medstar Washington Hospital Center, Washington, DC
| | - Danielle Davison
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma, Oklahoma City, OK
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14
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Van Den Helm S, Letunica N, Barton R, Weaver A, Yaw HP, Karlaftis V, McCafferty C, Cai T, Newall F, Horton SB, Chiletti R, Johansen A, Best D, McKittrick J, Butt W, d'Udekem Y, MacLaren G, Linden MD, Ignjatovic V, Monagle P. Changes in von Willebrand Factor Multimers, Concentration, and Function During Pediatric Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med 2023; 24:268-276. [PMID: 36602314 DOI: 10.1097/pcc.0000000000003152] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVES To investigate changes in von Willebrand factor (VWF) concentration, function, and multimers during pediatric extracorporeal membrane oxygenation (ECMO) and determine whether routine monitoring of VWF during ECMO would be useful in predicting bleeding. DESIGN Prospective observational study of pediatric ECMO patients from April 2017 to May 2019. SETTING The PICU in a large, tertiary referral pediatric ECMO center. PATIENTS Twenty-five neonates and children (< 18 yr) supported by venoarterial ECMO. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Arterial blood samples were collected within 24 hours pre-ECMO, daily for the first 5 days of ECMO, every second day until decannulation, and 24 hours post-ECMO. The STA R Max analyzer was used to measure VWF antigen (VWF:Ag) and ristocetin cofactor (VWF:RCo) activity. VWF collagen binding (VWF:CB) was measured using an enzyme-linked immunosorbent assay. VWF multimers were measured using the semi-automated Hydragel 11 VWF Multimer assay. Corresponding clinical data for each patient was also recorded. A total of 25 venoarterial ECMO patients were recruited (median age, 73 d; interquartile range [IQR], 3 d to 1 yr). The median ECMO duration was 4 days (IQR, 3-8 d) and 15 patients had at least one major bleed during ECMO. The percentage of high molecular weight multimers (HMWM) decreased and intermediate molecular weight multimers increased while patients were on ECMO, irrespective of a bleeding status. VWF:Ag increased and the VWF:RCo/VWF:Ag and VWF:CB/VWF:Ag ratios decreased while patients were on ECMO compared with the baseline pre-ECMO samples and healthy children. CONCLUSIONS Neonates and children on ECMO exhibited a loss of HMWM and lower VWF:CB/VWF:Ag and VWF:RCo/VWF:Ag ratios compared with healthy children, irrespective of major bleeding occurring. Therefore, monitoring VWF during ECMO would not be useful in predicting bleeding in these patients and changes to other hemostatic factors should be investigated to further understand bleeding during ECMO.
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Affiliation(s)
- Suelyn Van Den Helm
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Natasha Letunica
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Rebecca Barton
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
- Department of Clinical Haematology, The Royal Children's Hospital, Melbourne, VIC, Australia
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, VIC, Australia
- Department of Intensive Care, The Royal Children's Hospital, Melbourne, VIC, Australia
- Paediatric Intensive Care Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
- Department of Cardiac Surgery, Children's National Heart Institute, Washington, DC
- Cardiothoracic Intensive Care Unit, National University Health System, Singapore
- School of Biomedical Sciences, The University of Western Australia, Perth, WA, Australia
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Asami Weaver
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Hui Ping Yaw
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Vasiliki Karlaftis
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Conor McCafferty
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Tengyi Cai
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Fiona Newall
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
- Department of Clinical Haematology, The Royal Children's Hospital, Melbourne, VIC, Australia
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, VIC, Australia
- Department of Intensive Care, The Royal Children's Hospital, Melbourne, VIC, Australia
- Paediatric Intensive Care Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
- Department of Cardiac Surgery, Children's National Heart Institute, Washington, DC
- Cardiothoracic Intensive Care Unit, National University Health System, Singapore
- School of Biomedical Sciences, The University of Western Australia, Perth, WA, Australia
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Stephen B Horton
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Roberto Chiletti
- Department of Intensive Care, The Royal Children's Hospital, Melbourne, VIC, Australia
- Paediatric Intensive Care Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Amy Johansen
- Department of Intensive Care, The Royal Children's Hospital, Melbourne, VIC, Australia
- Paediatric Intensive Care Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Derek Best
- Department of Intensive Care, The Royal Children's Hospital, Melbourne, VIC, Australia
- Paediatric Intensive Care Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Joanne McKittrick
- Department of Intensive Care, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Warwick Butt
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Yves d'Udekem
- Department of Cardiac Surgery, Children's National Heart Institute, Washington, DC
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Health System, Singapore
| | - Matthew D Linden
- School of Biomedical Sciences, The University of Western Australia, Perth, WA, Australia
| | - Vera Ignjatovic
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Paul Monagle
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
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15
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Perioperative diagnosis and impact of acquired von Willebrand syndrome in infants with congenital heart disease. Blood 2023; 141:102-110. [PMID: 36054926 DOI: 10.1182/blood.2022015699] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 07/06/2022] [Accepted: 08/11/2022] [Indexed: 01/28/2023] Open
Abstract
Acquired von Willebrand syndrome (aVWS) has been reported in patients with congenital heart diseases associated with shear stress caused by significant blood flow gradients. Its etiology and impact on intraoperative bleeding during pediatric cardiac surgery have not been systematically studied. This single-center, prospective, observational study investigated appropriate diagnostic tools of aVWS compared with multimer analysis as diagnostic criterion standard and aimed to clarify the role of aVWS in intraoperative hemorrhage. A total of 65 newborns and infants aged 0 to 12 months scheduled for cardiac surgery at our tertiary referral center from March 2018 to July 2019 were included in the analysis. The glycoprotein Ib M assay (GPIbM)/von Willebrand factor antigen (VWF:Ag) ratio provided the best predictability of aVWS (area under the receiver operating characteristic curve [AUC], 0.81 [95% CI, 0.75-0.86]), followed by VWF collagen binding assay/VWF:Ag ratio (AUC, 0.70 [0.63-0.77]) and peak systolic echocardiographic gradients (AUC, 0.69 [0.62-0.76]). A cutoff value of 0.83 was proposed for the GPIbM/VWF:Ag ratio. Intraoperative high-molecular-weight multimer ratios were inversely correlated with cardiopulmonary bypass (CPB) time (r = -0.57) and aortic cross-clamp time (r = -0.54). Patients with intraoperative aVWS received significantly more fresh frozen plasma (P = .016) and fibrinogen concentrate (P = .011) than those without. The amounts of other administered blood components and chest closure times did not differ significantly. CPB appears to trigger aVWS in pediatric cardiac surgery. The GPIbM/VWF:Ag ratio is a reliable test that can be included in routine intraoperative laboratory workup. Our data provide the basis for further studies in larger patient cohorts to achieve definitive clarification of the effects of aVWS and its potential treatment on intraoperative bleeding.
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16
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More to Learn About Acquired Von Willebrand Syndrome. ASAIO J 2023; 69:e53. [PMID: 35593748 DOI: 10.1097/mat.0000000000001744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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17
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Ahmad S, Ahsan MJ, Ikram S, Lateef N, Khan BA, Tabassum S, Naeem A, Qavi AH, Ardhanari S, Goldsweig AM. Impella versus extracorporeal membranous oxygenation (ECMO) for cardiogenic shock: a systematic review and meta-analysis. Curr Probl Cardiol 2022; 48:101427. [PMID: 36174742 DOI: 10.1016/j.cpcardiol.2022.101427] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND The use of mechanical circulatory support (MCS) in cardiogenic shock (CS) is increasing. We conducted a systematic review and meta-analysis to compare outcomes with the Impella device vs. ECMO in patients with CS. METHODS We searched the Medline, EMBASE, Cochrane, and Clinicaltrials.gov databases for observational studies comparing Impella to ECMO in patients with CS. Risk ratios (RRs) for categorical variables and standardized mean differences (SMDs) for continuous variables were calculated with 95% confidence intervals (CIs) using a random-effects model. RESULTS Twelve retrospective studies and one prospective study (Impella n=6652, ECMO n=1232) were identified. Impella use was associated with lower incidence of in-hospital mortality (RR 0.88 [95% CI 0.80-0.94], p=0.0004), stroke (RR 0.30 [0.21-0.42], p<0.00001), access-site bleeding (RR 0.50 [0.37-0.69], p<0.0001), major bleeding (RR 0.56 [0.39-0.80], p=0.002), and limb ischemia (RR 0.42 [0.27-0.65], p=0.0001). Baseline lactate levels were significantly lower in the Impella group (SMD -0.52 [-0.73- -0.31], p<0.00001). There was no significant difference in mortality at 6-12 months, MCS duration, need for MCS escalation, bridge-to-LVAD or heart transplant, and renal replacement therapy use between Impella and ECMO groups. CONCLUSION In patients with CS, Impella device use was associated with lower in-hospital mortality, stroke, and device-related complications than ECMO. However, patients in the ECMO group had higher baseline lactate levels.
