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Antonogiannakis A, Antonopoulos M, Elaiopoulos D, Leontiadis E, Ieromonachos K, Adamopoulos S, Chamogeorgakis T, Dimopoulos S. Successful management of harlequin syndrome due to pulmonary hemorrhage and atelectasis with VAV- ECMO. Perfusion 2024; 39:1259-1264. [PMID: 37272740 DOI: 10.1177/02676591231181847] [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: 06/06/2023]
Abstract
INTRODUCTION Pulmonary hemorrhage is a life-threatening complication of VA-ECMO occasionally presenting with Harlequin syndrome. CASE REPORT We present a case of a VA-ECMO patient complicated with pulmonary hemorrhage, complete right lung atelectasis and differential hypoxia refractory to conventional treatment including optimal mechanical ventilation and bronchoscopy interventions. Patient was successfully managed by conversion of VA to VAV-ECMO. DISCUSSION Pulmonary hemorrhage and atelectasis treatment in a VA-ECMO patient includes transfusion, hold and reversal of anticoagulation, bronchoscopy interventions and optimization of VA-ECMO and ventilator support. Differential hypoxia may ensue due to residual native cardiac function. If refractory to conservative treatment, a VAV-ECMO configuration may be utilized to improve upper body oxygenation by inserting an additional cannula to the superior vena cava. CONCLUSION VAV-ECMO is an ECMO configuration support in patients at risk of Harlequin syndrome presenting with pulmonary hemorrhage.
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Kahveci F, Coşkun MK, Uçmak H, Özen H, Gurbanov A, Balaban B, Dikmen N, Karagözlü S, Sarıcaoğlu MC, Botan E, Gün E, Havan M, Ramoğlu MG, Uçar T, Eyileten Z, Tutar E, Akar AR, Kendirli T. Hybrid extracorporeal membrane oxynegation in pediatric intensive care patients: A single center experience: More is better? Perfusion 2024; 39:902-910. [PMID: 37010553 DOI: 10.1177/02676591231168537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
BACKGROUND The initial extracorporeal membrane oxygenation (ECMO) configuration is inefficient for patient oxygenation and flow, but by adding a Y-connector, a third or fourth cannula can be used to support the system, which is called hybrid ECMO. METHODS This was a single-center retrospective study consisting of patients receiving hybrid and standard ECMO in our PICU between January 2014 and January 2022. RESULTS The median age of the 12 patients who received hybrid ECMO and were followed up with hybrid ECMO was 140 (range, 82-213) months. The total median ECMO duration of the patients who received hybrid ECMO was 23 (8-72) days, and the median follow-up time on hybrid ECMO was 18 (range, 3-46) days. The mean duration of follow-up in the PICU was 34 (range, 14-184) days. PICU length of stay was found to be statistically significant and was found to be longer in the hybrid ECMO group (p = 0.01). Eight (67%) patients died during follow-up with ECMO. Twenty-eight-day mortality was found to be statistically significant and was found to be higher in the standard ECMO group (p = 0.03). The hybrid ECMO mortality rate was 66% (decannulation from ECMO). The hybrid ECMO hospital mortality rate was 75%. The standard ECMO mortality rate was 52% (decannulation from ECMO). The standard ECMO hospital mortality rate was 65%. CONCLUSIONS Even though hybrid ECMO use is rare, with increasing experience and new methods, more successful experience will be gained. Switching to hybrid ECMO from standard ECMO at the right time with the right technique can increase treatment success and survival.
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Affiliation(s)
- Fevzi Kahveci
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Mert Kaan Coşkun
- Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Hacer Uçmak
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Hasan Özen
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Anar Gurbanov
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Burak Balaban
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Nur Dikmen
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Selen Karagözlü
- Division of Pediatric Cardiology, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | | | - Edin Botan
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Emrah Gün
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Merve Havan
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Mehmet Gökhan Ramoğlu
- Division of Pediatric Cardiology, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Tayfun Uçar
- Division of Pediatric Cardiology, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Zeynep Eyileten
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ercan Tutar
- Division of Pediatric Cardiology, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ahmet Rüçhan Akar
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Tanıl Kendirli
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
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Sahli SD, Kaserer A, Braun J, Aser R, Spahn DR, Wilhelm MJ. A Descriptive Analysis of Hybrid Cannulated Extracorporeal Life Support. J Pers Med 2024; 14:179. [PMID: 38392612 PMCID: PMC10889992 DOI: 10.3390/jpm14020179] [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: 12/13/2023] [Revised: 01/28/2024] [Accepted: 02/02/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Extracorporeal life support (ECLS) is pivotal for sustaining the function of failing hearts and lungs, and its utilization has risen. In cases where conventional cannulation strategies prove ineffective for providing adequate ECLS support, the implementation of an enhanced system with a third cannula may become necessary. Hybrid ECLS may be warranted in situations characterized by severe hypoxemia of the upper extremity, left ventricular congestion, and dilatation. Additionally, it may also be considered for patients requiring respiratory support or experiencing hemodynamic instability. METHOD All hybrid ECLS cases of adults at the University Hospital Zurich, Switzerland, between January 2007 and December 2019 with initial triple cannulation were included. Data were collected via a retrospective review of patient records and direct export of the clinical information system. RESULTS 28 out of 903 ECLS cases were initially hybrid cannulated (3.1%). The median age was 57 (48.2 to 60.8) years, and the sex was equally distributed. The in-hospital mortality of hybrid ECLS was high (67.9%). In-hospital mortality rates differ depending on the indication (ARDS: 36.4%, refractory cardiogenic shock: 88.9%, cardiopulmonary resuscitation: 100%, post-cardiotomy: 100%, others: 75%). Survivors exhibited a lower SAPS II level compared with non-survivors (20.0 (12.0 to 65.0) vs. 55.0 (45.0 to 73.0)), and the allogenic transfusion of platelet concentrate was observed to be less frequent for survivors (0.0 (0.0) vs. 1.8 (2.5) units). CONCLUSION The in-hospital mortality rate for hybrid ECLS was high. Different indications showed varying mortality rates, with survivors having lower SAPS II scores and requiring fewer platelet concentrate transfusions. These findings highlight the complexities of hybrid ECLS outcomes in different clinical scenarios and underline the importance of rigorous patient selection.
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Affiliation(s)
- Sebastian D Sahli
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland
| | - Alexander Kaserer
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland
| | - Julia Braun
- Epidemiology, Biostatistics and Prevention Institute, Departments of Epidemiology and Biostatistics, University of Zurich, 8057 Zurich, Switzerland
| | - Raed Aser
- Clinic for Cardiac Surgery, University Heart Center, University and University Hospital Zurich, 8091 Zurich, Switzerland
| | - Donat R Spahn
- Formerly, Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland
| | - Markus J Wilhelm
- Clinic for Cardiac Surgery, University Heart Center, University and University Hospital Zurich, 8091 Zurich, Switzerland
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Sandrio S, Thiel M, Krebs J. The Outcome Relevance of Pre-ECMO Liver Impairment in Adults with Acute Respiratory Distress Syndrome. J Clin Med 2023; 12:4860. [PMID: 37510975 PMCID: PMC10381435 DOI: 10.3390/jcm12144860] [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: 05/04/2023] [Revised: 07/13/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023] Open
Abstract
We hypothesize that (1) a significant pre-ECMO liver impairment, which is evident in the presence of pre-ECMO acute liver injury and a higher pre-ECMO MELD (model for end-stage liver disease) score, is associated with increased mortality; and (2) the requirement of veno-veno-arterial (V-VA) ECMO support is linked to a higher prevalence of pre-ECMO acute liver injury, a higher pre-ECMO MELD score, and increased mortality. We analyze 187 ECMO runs (42 V-VA and 145 veno-venous (V-V) ECMO) between January 2017 and December 2020. The SAPS II score is calculated at ICU admission; hepatic function and MELD score are assessed at ECMO initiation (pre-ECMO) and during the first five days on ECMO. SOFA, PRESERVE and RESP scores are calculated at ECMO initiation. Pre-ECMO cardiac failure, acute liver injury, ECMO type, SAPS II and MELD, SOFA, PRESERVE, and RESP scores are associated with mortality. However, only the pre-ECMO MELD score independently predicts mortality (p = 0.04). In patients with a pre-ECMO MELD score > 16, V-VA ECMO is associated with a higher mortality risk (p = 0.0003). The requirement of V-VA ECMO is associated with the development of acute liver injury during ECMO support, a higher pre-ECMO MELD score, and increased mortality.
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Affiliation(s)
- Stany Sandrio
- Department of Anesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68165 Mannheim, Germany; (M.T.); (J.K.)
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Brown TN, Brogan TV. Right ventricular dysfunction in patients with acute respiratory distress syndrome receiving venovenous extracorporeal membrane oxygenation. Front Cardiovasc Med 2023; 10:1027300. [PMID: 37265572 PMCID: PMC10229794 DOI: 10.3389/fcvm.2023.1027300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 04/10/2023] [Indexed: 06/03/2023] Open
Abstract
Acute respiratory distress syndrome is characterized by non-cardiogenic pulmonary edema, decreased pulmonary compliance, and abnormalities in gas exchange, especially hypoxemia. Patients with acute respiratory distress syndrome (ARDS) who receive support with venovenous (V-V) extracorporeal membrane oxygenation (ECMO) usually have severe lung disease. Many patients with ARDS have associated pulmonary vascular injury which can result in elevated pulmonary vascular resistance and right heart dysfunction. Since V-V ECMO relies upon preserved cardiac function, right heart failure has important implications for patient evaluation, management, and outcomes. Worsening right heart function complicates ARDS and disease processes. Given the increasing use of ECMO to support patients with ARDS, an understanding of right ventricular-ECMO and cardiopulmonary interactions is essential for the clinician. A narrative review of the manifestations of right heart dysfunction, as well as diagnosis and management strategies for the patient with ARDS on ECMO, is provided.
