Extracorporeal Membrane Oxygenation after Heart Transplantation: Impact of Type of Cannulation

Abstract Background Primary graft dysfunction (PGD) is a common cause of early death after heart transplantation (htx). The use of extracorporeal life support (ECLS) after htx has increased during the last years. It is still discussed controversially whether peripheral cannulation is favorable compared to central cannulation. We aimed to compare both cannulation techniques. Methods Ninety patients underwent htx in our department between 2010 and 2017. Twenty-five patients were treated with ECLS due to PGD (10 central extracorporeal membrane oxygenator [cECMO] and 15 peripheral extracorporeal membrane oxygenator [pECMO] cannulation). Pre- and intraoperative parameters were comparable between both groups. Results Thirty-day mortality was comparable between the ECLS-groups (cECMO: 30%; pECMO: 40%, p = 0.691). Survival at 1 year (n = 18) was 40 and 30.8% for cECMO and pECMO, respectively. The incidence of postoperative renal failure, stroke, limb ischemia, and infection was comparable between both groups. We also did not find significant differences in duration of mechanical ventilation, intensive care unit stay, or in-hospital stay. The incidence of bleeding complications was also similar (cECMO: 60%; pECMO: 67%). Potential differences in support duration in pECMO group (10.4 ± 9.3 vs. 5.7 ± 4.7 days, p = 0.110) did not reach statistical significance. Conclusions In patients supported for PGD, peripheral and central cannulation strategies are safe and feasible for prolonged venoarterial ECMO support. There was no increase in bleeding after central implantation. With regard to the potential complications of a pECMO, we think that aortic cannulation with tunneling of the cannula and closure of the chest could be a good option in patients with PGD after htx.

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Abstract 16064: Mechanical Left Ventricular Venting is Associated With Improved Survival in Adults Undergoing Venoarterial Extracorporeal Life Support: An ELSO Registry Analysis

Circulation ◽

10.1161/circ.142.suppl_3.16064 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Jose I Nunez ◽

Brooks Willar ◽

Kevin Kennedy ◽

Peter Rycus ◽

Joseph Tonna ◽

...

Keyword(s):

Adverse Events ◽

Renal Injury ◽

Life Support ◽

Extracorporeal Life Support ◽

Limb Ischemia ◽

Aortic Disease ◽

Left Ventricular ◽

Ventricular Assist ◽

Clinical Covariates ◽

Central Cannulation

Introduction: Venoarterial extracorporeal life support (VA-ECLS) imposes increased afterload on the left ventricle (LV), potentially provoking LV distension and impaired ventricular recovery. Prior studies have suggested a survival benefit with LV mechanical venting (MV), but multi-center data are lacking. Methods: We queried the ELSO registry for adults undergoing VA-ECLS and stratified them by the use of MV, including intra-aortic balloon pump and percutaneous ventricular assist device. We excluded patients with pulmonary embolism, heart transplant, congenital and valvular heart disease, aortic disease, and central cannulation. The primary outcome was in-hospital mortality. Secondary outcomes were on-support mortality and major adverse events, including bleeding, hemolysis, ischemic stroke, limb ischemia, and renal injury. We used multivariable logistic regression modeling to adjust for relevant clinical covariates. Results: Among 12734 patients undergoing VA-ECLS, 3353 (26.3%) received MV devices. Patients with MV were older (mean age 56.3 vs 52.7 years), more often male (76.3% vs 68.5%), and more often supported for acute myocardial infarction (43.0% vs 21.7%), p<0.001 for all. Prior to ECLS, patients with MV had lower rates of cardiac arrest (51.7% vs 55.1%) but more commonly needed >2 vasopressors (41.8% vs 27.2%) and had a higher incidence of acute renal (17.1% vs 10.5%), liver (4.4% vs 3.1%), and respiratory failure (20.9% vs 15.9%), p<0.001 for all. Crude on-support (41.6% vs 47.8%, p<0.001) and in-hospital (56.7% vs 59.2%, p=0.01) mortality were lower in the MV group. In multivariable modeling, MV was associated with a significantly lower odds of mortality but higher odds of adverse events including medical and cannula site bleeding, hemolysis, limb ischemia and renal injury (Figure). Conclusions: Among adults supported with peripheral VA-ECLS, LV MV was associated with lower mortality despite a higher rate of important adverse events.