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Affiliation(s)
- Soban Ahmad
- Department of Internal Medicine, East Carolina University, Greenville, NC.
| | | | - Sundus Ikram
- Department of Internal Medicine, SEGi University, Petaling Jaya, MY
| | - Noman Lateef
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Behram A Khan
- Department of Internal Medicine, The Jewish Hospital - Mercy Health, Cincinnati, Ohio
| | - Shehroze Tabassum
- Department of Internal Medicine, King Edward Medical University, Lahore, PK
| | - Aroma Naeem
- Department of Internal Medicine, King Edward Medical University, Lahore, PK
| | - Ahmed H Qavi
- Division of Cardiovascular Medicine, East Carolina University, Greenville, NC
| | - Sivakumar Ardhanari
- Division of Cardiovascular Medicine, East Carolina University, Greenville, NC
| | - Andrew M Goldsweig
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE
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Székely M, Ruttkay T, Suhai FI, Bóna Á, Merkely B, Székely L. Minimally invasive apical cannulation and cannula design for short-term mechanical circulatory support devices. BMC Cardiovasc Disord 2022; 22:395. [PMID: 36058933 PMCID: PMC9441023 DOI: 10.1186/s12872-022-02826-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 08/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Refractory cardiogenic shock is still a major clinical challenge with high mortality rates, although several devices can be used to conquer this event. These devices have different advantages and disadvantages originating from their insertion or cannulation method, therefore many complications can occur during their use. The aim of our study was to develop and create prototypes of a novel minimal invasively insertable, transapical cannula for surgical ventricular assist devices, which uniquely incorporates the inflow and outflow routes for the blood of the patient in itself, therefore it enables the use for only one cannula for patients in cardiogenic shock. METHODS To define the available space for the planned cannula in the left ventricle and ascending aorta, we analyzed computed tomography scans of 24 heart failure patients, who were indicated to left ventricular assist device therapy. Parallel to these measurements, hydrodynamical calculations were performed to determine the sizes of the cannulas, which were necessary to provide effective cardiac output. RESULTS After the designing steps, we produced prototypes of double-lumened, tube-in-tube apically insertable devices for three different patient groups, which included a separated venous and an arterial part using 3D modelling and printing technology. All the created cannulas are able to provide 5 l/min circulatory support. CONCLUSION As a result of our research we created a sizing method based on the specific analysis of computed tomography pictures of end stage heart failure patients and a cannula concept, which can provide effective antegrade flow for patients in cardiogenic shock. We believe the improved version of our tool could have a significant therapeutic role in the future after further development based on animal and in vivo tests.
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Affiliation(s)
- Marcell Székely
- Laboratory for Applied and Clinical Anatomy, Department of Anatomy, Histology, and Embryology, Semmelweis University, 58 Tűzoltó Street, Budapest, 1094, Hungary.
| | - Tamás Ruttkay
- Laboratory for Applied and Clinical Anatomy, Department of Anatomy, Histology, and Embryology, Semmelweis University, 58 Tűzoltó Street, Budapest, 1094, Hungary
| | - Ferenc Imre Suhai
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Road, Budapest, 1122, Hungary
| | - Áron Bóna
- Soós Research and Development Center, University of Pannonia, 18 Zrínyi Miklós Street, Nagykanizsa, 8800, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Road, Budapest, 1122, Hungary
| | - László Székely
- Military Hospital Medical Centre, Cardiovascular and Thoracic Surgery Department, Hungarian Defense Forces, 44 Róbert Károly Boulevard, Budapest, 1134, Hungary
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19
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Teng Y, Yan S, Liu G, Lou S, Zhang Y, Ji B. An Agreement Study Between Point-of-Care and Laboratory Activated Partial Thromboplastin Time for Anticoagulation Monitoring During Extracorporeal Membrane Oxygenation. Front Med (Lausanne) 2022; 9:931863. [PMID: 35847800 PMCID: PMC9276956 DOI: 10.3389/fmed.2022.931863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/07/2022] [Indexed: 11/30/2022] Open
Abstract
Background Laboratory activated partial thromboplastin time (LAB-aPTT) is a widely used laboratory assay for monitoring unfractionated heparin (UFH) therapy during extracorporeal membrane oxygenation (ECMO). But LAB-aPTT is confined to a central laboratory, and the procedure is time-consuming. In comparison, point-of-care aPTT (POC-aPTT) is a convenient and quick assay, which might be a promising method for anticoagulation monitoring in ECMO. This study was aimed to evaluate the agreement between POC-aPTT (hemochron Jr. Signature instruments) and LAB-aPTT for anticoagulation monitoring in adult ECMO patients. Methods Data of ECMO-supported adult patients anticoagulated with UFH in our institute from January 2017 to December 2020 was retrospectively reviewed. POC-aPTT and LAB-aPTT results measured simultaneously were paired and included in the analysis. The correlation between POC-aPTT and LAB-aPTT was assessed using Spearman’s correlation coefficient. Bias between POC-aPTT and LAB-aPTT were described with the Bland-Altman method. Influence factors for bias were identified using multinomial logistic regression analysis. Results A total 286 pairs of aPTT results from 63 patients were included in the analysis. POC-aPTT and LAB-aPTT correlated weakly (r = 0.385, P < 0.001). The overall bias between POC-aPTT and LAB-aPTT was 7.78 [95%CI (−32.49, 48.05)] s. The overall bias between POC-aPTT and LAB-aPTT ratio (to normal value) was 0.54 [95%CI (−0.68, 1.76)]. A higher plasma fibrinogen level [OR 1.353 (1.057, 1.733), P = 0.017] was associated with a higher chance of POC-aPTT underestimating LAB-aPTT. While a lower plasma fibrinogen level [OR 0.809 (0.679, 0.963), P = 0.017] and lower UFH rate [OR 0.928 (0.868, 0.992), P = 0.029] were associated with a higher chance of POC-aPTT overestimating LAB-aPTT. Conclusion The present study showed poor agreement between POC-aPTT and LAB-aPTT. POC-aPTT was not suitable for anticoagulation monitoring in adult ECMO patients.
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Affiliation(s)
- Yuan Teng
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Shujie Yan
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Gang Liu
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Song Lou
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Zhang
- Center of Laboratory Medicine, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Bingyang Ji,
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20
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The Role of Excessive Anticoagulation and Missing Hyperinflammation in ECMO-Associated Bleeding. J Clin Med 2022; 11:jcm11092314. [PMID: 35566439 PMCID: PMC9102211 DOI: 10.3390/jcm11092314] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/26/2022] [Accepted: 04/19/2022] [Indexed: 12/30/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is increasingly used in carefully selected patients with cardiac or respiratory failure. However, complications are common and can be associated with worse outcomes, while data on risk factors and outcomes are inconsistent and sparse. Therefore, we sought to investigate potential risk factors and predictors of haemorrhage and adverse events during ECMO and its influence on mortality. We retrospectively reviewed all patients on ECMO support admitted to intensive care units of a tertiary university centre in Austria. In a period of ten years, ECMO support was used in 613 patients, with 321 patients meeting the inclusion criteria of this study. Haemorrhage, occurring in more than one third of the included patients (123, 38%), represented the most common and serious ECMO complication, being associated with an increased one year mortality (51% vs. 35%, p = 0.005). The main risk factors for haemorrhage were severity of the disease (hazard ratio (HR) = 1.01, p = 0.047), a prolonged activated partial thromboplastin time (HR = 1.01, p = 0.007), and lower values of C-reactive protein (HR = 0.96, p = 0.005) and procalcitonin (HR = 0.99, p = 0.029). In summary, haemorrhage remained the main ECMO complication with increased mortality. Moreover, we reported a possible association of lower inflammation and bleeding during ECMO support for the first time. This generated a new hypothesis that warrants further research. Finally, we recommend stricter monitoring of anticoagulation especially in patients without hyperinflammation.
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21
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Brokmeier HM, Wieruszewski ED, Nei SD, Loftsgard TO, Wieruszewski PM. Hemostatic Management in Extracorporeal Membrane Oxygenation. Crit Care Nurs Q 2022; 45:132-143. [PMID: 35212653 DOI: 10.1097/cnq.0000000000000396] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The use of extracorporeal membrane oxygenation (ECMO) for acute cardiac and/or respiratory failure has grown exponentially in the past several decades. Systemic anticoagulation is a fundamental element of caring for ECMO patients. Hemostatic management during ECMO walks a fine line to balance the risk of safe and effective anticoagulant delivery to mitigate thromboembolic complications and minimizing hemorrhagic sequelae. This review discusses the pharmacology, monitoring parameters, and special considerations for anticoagulation in patients requiring ECMO.
