Spinal cord infarction and peripheral extra corporeal membrane oxygenation- Case series

Abstract Background Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is increasingly utilized in patients with cardiogenic shock due to improved technology and outcomes. Peripheral VA ECMO offers several advantages over central ECMO and is becoming increasingly popular. However, when configured via the femoral vessels, retrograde flow to the descending aorta and arch of aorta competes with antegrade ventricular output and can be associated with a watershed phenomenon and increased risk of neurologic and visceral injury. Case Summary In this case series we report three patients who were supported with peripheral VA ECMO for cardiogenic shock. All three were successfully weaned from peripheral VA ECMO, however they had developed bilateral lower limb paralysis. MRI revealed spinal cord infarction in all three patients. All patients subsequently succumbed to multiorgan failure and did not survive to hospital discharge. Discussion The use of mechanical circulatory support, in particular, peripheral ECMO, has escalated with advances in technology, better understanding of cardiac physiology and improving outcomes. Spinal cord infarction is a rare but serious complication of peripheral VA ECMO support with only a few case reports published. Further studies are needed to identify the exact cause and prevention of this rare but often terminal complication. Through this series of three patients supported on peripheral VA ECMO complicated by spinal cord infarction, we review previously published reports, analyse possible mechanisms, and propose alternate management strategies to be considered in patients at risk.

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Biventricular Unloading with Impella and Venoarterial Extracorporeal Membrane Oxygenation in Severe Refractory Cardiogenic Shock: Implications from the Combined Use of the Devices and Prognostic Risk Factors of Survival

Journal of Clinical Medicine ◽

10.3390/jcm10040747 ◽

2021 ◽

Vol 10 (4) ◽

pp. 747

Author(s):

Georgios Chatzis ◽

Styliani Syntila ◽

Birgit Markus ◽

Holger Ahrens ◽

Nikolaos Patsalis ◽

...

Keyword(s):

Risk Factors ◽

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Risk Scores ◽

Circulatory Support ◽

Membrane Oxygenation ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Refractory Cardiogenic Shock ◽

Lactate Levels ◽

Va Ecmo

Since mechanical circulatory support (MCS) devices have become integral component in the therapy of refractory cardiogenic shock (RCS), we identified 67 patients in biventricular support with Impella and venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) for RCS between February 2013 and December 2019 and evaluated the risk factors of mortality in this setting. Mean age was 61.07 ± 10.7 and 54 (80.6%) patients were male. Main cause of RCS was acute myocardial infarction (AMI) (74.6%), while 44 (65.7%) were resuscitated prior to admission. The mean Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment Score (SOFA) score on admission was 73.54 ± 16.03 and 12.25 ± 2.71, respectively, corresponding to an expected mortality of higher than 80%. Vasopressor doses and lactate levels were significantly decreased within 72 h on biventricular support (p < 0.05 for both). Overall, 17 (25.4%) patients were discharged to cardiac rehabilitation and 5 patients (7.5%) were bridged successfully to ventricular assist device implantation, leading to a total of 32.8% survival on hospital discharge. The 6-month survival was 31.3%. Lactate > 6 mmol/L, vasoactive score > 100 and pH < 7.26 on initiation of biventricular support, as well as Charlson comorbity index > 3 and prior resuscitation were independent predictors of survival. In conclusion, biventricular support with Impella and VA-ECMO in patients with RCS is feasible and efficient leading to a better survival than predicted through traditional risk scores, mainly via significant hemodynamic improvement and reduction in lactate levels.

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Venoarterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock: Lifeline of Modern Day CICU

Journal of Intensive Care Medicine ◽

10.1177/0885066619894541 ◽

2019 ◽

pp. 088506661989454

Author(s):

Aniket S. Rali ◽

Jonathan Chandler ◽

Andrew Sauer ◽

Michael A. Solomon ◽

Zubair Shah

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Treatment Modalities ◽

Circulatory Support ◽

Steady Increase ◽

Membrane Oxygenation ◽

Cardiopulmonary Support ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Va Ecmo

Cardiogenic shock (CS) portends an extremely high mortality of nearly 50% during index hospitalization. Prompt diagnoses of CS, its underlying etiology, and efficient implementation of treatment modalities, including mechanical circulatory support (MCS), are critical especially in light of such high predicted mortality. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides the most comprehensive cardiopulmonary support in critically ill patients and hence has seen a steady increase in its utilization over the past decade. Hence, a good understanding of VA-ECMO, its role in treatment of CS, especially when compared with other temporary MCS devices, and its complications are vital for any critical care cardiologist. Our review of VA-ECMO aims to provide the same.

