Veno-arterial extracorporeal membrane oxygenation for cardiogenic shock due to myocarditis in adult patients

Effect of veno-arterial extracorporeal membrane oxygenation lower-extremity cannulation on intra-arterial flow characteristics, oxygen content, and thrombosis risk

PURPOSE

This study aimed to investigate the effects of lower-extremity cannulation on the intra-arterial hemodynamic environment, oxygen content, blood damage, and thrombosis risk under different levels of veno-arterial (V-A) ECMO support.

METHODS

Computational fluid dynamics methods were used to investigate the effects of different levels of ECMO support (ECMO flow ratios supplying oxygen-rich blood 100-40 %). Flow rates and oxygen content in each arterial branch were used to determine organ perfusion. A new thrombosis model considering platelet activation and deposition was proposed to determine the platelet activation and thrombosis risk at different levels of ECMO support. A red blood cell damage model was used to explore the risk of hemolysis.

RESULTS

Our study found that partial recovery of cardiac function improved the intra-arterial hemodynamic environment, with reduced impingement of the intra-arterial flow field by high-velocity blood flow from the cannula, a flow rate per unit time into each arterial branch closer to physiological levels, and improved perfusion in the lower extremities. Partial recovery of cardiac function helps reduce intra-arterial high shear stress and residence time, thereby reducing blood damage. The overall level of hemolysis and platelet activation in the aorta decreased with the gradual recovery of cardiac contraction function. The areas at high risk of thrombosis under V-A ECMO femoral cannulation support were the aortic root and the area distal to the cannula, which moved to the descending aorta when cardiac function recovered to 40-60 %. However, with the recovery of cardiac contraction function, hypoxic blood pumped by the heart is insufficient in supplying oxygen to the front of the aortic arch, which may result in upper extremity hypoxia.

CONCLUSION

We developed a thrombosis risk prediction model applicable to ECMO cannulation and validated the model accuracy using clinical data. Partial recovery of cardiac function contributed to an improvement in the aortic hemodynamic environment and a reduction in the risk of blood damage; however, there is a potential risk of insufficient perfusion of oxygen-rich blood to organs.

Myocardial Oedema as a Consequence of Viral Infection and Persistence-A Narrative Review with Focus on COVID-19 and Post COVID Sequelae

Microvascular integrity is a critical factor in myocardial fluid homeostasis. The subtle equilibrium between capillary filtration and lymphatic fluid removal is disturbed during pathological processes leading to inflammation, but also in hypoxia or due to alterations in vascular perfusion and coagulability. The degradation of the glycocalyx as the main component of the endothelial filtration barrier as well as pericyte disintegration results in the accumulation of interstitial and intracellular water. Moreover, lymphatic dysfunction evokes an increase in metabolic waste products, cytokines and inflammatory cells in the interstitial space contributing to myocardial oedema formation. This leads to myocardial stiffness and impaired contractility, eventually resulting in cardiomyocyte apoptosis, myocardial remodelling and fibrosis. The following article reviews pathophysiological inflammatory processes leading to myocardial oedema including myocarditis, ischaemia-reperfusion injury and viral infections with a special focus on the pathomechanisms evoked by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In addition, clinical implications including potential long-term effects due to viral persistence (long COVID), as well as treatment options, are discussed.

Fulminant Lymphocytic Myocarditis Successfully Managed with Intra-Aortic Balloon Pump and Extracorporeal Membrane Oxygenation: A Case Report