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Affiliation(s)
- Hannah M Brokmeier
- Departments of Pharmacy (Drs Brokmeier, E. D. Wieruszewski, Nei, and P. M. Wieruszewski), Cardiovascular Surgery (Mr Loftsgard), and Anesthesiology (Dr P. M. Wieruszewski), Mayo Clinic, Rochester, Minnesota
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22
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Fujimura Y, Holland LZ. COVID-19 microthrombosis: unusually large VWF multimers are a platform for activation of the alternative complement pathway under cytokine storm. Int J Hematol 2022; 115:457-469. [PMID: 35316498 PMCID: PMC8938647 DOI: 10.1007/s12185-022-03324-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/27/2022] [Accepted: 03/01/2022] [Indexed: 02/08/2023]
Abstract
ADAMTS13, a metalloproteinase, specifically cleaves unusually large multimers of von Willebrand factor (VWF), newly released from vascular endothelial cells. The ratio of ADAMTS13 activity to VWF antigen (ADAMTS13/VWF) and indicators of the alternative complement pathway (C3a and sC5b-9) are both related to the severity of COVID-19. The ADAMTS13/VWF ratio is generally moderately decreased (0.18–0.35) in patients with severe COVID-19. When these patients experience cytokine storms, both interleukin-8 and TNFα stimulate VWF release from vascular endothelial cells, while interleukin-6 inhibits both production of ADAMTS13 and its interaction with VWF, resulting in localized severe deficiency of ADAMTS13 activity. Platelet factor 4 and thrombospondin-1, both released upon platelet activation, bind to the VWF-A2 domain and enhance the blockade of ADAMTS13 function. Thus, the released unusually-large VWF multimers remain associated with the vascular endothelial cell surface, via anchoring with syndecan-1 in the glycocalyx. Unfolding of the VWF-A2 domain, which has high sequence homology with complement factor B, allows the domain to bind to activated complement C3b, providing a platform for complement activation of the alternative pathway. The resultant C3a and C5a generate tissue factor-rich neutrophil extracellular traps (NETs), which induce the mixed immunothrombosis, fibrin clots and platelet aggregates typically seen in patients with severe COVID-19.
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Affiliation(s)
- Yoshihiro Fujimura
- Department of Blood Transfusion Medicine, Nara Medical University, Shijyocho-840, Kashihara City, Nara, Japan.
| | - Linda Z Holland
- Marine Biology Research Division, Scripps Institution Oceanography, University California San Diego, 4400 Hubbs Hall, La Jolla, CA, 92093-0202, USA
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23
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Zheng A, Zhang W, Li C, Guo Z, Li C, Zhang C, Yao J, Zhang Z, Li J, Zhao S, Zhou L. The heparinase-linked differential time method allows detection of heparin potency in whole blood with high sensitivity and dynamic range. Biosens Bioelectron 2022; 198:113856. [PMID: 34871836 DOI: 10.1016/j.bios.2021.113856] [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: 10/19/2021] [Revised: 11/26/2021] [Accepted: 11/28/2021] [Indexed: 11/18/2022]
Abstract
Anticoagulation therapy with heparin is an effective treatment against thrombosis. Heparin tends to cause spontaneous bleeding and requires regular monitoring during therapy. Most high-sensitivity heparin sensors have focused on the concentration detection in clarified buffer solution. However, the pharmacodynamics of heparin vary depending on individual patient or disease, while potency detection with high sensitivity and dynamic range outperforms concentration detection in clinical diagnosis. In this study, a novel heparinase-linked differential time (HLDT) method was established with a two-zone of Graphene modified Carbon (GR-C) sensor, which was utilized to evaluate heparin potency in whole blood. It was based on electrochemical measurement of clotting time shifting associated with presence or absence of heparinase. Heparinase inhibits the anticoagulant ability of heparin by forming a heparin-antithrombin-thrombin complex during coagulation. And the intensity and peak time of electrochemical current were associated with thrombin activity and clotting on the electrode. The results demonstrated that the sensor had high selectivity for heparin potency in 10 μL of whole blood with a detection limit of 0.1 U/mL, and the linear detection range was 0.1-5 U/mL. The coefficient of variation (CV) of the peak time was less than 5%, and linear correlation between the GR-C sensor and the TEG-5000 instrument was 0.987. Thus, the HLDT method has better clinical application due to its good repeatability, high sensitivity and wide range in heparin potency evaluation.
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Affiliation(s)
- Anran Zheng
- School of Biomedical Engineering (Suzhou), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230026, China; CAS Key Lab of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163, China
| | - Wei Zhang
- School of Biomedical Engineering (Suzhou), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230026, China; CAS Key Lab of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163, China
| | - Chao Li
- School of Biomedical Engineering (Suzhou), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230026, China; CAS Key Lab of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163, China; Ji Hua Laboratory, Foshan, 528000, China
| | - Zhen Guo
- School of Biomedical Engineering (Suzhou), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230026, China; CAS Key Lab of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163, China; Suzhou CASENS Co., Ltd, Suzhou, 215163, China; Ji Hua Laboratory, Foshan, 528000, China
| | - Chuanyu Li
- School of Biomedical Engineering (Suzhou), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230026, China; CAS Key Lab of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163, China; Suzhou CASENS Co., Ltd, Suzhou, 215163, China
| | - Changsong Zhang
- Department of Laboratory Medicine, The Affiliated Suzhou Science and Technology Town Hospital, Nanjing Medical University, Suzhou 215153, Jiangsu Province, China
| | - Jia Yao
- School of Biomedical Engineering (Suzhou), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230026, China; CAS Key Lab of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163, China
| | - Zhiqi Zhang
- School of Biomedical Engineering (Suzhou), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230026, China; CAS Key Lab of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163, China
| | - Jinze Li
- School of Biomedical Engineering (Suzhou), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230026, China; CAS Key Lab of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163, China
| | - Shasha Zhao
- CAS Key Lab of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163, China
| | - Lianqun Zhou
- School of Biomedical Engineering (Suzhou), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230026, China; CAS Key Lab of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163, China; Ji Hua Laboratory, Foshan, 528000, China.
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24
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Mazzeffi M, Henderson R, Krause E, Rabin J, Madathil R, Chow J, Grazioli A, Meyer M, Wu Z, Tanaka K. In Vitro Comparison of Recombinant and Plasma-Derived von Willebrand Factor Concentrate for Treatment of Acquired von Willebrand Syndrome in Adult Extracorporeal Membrane Oxygenation Patients. Anesth Analg 2021; 134:312-321. [PMID: 34903705 DOI: 10.1213/ane.0000000000005831] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Coagulopathic bleeding is common during adult extracorporeal membrane oxygenation (ECMO), and acquired von Willebrand syndrome is a contributing factor. We compared ECMO patient blood samples that were treated in vitro with recombinant von Willebrand Factor concentrate and plasma-derived von Willebrand Factor concentrate. Our hypothesis was that recombinant von Willebrand Factor (vWF) would have greater efficacy in increasing vWF function. Secondarily, we hypothesized that recombinant vWF would have less impact on thrombin generation. METHODS Thirty ECMO patients and 10 cardiac surgical controls were enrolled in the study. ECMO patient blood samples were treated in vitro with low- and high-dose recombinant vWFs and low- and high-dose plasma-derived vWFs. Whole blood ristocetin-induced platelet aggregation (RIPA), plasma ristocetin cofactor activity (RCo), and thrombin generation were compared between ECMO patient blood samples and control blood samples and between vWF-treated ECMO patient blood samples and nontreated samples. RESULTS ECMO patient blood samples had severely reduced median RIPA compared to control samples 2 ohms (1-12 [25th-75th percentile]) vs 20 ohms (11-42) (P < .001). Treatment of ECMO patient blood samples with high-dose recombinant vWF significantly increased median RIPA to 10 ohms (2-15) (P < .001), while low-dose recombinant vWF and low- and high-dose plasma-derived vWFs did not significantly increase RIPA; 6 ohms (3-14), 4 ohms (1-13), and 6 ohms (2-10), respectively (P = .25, >.99, and >.99). Treatment with high-dose recombinant vWF and low- and high-dose plasma-derived vWFs significantly increased median plasma RCo to 4.7 international units (IU)/mL (3.7-5.9), 3.3 IU/mL (2.7-4.8), and 3.9 IU/mL (3.4-5.3), respectively, compared to controls 1.8 IU/mL (1.5-2.3) (all P < .001). Treatment with low- and high-dose plasma-derived vWFs significantly increased mean endogenous thrombin potential (6270.2 ± 2038.7 and 6313.1 ± 1913.3) compared to nontreated samples (5856.7 ± 1924.6) (P = .04 and .006), whereas treatment with low- and high-dose recombinant vWFs had no significant effect on mean endogenous thrombin potential (5776.1 ± 2087.3 and 5856.2 ± 1946.4) (P > .99 for both comparisons). CONCLUSIONS In vitro treatment of ECMO patient blood samples with high-dose recombinant vWF was superior to low-dose recombinant vWF and plasma-derived vWF in terms of improving RIPA. In addition, recombinant vWF treatment did not increase endogenous thrombin potential, which may reduce overall thrombotic risk if it used to treat acquired von Willebrand syndrome in ECMO patients.