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Affiliation(s)
- Tyler N. Brown
- Pediatric Critical Care Medicine, University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, Washington, United States
| | - Thomas V. Brogan
- Department of Pediatrics, University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, Washington, United States
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Shoni M, Lazar S, Jackson A, Tonetti MK, Horak J, Gutsche J, Augoustides JG, Marchant BE, Fernando RJ, Jelly CA, Gallo PD, Mazzeffi MA. Parallel Venovenous Extracorporeal Membrane Oxygenation Circuits for Refractory Hypoxemia in a Super-Super-Obese Patient. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00176-3. [PMID: 37028990 DOI: 10.1053/j.jvca.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/03/2023] [Accepted: 03/06/2023] [Indexed: 04/09/2023]
Affiliation(s)
- Melina Shoni
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Sofiane Lazar
- Department of Anesthesiology and Perioperative Medicine, Jefferson University Hospital, Philadelphia, PA
| | - Andrea Jackson
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Mary Kate Tonetti
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jiri Horak
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Bryan E Marchant
- Department of Anesthesiology, Cardiothoracic and Critical Care Sections, Wake Forest University School of Medicine, Winston Salem, NC
| | - Rohesh J Fernando
- Department of Anesthesiology, Cardiothoracic Section, Wake Forest University School of Medicine, Winston Salem, NC.
| | - Christina Anne Jelly
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN
| | - Paul D Gallo
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA
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Hartwig M, van Berkel V, Bharat A, Cypel M, Date H, Erasmus M, Hoetzenecker K, Klepetko W, Kon Z, Kukreja J, Machuca T, McCurry K, Mercier O, Opitz I, Puri V, Van Raemdonck D. The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: The use of mechanical circulatory support in lung transplantation. J Thorac Cardiovasc Surg 2023; 165:301-326. [PMID: 36517135 DOI: 10.1016/j.jtcvs.2022.06.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/26/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The use of mechanical circulatory support (MCS) in lung transplantation has been steadily increasing over the prior decade, with evolving strategies for incorporating support in the preoperative, intraoperative, and postoperative settings. There is significant practice variability in the use of these techniques, however, and relatively limited data to help establish institutional protocols. The objective of the AATS Clinical Practice Standards Committee (CPSC) expert panel was to review the existing literature and establish recommendations about the use of MCS before, during, and after lung transplantation. METHODS The AATS CPSC assembled an expert panel of 16 lung transplantation physicians who developed a consensus document of recommendations. The panel was broken into subgroups focused on preoperative, intraoperative, and postoperative support, and each subgroup performed a focused literature review. These subgroups formulated recommendation statements for each subtopic, which were evaluated by the entire group. The statements were then developed via discussion among the panel and refined until consensus was achieved on each statement. RESULTS The expert panel achieved consensus on 36 recommendations for how and when to use MCS in lung transplantation. These recommendations included the use of veno-venous extracorporeal membrane oxygenation (ECMO) as a bridging strategy in the preoperative setting, a preference for central veno-arterial ECMO over traditional cardiopulmonary bypass during the transplantation procedure, and the benefit of supporting selected patients with MCS postoperatively. CONCLUSIONS Achieving optimal results in lung transplantation requires the use of a wide range of strategies. MCS provides an important mechanism for helping these critically ill patients through the peritransplantation period. Despite the complex nature of the decision making process in the treatment of these patients, the expert panel was able to achieve consensus on 36 recommendations. These recommendations should provide guidance for professionals involved in the care of end-stage lung disease patients considered for transplantation.
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Affiliation(s)
- Matthew Hartwig
- Division of Thoracic Surgery, Duke University Medical Center, Durham, NC.
| | | | | | | | - Hiroshi Date
- Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Michiel Erasmus
- University Academic Center Groningen, Groningen, The Netherlands
| | | | | | | | - Jasleen Kukreja
- University of California San Francisco, San Francisco, Calif
| | - Tiago Machuca
- University of Florida College of Medicine, Gainesville, Fla
| | | | - Olaf Mercier
- Université Paris-Saclay and Marie Lannelongue Hospital, Le Plessis-Robinson, France
| | | | - Varun Puri
- Washington University School of Medicine, St Louis, Mo
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8
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Erlebach R, Wild LC, Seeliger B, Rath AK, Andermatt R, Hofmaenner DA, Schewe JC, Ganter CC, Müller M, Putensen C, Natanov R, Kühn C, Bauersachs J, Welte T, Hoeper MM, Wendel-Garcia PD, David S, Bode C, Stahl K. Outcomes of patients with acute respiratory failure on veno-venous extracorporeal membrane oxygenation requiring additional circulatory support by veno-venoarterial extracorporeal membrane oxygenation. Front Med (Lausanne) 2022; 9:1000084. [PMID: 36213640 PMCID: PMC9539450 DOI: 10.3389/fmed.2022.1000084] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/05/2022] [Indexed: 12/05/2022] Open
Abstract
Objective Veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) is increasingly used to support patients with severe acute respiratory distress syndrome (ARDS). In case of additional cardio-circulatory failure, some experienced centers upgrade the V-V ECMO with an additional arterial return cannula (termed V-VA ECMO). Here we analyzed short- and long-term outcome together with potential predictors of mortality. Design Multicenter, retrospective analysis between January 2008 and September 2021. Setting Three tertiary care ECMO centers in Germany (Hannover, Bonn) and Switzerland (Zurich). Patients Seventy-three V-V ECMO patients with ARDS and additional acute cardio-circulatory deterioration required an upgrade to V-VA ECMO were included in this study. Measurements and main results Fifty-three patients required an upgrade from V-V to V-VA and 20 patients were directly triple cannulated. Median (Interquartile Range) age was 49 (28–57) years and SOFA score was 14 (12–17) at V-VA ECMO upgrade. Vasoactive-inotropic score decreased from 53 (12–123) at V-VA ECMO upgrade to 9 (3–37) after 24 h of V-VA ECMO support. Weaning from V-VA and V-V ECMO was successful in 47 (64%) and 40 (55%) patients, respectively. Duration of ECMO support was 12 (6–22) days and ICU length of stay was 32 (16–46) days. Overall ICU mortality was 48% and hospital mortality 51%. Two additional patients died after hospital discharge while the remaining patients survived up to two years (with six patients being lost to follow-up). The vast majority of patients was free from higher degree persistent organ dysfunction at follow-up. A SOFA score > 14 and higher lactate concentrations at the day of V-VA upgrade were independent predictors of mortality in the multivariate regression analysis. Conclusion In this analysis, the use of V-VA ECMO in patients with ARDS and concomitant cardiocirculatory failure was associated with a hospital survival of about 50%, and most of these patients survived up to 2 years. A SOFA score > 14 and elevated lactate levels at the day of V-VA upgrade predict unfavorable outcome.
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Affiliation(s)
- Rolf Erlebach
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Lennart C. Wild
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Benjamin Seeliger
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hanover, Germany
| | - Ann-Kathrin Rath
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hanover, Germany
| | - Rea Andermatt
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Daniel A. Hofmaenner
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Jens-Christian Schewe
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Christoph C. Ganter
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Mattia Müller
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Christian Putensen
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Ruslan Natanov
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hanover, Germany
| | - Christian Kühn
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hanover, Germany
- German Research Foundation (DFG), Clinical Research Group (KFO 311): “(Pre)terminal Heart and Lung Failure: Unloading and Repair”, Germany
| | - Johann Bauersachs
- German Research Foundation (DFG), Clinical Research Group (KFO 311): “(Pre)terminal Heart and Lung Failure: Unloading and Repair”, Germany
- Department of Cardiology and Angiology, Hannover Medical School, Hanover, Germany
| | - Tobias Welte
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hanover, Germany
- German Research Foundation (DFG), Clinical Research Group (KFO 311): “(Pre)terminal Heart and Lung Failure: Unloading and Repair”, Germany
| | - Marius M. Hoeper
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hanover, Germany
- German Research Foundation (DFG), Clinical Research Group (KFO 311): “(Pre)terminal Heart and Lung Failure: Unloading and Repair”, Germany
| | | | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
- *Correspondence: Sascha David,
| | - Christian Bode
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Klaus Stahl
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hanover, Germany
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Kukielski C, Jarrett Davis C, Saberi A, Chaudhary S. Veno-arteriovenous (V-AV) ECMO configuration: A single-center experience. J Card Surg 2022; 37:1254-1261. [PMID: 35191079 DOI: 10.1111/jocs.16348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/14/2021] [Accepted: 01/07/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND With increasing extracorporeal membrane oxygenation (ECMO) utilization over the last decade, clinicians have developed "hybrid" configurations to meet complex perfusion requirements. In the setting of differential hypoxemia, a veno-arteriovenous (V-AV) configuration provides oxygenated cardiac preload and hemodynamic support to satisfy physiologic demands. We aim to further characterize the patient population, indications, and outcomes associated with this hybrid configuration. METHODS We retrospectively reviewed all adult patients placed on V-AV ECMO at our institution from June 2016 to December 2019. Through a review of the electronic medical records, data describing demographic features, comorbidities, and ECMO-specific information were analyzed systematically. RESULTS 14 patients were placed on V-AV ECMO during the study period. Our cohort was 79% male with a median age of 54 and BMI of 30.3. These patients had a median SOFA-0 score of 15 and SAVE score of -12. Patients were treated with ECMO support for a median of 144.1 (IQR 98.5 - 183.1) hours, consisting of 0.2 (IQR 0 - 17.7) hours of VA and 92.4 (IQR 53.7 - 115.1) hours of V-AV followed by 67.4 (IQR 20.3 - 96.6) hours of VV support. Of these 14 patients, 11 survived to decannulation (79%) and 9 survived to hospital discharge (64%). CONCLUSION ECMO patients with recovering left ventricular function and persistent gas exchange abnormalities are at risk for developing differential hypoxemia. We describe an approach to utilizing V-AV configuration when the likelihood of differential hypoxemia is extremely high, with a survival rate that compares favorably to Extracorporeal Life Support Organization statistics and published case series.