BACKGROUND Lymphocytic myocarditis (LM) is a rare inflammatory disease of the heart. The clinical presentation of LM varies from mild flu-like symptoms to fulminant myocarditis with cardiogenic shock. Fulminant myocarditis has a poor prognosis and the usual treatment is inotropes with or without ventricular assist devices such as intra-aortic balloon pump (IABP) and venoarterial extracorporeal membrane oxygenation (V-A ECMO). We report the case of fulminant LM with severe cardiogenic shock that was successfully treated with concomitant use of IABP and V-A ECMO. CASE REPORT A 32-year-old woman with no medical history presented to the Emergency Department (ED) with chest pain with irradiation to the left upper limb, worse when supine. The electrocardiogram (ECG) on admission showed sinus rhythm with nonspecific ST-T repolarization abnormalities, and laboratory results showed elevated ultrasensitive troponin and C-reactive protein. Transthoracic echocardiography (TTE) showed left ventricular ejection fraction (LVEF) of 25% and diffuse hypokinesis. On the next day, she developed cardiogenic shock requiring vasoactive drugs, IABP, and V-A ECMO. Pulse therapy with methylprednisolone was started. Endomyocardial biopsy (EMB) revealed acute LM, and intravenous human immunoglobulin was administered. The patient evolved with progressive clinical improvement, being discharged 56 days after admission, with an improvement in the LVEF to 55%. CONCLUSIONS Fulminant LM is a rare and potentially fatal condition that requires immediate intervention. The combination of IABP and V-A ECMO among patients with LM-cardiogenic shock may provide survival benefits.

Venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock: The impact of cannulation strategy on survival

BACKGROUND

The optimal venoarterial extracorporeal membrane oxygenation (VA ECMO) cannulation strategy in patients with postcardiotomy cardiogenic shock is still debatable. Studies evaluating the effect of cannulation strategy on long-term survival are scarce.

OBJECTIVES

We investigated the impact of central versus peripheral cannulation strategy for ECMO insertion on hospital outcomes and survival in postcardiotomy cardiogenic shock patients.

METHODS

This retrospective study involved 101 patients who had either central or peripheral ECMO due to postcardiotomy shock between June 2009 and December 2020. Study endpoints were limb ischemia, bleeding, blood transfusion, wound infection, and overall survival.

RESULTS

Eighty-four patients received central (c) ECMO, and 17 patients had peripheral (p) ECMO. In the group of pECMO, limb ischemia was significantly higher (5 [29.41%] vs 6 [7.14%]; p = .01). Other endpoints were similar in both groups. Thirty-day mortality was nonsignificantly different between both cohorts (cECMO 34 [41.67%] vs pECMO 10 [58.82%]; p = .29). However, overall survival was better with cECMO (Log-rank p = .02). Patients' age [HR: 1.04 (95% CI: 1.02-1.06); p = .001], pECMO [HR: 1.98 (95% CI: 1.11-3.55), p = .002] and presence of infective endocarditis [HR: 3.54 (95% CI: 1.52-8.24), p = .03] were significant predictors of overall mortality.

CONCLUSIONS

Peripheral ECMO was associated with an increased risk of limb ischemia; however, bleeding, blood transfusion, infection, and 30-day mortality were comparable to central ECMO. Central cannulation was associated with a better 1-year survival rate. Therefore, central cannulation might be the preferred strategy for patients with postcardiotomy cardiogenic shock.

Influence of confirmed viral infection on adult acute fulminant myocarditis supported with extracorporeal membrane oxygenation

BACKGROUND

The impact of etiologies of acute fulminant myocarditis (AFM), which requires extracorporeal membrane oxygenation (ECMO), on clinical outcomes remains unknown. This study aimed to investigate the risk factors for ECMO weaning and mortality among patients with AFM due to viral etiologies in a tertiary referral medical center.

METHODS

We included 33 adults with AFM who received ECMO and were admitted between January 2002 and January 2021. General demographics, laboratory data, echocardiography findings, and long-term outcomes were analyzed for confirmed viral etiology and unconfirmed etiology groups.