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Affiliation(s)
- Michael Mazzeffi
- From the Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Reney Henderson
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Eric Krause
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Joseph Rabin
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ronson Madathil
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jonathan Chow
- From the Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Alison Grazioli
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael Meyer
- Vitalant Coagulation Laboratory, Pittsburgh, Pennsylvania
| | - Zhongjun Wu
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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25
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Garaj M, Durila M, Vajter J, Solcova M, Marecek F, Hrachovinová I. Extracorporeal membrane oxygenation seems to induce impairment of primary hemostasis pathology as measured by a Multiplate analyzer: An observational retrospective study. Artif Organs 2021; 46:899-907. [PMID: 34904233 DOI: 10.1111/aor.14142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/12/2021] [Accepted: 12/10/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) support is often associated with bleeding complications caused by secondary or primary hemostasis pathology. However, there are limited data investigating primary hemostasis using Multiplate aggregometry with specific diagnostics tests for vWF (von Willebrand factor) deficiency. AIMS The aim of this study was to find out whether short-term ECMO produces the pathology of primary hemostasis that is detected by Multiplate aggregometry and to investigate the pathology of vWF. METHODS In this study, blood samples of 20 patients undergoing lung transplantations with short-term perioperative ECMO support were analyzed. The multimeric structure, the levels of von Willebrand factor antigen (vWF), ristocetin cofactor (RCo), collagen-binding protein (CB), and the results of multiple electrode aggregometry RISTO (ristocetin), ADP (adenosine diphosphate), ASPI (Aspirin®; arachidonic acid), and TRAP (thrombin receptor activating peptide) tests were compared to the samples obtained before and after ECMO support. RESULTS The Multiplate ADP and RISTO tests showed the presence of significant pathology in primary hemostasis after surgery (p < 0.05), suggesting the presence of acquired platelet dysfunction. Although the RISTO tests suggest the presence of acquired vWF deficiency, laboratory tests for vWF antigen and RCo and CB tests showed an increase in this case. The multimeric structure of vWF did not show clinically significant deterioration. CONCLUSIONS Multiple aggregometry ADP, ASPI, and TRAP tests seem to be able to detect primary hemostasis pathology (platelets aggregation and adhesion pathology) that is present during short-term perioperative ECMO support in lung transplantation procedures. Interestingly, RISTO tests seem to be more suitable for the diagnosis of platelet dysfunction than the diagnosis of acquired vWF deficiency in this situation.
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Affiliation(s)
- Michal Garaj
- Department of Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, the Czech Republic
| | - Miroslav Durila
- Department of Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, the Czech Republic
| | - Jaromir Vajter
- Department of Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, the Czech Republic
| | - Michaela Solcova
- Department of Clinical Hematology, Motol University Hospital, Prague, the Czech Republic
| | - Frantisek Marecek
- Institute of Hematology and Blood Transfusion, Prague, the Czech Republic
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Abstract
Acquired von Willebrand syndrome can occur in the setting of myeloproliferative neoplasms; plasma cell dyscrasias and other lymphoproliferative disorders; autoimmune conditions; and causes of increased shear forces, such as aortic stenosis or other structural heart disease and mechanical circulatory support. The depletion of von Willebrand factor, especially high-molecular-weight multimers, can lead to mucocutaneous bleeding and the formation of arteriovenous malformations, particularly in the gastrointestinal tract. Management focuses on correction of the underlying cause when possible, but may include intravenous immunoglobulins, von Willebrand factor concentrate, rituximab, or antiangiogenic therapy depending on the clinical context.
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Affiliation(s)
- Arielle L Langer
- Division of Hematology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Nathan T Connell
- Division of Hematology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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27
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Hékimian G, Masi P, Lejeune M, Lebreton G, Chommeloux J, Desnos C, Pineton De Chambrun M, Martin-Toutain I, Nieszkowska A, Bréchot N, Schmidt M, Leprince P, Luyt CE, Combes A, Frere C. Extracorporeal Membrane Oxygenation Induces Early Alterations in Coagulation and Fibrinolysis Profiles in COVID-19 Patients with Acute Respiratory Distress Syndrome. Thromb Haemost 2021; 121:1031-1042. [PMID: 34130315 DOI: 10.1055/a-1529-2257] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hemostatic changes induced by extracorporeal membrane oxygenation (ECMO) support have been yet poorly documented in coronavirus-19 (COVID-19) patients who have a baseline complex hypercoagulable state. In this prospective monocentric study of patients with severe acute respiratory distress syndrome (ARDS) rescued by ECMO, we performed longitudinal measurements of coagulation and fibrinolysis markers throughout the course of ECMO support in 20 COVID-19 and 10 non-COVID-19 patients. Blood was sampled before and then 24 hours, 7, and 14 days after ECMO implantation. Clinical outcomes were prospectively assessed until discharge from the intensive care unit or death. The median age of participants was 47 (35-56) years, with a median body mass index of 30 (27-35) kg/m2, and a Sepsis-related Organ Failure Assessment score of 12 (8-16). Baseline levels of von Willebrand factor, fibrinogen, factor VIII, prothrombin F1 + 2, thrombin-antithrombin, D-dimer, and plasminogen activator inhibitor-1 (PAI-1) were elevated in both COVID-19 and non-COVID-19 ARDS patients, indicating that endothelial activation, endogenous thrombin generation, and fibrinolysis shutdown occur in all ARDS patients before ECMO implantation. From baseline to day 7, thrombin generation (prothrombin F1 + 2, p < 0.01) and fibrin formation markers (fibrin monomers, p < 0.001) significantly increased, further resulting in significant decreases in platelet count (p < 0.0001) and fibrinogen level (p < 0.001). PAI-1 levels significantly decreased from baseline to day 7 (p < 0.0001) in all ARDS patients. These changes were more marked in COVID-19 patients, resulting in 14 nonfatal and 3 fatal bleeding. Additional studies are warranted to determine whether monitoring of thrombin generation and fibrinolysis markers might help to early predict bleeding complications in COVID-19 patients supported by ECMO.
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Affiliation(s)
- Guillaume Hékimian
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France.,Sorbonne Université, INSERM UMRS_1166, Institute of Cardiometabolism And Nutrition, Paris, France
| | - Paul Masi
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Manon Lejeune
- Sorbonne Université, INSERM UMRS_1166, Institute of Cardiometabolism And Nutrition, Paris, France.,Department of Hematology, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Guillaume Lebreton
- Sorbonne Université, INSERM UMRS_1166, Institute of Cardiometabolism And Nutrition, Paris, France.,Department of Cardiothoracic Surgery, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Juliette Chommeloux
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Cyrielle Desnos
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Marc Pineton De Chambrun
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Isabelle Martin-Toutain
- Department of Hematology, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Ania Nieszkowska
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Nicolas Bréchot
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Matthieu Schmidt
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France.,Sorbonne Université, INSERM UMRS_1166, Institute of Cardiometabolism And Nutrition, Paris, France
| | - Pascal Leprince
- Sorbonne Université, INSERM UMRS_1166, Institute of Cardiometabolism And Nutrition, Paris, France.,Department of Cardiothoracic Surgery, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Charles-Edouard Luyt
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France.,Sorbonne Université, INSERM UMRS_1166, Institute of Cardiometabolism And Nutrition, Paris, France
| | - Alain Combes
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France.,Sorbonne Université, INSERM UMRS_1166, Institute of Cardiometabolism And Nutrition, Paris, France
| | - Corinne Frere
- Sorbonne Université, INSERM UMRS_1166, Institute of Cardiometabolism And Nutrition, Paris, France.,Department of Hematology, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
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Moussa MD, Soquet J, Lamer A, Labreuche J, Gantois G, Dupont A, Abou-Arab O, Rousse N, Liu V, Brandt C, Foulon V, Leroy G, Schurtz G, Jeanpierre E, Duhamel A, Susen S, Vincentelli A, Robin E. Evaluation of Anti-Activated Factor X Activity and Activated Partial Thromboplastin Time Relations and Their Association with Bleeding and Thrombosis during Veno-Arterial ECMO Support: A Retrospective Study. J Clin Med 2021; 10:jcm10102158. [PMID: 34067573 PMCID: PMC8156165 DOI: 10.3390/jcm10102158] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/08/2021] [Accepted: 05/10/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We aimed to investigate the relationship between anti-activated Factor X (anti-FXa) and activated Partial Thromboplastin Time (aPTT), and its modulation by other haemostasis co-variables during veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. We further investigated their association with serious bleeding and thrombotic complications. METHODS This retrospective single-center study included 265 adults supported by VA-ECMO for refractory cardiogenic shock from January 2015 to June 2019. The concordance of anti-FXa and aPTT and their correlations were assessed in 1699 paired samples. Their independent associations with serious bleeding or thrombotic complications were also analysed in multivariate analysis. RESULTS The concordance rate of aPTT with anti-FXa values was 50.7%, with 39.3% subtherapeutic aPTT values. However, anti-FXa and aPTT remained associated (β = 0.43 (95% CI 0.4-0.45) 10-2 IU/mL, p < 0.001), with a significant modulation by several biological co-variables. There was no association between anti-FXa nor aPTT values with serious bleeding or with thrombotic complications. CONCLUSION During VA-ECMO, although anti-FXa and aPTT were significantly associated, their values were highly discordant with marked sub-therapeutic aPTT values. These results should favour the use of anti-FXa. The effect of biological co-variables and the failure of anti-FXa and aPTT to predict bleeding and thrombotic complications underline the complexity of VA-ECMO-related coagulopathy.