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Multimodal Temporary Mechanically Circulatory Assistance for Primary Graft Dysfunction after Heart Transplantation—A Case Report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytab501 ◽

2021 ◽

Author(s):

Moritz B Immohr ◽

Artur Lichtenberg ◽

Payam Akhyari ◽

Udo Boeken

Keyword(s):

Heart Transplantation ◽

Life Support ◽

Extracorporeal Life Support ◽

Therapeutic Option ◽

Bleeding Complications ◽

Circulatory Support ◽

Primary Graft Dysfunction ◽

Graft Dysfunction ◽

Biventricular Failure ◽

Va Ecmo

Abstract Background Primary graft dysfunction (PGD) remains a serious complication after heart transplantation (HTx). Although there is no therapy available, veno-arterial extracorporeal life support (va-ECMO), may be a bailout strategy in selected cases. Especially in patients with severe biventricular failure, chances of survival remain poor. Case Summary Here we report a case of a 56-year old patient suffering from severe PGD after HTx with biventricular failure (ejection fraction < 20%) who was successfully bridged to recovery of the donor graft by temporary multimodal mechanically circulatory assistance by combining both, va-ECMO and a microaxial pump (Impella®, Abiomed, Inc., Danvers, MA, USA), a concept also referred as ECMELLA. During ECMELLA support, the patient experienced multiple severe thoracic bleeding complications with need for four re-thoracotomies and temporary open chest situation. Nevertheless, ventricular function recovered and the patient could be weaned from mechanical circulatory support after twelve days. During follow-up, the patient recovered and was successfully discharged. After the following rehabilitation, the patient now shows no persistent signs of heart failure with normal biventricular function of the cardiac graft. Discussion ECMELLA may offer a therapeutic option for patients with severe PGD after HTx. Special awareness and further studies addressing targeted anticoagulation strategies for patients on dual-mechanical support are needed to diminish the incidence of bleeding complications.

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Use of Extracorporeal Life Support for Heart Transplantation: Key Factors to Improve Outcome

10.21203/rs.3.rs-215156/v1 ◽

2021 ◽

Author(s):

Jun Ho Lee ◽

Ilkun Park ◽

Joo Yeon Kim ◽

Kiick Sung ◽

Wook Sung Kim ◽

...

Keyword(s):

Heart Transplantation ◽

Sofa Score ◽

Life Support ◽

Extracorporeal Life Support ◽

Multivariable Analysis ◽

Key Factors ◽

Central Type ◽

Significant Difference ◽

Failure Assessment ◽

Central Cannulation

Abstract Although patients receiving extracorporeal life support (ECLS) as a bridge to transplantation have demonstrated worse outcomes than those without ECLS, we investigated the key factors in the improvement of their posttransplant outcome. From December 2003 to December 2018, 257 adult patients who underwent heart transplantation (HTx) at our institution were included. We identified 100 patients (38.9%) who underwent HTx during ECLS (ECLS group). The primary outcome was 1-year mortality after HTx. The median duration of ECLS was 10.0 days. A central type of ECLS was used in 35.0% of patients in the ECLS group. The 1-year mortality rate was 12.8%, with no significant difference between the ECLS and non-ECLS groups (16.0% versus 10.8%, p = 0.227). Multivariable analysis indicated that the use of ECLS was not a predictor of 1-year mortality (p = 0.140). Independent predictors of 1-year mortality were found to be cardiopulmonary resuscitation before HTx (p = 0.002) and Sequential Organ Failure Assessment (SOFA) score (p < 0.001). A SOFA score greater than 10 was suggested the a cutoff value for 1-year survival. Early ECLS application, sophisticated ECLS and intensive care, and liberal use of central cannulation may be important steps in achieving favorable survival after HTx.

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Successful Treatment of Ulcerative Colitis-Related Fulminant Myocarditis Using Extracorporeal Life Support

The Heart Surgery Forum ◽

10.1532/hsf98.20121141 ◽

2013 ◽

Vol 16 (4) ◽

pp. 208 ◽

Cited By ~ 1

Author(s):

Prashant N. Mohite ◽

Bartlomiej Zych ◽

Aron F. Popov ◽

Nicholas R. Banner ◽

Andre R. Simon

Keyword(s):

Ulcerative Colitis ◽

Life Support ◽

Extracorporeal Life Support ◽

Fulminant Myocarditis ◽

Membrane Oxygenator ◽

Extraintestinal Manifestation ◽

Pump Failure ◽

Extracorporeal Membrane Oxygenator ◽

Bowel Diseases ◽

Inflammatory Bowel

Myocarditis is a known extraintestinal manifestation of inflammatory bowel diseases, but it rarely leads to acute cardiac pump failure. We report a case of fulminant myocarditis associated with ulcerative colitis treated successfully with an extracorporeal membrane oxygenator.