RESULTS

The overall hospital survival rate was 54.5%. The age, sex, severity of the hemodynamic condition, and cardiac rhythm were similar between the two groups. Multivariate Cox regression analysis revealed that a confirmed viral etiology (HR 4.201, 95% CI 1.061-16.666), peri-ECMO renal replacement therapy (RRT) (HR 9.804, 1.140-83.333) and a high positive end-expiratory pressure (PEEP) in the ventilator settings at 24 h after ECMO (HR 1.479, 1.020-2.143) were significant prognostic factors for in-hospital mortality. Peri-ECMO RRT was also a significant negative prognostic factor for successful ECMO weaning (OR 0.061, 0.006-0.600) in the multivariate logistic model.

CONCLUSIONS

Among AFM patients receiving ECMO support, RRT use was associated with a decreased chance of survival to ECMO weaning. Multiple organ dysfunction and a high PEEP were also predictive of a lower chance of hospital survival. Those with a confirmed diagnosis of viral myocarditis may require more medical attention due to the higher risk of hospital mortality than those without a definite diagnosis.

Emerging concepts in heart failure management and treatment: circulatory support with extracorporeal membrane oxygenation (ECMO)

Circulatory support with extracorporeal membrane oxygenation (ECMO) is being increasingly used in several critical situations but evidence of its impact on outcomes is inconsistent. Understanding of the specific indications and appropriate timing of implantation of this technology might lead to improved results. Indeed, the line between success and futility may be sometimes very thin when facing a patient in critical condition. New techniques with lighter, simpler and effective devices are being developed. Hence, ECMO has become an accessible technology that is being increasingly used outside of the operating room by heart failure specialists, critical care cardiologists and intensivists. Proper timing of utilization and choice of device may lead to better outcomes. We herein aim to improve this knowledge gap by conducting a literature review to provide simple information, evidence-based indications and a practical approach for cardiologists who may encounter acutely ill adult patients that may be ECMO candidates. This article is part of the Emerging concepts in heart failure management and treatment Special Issue: https://www.drugsincontext.com/special_issues/emerging-concepts-in-heart-failure-management-and-treatment.

Successful treatment of fulminant myocarditis with intra-aortic balloon pump counterpulsation combined with immunoglobulin and glucocorticoid in a young male adult

Background

Fulminant myocarditis (FM) is a serious non-specific inflammatory disease of the myocardium. FM tends to occur in adolescents and the course of the disease progresses rapidly. It is prone to cardiogenic shock (CGS) and multiple organ failure (MOF) with high mortality. We report a case of FM with CGS and MOF in a young male who was successfully treated with intra-aortic balloon pump counterpulsation (IABP) combined with intravenous immunoglobulin (IVIG) and glucocorticoid (GC).

Case summary

A 21-year-old previously healthy man presented with fever, headache, and chest tightness. He came to the hospital for emergency treatment. The laboratory data showed that the levels of serum cardiac troponin I (cTnI), N-terminal B-type natriuretic peptide (NT-proBNP), myocardial zymogram, and neutrophils increased. Echocardiography showed pericardial effusion and decreased left ventricular systolic function. ECG showed diffuse ST-segment elevation. He was clinically diagnosed with FM and admitted to the intensive care unit for treatment. Within 48 h of admission, the clinical course of the patient deteriorated rapidly, with CGS accompanied by MOF, high atrioventricular block (AVB), and ventricular tachycardia (VT). After using mechanical circulatory support (MCS) therapy with IABP, IVIG, GC, continuous renal replacement therapy (CRRT), and mechanical ventilation complicated with a temporary cardiac pacemaker, he recovered normal cardiac function. He made a full recovery and was discharged home on day 21.

Discussion

For patients with FM, early diagnosis, close monitoring, timely use of MCS devices, and active comprehensive treatment are very important. MCS devices such as IABP can become lifesaving tools for the treatment of FM.

Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part I, Technical Aspects of Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) is used to support patients with refractory cardiopulmonary failure. Given ECMO's increased use in adults and the fact that many ECMO patients are cared for by anesthesiologists, the Society of Cardiovascular Anesthesiologists ECMO working group created an expert consensus statement that is intended to help anesthesiologists manage adult ECMO patients who are cared for in the operating room. In the first part of this 2-part series, technical aspects of ECMO are discussed, and related expert consensus statements are provided.

Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: an Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part I, Technical Aspects of Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) is used to support patients with refractory cardiopulmonary failure. Given ECMO's increased use in adults and the fact that many ECMO patients are cared for by anesthesiologists, the Society of Cardiovascular Anesthesiologists ECMO working group created an expert consensus statement that is intended to help anesthesiologists manage adult ECMO patients who are cared for in the operating room. In the first part of this 2-part series, technical aspects of ECMO are discussed, and related expert consensus statements are provided.

Can VA-ECMO Be Used as an Adequate Treatment in Massive Pulmonary Embolism?

Introduction: Massive acute pulmonary embolism (MAPE) with obstructive cardiogenic shock is associated with a mortality rate of more than 50%. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been increasingly used in refractory cardiogenic shock with very good results. In MAPE, although it is currently recommended as part of initial resuscitation, it is not yet considered a stand-alone therapy. Material and Methods: All patients with MAPE requiring the establishment of VA-ECMO and admitted to our tertiary intensive care unit were analysed over a period of 10 years. The characteristics of these patients, before, during and after ECMO were extracted and analysed. Results: A total of 36 patients were included in the present retrospective study. Overall survival was 64%. In the majority of cases, the haemodynamic and respiratory status of the patient improved significantly within the first 24 h on ECMO. The 30-day survival significantly increased when ECMO was used as stand-alone therapy (odds ratio (OR) 15.58, 95% confidence interval (CI) 2.65–91.57, p = 0.002). Nevertheless, when ECMO was implanted following the failure of thrombolysis, the bleeding complications were major (17 (100%) vs. 1 (5.3%) patients, p < 0.001) and the 30-day mortality increased significantly (OR 0.11, 95% CI 0.022–0.520, p = 0.006). Conclusions: The present retrospective study is certainly one of the most important in terms of the number of patients with MAPE and shock treated with VA-ECMO. This short-term mechanical circulatory support, used as a stand-alone therapy in MAPE, allows for the optimal stabilisation of patients.

The Surgeon's Role in Cardiogenic Shock

PURPOSE OF REVIEW

Cardiogenic shock represents a very challenging patient population due to the undifferentiated pathologies presenting as cardiogenic shock, difficult decision-making, prognostication, and ever-expanding support options. The role of cardiac surgeons on this team is evolving.

RECENT FINDINGS

The implementation of a shock team is associated with improved outcomes in patients with cardiogenic shock. Early deployment of mechanical circulatory support devices may allow an opportunity to rescue these patients. Cardiothoracic surgeons are a critical component of the shock team who can deploy timely mechanical support and surgical intervention in selected patients for optimal outcomes.

Extracorporeal Cardiopulmonary Resuscitation for Management of Out-of-Hospital Cardiac Arrest in a Patient with Fulminant Myocarditis

A 68-year-old male with a witnessed out-of-hospital cardiac arrest while jogging who was managed with extracorporeal cardiopulmonary resuscitation (ECPR) is presented. The patient was found to be in refractory ventricular fibrillation by emergency medical service personnel and underwent advanced cardiac life support (ACLS) protocol with placement of an automated chest compression device. He was emergently transported to the cardiac catheterization laboratory. Due to refractory ventricular fibrillation, he was placed on venoarterial extracorporeal membranous oxygenation (VA-ECMO). Coronary angiography at that time showed nonobstructive coronary artery disease. Management with VA-ECMO and other supportive measures were continued for 5 days, after which a cardiac magnetic resonance imaging was performed with findings consistent with acute myocarditis. His condition substantially improved, and he was discharged from the hospital with good neurologic and functional status. Fulminant myocarditis is often fatal, but aggressive supportive measures with novel ECPR protocols may result in recovery, as it happened in this case.