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Affiliation(s)
- Mouhamed Djahoum Moussa
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
- Correspondence: ; Tel.: +33-320-445-962
| | - Jérôme Soquet
- CHU Lille, Service de Chirurgie Cardiaque, 59000 Lille, France; (J.S.); (N.R.); (A.V.)
| | - Antoine Lamer
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
- Univ. Lille, INSERM, CHU Lille, CIC-IT 1403, 59000 Lille, France
- Univ. Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, 59000 Lille, France; (J.L.); (A.D.)
| | - Julien Labreuche
- Univ. Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, 59000 Lille, France; (J.L.); (A.D.)
- CHU Lille, Department of Biostatistics, 59000 Lille, France
| | - Guillaume Gantois
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | - Annabelle Dupont
- CHU Lille, Pôle d’Hématologie-Transfusion, Centre de Biologie Pathologie Génétique, 59000 Lille, France; (A.D.); (E.J.); (S.S.)
| | - Osama Abou-Arab
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, 80054 Amiens, France;
- MP3CV, EA7517, CURS, Jules Verne University of Picardie, 80054 Amiens, France
| | - Natacha Rousse
- CHU Lille, Service de Chirurgie Cardiaque, 59000 Lille, France; (J.S.); (N.R.); (A.V.)
| | - Vincent Liu
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | - Caroline Brandt
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | - Valentin Foulon
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | - Guillaume Leroy
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | | | - Emmanuel Jeanpierre
- CHU Lille, Pôle d’Hématologie-Transfusion, Centre de Biologie Pathologie Génétique, 59000 Lille, France; (A.D.); (E.J.); (S.S.)
| | - Alain Duhamel
- Univ. Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, 59000 Lille, France; (J.L.); (A.D.)
- CHU Lille, Department of Biostatistics, 59000 Lille, France
| | - Sophie Susen
- CHU Lille, Pôle d’Hématologie-Transfusion, Centre de Biologie Pathologie Génétique, 59000 Lille, France; (A.D.); (E.J.); (S.S.)
| | - André Vincentelli
- CHU Lille, Service de Chirurgie Cardiaque, 59000 Lille, France; (J.S.); (N.R.); (A.V.)
| | - Emmanuel Robin
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez CA, Shah AS, D'Alessandro DA. 2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-cardiotomy Extracorporeal Life Support in Adult Patients. ASAIO J 2021; 67:e1-e43. [PMID: 33021558 DOI: 10.1097/mat.0000000000001301] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care Unit, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Milan Milojevic
- Department of Anaesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Giuseppe 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
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, WA, USA
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Christian A Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ashish S Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David A D'Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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30
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Hemostasis, coagulation and thrombin in venoarterial and venovenous extracorporeal membrane oxygenation: the HECTIC study. Sci Rep 2021; 11:7975. [PMID: 33846433 PMCID: PMC8042030 DOI: 10.1038/s41598-021-87026-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 03/23/2021] [Indexed: 02/06/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) support has a high incidence of both bleeding and thrombotic complications. Despite clear differences in patient characteristics and pathologies between veno-venous (VV) and veno-arterial (VA) ECMO support, anticoagulation practices are often the same across modalities. Moreover, there is very little data on their respective coagulation profiles and comparisons of thrombin generation in these patients. This study compares the coagulation profile and thrombin generation between patients supported with either VV and VA ECMO. A prospective cohort study of patients undergoing VA and VV ECMO at an Intensive care department of a university hospital and ECMO referral centre. In addition to routine coagulation testing and heparin monitoring per unit protocol, thromboelastography (TEG), multiplate aggregometry (MEA), calibrated automated thrombinography (CAT) and von-Willebrand’s activity (antigen and activity ratio) were sampled second-daily for 1 week, then weekly thereafter. VA patients had significantly lower platelets counts, fibrinogen, anti-thrombin and clot strength with higher d-dimer levels than VV patients, consistent with a more pronounced consumptive coagulopathy. Thrombin generation was higher in VA than VV patients, and the heparin dose required to suppress thrombin generation was lower in VA patients. There were no significant differences in total bleeding or thrombotic event rates between VV and VA patients when adjusted for days on extracorporeal support. VA patients received a lower median daily heparin dose 8500 IU [IQR 2500–24000] versus VV 28,800 IU [IQR 17,300–40,800.00]; < 0.001. Twenty-eight patients (72%) survived to hospital discharge; comprising 53% of VA patients and 77% of VV patients. Significant differences between the coagulation profiles of VA and VV patients exist, and anticoagulation strategies for patients of these modalities should be different. Further research into the development of tailored anticoagulation strategies that include the mode of ECMO support need to be completed.
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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez C, Shah A, D'Alessandro DA. 2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients. J Thorac Cardiovasc Surg 2021; 161:1287-1331. [PMID: 33039139 DOI: 10.1016/j.jtcvs.2020.09.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 04/03/2020] [Accepted: 04/21/2020] [Indexed: 12/26/2022]
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management, and avoidance of complications, appraisal of new approaches and ethics, education, and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Md.
| | - Milan Milojevic
- Department of Anaesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Giuseppe 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; Department of Anaesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, Wash
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Christian Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Ashish Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - David A D'Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, Mass
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32
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Steiger T, Philipp A, Hiller KA, Müller T, Lubnow M, Lehle K. Different mechanisms of oxygenator failure and high plasma von Willebrand factor antigen influence success and survival of venovenous extracorporeal membrane oxygenation. PLoS One 2021; 16:e0248645. [PMID: 33735282 PMCID: PMC7971568 DOI: 10.1371/journal.pone.0248645] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 03/03/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Failure of membrane oxygenator (MO) function of venovenous extracorporeal membrane oxygenators (VV ECMO) remains problematic. The development of device-induced coagulation disorder (COD) or worsened gas transfer (WGT) necessitates a system exchange. The aim was to correlate von Willebrand factor antigen (vWF:Ag) with the predisposition to MO failure and mortality. METHODS Laboratory parameters (inflammation, coagulation) and ECMO-related data from 31 VV ECMO patients were analyzed before and after the first MO exchange. Study groups were identified according to the exchange reasons (COD, WGT) and the extent of vWF:Ag (low, ≤425%; high, >425%). RESULTS vWF:Ag remained unchanged after system exchange. High vWF:Ag was associated with systemic endothelial activation of older and obese patients with elevated SOFA score, increased norepinephrine and higher requirement of continuous renal replacement therapy without an effect on MO runtime and mortality. Including the mechanism of MO failure (COD, WGT), various patient group emerged. COD/low vWF:Ag summarized younger and less critically ill patients that benefit mainly from ECMO by a significant improvement of their inflammatory and coagulation status (CRP, D-dimers, fibrinogen) and highest survival rate (91%). Instead, WGT/high vWF:Ag presented older and more obese patients with a two-digit SOFA score, highest norepinephrine, and aggravated gas transfer. They benefited temporarily from system exchange but with worst survival (33%). CONCLUSIONS vWF:Ag levels alone cannot predict early MO failure and outcome in VV ECMO patients. Probably, the mechanism of clotting disorder in combination with the vWF:Ag level seems to be essential for clot formation within the MO. In addition, vWF:Ag levels allows the identification different patient populations In particular, WGT/high vWF:Ag represented a critically ill population with higher ECMO-associated mortality.
