LIMB PERFUSION PROTECTION STRATEGIES IN VA-ECMO: A SYTEMATIC REVIEW AND META-ANALYSIS

Abstract Background While recommended by international societal guidelines in the paediatric population, the use of venoarterial extracorporeal membrane oxygenation (VA ECMO) as mechanical circulatory support for refractory septic shock in adults is controversial. We aimed to characterise the outcomes of adults with septic shock requiring VA ECMO, and identify factors associated with survival. Methods We searched Pubmed, Embase, Scopus and Cochrane databases from inception until 1st June 2021, and included all relevant publications reporting on > 5 adult patients requiring VA ECMO for septic shock. Study quality and certainty in evidence were assessed using the appropriate Joanna Briggs Institute checklist, and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach, respectively. The primary outcome was survival to hospital discharge, and secondary outcomes included intensive care unit length of stay, duration of ECMO support, complications while on ECMO, and sources of sepsis. Random-effects meta-analysis (DerSimonian and Laird) were conducted. Data synthesis We included 14 observational studies with 468 patients in the meta-analysis. Pooled survival was 36.4% (95% confidence interval [CI]: 23.6%–50.1%). Survival among patients with left ventricular ejection fraction (LVEF) < 20% (62.0%, 95%-CI: 51.6%–72.0%) was significantly higher than those with LVEF > 35% (32.1%, 95%-CI: 8.69%–60.7%, p = 0.05). Survival reported in studies from Asia (19.5%, 95%-CI: 13.0%–26.8%) was notably lower than those from Europe (61.0%, 95%-CI: 48.4%–73.0%) and North America (45.5%, 95%-CI: 16.7%–75.8%). GRADE assessment indicated high certainty of evidence for pooled survival. Conclusions When treated with VA ECMO, the majority of patients with septic shock and severe sepsis-induced myocardial depression survive. However, VA ECMO has poor outcomes in adults with septic shock without severe left ventricular depression. VA ECMO may be a viable treatment option in carefully selected adult patients with refractory septic shock.

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Effects of social protection on tuberculosis treatment outcomes in low or middle-income and in high-burden countries: systematic review and meta-analysis

Cadernos de Saúde Pública ◽

10.1590/0102-311x00153116 ◽

2018 ◽

Vol 34 (1) ◽

Cited By ~ 9

Author(s):

Kaio Vinicius Freitas de Andrade ◽

Joilda Silva Nery ◽

Ramon Andrade de Souza ◽

Susan Martins Pereira

Keyword(s):

Treatment Outcomes ◽

Social Protection ◽

Meta Analysis ◽

Treatment Success ◽

Qualitative Synthesis ◽

Middle Income ◽

High Burden ◽

Tb Treatment ◽

Protection Strategies ◽

Meta Analyses

Tuberculosis (TB) is a poverty infectious disease that affects millions of people worldwide. Evidences suggest that social protection strategies (SPS) can improve TB treatment outcomes. This study aimed to synthesize such evidences through systematic literature review and meta-analysis. We searched for studies conducted in low- or middle-income and in high TB-burden countries, published during 1995-2016. The review was performed by searching PubMed/MEDLINE, Scopus, Web of Science, ScienceDirect and LILACS. We included only studies that investigated the effects of SPS on TB treatment outcomes. We retained 25 studies for qualitative synthesis. Meta-analyses were performed with 9 randomized controlled trials, including a total of 1,687 participants. Pooled results showed that SPS was associated with TB treatment success (RR = 1.09; 95%CI: 1.03-1.14), cure of TB patients (RR = 1.11; 95%CI: 1.01-1.22) and with reduction in risk of TB treatment default (RR = 0.63; 95%CI: 0.45-0.89). We did not detect effects of SPS on the outcomes treatment failure and death. These findings revealed that SPS might improve TB treatment outcomes in lower-middle-income economies or countries with high burden of this disease. However, the overall quality of evidences regarding these effect estimates is low and further well-conducted randomized studies are needed.