Advanced heart failure with reduced ejection fraction

Patients suffering advanced heart failure with reduced ejection fraction (HFrEF) account for a large portion of patients admitted to hospitals worldwide. Mortality and 30-day readmission rates for HFrEF are now a focus of value-based payment models, making management of this disease a priority for hospitals, physicians, and payers alike. Angiotensin-converting enzyme inhibitors have been the cornerstone of therapy for decades. However, with treatment, the prognosis for patients with advanced HFrEF remains poor. Fortunately, advances in medical therapy and mechanical support offer some patients improvement in both survival and quality of life. We review advances in short- and long-term mechanical support and explore changes to organ allocation for cardiac transplantation. In addition, we provide a guide to facilitate appropriate referral to an advanced heart failure team.

The Heart and COVID-19: What Cardiologists Need to Know

In face of the pandemic of the novel coronavirus disease 2019 (COVID-19), the management of patients with cardiovascular risk factors and/or disease is challenging. The cardiovascular complications evidenced in patients with COVID-19 derive from several mechanisms, ranging from direct viral injury to complications secondary to the inflammatory and thrombotic responses to the infection. The proper care of patients with COVID-19 requires special attention to the cardiovascular system aimed at better outcomes.

Viral Myocarditis-Incidence, Diagnosis and Management

Viral myocarditis has an incidence rate of 10 to 22 per 100,000 individuals. The presentation pattern of viral myocarditis can range from nonspecific symptoms of fatigue and shortness of breath to more aggressive symptoms that mimic acute coronary syndrome. After the initial acute phase presentation of viral myocarditis, the virus may be cleared, resulting in full clinical recovery; the viral infection may persist; or the viral infection may lead to a persistent autoimmune-mediated inflammatory process with continuing symptoms of heart failure. As a result of these 3 possibilities, the diagnosis, prognosis, and treatment of viral myocarditis can be extremely unpredictable and challenging for the clinician. Herein, the incidence, etiology, definition and classification, clinical manifestation, diagnosis, pathogenesis, prognosis, and treatment of viral myocarditis are reviewed, and how acute clinical care teams might differentiate between viral myocarditis and other acute cardiac conditions is discussed.

Chinese society of cardiology expert consensus statement on the diagnosis and treatment of adult fulminant myocarditis

Fulminant myocarditis is primarily caused by infection with any number of a variety of viruses. It arises quickly, progresses rapidly, and may lead to severe heart failure or circulatory failure presenting as rapid-onset hypotension and cardiogenic shock, with mortality rates as high as 50%–70%. Most importantly, there are no treatment options, guidelines or an expert consensus statement. Here, we provide the first expert consensus, the Chinese Society of Cardiology Expert Consensus Statement on the Diagnosis and Treatment of Fulminant Myocarditis, based on data from our recent clinical trial (NCT03268642). In this statement, we describe the clinical features and diagnostic criteria of fulminant myocarditis, and importantly, for the first time, we describe a new treatment regimen termed life support-based comprehensive treatment regimen. The core content of this treatment regimen includes (i) mechanical life support (applications of mechanical respirators and circulatory support systems, including intraaortic balloon pump and extracorporeal membrane oxygenation, (ii) immunological modulation by using sufficient doses of glucocorticoid, immunoglobulin and (iii) antiviral reagents using neuraminidase inhibitor. The proper application of this treatment regimen may and has helped to save the lives of many patients with fulminant myocarditis.

Clinical complications during veno-arterial extracorporeal membrane oxigenation in post-cardiotomy and non post-cardiotomy shock: still the achille's heel

Extracorporeal membrane oxygenation (ECMO) is life-saving for potentially reversible heart failure and respiratory injuries not responsive to conventional therapies. Technological innovations have produced over the years significant improvements in ECMO devices (pump, cannula design and oxygenator) and have allowed a better risk/benefit profile. Alongside with recognized advantages in the treatment of very sick patients, ECMO remains an invasive procedure for mechanical circulatory support (MCS) and it is associated with complications that strongly influence the prognosis. Current review was designed to provide a comprehensive outline on ECMO complications, analyzing risk factors and strategies of management, focusing on adult population undergoing veno-arterial ECMO (VA-ECMO) therapy.