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Predictors and Outcome of Extracorporeal Life Support After Pediatric Heart Transplantation

The Annals of Thoracic Surgery ◽

10.1016/j.athoracsur.2015.02.047 ◽

2015 ◽

Vol 99 (6) ◽

pp. 2166-2172 ◽

Cited By ~ 5

Author(s):

Jacob Simmonds ◽

Troy Dominguez ◽

Joanna Longman ◽

Nitin Shastri ◽

Maura O’Callaghan ◽

...

Keyword(s):

Heart Transplantation ◽

Life Support ◽

Extracorporeal Life Support ◽

Pediatric Heart Transplantation

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Risk factors for bleeding in pediatric post-cardiotomy patients requiring ECLS

Perfusion ◽

10.1177/0267659109346667 ◽

2009 ◽

Vol 24 (3) ◽

pp. 191-197 ◽

Cited By ~ 3

Author(s):

Kathryn Nardell ◽

Gail M Annich ◽

Jennifer C Hirsch ◽

Cathe Fahrner ◽

Pat Brownlee ◽

...

Keyword(s):

Risk Factors ◽

Blood Loss ◽

Blood Product ◽

Life Support ◽

Extracorporeal Life Support ◽

Bleeding Complications ◽

Excessive Bleeding ◽

Surgical Exploration ◽

Platelet Counts ◽

Protamine Administration

Background/Objective: There is limited literature documenting bleeding patterns in pediatric post-cardiotomy patients on extracorporeal life support (ECLS). This retrospective review details bleeding complications and identifies risk factors for bleeding in these patients. Methods: Records from 145 patients were reviewed. Patients were divided into excessive (E) and non-excessive (NE) bleeding groups based on blood loss. Results: Excessive bleeding occurred predominantly from 0-6h. Longer CPB duration (NE=174±8min; E=212±16; p=0.02) and lower platelet counts (NE=104.8±50K; E=84.3±41K; p=0.01) were associated with excessive bleeding during the first 6h (p=0.005). Use of intraoperative protamine with normal platelets was associated with decreased bleeding from 7-12h post-ECLS (p=0.002). Most mediastinal exploration occurred >49h post-ECLS, with decreased bleeding post-exploration in E patients. Conclusions: The majority of pediatric post-cardiotomy ECLS bleeding occurs early after support initiation. Longer CPB time and thrombocytopenia increased bleeding 0-6h post-ECLS. Since early bleeding may be coagulopathic in origin, an approach to minimize bleeding includes protamine administration and aggressive blood product replacement with target platelet counts of 100-120K. Surgical exploration should follow if additional hemostasis is necessary.

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Outcomes of Pediatric Patients with Abdominal Sepsis Requiring Surgery and Extracorporeal Membrane Oxygenation Using the Extracorporeal Life Support Organization Database

The American Surgeon ◽

10.1177/000313481508100325 ◽

2015 ◽

Vol 81 (3) ◽

pp. 245-251 ◽

Cited By ~ 6

Author(s):

Michael R. Phillips ◽

Amal L. Khoury ◽

Briana J. K. Stephenson ◽

Lloyd J. Edwards ◽

Anthony G. Charles ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Pediatric Patients ◽

Clinical Decision Making ◽

Life Support ◽

Extracorporeal Life Support ◽

Abdominal Sepsis ◽

Bleeding Complications ◽

Extracorporeal Life Support Organization ◽

Membrane Oxygenation ◽

Support Organization

No study describes the use of extracorporeal membrane oxygenation (ECMO) in pediatric patients with abdominal sepsis (AS) requiring surgery. A description of outcomes in this patient population would assist clinical decision-making and provide a context for discussions with patients and families. The Extracorporeal Life Support Organization database was queried for pediatric patients (30 days to 18 years) with AS requiring surgery. Forty-five of 61 patients survived (73.8%). Reported bleeding complications (57.1 vs 48.8%), the number of pre-ECMO ventilator hours (208.1 vs 178.9), and the timing of surgery before (50 vs 66.7%) and on-ECMO (50 vs 26.7%) were similar in survivors and nonsurvivors. Decreased pre-ECMO mean pH (7.1 vs 7.3) was associated with increased mortality (odds ratio, 1.49; 95% confidence interval, 1.04 to 2.14). ECMO use for pediatric patients with AS requiring surgery is associated with increased mortality and an increased rate of bleeding complications compared with all pediatric patients receiving ECMO support. Acidemia predicts mortality and provides a potential target of examination for future studies.

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