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Efficacy of left ventricular unloading strategies during venoarterial extracorporeal membrane oxygenation in patients with cardiogenic shock: a protocol for a systematic review and Bayesian network meta-analysis

BMJ Open ◽

10.1136/bmjopen-2020-047046 ◽

2021 ◽

Vol 11 (10) ◽

pp. e047046

Author(s):

Pengbin Zhang ◽

Shilin Wei ◽

Kerong Zhai ◽

Jian Huang ◽

Xingdong Cheng ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Bayesian Network ◽

Meta Analysis ◽

Left Ventricular ◽

Cochrane Library ◽

Membrane Oxygenation ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Patient Consent ◽

Va Ecmo

IntroductionVenoarterial extracorporeal membrane oxygenation (VA-ECMO) has been widely used for patients with refractory cardiogenic shock. A common side effect of this technic is the resultant increase in left ventricular (LV) afterload which could potentially aggravate myocardial ischaemia, delay ventricular recovery and increase the risk of pulmonary congestion. Several LV unloading strategies have been proposed and implemented to mitigate these complications. However, it is still indistinct that which one is the best choice for clinical application. This Bayesian network meta-analysis (NMA) aims to compare the efficacy of different LV unloading strategies during VA-ECMO.Methods and analysisPubMed, Embase, the Cochrane Library and the International Clinical Trials Registry Platform will be explored from their inception to 31 December 2020. Random controlled trials and cohort studies that compared different LV unloading strategies during VA-ECMO will be included in this study. The primary outcome will be in-hospital mortality. The secondary outcomes will include neurological complications, haemolysis, bleeding, limb ischaemia, renal failure, gastrointestinal complications, sepsis, duration of mechanical ventilation, length of intensive care unit and hospital stays. Pairwise and NMA will respectively be conducted using Stata (V.16, StataCorp) and Aggregate Data Drug Information System (V.1.16.5), and the cumulative probability will be used to rank the included LV unloading strategies. The risk of bias will be conducted using the Cochrane Collaboration’s tool or Newcastle-Ottawa Quality Assessment Scale according to their study design. Subgroup analysis, sensitivity analysis and publication bias assessment will be performed. The Grading of Recommendations Assessment, Development and Evaluation will be conducted to explore the quality of evidence.Ethics and disseminationEither ethics approval or patient consent is not necessary, because this study will be based on literature. The results will be disseminated through peer-reviewed publications and conference presentations.PROSPERO registration numberCRD42020165093.

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Abstract 16853: Retrograde Peripheral Limb Perfusion for Formidable Femoral Arterial Access in Veno-Arterial ECMO Treatment

Circulation ◽

10.1161/circ.142.suppl_3.16853 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Laszlo Gobolos ◽

Maurice Hogan ◽

Vivek Kakar ◽

Stefan Sanger ◽

Nuno Raposo ◽

...

Keyword(s):

Posterior Tibial Artery ◽

The Body ◽

Anterior Tibial Artery ◽

Arterial Perfusion ◽

Arterial Access ◽

Tibial Artery ◽

Limb Perfusion ◽

Va Ecmo ◽

Ultrasonographic Guidance ◽

Peripheral Arterial

Introduction: VA ECMO has emerged to a well-established therapeutic method in severe acute heart failure. In the case of peripheral ECMO placement, especially applying direct arterial cannulation, the limb perfusion is often compromised by an occlusive effect of the cannula positioned in the femoral artery. The classical proximal femoral arterial reperfusion branch provides sufficient blood flow via a small auxiliary cannula, but in patients with severe peripheral arterial vasculopathy or with significant tissue depth resulting from obesity, the placement of a peripheral arterial perfusion loop may pose a technical challenge. Methods: In case of emerging peripheral ischemic symptoms at femoral VA ECMO placement, ultrasound scanning of the lower limb vessels is performed. In an uncomplicated vascular situation, antegrade distal perfusion can be established. If a significant vasculopathy is present in the proximal vessels, or any further hindrances, including extreme obesity, physically not allowing a subtle perfusion cannula placement resulting from the discrepancy between the tissue depth and cannula length, retrograde peripheral perfusion could be established via the dorsal pedal artery utilising the Seldinger method. An ultrasonographic guidance is essential; hence there is sometimes no backflow present on the inserted cannula in a critically ischemic limb. Following sufficient de-airing manoeuvres, the retrograde femoral flow can be safely established; NIRS confirms the successful reperfusion in a short timeframe. If the dorsal pedal artery is not sufficient for cannulation purposes, the postmalleolar posterior tibial artery segment or the anterior tibial artery through the similarly named muscle can be utilised for cannulation purposes. Results: Two patients showed a pre-reperfusion calf saturation of 29% and 38%, which has increased to 61% and 64% after re-establishing the distal flow within minutes, respectively. We have experienced no complications emerging during the application of the above method. Conclusions: In case of peripheral vascular disease or the body habitus does not allow safe installation of an antegrade flow device, our retrograde perfusion option can save the affected limb on VA ECMO therapy.