Associations with the In-Hospital Survival Following Extracorporeal Membrane Oxygenation in Adult Acute Fulminant Myocarditis

Background: Acute fulminant myocarditis (AFM) is a serious disease that progresses rapidly, and leads to failing respiratory and circulatory systems. When medications fail to reverse the patient’s clinical course, extracorporeal membrane oxygenation (ECMO) is considered the most effective, supportive and adjunct strategy. In this paper we analyzed our experience in managing AFM with ECMO support. Methods: During October 2003 and February 2017, a total of 35 patients (≥18 years) were enrolled in the study. Twenty patients survived, and another 15 patients expired. General demographics, the hemodynamic condition, timing of ECMO intervention, and laboratory data were compared for the survival and non-survival groups. Univariate and multivariate Cox regression analyses were performed to identify the associations with in-hospital mortality following ECMO use in this situation. Results: The survival rate was 57.1% during the in-hospital period. The average age, gender, severity of the hemodynamic condition, and cardiac rhythm were similar between the survival and non-survival groups. Higher serum lactic acid (initial and 24 h later), higher peak cardiac biomarkers, higher incidence of acute kidney injury and the need for hemodialysis were noted in the non-survival group. Higher 24-h lactic acid levels and higher peak troponin-I levels were associated with in-hospital mortality. Conclusions: When ECMO was used for AFM, related cardiogenic shock and decompensated heart failure, higher peak serum troponin-I levels and 24-h serum lactic acid levels following ECMO use were independently associated with in-hospital mortality.

The Impella Microaxial Flow Catheter Is Safe and Effective for Treatment of Myocarditis Complicated by Cardiogenic Shock: An Analysis From the Global cVAD Registry

BACKGROUND

Myocarditis complicated by cardiogenic shock remains a complex problem. The use of acute mechanical circulatory support devices for cardiogenic shock is growing. We explored the utility of Impella transvalvular microaxial flow catheters in the setting of myocarditis with cardiogenic shock.

METHODS AND RESULTS

We retrospectively analyzed data from 21 sites within the cVAD registry, an ongoing multicenter voluntary registry at sites in North America and Europe that have used Impella in patients with myocarditis. Myocarditis was defined by endomyocardial biopsy (n = 11) or by clinical history without angiographic evidence of coronary disease (n = 23). A total of 34 patients received an Impella 2.5, CP, 5.0, or RP device for cardiogenic shock complicating myocarditis. Baseline characteristics included age 42 ± 17 years, left ventricular ejection fraction (LVEF) 18% ± 10%, cardiac index 1.82 ± 0.46 L·min^-1·m^-2, pulmonary capillary wedge pressure 25 ± 7 mm Hg, and lactate 27 ± 31 mg/dL. Before Impella placement, 32% (n = 11) of patients required intra-aortic balloon pump. Mean duration of Impella support was 91 ± 74 hours; 21 of 34 patients (62%) survived the index hospitalization and were discharged with an improved mean LVEF of 37.32% ± 20.31% (P = .001); 15 patients recovered with successful support, 5 patients were transferred to another hospital on initial Impella support, 1 patient underwent orthotopic heart transplantation. Ten patients required transition to another mechanical circulatory support device.

CONCLUSIONS

This is the largest analysis of Impella-supported myocarditis cases to date. The use of Impella appears to be safe and effective in the settings of myocarditis complicated by cardiogenic shock.