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Affiliation(s)
- Tamara Steiger
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Karl-Anton Hiller
- Department of Conservative Dentistry and Periodontology, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Karla Lehle
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
- * E-mail:
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33
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Mazzeffi M, Judd M, Rabin J, Tabatabai A, Menaker J, Menne A, Chow J, Shah A, Henderson R, Herr D, Tanaka K. Tissue Factor Pathway Inhibitor Levels During Veno-Arterial Extracorporeal Membrane Oxygenation in Adults. ASAIO J 2021; 67:878-883. [PMID: 33606392 DOI: 10.1097/mat.0000000000001322] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Tissue factor pathway inhibitor (TFPI) has multiple anticoagulant properties. To our knowledge, no studies have measured TFPI levels in adult veno-arterial (VA) extracorporeal membrane oxygenation patients. We hypothesized that adult VA ECMO patients would have increased TFPI levels and slowed tissue factor triggered thrombin generation. Twenty VA ECMO patients had TFPI levels and thrombin generation lag time measured on ECMO day 1 or 2, day 3, and day 5. TFPI levels and thrombin generation lag time were compared against healthy control plasma samples. Mean TFPI levels were significantly higher in ECMO patients on ECMO day 1 or 2 = 81,877 ± 19,481 pg/mL, day 3 = 73,907 ± 26,690 pg/mL, and day 5 = 77,812 ± 23,484 pg/mL compared with control plasma = 38,958 ± 9,225 pg/mL (P < 0.001 for all comparisons). Median thrombin generation lag time was significantly longer in ECMO patients on ECMO day 1 or 2 = 10.0 minutes [7.5, 13.8], day 3 = 9.0 minutes [6.8, 12.1], and day 5 = 10.7 minutes [8.3, 15.2] compared with control plasma = 3.6 minutes [2.9, 4.2] (P < 0.001 for all comparisons). TFPI is increased in VA ECMO patients and tissue factor triggered thrombin generation is slowed. Increased TFPI levels could contribute to the multifactorial coagulopathy that occurs during ECMO.
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Affiliation(s)
| | | | - Joseph Rabin
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center
| | - Ali Tabatabai
- Department of Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center
| | - Jay Menaker
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center
| | - Ashley Menne
- Department of Emergency Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center
| | | | - Aakash Shah
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | | | - Daniel Herr
- Department of Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center
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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez CA, Shah AS, D’Alessandro DA. 2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients. Eur J Cardiothorac Surg 2020; 59:12-53. [DOI: 10.1093/ejcts/ezaa283] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 04/03/2020] [Accepted: 04/21/2020] [Indexed: 12/13/2022] Open
Abstract
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Milan Milojevic
- Department of Anaesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Giuseppe 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
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, WA, USA
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Christian A Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ashish S Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David A D’Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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35
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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez CA, Shah AS, D'Alessandro DA. 2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-Cardiotomy Extracorporeal Life Support in Adult Patients. Ann Thorac Surg 2020; 111:327-369. [PMID: 33036737 DOI: 10.1016/j.athoracsur.2020.07.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 12/16/2022]
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Center, Maastricht University Medical Center, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands.
| | - Glenn Whitman
- Cardiac Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Maryland
| | - Milan Milojevic
- Department of Anesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Giuseppe 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
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, Washington
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Christian A Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ashish S Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David A D'Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Mazzeffi M, Bathula A, Tabatabai A, Menaker J, Kaczorowski D, Madathil R, Galvagno S, Pasrija C, Rector R, Tanaka K, Herr D. Von Willebrand Factor Concentrate Administration for Acquired Von Willebrand Syndrome- Related Bleeding During Adult Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2020; 35:882-887. [PMID: 32758410 DOI: 10.1053/j.jvca.2020.06.083] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/26/2020] [Accepted: 06/27/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To review the use of Von Willebrand Factor (VWF) concentrate for treatment of acquired Von Willebrand syndrome (VWS)-related bleeding in adult extracorporeal membrane oxygenation (ECMO) patients and determine if it was associated with improved VWF laboratory parameters. DESIGN Retrospective observational cohort study. SETTING Tertiary care academic medical center. PARTICIPANTS Adult ECMO patients who received VWF concentrate for treatment of acquired VWS- related bleeding. INTERVENTIONS None, observational study. MEASUREMENTS AND MAIN RESULTS Ten adult ECMO patients received VWF concentrate for treatment of bleeding with evidence of acquired VWS over a 15-month period. Six patients were on veno-arterial ECMO and 4 were on veno-venous ECMO. The most common site of bleeding was airway or tracheal bleeding. The mean dose of VWF concentrate was 41 IU/kg. Mean VWF antigen was 263 ± 93 IU/dL before treatment and 394 ± 54 after treatment. Mean ristocetin cofactor activity was 127 ± 47 IU/dL before treatment and 240 ± 33 after treatment. The mean VWF ristocetin cofactor activity antigen ratio increased from 0.52 ± 0.14 before treatment to 0.62 ± 0.04 after treatment. Four of 10 patients had complete resolution of their bleeding within 24 hours, and 6 of 10 had complete resolution of their bleeding within 2- to- 4 days. There were 3 patients who had thrombotic events potentially related to VWF concentrate administration. No patient had an arterial thrombosis, stroke, or myocardial infarction. CONCLUSIONS VWF concentrate administration increases VWF function in adult ECMO patients, but also may be associated with increased thrombotic risk. Larger studies are needed to determine VWF concentrate's safety, efficacy, and optimal dosing in adult ECMO patients.
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Affiliation(s)
- Michael Mazzeffi
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD.
| | - Allison Bathula
- University of Maryland Medical Center, Department of Pharmacy, Baltimore, MD
| | - Ali Tabatabai
- University of Maryland School of Medicine, Department of Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
| | - Jay Menaker
- University of Maryland School of Medicine, Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
| | - David Kaczorowski
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Ronson Madathil
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Samuel Galvagno
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD
| | - Chetan Pasrija
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Raymond Rector
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Kenichi Tanaka
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD
| | - Daniel Herr
- University of Maryland School of Medicine, Department of Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
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Cavayas YA, Del Sorbo L, Munshi L, Sampson C, Fan E. Intracranial hemorrhage on extracorporeal membrane oxygenation: an international survey. Perfusion 2020; 36:161-170. [PMID: 32579070 DOI: 10.1177/0267659120932705] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Intracranial hemorrhage is one of the most dreaded complications associated with extracorporeal membrane oxygenation. However, robust data to guide clinical practice are lacking. We aimed to describe the current perceptions and practices surrounding the risk, prevention, diagnosis, management, and prognosis of intracranial hemorrhage in patients on extracorporeal membrane oxygenation. METHODS We conducted an international, cross-sectional survey of adult extracorporeal membrane oxygenation centers using a self-administered electronic questionnaire sent to medical directors and program coordinators of all 290 adult centers member of the Extracorporeal Life Support Organization. RESULTS There were 143 respondents (49%). The median proportion of patients having neuroimaging performed was only 1-25% in venovenous-extracorporeal membrane oxygenation patients and 26-50% in venoarterial-extracorporeal membrane oxygenation and extracorporeal cardiopulmonary resuscitation. The majority of participants (58%) tolerated a PaO2 < 60 mm Hg on venovenous-extracorporeal membrane oxygenation. Lower PaO2 targets were inversely correlated with the reported incidence of intracranial hemorrhage (r =-0.247; p = 0.024). In patients with intracranial hemorrhage, most participants reported stopping anticoagulation, and median targets for blood product administration were 70,000-99,000 platelets/µL, 1.5-1.9 of international normalized ratio, and 1.6-2.0 g/L of fibrinogen. CONCLUSION We found significant heterogeneity in the perceptions and practices. This underlines the need for more research to appropriately guide patient management. Importantly, neuroimaging was performed only in a minority of patients. Considering the important management implications reported by most centers when intracranial hemorrhage is diagnosed, perhaps clinicians should consider widening their indications for early neuroimaging.