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Affiliation(s)
- Casey Kukielski
- Department of Anesthesiology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - C Jarrett Davis
- Department of Anesthesiology, Emory University Hospital, Atlanta, Georgia, USA
| | - Asif Saberi
- Division of Critical Care Medicine, Wellstar Kennestone Hospital, Marietta, Georgia, USA
| | - Sanjay Chaudhary
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, USA
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Li C, Xie H, Li J, Qin B, Lu J, Zhang J, Lv L, Li B, Zhou C, Yin Y, Qiu H, Li Y, Liu X, Hou X. Dynamic and Hybrid Configurations for Extracorporeal Membrane Oxygenation: An Analysis of the Chinese Extracorporeal Life Support Registry. ASAIO J 2021; 68:547-552. [PMID: 34352813 DOI: 10.1097/mat.0000000000001535] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Dynamic or hybrid configurations for extracorporeal membrane oxygenation (ECMO) are needed when patient physiology or clinical conditions change. Dynamic configurations included configurations converting from veno-arterial (V-A) ECMO or veno-venous (V-V) ECMO to other forms. Hybrid configurations included venous-arteriovenous (V-AV) and venovenous-arterial (VV-A) ECMO. This study retrospectively analyzed a total of 3,814 ECMO cases (3,102 adult cases) reported to the Chinese Society of Extracorporeal Life Support from January 1, 2017 to December 31, 2019. Eight-three adult patients had dynamic or hybrid ECMO configurations, whose primary diagnoses included cardiogenic shock (33.7%), cardiac arrest (6.0%), acute respiratory failure (39.8%), septic shock (9.6%), multiple trauma (3.6%), pulmonary hypertension (3.6%), and others (3.6%). Configuration changes occurred in 37 patients with the initial configuration of VA (20 to VV, 13 to V-AV, and 4 to VV-A) and 27 with the initial configuration of VV (7 to VA, and 20 to V-AV). A total of 46 (55.4%) patients received hybrid configurations of V-AV and 10 (12.0%) received VV-A. Patients with the initial configuration of VV who converted to other configurations had higher in-hospital mortality (74.1%) than other initial configurations (VA 45.9%, V-AV 76.9%, VV-A 66.7%, P = 0.021). We concluded that dynamic or hybrid ECMO configurations were used in various underlying diseases, in which V-AV was most commonly used. Patients receiving VV ECMO for respiratory support initially, who then converted to other configurations for both respiratory and circulatory support, had significantly worst outcomes among the groups studied. The initial configuration should be selected carefully after thorough assessment of patient condition.
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Affiliation(s)
- Chenglong Li
- From the Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, P.R. China Extracorporeal Support Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, P.R. China Department of Critical Care Medicine, Henan Provincial People`s Hospital, Zhengzhou Henan, P.R. China Intensive Care Unit, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, P.R. China Department of Emergency, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, P.R. China Department of Emergency, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, P.R. China Department of Anesthesiology, Zhongshan City People's Hospital, Zhongshan, Guangdong, P.R. China Department of Cardiovascular Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, P.R. China Department of Emergency and Critical Care Medicine, The Second Hospital of Jilin University, Changchun, Jilin, P.R. China Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, P.R. China The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, P.R. China Intensive Care Unit, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, P.R. China
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Sauza-Sosa JC, Rojas-Gomez CA, Montes de Oca-Sandoval MA, Hernandez-Rendon E, Lima-Linares R, Camarena-Alejo G. Acute Cor Pulmonale in a Critically Ill Patient with COVID-19 Resolved with Venoarteriovenous Extracorporeal Membrane Oxygenation. CASE (PHILADELPHIA, PA.) 2021; 5:138-142. [PMID: 33681542 PMCID: PMC7914011 DOI: 10.1016/j.case.2021.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
•Early detection of RV dysfunction may lead to decreased mortality in patients with COVID-19. •VAV-ECMO appears to be a viable treatment for patients with SARS-CoV-2 and RV failure. •Transesophageal echocardiogram played a critical role in therapeutic decisions.
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Affiliation(s)
- Julio C Sauza-Sosa
- Cardiology and Echocardiography Department, The American British Cowdray Medical Center, Mexico City, Mexico
| | - Cesar A Rojas-Gomez
- Critical Care Department, The American British Cowdray Medical Center, Mexico City, Mexico
| | | | - Edgar Hernandez-Rendon
- Cardiothoracic Surgery Department, The American British Cowdray Medical Center, Mexico City, Mexico
| | - Rafael Lima-Linares
- Cardiovascular Anesthesia Department, The American British Cowdray Medical Center, Mexico City, Mexico
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12
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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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13
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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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14
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Shah A, Dave S, Goerlich CE, Kaczorowski DJ. Hybrid and parallel extracorporeal membrane oxygenation circuits. JTCVS Tech 2021; 8:77-85. [PMID: 34401820 PMCID: PMC8350616 DOI: 10.1016/j.xjtc.2021.02.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/03/2021] [Indexed: 12/05/2022] Open
Affiliation(s)
- Aakash Shah
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Sagar Dave
- Program in Trauma, Department of Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Corbin E Goerlich
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - David J Kaczorowski
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Md
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15
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Early Findings after Implementation of Veno-Arteriovenous ECMO: A Multicenter European Experience. MEMBRANES 2021; 11:membranes11020081. [PMID: 33499236 PMCID: PMC7912524 DOI: 10.3390/membranes11020081] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/15/2021] [Accepted: 01/20/2021] [Indexed: 11/16/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is increasingly used to treat cardiopulmonary failure in critically ill patients. Peripheral cannulation may be complicated by a persistent low cardiac output in case of veno-venous cannulation (VV-ECMO) or by differential hypoxia (e.g., lower PaO2 in the upper than in the lower body) in case of veno-arterial cannulation (VA-ECMO) and severe impairment of pulmonary function associated with cardiac recovery. The treatment of such complications remains challenging. We report the early effects of the use of veno-arterial-venous (V-AV) ECMO in this setting. Methods: Retrospective analysis including patients from five different European ECMO centers (January 2013 to December 2016) who required V-AV ECMO. We collected demographic data as well as comorbidities and ECMO characteristics, hemodynamics, and arterial blood gas values before and immediately after (i.e., within 2 h) V-AV implementation. Results: A total of 32 patients (age 53 (interquartiles, IQRs: 31–59) years) were identified: 16 were initially supported with VA-ECMO and 16 with VV-ECMO. The median time to V-AV conversion was 2 (1–5) days. After V-AV implantation, heart rate and norepinephrine dose significantly decreased, while PaO2 and SaO2 significantly increased compared to baseline values. Lactate levels significantly decreased from 3.9 (2.3–7.1) to 2.8 (1.4–4.4) mmol/L (p = 0.048). A significant increase in the overall ECMO blood flow (from 4.5 (3.8–5.0) to 4.9 (4.3–5.9) L/min; p < 0.01) was observed, with 3.0 (2.5–3.2) L/min for the arterial and 2.8 (2.1–3.6) L/min for the venous return flows. Conclusions: In ECMO patients with differential hypoxia or persistently low cardiac output syndrome, V-AV conversion was associated with improvement in some hemodynamic and respiratory parameters. A significant increase in the overall ECMO blood flow was also observed, with similar flow distributed into the arterial and venous return cannulas.