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Veno-Arterial Extracorporeal Membrane Oxygenation for Patients Undergoing Heart Transplantation: A 7-Year Experience

Frontiers in Medicine ◽

10.3389/fmed.2021.774644 ◽

2021 ◽

Vol 8 ◽

Author(s):

Jun-yi Hou ◽

Xin Li ◽

Shou-guo Yang ◽

Ji-li Zheng ◽

Jie-fei Ma ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Heart Transplantation ◽

Graft Function ◽

Vena Cava ◽

Ecmo Support ◽

Circulatory Support ◽

Orthotopic Heart Transplantation ◽

Membrane Oxygenation ◽

Va Ecmo

Objective: Primary graft dysfunction (PGD) is the leading cause of early death after heart transplantation. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide temporary mechanical circulatory support and time for functional recovery of the transplanted heart. The purpose of this study was to analyze the timing and prognoses of VA-ECMO in patients with severe PGD after heart transplantation.Methods: A total of 130 patients underwent heart transplantation at the Zhongshan Hospital Affiliated with Fudan University between January 2014 and December 2020. All patients received basiliximab immunoinduction and a classic double vena cava anastomosis orthotopic heart transplantation. Among them, 29 patients (22.3%) developed severe PGD in the early postoperative period. VA-ECMO was performed in patients with difficulty weaning from cardiopulmonary bypass (CPB) or postoperative refractory cardiogenic shock. Patients were divided into two groups according to whether or not they were successfully weaned from VA-ECMO (patients who survived for 48 h after weaning and did not need VA-ECMO assistance again). The perioperative clinical data were recorded, and all patients were followed up until discharge. Early outcomes were compared between groups.Results: A total of 29 patients with VA-ECMO support after heart transplantation were included in this study. The proportion of patients receiving VA-ECMO was 22.3% (29/130). Nineteen patients (65.5%) needed VA-ECMO due to difficulty with weaning from CPB, and 10 patients required VA-ECMO for postoperative cardiogenic shock. Nineteen patients (65.5%) were successfully weaned from VA-ECMO. Overall, in-hospital mortality of VA-ECMO support patients was 55.2%. The main causes of death were ventricular fibrillation (four cases), major bleeding (three cases), infection (four cases), and graft failure (five cases).Conclusion: Despite advances in heart transplantation, severe PGD remains a lethal complication after heart transplantation. At present, the treatment for severe PGD after heart transplantation is a challenge. VA-ECMO provides an effective treatment for severe PGD after heart transplantation, which can promote graft function recovery.

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Overview of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) Support for the Management of Cardiogenic Shock

Frontiers in Cardiovascular Medicine ◽

10.3389/fcvm.2021.686558 ◽

2021 ◽

Vol 8 ◽

Author(s):

Adamantios Tsangaris ◽

Tamas Alexy ◽

Rajat Kalra ◽

Marinos Kosmopoulos ◽

Andrea Elliott ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Life Support ◽

Hospital Admissions ◽

The United States ◽

Ecmo Support ◽

Circulatory Support ◽

Hemodynamic Support ◽

Membrane Oxygenation ◽

Va Ecmo

Cardiogenic shock accounts for ~100,000 annual hospital admissions in the United States. Despite improvements in medical management strategies, in-hospital mortality remains unacceptably high. Multiple mechanical circulatory support devices have been developed with the aim to provide hemodynamic support and to improve outcomes in this population. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is the most advanced temporary life support system that is unique in that it provides immediate and complete hemodynamic support as well as concomitant gas exchange. In this review, we discuss the fundamental concepts and hemodynamic aspects of VA-ECMO support in patients with cardiogenic shock of various etiologies. In addition, we review the common indications, contraindications and complications associated with VA-ECMO use.