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Cerebral protection strategies in aortic arch surgery: A network meta-analysis

Journal of Thoracic and Cardiovascular Surgery ◽

10.1016/j.jtcvs.2019.02.045 ◽

2020 ◽

Vol 159 (1) ◽

pp. 18-31 ◽

Cited By ~ 15

Author(s):

Irbaz Hameed ◽

Mohamed Rahouma ◽

Faiza M. Khan ◽

Matthew Wingo ◽

Michelle Demetres ◽

...

Keyword(s):

Aortic Arch ◽

Meta Analysis ◽

Cerebral Protection ◽

Aortic Arch Surgery ◽

Protection Strategies

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The isolated effect of age on the risk of COVID-19 severe outcomes: a systematic review with meta-analysis

10.1101/2021.05.27.21257909 ◽

2021 ◽

Author(s):

Karla Romero Starke ◽

David Reissig ◽

Gabriela Petereit-Haack ◽

Stefanie Schmauder ◽

Albert Nienhaus ◽

...

Keyword(s):

Mechanical Ventilation ◽

Hospital Mortality ◽

Disease Severity ◽

Meta Analysis ◽

High Quality Research ◽

Continuous Increase ◽

Increased Risk ◽

Protection Strategies ◽

Case Mortality ◽

Effect Of Age

Introduction Increased age has been reported to be a factor for COVID-19 severe outcomes. However, many studies do not consider the age-dependency of comorbidities, which influence the course of disease. Protection strategies often target individuals after a certain age, which may not necessarily be evidence-based. The aim of this review was to quantify the isolated effect of age on hospitalization, admission to ICU, mechanical ventilation, and death. Methods This review was based on an umbrella review, in which Pubmed, Embase, and pre-print databases were searched on December 10, 2020 for relevant reviews on COVID-19 disease severity. Two independent reviewers evaluated the primary studies using predefined inclusion and exclusion criteria. The results were extracted, and each study was assessed for risk of bias. The isolated effect of age was estimated by meta-analysis, and the quality of evidence was assessed using GRADE. Results Seventy studies met our inclusion criteria (case mortality n=14, in-hospital mortality n=44, hospitalization n=16, admission to ICU n=12, mechanical ventilation n=7). The risk of in-hospital and case mortality increased per age year by 5.7% and 7.4%, respectively (Effect Size (ES) in-hospital mortality=1.057, 95% CI:1.038-1.054; ES case mortality= 1.074, 95% CI:1.061-1.087), while the risk of hospitalization increased by 3.4% per age year (ES=1.034, 95% CI:1.021-1.048). No increased risk was observed for ICU admission and intubation by age year. There was no evidence of a specific age threshold at which the risk accelerates considerably. The confidence of evidence was high for mortality and hospitalization. Conclusions Our results show a best-possible quantification of the increase in COVID-19 disease severity due to age. Rather than implementing age thresholds, prevention programs should consider the continuous increase in risk. There is a need for continuous, high-quality research and living reviews to evaluate the evidence throughout the pandemic, as results may change due to varying circumstances.

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Use of mechanical pulmonary reperfusion and fibrinolysis in acute massive pulmonary embolism requiring extracorporeal membrane oxygenation support: a systematic review and meta-analysis

European Heart Journal ◽

10.1093/eurheartj/ehab724.1924 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

R Chopard ◽

P Nielsen ◽

F Ius ◽

H Pilichowski ◽

N Meneveau

Keyword(s):

Systematic Review ◽

Pulmonary Embolism ◽

Meta Analysis ◽

Reperfusion Therapy ◽

Massive Pulmonary Embolism ◽

Membrane Oxygenation ◽

Funding Sources ◽

Surgical Embolectomy ◽

Meta Regression ◽

Va Ecmo

Abstract Background and objectives The optimal pulmonary revascularization strategy in acute massive pulmonary embolism (PE) requiring the implantation extra corporeal membrane oxygenation remains controversial, and data are sparse. Methods We conducted a systematic review and meta-analysis of available evidence regarding the use of mechanical reperfusion (i.e. surgical or catheter-based embolectomy) and fibrinolytic strategies (i.e. systemic fibrinolysis, catheter-directed fibrinolysis, or as stand-alone therapy) in terms of mortality and bleeding outcomes. Results The literature search identified 835 studies, 17 of which were included or a total of 321 PE patients with ECMO. In total, 31.1% were treated with mechanical pulmonary reperfusion, while 78.9% received fibrinolytic strategies. The mortality rate was 23.0% in the mechanical reperfusion group and 43.1% in the fibrinolysis group (Figure). The pooled OR for mortality with mechanical reperfusion was 0.46 (95% CI, 0.213–0.997; I2=28.3%) versus fibrinolysis. The rate of bleeding in PE patients under ECMO was 29.1% in the mechanical reperfusion group and 26.0% in the fibrinolytic reperfusion (OR, 1.09; 95% CI, 0.46–2.54; I2=0.0%) among 10 eligible studies with available bleeding data. The meta-regression model did not identify any relationship between the covariates “more than one pulmonary reperfusion therapy” and “ECMO implantation before pulmonary reperfusion therapy”, and outcomes. Conclusions The results of the present meta-analysis and meta-regression suggest that surgical embolectomy yields the best results, regardless of the timing of VA-ECMO implantation in the reperfusion timeline, and regardless of whether fibrinolysis has been administered or not. FUNDunding Acknowledgement Type of funding sources: None.