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16
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The Effect of Additional Stepwise Venous Inflow on Differential Hypoxia of Veno-Arterial Extracorporeal Membrane Oxygenation. ASAIO J 2021; 66:803-808. [PMID: 31425264 PMCID: PMC7316147 DOI: 10.1097/mat.0000000000001052] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Use of femoral-femoral veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) for cardiopulmonary support during lung transplantation can be inadequate for efficient distribution of oxygenated blood into the coronary circulation. We hypothesized that creating a left-to-right shunt flow using veno-arterio-venous (VAV) ECMO would alleviate the differential hypoxia. Total 10 patients undergoing lung transplantation were enrolled in this study. An additional inflow cannula was inserted into the right internal jugular (RIJ) vein for VAV ECMO. During left one-lung ventilation using a 1.0 inspired oxygen fraction (FiO2), the left-to-right shunt flow was incrementally increased from 0 to 500, 1,000, and 1,500 ml/min. The arterial oxygen partial pressure (PaO2) and oxygen saturation (SaO2) were measured at the proximal ascending aorta and right radial artery. The ascending aorta gas analysis revealed that six patients had a PaO2/FiO2 ratio less than 200 mm Hg at a 0 ml/min shunt flow. The PaO2 (SaO2) values were 48.5 ± 14.8 mm Hg (80.9 ± 11.6%) at the ascending aorta and 77.8 ± 69.7 mm Hg (83.3 ± 13.2%) at the right radial artery. As the left-to-right shunt flow rate increased over 1,000 ml/min, the PaO2 and SaO2 values for the ascending aorta and right radial artery significantly increased. In conclusion, femoral-femoral VA ECMO can produce suboptimal coronary oxygenation in patients unable to tolerate one-lung ventilation. A left-to-right shunt using VAV ECMO can alleviate the differential hypoxia.
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17
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Redwan B, Freermann C, Akil A, Fischer S. [Extracorporeal Lung Support in Thoracic Surgery: Basics and Pathophysiology]. Pneumologie 2021; 75:60-66. [PMID: 33461235 DOI: 10.1055/a-1172-7202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Extracorporeal lung support (ECLS) is of increasing importance in general thoracic surgery. Different modes of ECLS may be applied in several situations throughout the perioperative phase and are adapted to the individual patient's needs and the planned surgical procedures. ECLS is not a static procedure and should be always evaluated according to the present condition of the patient. Therefore, it is essential to understand the pathophysiology of the disease and the different ECLS modes, as well as the different cannulation options, in order to be able to use the different escalation and de-escalation techniques in accordance with the clinical situation.
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Affiliation(s)
- B Redwan
- Sektion für Thoraxchirurgie, Universitätsklinik Münster, Deutschland
| | - C Freermann
- Klinik für Thoraxchirurgie und Lungenunterstützung, Klinikum Ibbenbüren, Deutschland
| | - A Akil
- Klinik für Thoraxchirurgie und Lungenunterstützung, Klinikum Ibbenbüren, Deutschland
| | - S Fischer
- Klinik für Thoraxchirurgie und Lungenunterstützung, Klinikum Ibbenbüren, Deutschland
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18
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Rosenbaum AN, Bohman JK, Rehfeldt KH, Stulak JM, Daly RC, Klompas AM, Behfar A, Yalamuri SM. Dual RVAD-ECMO Circuits to Treat Cardiogenic Shock and Hypoxemia Due to Necrotizing Lung Infection: A Case Report. A A Pract 2020; 14:e01181. [PMID: 32224696 DOI: 10.1213/xaa.0000000000001181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Utilization of venoarterial extracorporeal membrane oxygenation (VA-ECMO) is expanding, but dual VA-ECMO circuits to treat cardiogenic shock with refractory hypoxemia is unreported. We describe the case of combined cardiogenic and distributive shock due to necrotizing pulmonary blastomycosis. After initial central VA-ECMO cannulation, acute respiratory distress syndrome (ARDS) with increasing shunt resulted in significant central hypoxemia due to progressive ventilation-perfusion mismatch. An additional circuit provided complete oxygenation of the high circulating volume. After 4 months on support, he underwent successful heart-lung-kidney transplantation. Dual ECMO circuits are technically feasible and may be advantageous in specific circumstances of high pulmonary shunting resulting in excessive hypoxemia unbalanced with appropriate oxygen delivery.
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Affiliation(s)
| | - John K Bohman
- Department of Anesthesiology and Perioperative Medicine
| | | | | | | | | | - Atta Behfar
- From the Department of Cardiovascular Diseases.,William J. von Liebig Center for Transplantation and Clinical Regeneration.,VanCleve Cardiac Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota
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19
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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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20
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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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21
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Belliato M, Caneva L, Aina A, Degani A, Mongodi S, Prahl Wittberg L, Pellegrini C, Broman LM, Iotti GA. An experimental model of veno-venous arterial extracorporeal membrane oxygenation. Int J Artif Organs 2019; 43:268-276. [PMID: 31692415 DOI: 10.1177/0391398819882024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Veno-venous arterial extracorporeal membrane oxygenation is a hybrid-modality of extracorporeal membrane oxygenation combining veno-venous and veno-arterial extracorporeal membrane oxygenation. It may be applied to patients with both respiratory and cardio-circulatory failure. AIM To describe a computational spreadsheet regarding an ex vivo experimental model of veno-venous arterial extracorporeal membrane oxygenation to determine the return of cannula pairs in a single pump-driven circuit. METHODS We developed an ex vivo model of veno-venous arterial extracorporeal membrane oxygenation with a single pump and two outflow cannulas, and a glucose solution was used to mimic the features of blood. We maintained a fixed aortic impedance and physiological pulmonary resistance. Both flow and pressure data were collected while testing different pairs of outflow cannulas. Six simulations of different cannula pairs were performed, and data were analysed by a custom-made spreadsheet, which was able to predict the flow partition at different flow levels. RESULTS In all simulations, the flow in the arterial cannula gradually increased differently depending on the cannula pair. The best cannula pair was a 19-Fr/18-cm arterial with a 17-Fr/50-cm venous cannula, where we observed an equal flow split and acceptable flow into the arterial cannula at a lower flow rate of 4 L/min. CONCLUSION Our computational spreadsheet identifies the suitable cannula pairing set for correctly splitting the outlet blood flow into the arterial and venous return cannulas in a veno-venous arterial extracorporeal membrane oxygenation configuration without the use of external throttles. Several limitations were reported regarding fixed aortic impedance, central venous pressure and the types of cannulas tested; therefore, further studies are mandatory to confirm our findings.
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Affiliation(s)
- Mirko Belliato
- UOC Anestesia e Rianimazione, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Luca Caneva
- UOC Anestesia e Rianimazione, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alessandro Aina
- Department of Cardiac Surgery and Cardiovascular Perfusion,Ospedale San Raffaele Milano, Italy
| | - Antonella Degani
- UOC Cardiochirurgia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Silvia Mongodi
- UOC Anestesia e Rianimazione, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Lisa Prahl Wittberg
- The Linné Flow Centre and BioMEx Centre, Department of Mechanics, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Carlo Pellegrini
- UOC Cardiochirurgia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Surgical, Pediatric, and Diagnostic Sciences, University of Pavia, Pavia, Italy
| | - Lars M Broman
- ECMO Center Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Giorgio Antonio Iotti
- UOC Anestesia e Rianimazione, IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Surgical, Pediatric, and Diagnostic Sciences, University of Pavia, Pavia, Italy
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22
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Rupprecht L, Camboni D, Philipp A, Lunz D, Müller T, Schmid C, Keyser A. Further options and survival results after failure following extracorporeal life support implantation. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 60:128-135. [PMID: 29616522 DOI: 10.23736/s0021-9509.18.10283-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND A retrospective study was designed to analyze the outcome of patients with extracorporeal life support (ECLS) who needed a consecutive cardiac or pulmonary support system. METHODS From 2006 to 2016, 93 out of 587 patients with their age ranging from 2.4 to 77.3 years required an exchange of an ECLS by another mechanical support system. Sixty-one patients were inhospital cases, 39 patients were referred with ECLS from other institutions by ambulance car (N.=15) or helicopter (N.=24). Sixty-five patients came from internal medicine wards, of which 38 patients had CPR, whereas 24 patients suffered postcardiotomy failure with CPR in 11 cases. Ten patients were referred from other hospitals for failure to wean from ECLS. RESULTS Leading symptoms were continuing cardiac failure in 43 patients (46%) and ongoing respiratory failure after cardiac recovery in 50 patients (54%). Patients with cardiac failure underwent implantation of a ventricular assist device (N.=36) or remained on long-term ECLS (N.=7) until a donor organ for heart transplantation was available (mean waiting time 43 days). Respiratory failure was treated by veno-venous ECMO (N.=34) or vav-ECMO (N.=16). Overall inhouse survival was 50.5% (N.=47). Only 22.6% of patients (N.=21) died during ongoing support. In contrast, 26.9% of patients (N.=25) deceased 35+/-51 days after weaning from vv- or vav-ECMO. Major reasons of death were multi-organ failure in 16 patients, cerebral hypoxia in 12 patients, sepsis in 10 patients, and intractable ow output in 5 patients. CONCLUSIONS Despite a switch from ECLS to another mechanical support system, survival remains limited as irreversible multi-organ failure and sepsis still jeopardize the patients' life.