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Perioperative, protective use of extracorporeal membrane oxygenation in complex thoracic surgery

Perfusion ◽

10.1177/02676591211011044 ◽

2021 ◽

pp. 026765912110110

Author(s):

Yan Zhang ◽

Ming Luo ◽

Bo Wang ◽

Zhen Qin ◽

Ronghua Zhou

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Thoracic Surgery ◽

Case Reports ◽

Vena Cava ◽

Circulatory Support ◽

Hospital Death ◽

Membrane Oxygenation ◽

Thoracic Surgical Procedures ◽

One Year ◽

Va Ecmo

Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used in patients undergoing complex thoracic surgical procedures. However, studies reporting the clinical outcomes of these patients are limited to case reports, without real consensus. Our aim was to evaluate the perioperative use of ECMO as respiratory and/or circulatory support in thoracic surgery: indications, benefits, and perioperative management. Methods: Between May 2013 and December 2018, we reviewed the clinical data of 15 patients (11 males and 4 females; mean age: 47 years old; range, 25–73 years) undergoing ECMO-assisted thoracic surgery in our hospital. Results: Of the 15 patients, 10 cases received peripheral veno-arterial (VA) ECMO and five cases received veno-venous (VV) ECMO. Indications for ECMO were pulmonary transplantation with hard-to-maintain oxygenation (n = 5), traumatic main bronchial rupture (n = 2), traumatic lung injury (n = 1), airway tumor leading to severe airway stenosis (n = 2), huge thoracic mass infiltrated vena cava (n = 5). The ECMO duration was 1–51 hours. All patients were successfully extubated and weaned from ECMO postoperatively. The main complications were hemorrhage (26.7%), infection (33.3%), acute hepatic dysfunction (33.3%), and venous thrombosis (26.7%). There was only one hospital death and postoperative one-year survival rate was 86%. Conclusion: Our experience indicates that ECMO is a feasible method for complex trachea-bronchial surgery, huge thoracic mass excision and lung transplantation, and the ECMO-related risks may be justified. With further accumulation of experience with ECMO, a more sophisticated protocol for management of critical airway or heart failure problems in thoracic surgeries can be derived.

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IMPELLA® or Extracorporeal Membrane Oxygenation for Left Ventricular Dominant Refractory Cardiogenic Shock

Journal of Clinical Medicine ◽

10.3390/jcm10040759 ◽

2021 ◽

Vol 10 (4) ◽

pp. 759

Author(s):

Guillaume Schurtz ◽

Natacha Rousse ◽

Ouriel Saura ◽

Vincent Balmette ◽

Flavien Vincent ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Left Ventricular ◽

Circulatory Support ◽

Membrane Oxygenation ◽

Refractory Cardiogenic Shock ◽

Significant Difference ◽

Va Ecmo ◽

Unadjusted Analysis

Mechanical circulatory support (MCS) devices are effective tools in managing refractory cardiogenic shock (CS). Data comparing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and IMPELLA® are however scarce. We aimed to assess outcomes of patients implanted with these two devices and eligible to both systems. From 2004 to 2020, we retrospectively analyzed 128 patients who underwent VA-ECMO or IMPELLA® in our institution for refractory left ventricle (LV) dominant CS. All patients were eligible to both systems: 97 patients were first implanted with VA-ECMO and 31 with IMPELLA®. The primary endpoint was 30-day all-cause death. VA-ECMO patients were younger (52 vs. 59.4, p = 0.006) and had a higher lactate level at baseline than those in the IMPELLA® group (6.84 vs. 3.03 mmol/L, p < 0.001). Duration of MCS was similar between groups (9.4 days vs. 6 days in the VA-ECMO and IMPELLA® groups respectively, p = 0.077). In unadjusted analysis, no significant difference was observed between groups in 30-day mortality: 43.3% vs. 58.1% in the VA-ECMO and IMPELLA® groups, respectively (p = 0.152). After adjustment, VA-ECMO was associated with a significant reduction in 30-day mortality (HR = 0.25, p = 0.004). A higher rate of MCS escalation was observed in the IMPELLA® group: 32.3% vs. 10.3% (p = 0.003). In patients eligible to either VA-ECMO or IMPELLA® for LV dominant refractory CS, VA-ECMO was associated with improved survival rate and a lower need for escalation.

