Simple technique of distal leg perfusion during heart transplant in patients with preoperative veno-arterial extracorporeal membrane oxygenation support

Direct heart transplant from veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support is challenging. Continuation of postoperative VA-ECMO support may be required in the setting of primary graft dysfunction or severe vasoplegia. We describe a simple technique to perfuse the ipsilateral leg of an arterial ECMO cannula during heart transplant while the ECMO circuit is turned off but maintaining the arterial cannula and distal perfusion catheter in place. This technique minimizes the number of intraoperative procedures with a minimal risk of leg ischemia, and provides a smooth transition to postoperative VA-ECMO support if necessary.

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A retrospective cohort analysis of percutaneous versus side-graft perfusion techniques for veno-arterial extracorporeal membrane oxygenation in patients with refractory cardiogenic shock

Perfusion ◽

10.1177/0267659116683792 ◽

2016 ◽

Vol 32 (5) ◽

pp. 363-371 ◽

Cited By ~ 5

Author(s):

Mehmet Cakici ◽

Evren Ozcinar ◽

Cagdas Baran ◽

Ahmet Onat Bermede ◽

Mehmet Cahit Sarıcaoglu ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Femoral Artery ◽

Vascular Complications ◽

Ecmo Support ◽

Acute Limb Ischemia ◽

Membrane Oxygenation ◽

Refractory Cardiogenic Shock ◽

Cannulation Site ◽

Va Ecmo

Objectives: This study was designed to compare vascular complications and the outcomes of ultrasound (US)-guided percutaneous cannulation with distal perfusion catheter (PC-DP) and arterial side-graft perfusion (SGP) techniques in patients who require veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support for refractory cardiogenic shock (RCS). Methods: We conducted a retrospective, observational cohort study of consequtive patients with RCS treated with VA-ECMO at a single transplant center from March 2010 until August 2015. Overall, 148 patients underwent VA-ECMO for RCS (99 men, aged 56.6 ± 12.0 years; BSA, 1.85 ± 0.19). Patients were categorized based on VA-ECMO perfusion technique into PC-DP via femoral artery and SGP via axillary/femoral artery groups. Results: The median duration of VA-ECMO support was 5 days (range, 8 hours–80 days). Hospital mortality (PC-DP group, 54.7%; SGP group, 64.4%; p=0.23) and overall ECMO survival (PC-DP group, 36.9%; SGP group, 32.2%; p=0.47) was similar between the groups. There were no significant between-group differences in the rate of acute limb ischemia (PC-DP group, 4/75, 5.3%; SGP group, 2/73, 2.7%; p=0.68). However, the rate of surgical/cannulation site bleeding (PC-DP, 9/75 (12%) vs SGP, 18/73 (24.7%), p=0.05) and hyperperfusion syndrome (PC-DP, 2/75 (2.7%) vs SGP, 22/73 (30.1%),p=0.001) were higher in the SGP group than in the PC-DP group. Conclusions: We observed no significant difference in major vascular complications or survival between patients who underwent the PC-DP technique and those who underwent arterial SGP.

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Double Distal Perfusion Catheters for Severe Limb Ischemia on the IABP Side in Patients Who Received Femoro-Femoral VA-ECMO With IABP

Frontiers in Medicine ◽

10.3389/fmed.2021.692399 ◽

2021 ◽

Vol 8 ◽

Author(s):

Meng Xin ◽

Liangshan Wang ◽

Xiaqiu Tian ◽

Dengbang Hou ◽

Hong Wang ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Near Infrared ◽

Limb Ischemia ◽

Symptomatic Treatment ◽

Acute Limb Ischemia ◽

Membrane Oxygenation ◽

Number Of Patients ◽

Distal Perfusion ◽

Va Ecmo ◽

Postcardiotomy Cardiogenic Shock

Background: Limited research is available on the pattern of double distal perfusion catheters in patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) with an intra-aortic balloon pump(IABP). Here, we compared the outcomes of a double distal perfusion catheter and conventional treatment in patients who received VA-ECMO with IABP and had severe lower limb ischemia on the IABP side.Methods: We reviewed the data of 15 adult patients with postcardiotomy cardiogenic shock who received VA-ECMO via femoral cannulation combined with an IABP in the contralateral artery that was complicated with severe acute limb ischemia (ALI) on the same side as the IABP between January 2004 and December 2016. Patients underwent symptomatic treatment (conventional group, n = 9) and double distal perfusion catheterization treatment (DDPC group, n = 6). ALI was monitored using near-infrared spectroscopy placed on both calves after double distal perfusion catheters. The outcomes were compared.Results: All 6 patients who underwent double distal perfusion catheters were successfully decannulated without the development of osteofascial compartment syndrome, amputation, or bleeding and infection of the double distal perfusion catheters. The number of patients who weaned from extracorporeal membrane oxygenation successfully in the DDPC and conventional groups was 6 (100%) and 3 (33%, p = 0.028), respectively. The in-hospital mortality rates were 17% and 89% for the DDPC and conventional groups, respectively (p = 0.011).Conclusions: DDPC can be considered a strategy for severe limb ischemia on the IABP side in patients who received femoro-femoral VA-ECMO with IABP.