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Affiliation(s)
- Leopold Rupprecht
- Department of Cardiothoracic Surgery, University Medical Center, Regensburg, Germany
| | - Daniele Camboni
- Department of Cardiothoracic Surgery, University Medical Center, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Medical Center, Regensburg, Germany
| | - Dirk Lunz
- Department of Cardiothoracic Surgery, University Medical Center, Regensburg, Germany
| | - Thomas Müller
- Department of Cardiothoracic Surgery, University Medical Center, Regensburg, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center, Regensburg, Germany -
| | - Andreas Keyser
- Department of Cardiothoracic Surgery, University Medical Center, Regensburg, Germany
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23
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Brasseur A, Scolletta S, Lorusso R, Taccone FS. Hybrid extracorporeal membrane oxygenation. J Thorac Dis 2018; 10:S707-S715. [PMID: 29732190 DOI: 10.21037/jtd.2018.03.84] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Veno-venous (VV) and veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) therapy is widely used in critically ill patients with refractory cardiogenic shock and cardiac arrest or suffering from severe respiratory failure. Besides traditional ECMO cannulation, changes in patients' conditions or the occurrence of specific complications (i.e., cerebral hypoxia or left ventricular dilation) may require modifications in cannulation strategies or the combination of ECMO with additional invasive or minimally invasive procedures, to improve organ function and ECMO efficiency. In this review, we described all these "hybrid" approaches, such as the addition of a third or fourth ECMO cannula to improve venous drainage and/or optimize systemic hemodynamics/oxygenation, or the implementation of surgical or percutaneous unloading of the left ventricle (LV), to reduce cardiac dilation and pulmonary edema. Although few data are still available about the effectiveness of such interventions, clinicians should be aware of these advances in ECMO management to improve the management of more complex cases.
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Affiliation(s)
- Alexandre Brasseur
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, ULB, Brussels, Belgium
| | - Sabino Scolletta
- Department of Anesthesia and Intensive Care, Università di Siena - Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, ULB, Brussels, Belgium
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Rituximab Induced Pulmonary Edema Managed with Extracorporeal Life Support. Case Rep Crit Care 2018; 2018:6039045. [PMID: 29593914 PMCID: PMC5822923 DOI: 10.1155/2018/6039045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 12/21/2017] [Indexed: 11/22/2022] Open
Abstract
Though rare, rituximab has been reported to induce severe pulmonary edema. We describe the first report of ECLS utilization for this indication. A 31-year-old female with severe thrombotic thrombocytopenic purpura developed florid pulmonary edema after rituximab infusion. Despite advanced ventilatory settings, she developed severe respiratory acidosis and remained hypoxemic with a significant vasopressor requirement. Since her pulmonary insult was likely transient, ECLS was considered. Due to combined cardiorespiratory failure, she received support with peripheral venoarterial ECLS. During her ECLS course, she received daily plasmapheresis and high dose steroids. Her pulmonary function recovered and she was decannulated after 8 days. She was discharged after 23 days without residual sequelae.
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Huang L, Zhang W, Yang Y, Wu W, Lu W, Xue H, Zhao H, Wu Y, Shang J, Cai L, Liu L, Liu D, Wang Y, Cao B, Zhan Q, Wang C. Application of extracorporeal membrane oxygenation in patients with severe acute respiratory distress syndrome induced by avian influenza A (H7N9) viral pneumonia: national data from the Chinese multicentre collaboration. BMC Infect Dis 2018; 18:23. [PMID: 29310581 PMCID: PMC5759204 DOI: 10.1186/s12879-017-2903-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 12/10/2017] [Indexed: 02/08/2023] Open
Affiliation(s)
- Linna Huang
- Department of Pulmonary and Critical Care Medicine, Centre for Respiratory Diseases, China-Japan Friendship Hospital, No. 2 Yinghua East Road, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Wei Zhang
- The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China
| | - Yi Yang
- Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, Jiangsu Province, People's Republic of China
| | - Wenjuan Wu
- Department of Intensive Care Unit, Wuhan Medical Treatment Center Hospital, Wuhan, Hubei Province, People's Republic of China
| | - Weihua Lu
- Department of Intensive Care Unit, The First Affiliated Hospital of Wannan Medical College, Yijishan Hospital, Wuhu, Anhui Province, People's Republic of China
| | - Han Xue
- Department of Intensive Care Unit, Taizhou People's Hospital, Taizhou, Jiangsu Province, People's Republic of China
| | - Hongsheng Zhao
- Department of Intensive Care Unit, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, People's Republic of China
| | - Yunfu Wu
- Department of Intensive Care Unit, Suzhou Municipal Hospital, Suzhou, Jiangsu Province, People's Republic of China
| | - Jia Shang
- Department of Infectious Diseases, Henan Provincial People's Hospital, Zhengzhou, Henan Province, People's Republic of China
| | - Lihua Cai
- Department of Intensive Care Unit, Dongguan People's Hospital, Dongguan, Guangdong Province, People's Republic of China
| | - Long Liu
- Department of Intensive Care Unit, The First People's Hospital of Kunshan, Kunshan, Jiangsu Province, People's Republic of China
| | - Donglin Liu
- Department of Pulmonary and Critical Care Medicine, Centre for Respiratory Diseases, China-Japan Friendship Hospital, No. 2 Yinghua East Road, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Yeming Wang
- Department of Pulmonary and Critical Care Medicine, Centre for Respiratory Diseases, China-Japan Friendship Hospital, No. 2 Yinghua East Road, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Bin Cao
- Department of Pulmonary and Critical Care Medicine, Centre for Respiratory Diseases, China-Japan Friendship Hospital, No. 2 Yinghua East Road, Chaoyang District, Beijing, 100029, People's Republic of China.
| | - Qingyuan Zhan
- Department of Pulmonary and Critical Care Medicine, Centre for Respiratory Diseases, China-Japan Friendship Hospital, No. 2 Yinghua East Road, Chaoyang District, Beijing, 100029, People's Republic of China.
| | - Chen Wang
- Department of Pulmonary and Critical Care Medicine, Centre for Respiratory Diseases, China-Japan Friendship Hospital, No. 2 Yinghua East Road, Chaoyang District, Beijing, 100029, People's Republic of China
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Kan CD, Chen WL, Lin CH, Chen YS. Predictable capability control scheme for oxygen-exchange blood flow regulation in an extracorporeal membrane oxygenation system. IET Syst Biol 2017; 11:155-162. [PMID: 29125124 PMCID: PMC8687325 DOI: 10.1049/iet-syb.2017.0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 06/03/2017] [Accepted: 06/26/2017] [Indexed: 11/09/2023] Open
Abstract
Extracorporeal membrane oxygenation system is used for rescue treatment strategies for temporary cardiopulmonary function support to facilitate adequately oxygenated blood to return into the systemic and pulmonary circulation systems. Therefore, a servo flow regulator is used to adjust the roller motor speed, while support blood flow can match the sweep gas flow (GF) in a membrane oxygenator. A generalised regression neural network is designed as an estimator to automatically estimate the desired roller pump speed and control parameters. Then, the proportional-integral-derivative controller with tuning control parameters showed good performance to achieve speed regulation and speed tracking in the desired operating point. Given the pressure of carbon dioxide, drainage blood flow, and cannula size, the proposed predictable capability control scheme can be validated to meet the intended uses in clinical applications.
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Affiliation(s)
- Chung-Dann Kan
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City, 70101, Taiwan
| | - Wei-Ling Chen
- Department of Engineering and Maintenance, Kaohsiung Veterans General Hospital, Kaohsiung City, 81362, Taiwan
| | - Chia-Hung Lin
- Department of Electrical Engineering, Kao-Yuan University, Kaohsiung City, 82151, Taiwan.
| | - Ying-Shin Chen
- Department of Electrical Engineering, Kao-Yuan University, Kaohsiung City, 82151, Taiwan
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Pitfalls of cannulation for extracorporeal life support: review of the literature and illustrative case presentation. J Artif Organs 2017; 21:8-16. [PMID: 29124458 DOI: 10.1007/s10047-017-1004-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 10/05/2017] [Indexed: 10/18/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) are an increasingly established advanced therapy for emerging severe lung and/or cardiocirculatory dysfunction or failure. Several reports have provided evidence for a potential benefit in prognosis by ECLS in cases of cardiogenic shock including cardiopulmonary resuscitation. Routine use in specialized centers reduces the incidence of negative side effects (e.g., vascular/ischemic, embolic, hemorrhagic, hemolytic and, furthermore, septic). Vascular complications like not only limb ischemia but also hypoxia proximal to the cannulation site up to complete sectorial hypoxia called "harlequin phenomenon" could refer to be a major adverse event in ECLS which, therefore, should be limited primarily to cardiocirculatory indications. Here we report on a case with "harlequin phenomenon" after ECLS implementation as a relevant complication of the mode of cannulation and review benefits and risks of commonly used variants of vascular access.
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Abstract
Cardiogenic shock is an acute emergency, which is classically managed by medical support with inotropes or vasopressors and frequently requires invasive ventilation. However, both catecholamines and ventilation are associated with a worse prognosis, and many patients deteriorate despite all efforts. Mechanical circulatory support is increasingly considered to allow for recovery or to bridge until making a decision or definite treatment. Of all devices, extracorporeal membrane oxygenation (ECMO) is the most widely used. Here we review features and strategical considerations for the use of ECMO in cardiogenic shock and cardiac arrest.