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Extracorporeal membrane oxygenation for multisystem inflammatory syndrome in children

Perfusion ◽

10.1177/02676591211020904 ◽

2021 ◽

pp. 026765912110209

Author(s):

Jordan Schneider ◽

Bradley Tilford ◽

Raya Safa ◽

John Dentel ◽

Michelle Veenstra ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Myocardial Function ◽

Case Series ◽

Disease Process ◽

Organ Injury ◽

Healthy Children ◽

Membrane Oxygenation ◽

Va Ecmo ◽

Inflammatory Syndrome

Early reports suggested that pediatric COVID-19 cases were less severe in children. Most children requiring intensive care admission in these reports had underlying medical conditions. Shortly after the surge of adult COVID-19 cases in Detroit, Michigan, previously healthy children began to present with shock with multiorgan dysfunction, elevated inflammatory markers, and physical exam findings with features of Kawasaki disease. This disease process was later called multisystem inflammatory syndrome in children (MIS-C.) In this case series, we describe three previously healthy children who presented with severe manifestations of MIS-C, including cardiogenic shock and profound systemic inflammation. These children developed severely depressed myocardial function with end-organ injury and were cannulated to veno-arterial extracorporeal membrane oxygenation (VA-ECMO) due to cardiogenic shock with arrhythmia. All three children improved with VA-ECMO support and anti-inflammatory treatment. All had complete recovery of myocardial function at discharge and 6-month follow-up with no significant morbidity.

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Abstract 14670: A Meta-analysis of Survival Outcomes Between Two Uncommon Mechanical Circulatory Support Device Combinations

Circulation ◽

10.1161/circ.142.suppl_3.14670 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Kaushik Amancherla ◽

Jay Patel ◽

Tara Holder ◽

Jared O'Leary

Keyword(s):

Cardiogenic Shock ◽

Publication Bias ◽

Case Reports ◽

Meta Analysis ◽

Limb Ischemia ◽

Left Ventricular ◽

Small Sample ◽

Circulatory Support ◽

Significant Difference ◽

Va Ecmo

Introduction: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and Impella devices are being used in increasing frequency for cardiogenic shock. Left ventricular unloading strategies are often used in VA-ECMO. The combination of simultaneous left- and right-sided Impellas, colloquially called “BIPELLA”, also offers biventricular support. There is a paucity of data regarding these combinations of platforms. We performed a systematic review of the literature to assess clinical outcomes in patients treated with ECPELLA and BIPELLA for cardiogenic shock. Methods: A systematic search of PubMed using the terms “ECMO”, “ECPELLA”, “BIPELLA”, and “Impella” was performed. Included studies evaluated mortality and complications associated with use of ECPELLA and/or BiPELLA. Reference lists of eligible studies helped identify additional publications meeting inclusion criteria. Case reports and conference abstracts were excluded. Heterogeneity among eligible studies was assessed using the I2 statistic. Publication bias was assessed using Egger’s regression and visual inspection of funnel plots. The primary outcome was in-hospital or 30-day mortality. Secondary outcomes assessed complications. Results: The results of publication bias assessment are provided in Figure 1A. Egger’s test was not significant (p = 0.56). A total of 139 patients underwent ECPELLA implantation and 20 underwent BIPELLA implantation. Mortality for the overall cohort was 51% with no significant difference between groups (p = 0.93) (Figure 1B). There was no significant difference between the groups with bleeding (p = 0.74), hemolysis (p = 0.34), and limb ischemia (p = 0.58). Conclusion: These data suggest no differences in short-term mortality and certain complications between ECPELLA and BIPELLA strategies. However, the available literature is sparse, with small sample sizes and suffers from a paucity of significant hemodynamic data. Further prospective data are needed.

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Prevention and treatment of pulmonary congestion in patients undergoing venoarterial extracorporeal membrane oxygenation for cardiogenic shock

European Heart Journal ◽

10.1093/eurheartj/ehaa547 ◽

2020 ◽

Vol 41 (38) ◽

pp. 3753-3761 ◽

Cited By ~ 2

Author(s):

Enzo Lüsebrink ◽

Mathias Orban ◽

Danny Kupka ◽

Clemens Scherer ◽

Christian Hagl ◽

...