Prognostic Value of Electrocardiography in Patients With Fulminant Myocarditis Supported by Percutaneous Venoarterial Extracorporeal Membrane Oxygenation - Analysis From the CHANGE PUMP Study

BACKGROUND

Fulminant myocarditis (FM) presents various abnormal findings on ECG, the prognostic impact of which has not been not fully elucidated. The aim of this study was therefore to clarify the prognostic value of ECG data in FM patients supported by venoarterial extracorporeal membrane oxygenation (VA-ECMO).Methods and Results:In this multicenter chart review, we investigated 99 patients with FM supported by VA-ECMO. The final cohort consisted of 87 patients (mean age, 52±16 years; female, 42%) after 12 patients who required conversion to other forms of mechanical circulatory support were excluded. The median LVEF was 14.5%. At the time of VA-ECMO initiation, 38 patients (44%) had arrhythmias including atrial fibrillation (6%), complete atrioventricular block (CAVB; 17%), and ventricular tachycardia or fibrillation (VT/VF; 15%). Of the 49 patients with sinus rhythm (SR), 26 had QRS duration ≥120 ms (wide QRS). On logistic regression analysis, wide QRS predicted in-hospital death in patients with SR (OR, 3.6; 95% CI: 1.07-13.61, P=0.04). Compared with SR with narrow QRS (QRS duration <120 ms), CAVB and VT/VF had a higher risk of in-hospital death (CAVB: OR, 7.20; 95% CI: 1.78-34.15, P=0.005; VT/VF: OR, 8.10; 95% CI: 1.86-42.31, P=0.005).

CONCLUSIONS

In patients with FM, CAVB and VT/VF carried a higher risk of in-hospital death. Wide QRS also predicted a higher risk of in-hospital death in patients with SR.

Early Prediction Model for Successful Bridge to Recovery in Patients With Fulminant Myocarditis Supported With Percutaneous Venoarterial Extracorporeal Membrane Oxygenation - Insights From the CHANGE PUMP Study

BACKGROUND

Cardiac recovery and prevention of end-organ damage are the cornerstones of establishing successful bridge to recovery (BTR) in patients with fulminant myocarditis (FM) supported with percutaneous venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, the timing and method of successful BTR prediction still remain unclear. We aimed to develop a prediction model for successful BTR in patients with FM supported with percutaneous VA-ECMO.Methods and Results:This was a retrospective multicenter chart review enrolling 99 patients (52±16 years; female, 42%) with FM treated with percutaneous VA-ECMO. The S-group comprised patients who experienced percutaneous VA-ECMO decannulation and subsequent discharge (n=46), and the F-group comprised patients who either died in hospital or required conversion to other forms of mechanical circulatory support (n=53). At VA-ECMO initiation (0-h), the S-group had significantly higher left ventricular ejection fraction (LVEF) and lower aspartate aminotransferase (AST) concentration than the F-group. At 48 h, the LVEF, increase in the LVEF, and reduction of AST from 0-h were identified as independent predictors in the S-group. Finally, we developed an S-group prediction model comprising these 3 variables (area under the curve, 0.844; 95% confidence interval, 0.745-0.944).

CONCLUSIONS

We developed a model for use 48 h after VA-ECMO initiation to predict successful BTR in patients with FM.

Veno-arterial extracorporeal membrane oxygenation: an overview of different cannulation techniques

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has known a widespread application over the last decade and is now an effective and valuable therapeutic option in refractory cardiogenic shock of various etiologies. In this subgroup of critically ill and unstable patients in cardiogenic shock, VA-ECMO allows, on the one hand, temporary hemodynamic stabilization with improvement of end-organ function and, on the other hand, gives the time to perform complementary diagnostic exams and to decide the therapeutic strategy in these high-risk candidates for immediate long-term mechanical circulatory support (MCS) implantation. VA-ECMO could also be suggested as a rescue therapeutic option for refractory cardiac arrest. It showed promising results in the specific setting of in-hospital cardiac arrest and survival rates with good neurological outcome are reported between 20% and 40%. Conversely, there are contrasting data in the literature about survival after VA-ECMO for out-of-hospital cardiac arrest, as results are highly dependent on low-flow time. The aim of the present report is to offer an overview of different cannulation techniques of VA-ECMO.