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Mohite PN, Rosenberg A, Caballero CH, Soresi S, Fatullayev J, Reed A, Popov AF, Sabashnikov A, Simon AR. Escalation of extracorporeal life support as a bridge to lung transplantation in end-stage lung disease. Perfusion 2017; 32:606-608. [PMID: 28985703 DOI: 10.1177/0267659117702440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplant (LTx) is not uncommon, but it is not commonplace yet. We present a case of a 45-year-old man with cystic fibrosis with recent deterioration in lung function who was initially supported with veno-venous (VV) ECMO. However, he subsequently required conversion to veno-veno-arterial (VVA) ECMO. After 21 days of support, he underwent double lung transplantation, with an uneventful postoperative course. This case shows that, in patients with end-stage respiratory failure awaiting lung transplantation, extracorporeal life support may require escalation to improve gas exchange and address circulatory requirements.
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Affiliation(s)
- Prashant N Mohite
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, Harefield, UK
| | - Alexander Rosenberg
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, Harefield, UK
| | - Clara Hernández Caballero
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, Harefield, UK
| | - Simona Soresi
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, Harefield, UK
| | - Javid Fatullayev
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, Harefield, UK
| | - Anna Reed
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, Harefield, UK
| | - Aron-Frederik Popov
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, Harefield, UK
| | - Anton Sabashnikov
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, Harefield, UK
| | - André R Simon
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, Harefield, UK
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Veno–veno–arterial extracorporeal membrane oxygenation for acute respiratory distress syndrome with septic-induced cardiomyopathy due to severe pulmonary tuberculosis. J Artif Organs 2017; 20:359-364. [DOI: 10.1007/s10047-017-0982-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 08/24/2017] [Indexed: 01/21/2023]
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Lee SN, Jo MS, Yoo KD. Impact of age on extracorporeal membrane oxygenation survival of patients with cardiac failure. Clin Interv Aging 2017; 12:1347-1353. [PMID: 28883715 PMCID: PMC5576703 DOI: 10.2147/cia.s142994] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Extracorporeal membrane oxygenation (ECMO) is used to treat patients in critical condition with cardiogenic shock. However, few studies have examined the effect of old age in ECMO survival. This study analyzed the impact of age on ECMO survival of patients with cardiac failure, and analyzed predictive factors for survival according to age. Materials and methods We retrospectively reviewed the medical records of 95 patients who required veno-arterial (V-A) ECMO between May 2009 and May 2016 at a single center. Patients were classified into “age ≥65” (n=48, 50.5%) and “age <65” (n=47, 49.5%) groups. Results The age ≥65 group was significantly associated with increased mortality (HR: 1.715; 95% CI =1.038–2.831) at 90 days after ECMO initiation. These associations were attenuated and did not retain statistical significance after adjustment for comorbidities (HR: 1.485; 95% CI =0.844–2.614). To determine predictive factors of mortality, multivariate logistic analysis revealed that age ≥65 (OR 5.750; 95% CI [1.508–21.920]; P=0.010), low pre-ECMO serum bicarbonate (OR 0.884; 95% CI [0.788–0.991]; P=0.035), and high pre-ECMO serum creatinine (OR 4.546; 95% CI [1.021–20.239]; P=0.047) were significantly associated with survival to 90 days. By analyzing two groups separately, high pre-ECMO serum potassium level (OR 3.552; 95% CI [1.023–12.331]; P=0.046) was the only independent predictor in patients aged <65 years while low Glasgow Coma Scale score (OR 0.698; 95% CI [0.478–1.019]; P=0.063) showed a considerable trend toward significance in patients aged ≥65. Conclusion Older age was not an independent risk factor for mortality at 90 days among V-A ECMO patients. In addition, our study provides understanding of the differences in predictive factors for ECMO survival according to age. Pre-ECMO laboratory findings and mental status can assist clinicians in the prediction of a patient’s prognosis.
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Affiliation(s)
- Su Nam Lee
- Department of Internal Medicine, St Vincent's Hospital, The Catholic University of Korea, Suwon, South Korea
| | - Min Seop Jo
- Department of Thoracic and Cardiovascular Surgery, St Vincent's Hospital, The Catholic University of Korea, Suwon, South Korea
| | - Ki-Dong Yoo
- Department of Internal Medicine, St Vincent's Hospital, The Catholic University of Korea, Suwon, South Korea
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Controlled flow diversion in hybrid venoarterial–venous extracorporeal membrane oxygenation. Interact Cardiovasc Thorac Surg 2017; 26:112-118. [DOI: 10.1093/icvts/ivx259] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 07/09/2017] [Indexed: 12/25/2022] Open
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Mongodi S, Orlando A, Tavazzi G, Pozzi M, Maggio G, Braschi A, Iotti GA, Mojoli F. Veno-Venous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome in a Patient With Acute Right Heart Failure. J Cardiothorac Vasc Anesth 2017; 31:1374-1377. [DOI: 10.1053/j.jvca.2016.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Indexed: 01/06/2023]
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Iyengar A, Zhu A, Samson J, Reemtsen B, Biniwale R. Childhood Obesity and Extracorporeal Membrane Oxygenation: Special Considerations for Successful Outcomes. J Pediatr Intensive Care 2017; 6:109-116. [PMID: 31073433 DOI: 10.1055/s-0036-1584681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 03/19/2016] [Indexed: 10/21/2022] Open
Abstract
The effects of obesity on venoarterial extracorporeal membrane oxygenation (VA-ECMO) outcomes in pediatric population are unknown. We performed retrospective analysis of 41 children (age 2-18 years) undergoing VA-ECMO. The percentage difference between actual body weight and lean body weight, referred to as Δmass, was calculated. Ratios of Δmass to ECMO flow were calculated at 4 and 24 hours. In patients with Δmass:flow ≥ 0.1 at 4 hours, higher 24-hour lactates (20.0 vs. 14.5 mg/dL; p = 0.002) and inotrope scores (17.3 vs. 11.2; p = 0.015) were observed. However, elevated Δmass:flow was not associated with mortality, and in-hospital mortality rates between groups were similar (53 vs. 45%; p = 0.647). In obese pediatric patients requiring VA-ECMO, increased flow is necessary to avoid complications of hypoperfusion and related complications.
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Affiliation(s)
- Amit Iyengar
- David Geffen School of Medicine, University of California, Los Angeles, California, United States
| | - Allen Zhu
- David Geffen School of Medicine, University of California, Los Angeles, California, United States
| | - Jessica Samson
- Department of Perfusion Services, University of California, Los Angeles, California, United States
| | - Brian Reemtsen
- Department of Cardiothoracic Surgery, Ronald Reagan Medical Center, University of California, Los Angeles, California, United States
| | - Reshma Biniwale
- Department of Cardiothoracic Surgery, Ronald Reagan Medical Center, University of California, Los Angeles, California, United States
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Sorokin V, MacLaren G, Vidanapathirana PC, Delnoij T, Lorusso R. Choosing the appropriate configuration and cannulation strategies for extracorporeal membrane oxygenation: the potential dynamic process of organ support and importance of hybrid modes. Eur J Heart Fail 2017; 19 Suppl 2:75-83. [DOI: 10.1002/ejhf.849] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Vitaly Sorokin
- Department of Surgery, Yong Loo Lin School of Medicine; National University of Singapore; Singapore
- Department of Cardiac, Thoracic and Vascular Surgery; National University Heart Center; Singapore
| | - Graeme MacLaren
- Department of Surgery, Yong Loo Lin School of Medicine; National University of Singapore; Singapore
- Department of Cardiac, Thoracic and Vascular Surgery; National University Heart Center; Singapore
- Pediatric Intensive Care Unit, Department of Pediatrics; The Royal Children's Hospital; University of Melbourne Australia
| | | | - Thijs Delnoij
- Department of Cardiology; Maastricht University Medical Centre; Maastricht The Netherlands
- Department of Intensive Care Unit; Maastricht University Medical Centre; Maastricht The Netherlands
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department; Maastricht University Medical Centre; Maastricht The Netherlands
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Extracorporeal membrane oxygenation (ECMO) as a treatment strategy for severe acute respiratory distress syndrome (ARDS) in the low tidal volume era: A systematic review. J Crit Care 2017; 41:64-71. [PMID: 28499130 DOI: 10.1016/j.jcrc.2017.04.041] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 04/06/2017] [Accepted: 04/24/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To evaluate the hospital survival in patients with severe ARDS managed with ECMO and low tidal volume ventilation as compared to patients managed with low tidal volume ventilation alone. METHODS Electronic databases were searched for studies of at least 10 adult patients with severe ARDS comparing the use of ECMO with low tidal volume ventilation to mechanical ventilation with a low tidal volume alone. Only studies reporting hospital or ICU survival were included. All identified studies were assessed independently by two reviewers. RESULTS Of 1782 citations, 27 studies (n=1674) met inclusion criteria. Hospital survival for ECMO patients ranged from 33.3 to 86%, while survival with conventional therapy ranged from 36.3 to 71.2%. Five studies were identified with appropriate control groups allowing comparison, but due to the high degree of variability between studies (I2=63%), their results could not be pooled. Two of these studies demonstrated a significant difference, both favouring ECMO over conventional therapy. CONCLUSION Given the lack of studies with appropriate control groups, our confidence in a difference in outcome between the two therapies remains weak. Future studies on the use of ECMO for severe ARDS are needed to clarify the role of ECMO in this disease.