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No Difference in Risk of Acute Kidney Injury Between Adult Patients Receiving Different Types of Extracorporeal Membrane Oxygenation

10.1101/2020.03.25.20043950 ◽

2020 ◽

Author(s):

Zhixiang Mou ◽

Xu Zhang

Keyword(s):

Acute Kidney Injury ◽

Extracorporeal Membrane Oxygenation ◽

Web Of Science ◽

Meta Analysis ◽

Kidney Injury ◽

Adult Patients ◽

Membrane Oxygenation ◽

Significant Difference ◽

Different Types ◽

Va Ecmo

AbstractAcute kidney injury (AKI) has been reported as one of the most common complications in patients receiving extracorporeal membrane oxygenation (ECMO), yet the risk of AKI on different types of ECMO remains unclear. This meta-analysis aimed to compare risk of AKI among adult patients requiring different types of ECMO. Two authors independently performed a literature search using PubMed, Web of Science, and Embase, encompassing publications up until Arpril 20, 2020 (inclusive). The number of AKI patients, non-AKI patients, patients required RRT and patients not required RRT receiving different types of ECMO were derived and analyzed by STATA. The results indicated there was no significant difference in risk of AKI (OR, 1.54; 95% CI: 0.75-3.16; P= 0.235) and severe AKI required RRT (OR, 1.0; 95% CI: 0.66-1.5, P= 0.994) in patients receiving different types of ECMO. In Conclusion, no difference in risk of AKI and severe AKI required RRT between patients receiving VA ECMO and VV ECMO. More studies are required to support the findings.

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Impella as unloading strategy during VA-ECMO: systematic review and meta-analysis

Reviews in Cardiovascular Medicine ◽

10.31083/j.rcm2204154 ◽

2021 ◽

Vol 22 (4) ◽

pp. 1503

Author(s):

Francesca Fiorelli ◽

Vasileios Panoulas

Keyword(s):

Systematic Review ◽

Meta Analysis ◽

Va Ecmo

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Left Ventricle Unloading with Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock. Systematic Review and Meta-Analysis

Journal of Clinical Medicine ◽

10.3390/jcm9041039 ◽

2020 ◽

Vol 9 (4) ◽

pp. 1039 ◽

Cited By ~ 5

Author(s):

Mariusz Kowalewski ◽

Pietro Giorgio Malvindi ◽

Kamil Zieliński ◽

Gennaro Martucci ◽

Artur Słomka ◽

...

Keyword(s):

Systematic Review ◽

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Mortality Risk ◽

Meta Analysis ◽

Left Ventricular ◽

Membrane Oxygenation ◽

Va Ecmo ◽

Critically Ill Adults ◽

Meta Analyses

During veno-arterial extracorporeal membrane oxygenation (VA-ECMO), the increase of left ventricular (LV) afterload can potentially increase the LV stress, exacerbate myocardial ischemia and delay recovery from cardiogenic shock (CS). Several strategies of LV unloading have been proposed. Systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement included adult patients from studies published between January 2000 and March 2019. The search was conducted through numerous databases. Overall, from 62 papers, 7581 patients were included, among whom 3337 (44.0%) received LV unloading concomitant to VA-ECMO. Overall, in-hospital mortality was 58.9% (4466/7581). A concomitant strategy of LV unloading as compared to ECMO alone was associated with 12% lower mortality risk (RR 0.88; 95% CI 0.82–0.93; p < 0.0001; I2 = 40%) and 35% higher probability of weaning from ECMO (RR 1.35; 95% CI 1.21–1.51; p < 0.00001; I2 = 38%). In an analysis stratified by setting, the highest mortality risk benefit was observed in case of acute myocardial infarction: RR 0.75; 95%CI 0.68–0.83; p < 0.0001; I2 = 0%. There were no apparent differences between two techniques in terms of complications. In heterogeneous populations of critically ill adults in CS and supported with VA-ECMO, the adjunct of LV unloading is associated with lower early mortality and higher rate of weaning.

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