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Affiliation(s)
- Yiorgos Alexandros Cavayas
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, Toronto, ON, Canada.,Hôpital Sacré-Coeur de Montréal, Montreal, QC, Canada.,Montreal Heart Institute, Montreal, QC, Canada
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, Toronto, ON, Canada
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Mount Sinai Hospital, Toronto, ON, Canada
| | | | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, Toronto, ON, Canada
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Ortoleva J, Penney E. WITHDRAWN Intracranial Hemorrhage in COVID-19 Patients on ECMO: Challenges and Future Directions. J Cardiothorac Vasc Anesth 2020. [PMCID: PMC7280122 DOI: 10.1053/j.jvca.2020.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
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Multi-Modal Characterization of the Coagulopathy Associated With Extracorporeal Membrane Oxygenation. Crit Care Med 2020; 48:e400-e408. [DOI: 10.1097/ccm.0000000000004286] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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40
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Challa A, Latona J, Fraser J, Spanevello M, Scalia G, Burstow D, Platts D. Mitral valve bio-prosthesis and annuloplasty thrombosis during extracorporeal membrane oxygenation: case series. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-6. [PMID: 32617486 PMCID: PMC7319831 DOI: 10.1093/ehjcr/ytaa085] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 08/29/2019] [Accepted: 03/23/2020] [Indexed: 11/14/2022]
Abstract
Background Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a well-recognized form of haemodynamic support for patients with refractory cardiogenic shock, who are unable to be weaned off cardiopulmonary bypass. Thrombosis or bleeding from cannula sites or surgical wounds are the leading cause of morbidity and mortality in these patients, and presents a delicate balance of anticoagulation during management of patients undergoing circulatory support. Case summary In this case series, we discuss three cases of patients undergoing mitral valve replacements or repair with thrombosis of their new bio-prosthesis in the immediate post-operative setting. All three patients were supported with VA-ECMO post-operatively, and thrombosis occurred despite anticoagulation. Discussion During extracorporeal membrane oxygenation, the reduced flow throughout the heart increases the risk of intra-cardiac thrombosis. This is of particular importance in the context of mitral valve replacements and repairs, where the bio-prosthesis is an additional risk factor for thrombosis. Our cases demonstrate the morbidity and mortality of such complications, with the likely aetiology being low transvalvular flow in a newly inserted valve combined with the pro-thrombotic state created by the VA-ECMO circuit.
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Affiliation(s)
- Abhinay Challa
- Department of Cardiology, The Prince Charles Hospital, Chermside, 4032 Brisbane, Australia.,Bond University, Robina, 4226 Gold Coast, Australia
| | - Jilani Latona
- Department of Cardiology, The Prince Charles Hospital, Chermside, 4032 Brisbane, Australia
| | - John Fraser
- University of Queensland, St Lucia, 4072 Brisbane, Australia.,Critical Care Research Group, The Prince Charles Hospital, Chermside, 4032 Brisbane, Australia
| | - Michelle Spanevello
- University of Queensland, St Lucia, 4072 Brisbane, Australia.,Department of Haematology, Cancer Care Services, Royal Brisbane and Women's Hospital, Herston, 4029 Brisbane, Australia
| | - Gregory Scalia
- Department of Cardiology, The Prince Charles Hospital, Chermside, 4032 Brisbane, Australia.,University of Queensland, St Lucia, 4072 Brisbane, Australia
| | - Darryl Burstow
- Department of Cardiology, The Prince Charles Hospital, Chermside, 4032 Brisbane, Australia.,University of Queensland, St Lucia, 4072 Brisbane, Australia
| | - David Platts
- Department of Cardiology, The Prince Charles Hospital, Chermside, 4032 Brisbane, Australia.,University of Queensland, St Lucia, 4072 Brisbane, Australia.,Critical Care Research Group, The Prince Charles Hospital, Chermside, 4032 Brisbane, Australia
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Tortuosity-powered microfluidic device for assessment of thrombosis and antithrombotic therapy in whole blood. Sci Rep 2020; 10:5742. [PMID: 32238835 PMCID: PMC7113244 DOI: 10.1038/s41598-020-62768-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 03/18/2020] [Indexed: 11/29/2022] Open
Abstract
Accurate assessment of blood thrombosis and antithrombotic therapy is essential for the management of patients in a variety of clinical conditions, including surgery and on extracorporeal life support. However, current monitoring devices do not measure the effects of hemodynamic forces that contribute significantly to coagulation, platelet function and fibrin formation. This limits the extent to which current assays can predict clotting status in patients. Here, we demonstrate that a biomimetic microfluidic device consisting stenosed and tortuous arteriolar vessels would analyze blood clotting under flow, while requiring a small blood volume. When the device is connected to an inline pressure sensor a clotting time analysis is applied, allowing for the accurate measurement of coagulation, platelets and fibrin content. Furthermore, this device detects a prolonged clotting time in clinical blood samples drawn from pediatric patients on extracorporeal membrane oxygenation receiving anticoagulant therapy. Thus, this tortuosity activated microfluidic device could lead to a more quantitative and rapid assessment of clotting disorders and their treatment.
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Mazzeffi M. Patient Blood Management in Adult Extracorporeal Membrane Oxygenation Patients. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00384-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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43
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Ki KK, Passmore MR, Chan CHH, Malfertheiner MV, Bouquet M, Cho HJ, Suen JY, Fraser JF. Effect of ex vivo extracorporeal membrane oxygenation flow dynamics on immune response. Perfusion 2020; 34:5-14. [PMID: 30966901 DOI: 10.1177/0267659119830012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation is a life-saving support for heart and/or lung failure patients. Despite technological advancement, abnormal physiology persists and has been associated with subsequent adverse events. These include thrombosis, bleeding, systemic inflammatory response syndrome and infection. However, the underlying mechanisms are yet to be elucidated. We aimed to investigate whether the different flow dynamics of extracorporeal membrane oxygenation would alter immune responses, specifically the overall inflammatory response, leukocyte numbers and activation/adhesion surface antigen expression. METHODS An ex vivo model was used with human whole blood circulating at 37°C for 6 hours at high (4 L/minute) or low (1.5 L/minute) flow dynamics, with serial blood samples taken for analysis. RESULTS During high flow, production of interleukin-1β (p < 0.0001), interleukin-6 (p = 0.0075), tumour necrosis factor-α (p = 0.0013), myeloperoxidase (p < 0.0001) and neutrophil elastase (p < 0.0001) were significantly elevated over time compared to low flow, in particular at 6 hours. While the remaining assessments exhibited minute changes between flow dynamics, a consistent trend of modulation in leukocyte subset numbers and phenotype was observed at 6 hours. CONCLUSION We conclude that prolonged circulation at high flow triggers a prominent pro-inflammatory cytokine response and activates neutrophil granule release, but further research is needed to better characterize the effect of flow during extracorporeal membrane oxygenation.
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Affiliation(s)
- Katrina K Ki
- 1 Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Margaret R Passmore
- 1 Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Chris Hoi Houng Chan
- 2 Critical Care Research Group, Innovative Cardiovascular Engineering and Technology Laboratory, The Prince Charles Hospital, Brisbane, QLD, Australia.,3 School of Engineering and Built Environment, Griffith University, Brisbane, QLD, Australia
| | - Maximillian V Malfertheiner
- 4 Department of Internal Medicine II, Cardiology and Pneumology, University Medical Center Regensburg, Regensburg, Germany
| | - Mahe Bouquet
- 1 Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Hwa Jin Cho
- 5 Department of Pediatrics, Chonnam National University Children's Hospital and Medical School, Gwangju, South Korea
| | - Jacky Y Suen
- 1 Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, QLD, Australia
| | - John F Fraser
- 1 Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, QLD, Australia.,2 Critical Care Research Group, Innovative Cardiovascular Engineering and Technology Laboratory, The Prince Charles Hospital, Brisbane, QLD, Australia
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44
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Oude Lansink-Hartgring A, de Vries AJ, Droogh JM, van den Bergh WM. Hemorrhagic complications during extracorporeal membrane oxygenation – The role of anticoagulation and platelets. J Crit Care 2019; 54:239-243. [DOI: 10.1016/j.jcrc.2019.09.013] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 08/15/2019] [Accepted: 09/11/2019] [Indexed: 11/27/2022]
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45
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Penk JS, Reddy S, Polito A, Cisco MI, Allan CK, Bembea M, Giglia TM, Cheng HH, Thiagarajan RR, Dalton HJ. Bleeding and Thrombosis With Pediatric Extracorporeal Life Support: A Roadmap for Management, Research, and the Future From the Pediatric Cardiac Intensive Care Society: Part 2. Pediatr Crit Care Med 2019; 20:1034-1039. [PMID: 31517728 PMCID: PMC7433702 DOI: 10.1097/pcc.0000000000002104] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To make recommendations on improving understanding of bleeding and thrombosis with pediatric extracorporeal life support including future research directions. DATA SOURCES Evaluation of literature and consensus conferences of pediatric critical care and extracorporeal life support experts. STUDY SELECTION A team of 10 experts with pediatric cardiac and extracorporeal membrane oxygenation experience and expertise met through the Pediatric Cardiac Intensive Care Society to review current knowledge and make recommendations for future research to establish "best practice" for anticoagulation management related to extracorporeal life support. DATA EXTRACTION/DATA SYNTHESIS This white paper focuses on clinical understanding and limitations of current strategies to monitor anticoagulation. For each test of anticoagulation, limitations of current knowledge are addressed and future research directions suggested. CONCLUSIONS No consensus on best practice for anticoagulation monitoring exists. Structured scientific evaluation to answer questions regarding anticoagulation monitoring and bleeding and thrombotic events should occur in multicenter studies using standardized approaches and well-defined endpoints. Outcomes related to need for component change, blood product administration, healthcare outcome, and economic assessment should be incorporated into studies. All centers should report data on patient receiving extracorporeal life support to a registry.