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38
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Banfi C, Pozzi M, Siegenthaler N, Brunner ME, Tassaux D, Obadia JF, Bendjelid K, Giraud R. Veno-venous extracorporeal membrane oxygenation: cannulation techniques. J Thorac Dis 2016; 8:3762-3773. [PMID: 28149575 DOI: 10.21037/jtd.2016.12.88] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The development of extracorporeal membrane oxygenation (ECMO) technology allows a new approach for the intensive care management of acute cardiac and/or respiratory failure in adult patients who are not responsive to conventional treatment. Current ECMO therapies provide a variety of options for the multidisciplinary teams who are involved in the management of these critically ill patients. In this regard, veno-venous ECMO (VV-ECMO) can provide quite complete respiratory support, even if this highly complex technique presents substantial risks, such as bleeding, thromboembolic events and infection. While VV-ECMO circuits usually include the cannulation of two vessels (double cannulation) in its classic configuration, the use of a single cannula is now possible for VV-ECMO support. Recently, experienced centers have employed more advanced approaches by cannulating three vessels (triple cannulation) which follows veno-arterio-venous (VAV) or veno-arterio-pulmonary-arterial cannulation (VAPa). However, 'triple' cannulation expands the field of application but increases the complexity of ECMO systems. In the present review, the authors focus on the indications for VV-ECMO, patient assessment prior to cannulation, the role of ultrasound-guided vessel puncture, double lumen single bicaval cannulations, and finally triple cannulation in VV-ECMO.
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Affiliation(s)
- Carlo Banfi
- Division of Cardiovascular Surgery, Geneva University Hospitals, Geneva, Switzerland;; Faculty of Medicine, University of Geneva, Geneva, Switzerland;; Geneva Hemodynamic Research Group, Geneva, Switzerland
| | - Matteo Pozzi
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, "Claude Bernard" University, Lyon, France
| | - Nils Siegenthaler
- Faculty of Medicine, University of Geneva, Geneva, Switzerland;; Geneva Hemodynamic Research Group, Geneva, Switzerland;; Intensive Care Service, Geneva University Hospitals, Geneva, Switzerland
| | - Marie-Eve Brunner
- Intensive Care Service, Geneva University Hospitals, Geneva, Switzerland
| | - Didier Tassaux
- Intensive Care Service, Geneva University Hospitals, Geneva, Switzerland
| | - Jean-Francois Obadia
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, "Claude Bernard" University, Lyon, France
| | - Karim Bendjelid
- Faculty of Medicine, University of Geneva, Geneva, Switzerland;; Geneva Hemodynamic Research Group, Geneva, Switzerland;; Intensive Care Service, Geneva University Hospitals, Geneva, Switzerland
| | - Raphaël Giraud
- Faculty of Medicine, University of Geneva, Geneva, Switzerland;; Geneva Hemodynamic Research Group, Geneva, Switzerland;; Intensive Care Service, Geneva University Hospitals, Geneva, Switzerland
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The University of Michigan Experience with Veno-Venoarterial Hybrid Mode of Extracorporeal Membrane Oxygenation. ASAIO J 2016; 62:578-83. [DOI: 10.1097/mat.0000000000000405] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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40
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Jeon YJ, Byun JH, Hwang SW, Park JH, Lee JH. Successful Application of Veno-Venoarterial Extracorporeal Membrane Oxygenation for Acute Exacerbation of Asthma Followed by Stress Cardiomyopathy. Yonsei Med J 2016; 57:536-7. [PMID: 26847314 PMCID: PMC4740554 DOI: 10.3349/ymj.2016.57.2.536] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 06/19/2015] [Accepted: 06/19/2015] [Indexed: 11/27/2022] Open
Affiliation(s)
- Yeong Jeong Jeon
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joung Hun Byun
- Department of Thoracic and Cardiovascular Surgery, Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea.
| | - Sang Won Hwang
- Department of Thoracic and Cardiovascular Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Jae Hong Park
- Department of Thoracic and Cardiovascular Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Ji Hyun Lee
- Department of Pulmonary Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
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Napp LC, Kühn C, Hoeper MM, Vogel-Claussen J, Haverich A, Schäfer A, Bauersachs J. Cannulation strategies for percutaneous extracorporeal membrane oxygenation in adults. Clin Res Cardiol 2015; 105:283-96. [PMID: 26608160 PMCID: PMC4805695 DOI: 10.1007/s00392-015-0941-1] [Citation(s) in RCA: 148] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 11/03/2015] [Indexed: 12/28/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) has revolutionized treatment of severe isolated or combined failure of lung and heart. Due to remarkable technical development the frequency of use is growing fast, with increasing adoption by interventional cardiologists independent of cardiac surgery. Nevertheless, ECMO support harbors substantial risk such as bleeding, thromboembolic events and infection. Percutaneous ECMO circuits usually comprise cannulation of two large vessels ('dual' cannulation), either veno-venous for respiratory and veno-arterial for circulatory support. Recently experienced centers apply more advanced strategies by cannulation of three large vessels ('triple' cannulation), resulting in veno-veno-arterial or veno-arterio-venous cannulation. While the former intends to improve drainage and unloading, the latter represents a very potent method to provide circulatory and respiratory support at the same time. As such triple cannulation expands the field of application at the expense of increased complexity of ECMO systems. Here, we review percutaneous dual and triple cannulation strategies for different clinical scenarios of the critically ill. As there is no unifying terminology to date, we propose a nomenclature which uses "A" and all following letters for supplying cannulas and all letters before "A" for draining cannulas. This general and unequivocal code covers both dual and triple ECMO cannulation strategies (VV, VA, VVA, VAV). Notwithstanding the technical evolution, current knowledge of ECMO support is mainly based on observational experience and mostly retrospective studies. Prospective controlled trials are urgently needed to generate evidence on safety and efficacy of ECMO support in different clinical settings.
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Affiliation(s)
- L Christian Napp
- Cardiac Arrest Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Christian Kühn
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Marius M Hoeper
- Department of Respiratory Medicine and German Center of Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - Jens Vogel-Claussen
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Andreas Schäfer
- Cardiac Arrest Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Johann Bauersachs
- Cardiac Arrest Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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Narotsky DL, Mosca MS, Mochari-Greenberger H, Beck J, Liao M, Mongero L, Bacchetta M. Short-term and longer-term survival after veno-arterial extracorporeal membrane oxygenation in an adult patient population: does older age matter? Perfusion 2015; 31:366-75. [DOI: 10.1177/0267659115609092] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: Veno-arterial (V-A) extracorporeal membrane oxygenation (ECMO) is increasingly being used for patients with refractory cardiopulmonary failure. This study evaluates the short-term (to discharge) and longer-term (1 year) survival among older (⩾65 years) versus younger (<65 years) adults, adjusted for comorbidities, in a diverse cohort of V-A ECMO patients. Methods: This was a retrospective cohort analysis of 131 adult patients (28% ⩾65 years old) who received V-A ECMO at an academic medical center from 2004-2013. Demographics, comorbidities and surgical characteristics were abstracted from the medical records and verified. Mortality status at discharge and at one year post-ECMO were determined by the hospital clinical information system, updated monthly with Social Security Death Index data. Cox proportional hazard analyses were conducted to evaluate associations between age strata and mortality at discharge and at one year post ECMO initiation, adjusted for covariates. Results: The survival rate following V-A ECMO was 48% (n=68/131) to discharge and 44% (n=58/131) to one year. Age ⩾65 versus <65 was significantly associated with increased mortality during hospitalization (HR:2.03; 95%CI=1.23-3.33) and at one year (HR:1.81; 95% CI=1.12-2.93); these associations were attenuated and did not retain statistical significance after adjustment for comorbidities (HR:1.61; 95%CI=0.90-2.88 and HR:1.42; 95% CI=0.81-2.50, respectively). Statistically significant predictors of mortality at discharge and one year included history of coronary artery bypass graft, peripheral vascular disease and renal failure/dialysis (p<0.05). Conclusions: Older age was not independently associated with short-term or longer-term survival among V-A ECMO patients, but may reflect greater comorbidity, suggesting that age alone may not disqualify patients from V-A ECMO therapy.
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Affiliation(s)
- David L Narotsky
- Columbia University Medical Center, Department of Medicine, New York, NY, USA
| | | | | | - James Beck
- Columbia University Medical Center/New York Presbyterian Hospital, Department of Cardiovascular Perfusion, New York, NY, USA
| | - Ming Liao
- Columbia University Medical Center, Department of Medicine, New York, NY, USA
| | - Linda Mongero
- Columbia University Medical Center/New York Presbyterian Hospital, Department of Cardiovascular Perfusion, New York, NY, USA
| | - Matthew Bacchetta
- Columbia University Medical Center, Department of Cardiothoracic Surgery, New York, NY, USA
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Raleigh L, Ha R, Hill C. Extracorporeal Membrane Oxygenation Applications in Cardiac Critical Care. Semin Cardiothorac Vasc Anesth 2015; 19:342-52. [PMID: 26403786 DOI: 10.1177/1089253215607065] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The use of extracorporeal membrane oxygenation therapy (ECMO) in cardiac critical care has steadily increased over the past decade. Significant improvements in the technology associated with ECMO have propagated this recent resurgence and contributed to improved patient outcomes in the fields of cardiac and transplant (heart and lung) surgery. Specifically, ECMO is being increasingly utilized as a bridge to heart and lung transplantation, as well as to ventricular assist device placement. ECMO is also employed during the administration of cardiopulmonary resuscitation, known as extracorporeal life support. In this review, we examine the recent literature regarding the applications of ECMO and also describe emerging topics involving current ECMO management strategies.