Keyword(s):

Critical Care ◽

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Left Ventricular ◽

Ventricular Assist Devices ◽

Circulatory Support ◽

Pulmonary Congestion ◽

Membrane Oxygenation ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Va Ecmo

Abstract Cardiogenic shock is still a major driver of mortality on intensive care units and complicates ∼10% of acute coronary syndromes with contemporary mortality rates up to 50%. In the meantime, percutaneous circulatory support devices, in particular venoarterial extracorporeal membrane oxygenation (VA-ECMO), have emerged as an established salvage intervention for patients in cardiogenic shock. Venoarterial extracorporeal membrane oxygenation provides temporary circulatory support until other treatments are effective and enables recovery or serves as a bridge to ventricular assist devices, heart transplantation, or decision-making. In this critical care perspective, we provide a concise overview of VA-ECMO utilization in cardiogenic shock, considering rationale, critical care management, as well as weaning aspects. We supplement previous literature by focusing on therapeutic issues related to the vicious circle of retrograde aortic VA-ECMO flow, increased left ventricular (LV) afterload, insufficient LV unloading, and severe pulmonary congestion limiting prognosis in a relevant proportion of patients receiving VA-ECMO treatment. We will outline different modifications in percutaneous mechanical circulatory support to meet this challenge. Besides a strategy of running ECMO at lowest possible flow rates, novel therapeutic options including the combination of VA-ECMO with percutaneous microaxial pumps or implementation of a venoarteriovenous-ECMO configuration based on an additional venous cannula supplying towards pulmonary circulation are most promising among LV unloading and venting strategies. The latter may even combine the advantages of venovenous and venoarterial ECMO therapy, providing potent respiratory and circulatory support at the same time. However, whether VA-ECMO can reduce mortality has to be evaluated in the urgently needed, ongoing prospective randomized studies EURO-SHOCK (NCT03813134), ANCHOR (NCT04184635), and ECLS-SHOCK (NCT03637205). These studies will provide the opportunity to investigate indication, mode, and effect of LV unloading in dedicated sub-analyses. In future, the Heart Teams should aim at conducting a dedicated randomized trial comparing VA-ECMO support with vs. without LV unloading strategies in patients with cardiogenic shock.

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Increasing use of the Impella®-pump in severe cardiogenic shock: a word of caution

Interactive CardioVascular and Thoracic Surgery ◽

10.1093/icvts/ivaa015 ◽

2020 ◽

Vol 30 (5) ◽

pp. 711-714

Author(s):

Sergey Vasin ◽

Alois Philipp ◽

Bernhard Floerchinger ◽

Priyank Rastogi ◽

Dirk Lunz ◽

...

Keyword(s):

Cardiogenic Shock ◽

Case Series ◽

Contralateral Side ◽

Serum Lactate ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Circulatory Support ◽

Pressure Amplitude ◽

Lactate Levels ◽

Va Ecmo

Abstract Impella® pumps are increasingly utilized in patients in cardiogenic shock. We report on a case series where Impella support was insufficient, and a switch to venoarterial extracorporeal membrane oxygenation (VA ECMO) became necessary. ECMO patients with previous Impella devices were identified utilizing our institutional ECMO database. Since 2014, 10 patients with a mean age of 62 ± 3 years were identified. Despite correct placement of all Impella pumps, cardiogenic shock persisted with progressive multi-organ failure (Impella type 2.5/CP n = 6/4 patients). Femoro-femoral VA ECMO was implanted percutaneously on the contralateral side with the Impella initially left on standby but retracted into the descending aorta for transport reasons after a mean support time of 20 ± 8 h. All patients were able to unload their heart by left ventricular ejection with a blood pressure amplitude of 15 ± 3 mmHg on VA ECMO support. After VA ECMO implantation haemodynamic parameters improved significantly within 24 h of support (mean serum lactate levels decreased from 92 ± 17 to 44 ± 10 mg/dl, P = 0.031). Survival to hospital discharge was 70%. These data indicate that the Impella 2.5® and CP® might not be sufficient in profound cardiogenic shock. Comparative studies are necessary to specify which patient population benefits from which type of circulatory support.

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