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Affiliation(s)
- Jamie S. Penk
- Division of Pediatric Cardiology, Department of Pediatrics, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Sushma Reddy
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, CA
| | - Angelo Polito
- Division of Neonatalogy and Pediatric Intensive Care, Department of Pediatrics, University Hospital of Geneva, Geneva, Switzerland
| | - Michael I Cisco
- Division of Critical Care Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Catherine K. Allan
- Division of Cardiac Critical Care, Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Melania Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Therese M. Giglia
- Division of Cardiology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Henry H. Cheng
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Ravi R. Thiagarajan
- Division of Cardiac Critical Care, Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Heidi J. Dalton
- Department of Pediatrics, INOVA Fairfax Hospital, Falls Church, VA
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Acquired von Willebrand Syndrome in Pediatric Extracorporeal Membrane Oxygenation: Sheared and Cleaved Everywhere, but What to Do About It? Pediatr Crit Care Med 2019; 20:998-999. [PMID: 31580279 DOI: 10.1097/pcc.0000000000002021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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47
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Acquired von Willebrand Syndrome in Pediatric Extracorporeal Membrane Oxygenation Patients: A Single Institution's Experience. Pediatr Crit Care Med 2019; 20:980-985. [PMID: 31246745 DOI: 10.1097/pcc.0000000000002009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES 1) Describe the prevalence of acquired von Willebrand syndrome in pediatric patients undergoing extracorporeal membrane oxygenation deemed to be at increased risk for the disease in our institution, 2) discuss the challenges of testing for acquired von Willebrand syndrome diagnosis, 3) describe the characteristics of the patient population found to have acquired von Willebrand syndrome and their outcomes, and 4) discuss the potential implications of acquired von Willebrand syndrome on bleeding complications. DESIGN Retrospective chart review. SETTING PICU and cardiovascular ICU in a single institution. PATIENTS All PICU and cardiovascular ICU extracorporeal membrane oxygenation patients 0-18 years old who underwent screening for acquired von Willebrand syndrome between January 2014 and December 2016. INTERVENTIONS Humate P administration to a small subset of acquired von Willebrand syndrome positive subjects. MEASUREMENTS AND MAIN RESULTS Laboratory data of identified patients were analyzed. The diagnosis of acquired von Willebrand syndrome was made based on decreased ristocetin cofactor activity to von Willebrand factor antigen ratio and/or abnormal multimer analysis. Clinical data were extracted from the chart and through the Pediatric Extracorporeal Membrane Oxygenation Outcome Registry to describe the demographics, comorbidities, and outcomes of this patient population. In the 2 years, 29 patients had laboratory testing performed for surveillance and in cases of clinical bleeding. Of these, 23 (79%) were positive by criteria. No significant difference in mortality rate was found between patients with acquired von Willebrand syndrome versus without. We also did not find a significant difference in the blood product utilization or bleeding complications between patients with acquired von Willebrand syndrome versus without. Humate P was administered in 39% of patients (9/23) who were positive for acquired von Willebrand syndrome, but no significant difference was seen in blood product utilization or bleeding complications between acquired von Willebrand syndrome patients receiving Humate P versus those who did not. CONCLUSIONS Acquired von Willebrand syndrome is a common but under recognized disorder in pediatric extracorporeal membrane oxygenation patients. The clinical implications of this disorder on bleeding and its potential treatments are still unclear.
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Sun GH, Bruguera C, Saadat S, Moss D, Schumann R, Welsby IJ, Brovman EY, Cobey FC. ABO Blood Group and Transfusions In the Intraoperative and Postoperative Period After LVAD Implantation. J Cardiothorac Vasc Anesth 2019; 34:906-911. [PMID: 31590941 DOI: 10.1053/j.jvca.2019.09.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 09/08/2019] [Accepted: 09/12/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To assess whether blood group O patients undergoing left ventricular assist device (LVAD) insertion have higher perioperative transfusion requirements, postoperative chest tube output, and postoperative changes in hematocrit. DESIGN Retrospective review of 116 LVAD patients from August 2015 to May 2018. SETTING Single-institution, urban academic medical center. PARTICIPANTS One hundred sixteen LVAD patients analyzed by blood group: group O (n = 49) versus non-O (n = 67). INTERVENTIONS Transfusions in the combined intraoperative and postoperative period at 7 days and 90 days after LVAD implantation, chest tube output in the first 24 hours, and hematocrit change in the first 48 hours postoperatively. RESULTS There was no difference between group O and non-O within the univariable analysis for both 7-day and 90-day transfusion rates. Adjusting for covariables, blood type O was not associated with packed red blood cells transfusion after accounting for multiple comparisons (odds ratio 1.33 [1.07-1.66], p = 0.01, where p < 0.005 was considered statistically significant as a Bonferroni correction was performed to control the familywise error rate). Additionally, there was no difference in chest tube output over the first 24 hours (1,129 v 1,057 mL, p = 0.47) or hematocrit change in the first 48 hours postoperatively (3.49 v 4.53%, p = 0.15). CONCLUSION O blood group is not a significant predictor of transfusion requirements in the combined intraoperative and postoperative period up to 90 days after LVAD implantation.
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Affiliation(s)
- Gina H Sun
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Claudia Bruguera
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | | | - David Moss
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Roman Schumann
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Ian J Welsby
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Ethan Y Brovman
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA.
| | - Frederick C Cobey
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
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Mazzeffi M, Strauss E, Meyer M, Hasan S, Judd M, Abuelkasem E, Chow J, Nandwani V, McCarthy P, Tanaka K. Coagulation Factor Levels and Underlying Thrombin Generation Patterns in Adult Extracorporeal Membrane Oxygenation Patients. Anesth Analg 2019; 129:659-666. [PMID: 31425204 DOI: 10.1213/ane.0000000000004275] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND There is a paucity of data on the underlying procoagulant-anticoagulant balance during extracorporeal membrane oxygenation (ECMO). We hypothesized that adult ECMO patients would have an imbalance between procoagulant and anticoagulant factors, leading to an abnormal underlying thrombin generation (TG) pattern. METHODS Twenty adult venoarterial (VA) ECMO patients had procoagulant and anticoagulant factor levels measured temporally on ECMO day 1 or 2, day 3, and day 5. In heparin-neutralized plasma, underlying TG patterns, and sensitivity to activated protein C were assessed using calibrated automated thrombogram. TG parameters including lag time, peak TG, and endogenous thrombin potential (ETP) were compared against 5 normal plasma controls (3 males and 2 females) obtained from a commercial supplier. Thrombomodulin (TM) was added to some samples to evaluate for activated protein C resistance. RESULTS Procoagulant factors (factor [F] II, FV, and FX) were mostly in normal reference ranges and gradually increased during the first 5 ECMO days (P = .022, <.001, <.001). FVIII levels were elevated at all time points and did not change (P = .766). In contrast, FXI was in the low-normal range but did not increase during ECMO (P = .093). Antithrombin (AT) and protein C levels were below normal but increased during the first 5 ECMO days (P = .002 and P = .014). Heparinase-treated samples showed prolonged lag time, increased peak TG, and increased ETP compared to controls; mean difference in lag time on ECMO day 1 or 2 = 6.0 minutes (99% confidence interval [CI], 2.8-9.2), peak TG = 193.4 (99% CI, 122.5-264.3), and ETP = 1170.4 (99% CI, 723.2-1617.6). After in vitro TM treatment, differences in TG parameters were accentuated and ECMO samples appeared insensitive to TM treatment; mean difference in lag time on ECMO day 1 or 2 = 9.3 minutes (99% CI, 6.2-12.4), peak TG = 233.0 (99% CI, 140.9-325.1), and ETP = 1322.5 (99% CI, 764.8-1880.2). Similar differences in TG parameters were observed on ECMO days 3 and 5. CONCLUSIONS Contact activation occurs during ECMO, but procoagulant factor levels are generally preserved. Although heparin-neutralized TG is delayed, peak TG and ETP are supranormal in the setting of high FVIII and low AT and protein C levels. Resistance to TM is also apparent. These changes demonstrate a possible mechanism for hypercoagulability during adult VA ECMO.
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Affiliation(s)
- Michael Mazzeffi
- From the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Erik Strauss
- From the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael Meyer
- Institute for Transfusion Medicine, Pittsburgh, Pennsylvania
| | - Shaheer Hasan
- From the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Miranda Judd
- From the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ezeldeen Abuelkasem
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan Chow
- From the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Veena Nandwani
- Department of Medicine, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Paul McCarthy
- Department of Medicine, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Kenichi Tanaka
- From the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
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50
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Large Dual-Lumen Extracorporeal Membrane Oxygenation Cannulas Are Associated with More Intracranial Hemorrhage. ASAIO J 2019; 65:674-677. [DOI: 10.1097/mat.0000000000000917] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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