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Affiliation(s)
- Lindsay Raleigh
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Rich Ha
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Charles Hill
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
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Veno-venous extracorporeal membrane oxygenation in a patient with severe acute respiratory failure - case report. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2015; 12:65-8. [PMID: 26336483 PMCID: PMC4520516 DOI: 10.5114/kitp.2015.50573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 02/05/2014] [Accepted: 04/22/2014] [Indexed: 11/30/2022]
Abstract
Acute respiratory failure resistant to conventional pulmonary therapy often requires intensive medical care. In rare cases, ventilator therapy proves insufficient, and only the option of employing veno-venous extracorporeal membrane oxygenation (ECMO V-V) remains. The present article describes the case of a 23-year-old patient who experienced severe acute respiratory distress syndrome with associated multiple organ failure. The patient was admitted to the pulmonary ward of the Alfred Sokołowski Regional Pulmonary Hospital in Szczecin-Zdunowo with suspected pneumonia of unknown etiology. After the initial 5 days of diagnostics at the pulmonary ward, the patient required a further 97 days of hospital treatment and spent 63 days at the Intensive Care Unit. There, he underwent ECMO V-V therapy lasting 22 days, which resulted in the improvement of his arterial blood gas parameters and clinical condition.
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45
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Zhang Z, Chen K, Ni H, Xu X. Incorporation of a hemofilter circuit into venoarterial extracorporeal membrane oxygenation: a novel approach to provide more oxygenation. Intensive Care Med 2015; 41:729-30. [PMID: 25708423 DOI: 10.1007/s00134-015-3706-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Zhongheng Zhang
- Department of Critical Care Medicine, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, 351#, Mingyue Street, Jinhua, Zhejiang, People's Republic of China,
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Ius F, Sommer W, Tudorache I, Avsar M, Siemeni T, Salman J, Puntigam J, Optenhoefel J, Greer M, Welte T, Wiesner O, Haverich A, Hoeper M, Kuehn C, Warnecke G. Veno-veno-arterial extracorporeal membrane oxygenation for respiratory failure with severe haemodynamic impairment: technique and early outcomes. Interact Cardiovasc Thorac Surg 2015; 20:761-7. [PMID: 25736272 DOI: 10.1093/icvts/ivv035] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 02/03/2015] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Patients with respiratory failure may benefit from veno-venous and veno-arterial extracorporeal membrane oxygenation (ECMO) support. We report on our initial experience of veno-veno-arterial (v-v-a) ECMO in patients with respiratory failure. METHODS Between January 2012 and February 2014, 406 patients required ECMO support at our institution. Here, we retrospectively analysed the characteristics and outcomes of patients commenced on either veno-venous or veno-arterial ECMO due to respiratory failure, and then switched to v-v-a ECMO. RESULTS Ten (2%) patients proceeded to v-v-a ECMO. The underlying conditions were acute respiratory distress syndrome (n = 3), end-stage pulmonary fibrosis (n = 5) and respiratory failure after major thoracic surgery (n = 1) and Caesarean section (n = 1). In all of these patients, ECMO was initially started as veno-venous (n = 9) or veno-arterial (n = 1) ECMO but was switched to a veno-veno-arterial (v-v-a) approach after a mean of 2 (range, 0-7) days. Reasons for switching were: haemodynamic instability (right heart failure, n = 5; pericardial tamponade, n = 1; severe mitral valve regurgitation, n = 1; haemodynamic instability following cardiopulmonary resuscitation, n = 1 and evidence of previously unknown atrial septal defect with pulmonary hypertension and Eisenmenger syndrome, n = 1) and upper-body hypoxaemia (n = 1). ECMO-related complications were bleeding (n = 3) and leg ischaemia (n = 2). Seven patients were successfully taken off ECMO with 4 being bridged to recovery and a further 3 to lung transplantation after a mean of 11 (range, 9-18) days. Five patients survived until hospital discharge and all of them were alive at the end of the follow-up. CONCLUSIONS Veno-veno-arterial ECMO is a technically feasible rescue strategy in treating patients presenting with combined respiratory and haemodynamic failure.
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Affiliation(s)
- Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Wiebke Sommer
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany German Centre for Lung Research (DZL), Hannover, Germany
| | - Igor Tudorache
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Murat Avsar
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Thierry Siemeni
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jawad Salman
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jakob Puntigam
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Joerg Optenhoefel
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Mark Greer
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Tobias Welte
- German Centre for Lung Research (DZL), Hannover, Germany Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Olaf Wiesner
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany German Centre for Lung Research (DZL), Hannover, Germany
| | - Marius Hoeper
- German Centre for Lung Research (DZL), Hannover, Germany Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Christian Kuehn
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Gregor Warnecke
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany German Centre for Lung Research (DZL), Hannover, Germany
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[Acute respiratory distress syndrome and septic cardiomyopathy : successful application of veno-venoarterial extracorporeal membrane oxygenation]. Anaesthesist 2013; 62:639-43. [PMID: 23917895 DOI: 10.1007/s00101-013-2213-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Revised: 06/30/2013] [Accepted: 07/01/2013] [Indexed: 10/26/2022]
Abstract
A 30-year-old patient was admitted to hospital with fever and respiratory insufficiency due to community acquired pneumonia. Within a few days the patient developed septic cardiomyopathy and severe acute respiratory distress syndrome (ARDS) which deteriorated under conventional mechanical ventilation. Peripheral venoarterial extracorporeal membrane oxygenation (va-ECMO) was initiated by the retrieval team of an ARDS/ECMO centre at a paO2/FIO2 ratio of 73 mmHg and a left ventricular ejection fraction (EF) of 10 %. After 12 h va-ECMO was converted to veno-venoarterial ECMO (vva-ECMO) for improvement of pulmonary and systemic oxygenation. Left ventricular function improved (EF 45 %) 36 h after starting ECMO and the patient was weaned from vva-ECMO and converted to vv-ECMO. The patient was weaned successfully from vv-ECMO after 5 additional days and transferred back to the referring hospital for weaning from the ventilator.
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Hori D, Noguchi K, Nomura Y, Tanaka H. Extracorporeal membrane oxygenation with double venous drainage. Ann Thorac Cardiovasc Surg 2013; 20 Suppl:836-8. [PMID: 23445789 DOI: 10.5761/atcs.cr.12.01993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We report on a successful configuration strategy of extracorporeal membrane oxygenation(ECMO) in two consecutive cases of acute lung injury. A 60-year-old woman with Streptococcus pneumoniae infection and a 22-year-old man with hemothorax were admitted to our hospital with failing lungs. Although treatment with a ventilator was started, oxygenation could not be maintained. ECMO with a femoro-femoral circuit was performed, which showed a slight improvement in oxygenation. However, not enough oxygen support was provided. To minimize the venous mixture at the right atrium, we added venous drainage from the right jugular vein which resulted in better oxygenation and patient survival.
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Affiliation(s)
- Daijiro Hori
- Department of Cardiovascular Surgery, Fujigaoka Hospital, Showa University, Yokohama, Kanagawa, Japan
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Zangrillo A, Biondi-Zoccai G, Landoni G, Frati G, Patroniti N, Pesenti A, Pappalardo F. Extracorporeal membrane oxygenation (ECMO) in patients with H1N1 influenza infection: a systematic review and meta-analysis including 8 studies and 266 patients receiving ECMO. Crit Care 2013; 17:R30. [PMID: 23406535 PMCID: PMC4057025 DOI: 10.1186/cc12512] [Citation(s) in RCA: 137] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 11/29/2012] [Indexed: 02/08/2023] Open
Abstract
Introduction H1N1 influenza can cause severe acute lung injury (ALI). Extracorporeal membrane oxygenation (ECMO) can support gas exchange in patients failing conventional mechanical ventilation, but its role is still controversial. We conducted a systematic review and meta-analysis on ECMO for H1N1-associated ALI. Methods CENTRAL, Google Scholar, MEDLINE/PubMed and Scopus (updated 2 January 2012) were systematically searched. Studies reporting on 10 or more patients with H1N1 infection treated with ECMO were included. Baseline, procedural, outcome and validity data were systematically appraised and pooled, when appropriate, with random-effect methods. Results From 1,196 initial citations, 8 studies were selected, including 1,357 patients with confirmed/suspected H1N1 infection requiring intensive care unit admission, 266 (20%) of whom were treated with ECMO. Patients had a median Sequential Organ Failure Assessment (SOFA) score of 9, and had received mechanical ventilation before ECMO implementation for a median of two days. ECMO was implanted before inter-hospital patient transfer in 72% of cases and in most patients (94%) the veno-venous configuration was used. ECMO was maintained for a median of 10 days. Outcomes were highly variable among the included studies, with in-hospital or short-term mortality ranging between 8% and 65%, mainly depending on baseline patient features. Random-effect pooled estimates suggested an overall in-hospital mortality of 28% (95% confidence interval 18% to 37%; I2 = 64%). Conclusions ECMO is feasible and effective in patients with ALI due to H1N1 infection. Despite this, prolonged support (more than one week) is required in most cases, and subjects with severe comorbidities or multiorgan failure remain at high risk of in-hospital death.
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