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An Ovine Model of Awake Veno-Arterial Extracorporeal Membrane Oxygenation

Frontiers in Veterinary Science ◽

10.3389/fvets.2021.809487 ◽

2021 ◽

Vol 8 ◽

Author(s):

Jiachen Qi ◽

Sizhe Gao ◽

Gang Liu ◽

Shujie Yan ◽

Min Zhang ◽

...

Keyword(s):

Animal Models ◽

Extracorporeal Membrane Oxygenation ◽

Management Strategies ◽

Ecmo Support ◽

Large Animal ◽

Ovine Model ◽

Membrane Oxygenation ◽

Large Animal Models ◽

Cannulation Site ◽

Va Ecmo

Background: Large animal models are developed to help understand physiology and explore clinical translational significance in the continuous development of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) technology. The purpose of this study was to investigate the establishment methods and management strategies in an ovine model of VA-ECMO.Methods: Seven sheep underwent VA-ECMO support for 7 days by cannulation via the right jugular vein and artery. The animals were transferred into the monitoring cages after surgery and were kept awake after anesthesia recovery. The hydraulic parameters of ECMO, basic hemodynamics, mental state, and fed state of sheep were observed in real time. Blood gas analysis and activated clotting time (ACT) were tested every 6 h, while the complete blood count, blood chemistry, and coagulation tests were monitored every day. Sheep were euthanized after 7 days. Necropsy was performed and the main organs were removed for histopathological evaluation.Results: Five sheep survived and successfully weaned from ECMO. Two sheep died within 24–48 h of ECMO support. One animal died of fungal pneumonia caused by reflux aspiration, and the other died of hemorrhagic shock caused by bleeding at the left jugular artery cannulation site used for hemodynamic monitoring. During the experiment, the hemodynamics of the five sheep were stable. The animals stayed awake and freely ate hay and feed pellets and drank water. With no need for additional nutrition support or transfusion, the hemoglobin concentration and platelet count were in the normal reference range. The ECMO flow remained stable and the oxygenation performance of the oxygenator was satisfactory. No major adverse pathological injury occurred.Conclusions: The perioperative management strategies and animal care are the key points of the VA-ECMO model in conscious sheep. This model could be a platform for further research of disease animal models, pathophysiology exploration, and new equipment verification.

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The Expanding Role of Extracorporeal Membrane Oxygenation Retrieval Services in Australia

Anaesthesia and Intensive Care ◽

10.1177/0310057x1704500114 ◽

2017 ◽

Vol 45 (1) ◽

pp. 92-93 ◽

Cited By ~ 4

Author(s):

J. J. B. Edelman ◽

M. K. Wilson ◽

M. P. Vallely ◽

P. G. Bannon ◽

G. McKay ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Ecmo Support ◽

Referral Hospital ◽

Model Of Care ◽

Tertiary Referral ◽

Tertiary Referral Hospital ◽

Membrane Oxygenation ◽

Va Ecmo ◽

Ecmo Centre

Herein we detail the cases of three patients transferred on veno-arterial extracorporeal membrane oxygenation (VA ECMO) from a tertiary referral hospital to an ECMO centre. We highlight the benefits of such a transfer and offer this as a model of care for unwell patients likely to require a prolonged period of ECMO support.

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Hemostasis, coagulation and thrombin in venoarterial and venovenous extracorporeal membrane oxygenation: the HECTIC study

Scientific Reports ◽

10.1038/s41598-021-87026-z ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Bruce Cartwright ◽

Hannah M. Bruce ◽

Geoffrey Kershaw ◽

Nancy Cai ◽

Jad Othman ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Thrombin Generation ◽

Thrombotic Event ◽

Patient Characteristics ◽

Ecmo Support ◽

University Hospital ◽

Heparin Dose ◽

Membrane Oxygenation ◽

Thrombotic Complications ◽

Va Ecmo

AbstractExtracorporeal membrane oxygenation (ECMO) support has a high incidence of both bleeding and thrombotic complications. Despite clear differences in patient characteristics and pathologies between veno-venous (VV) and veno-arterial (VA) ECMO support, anticoagulation practices are often the same across modalities. Moreover, there is very little data on their respective coagulation profiles and comparisons of thrombin generation in these patients. This study compares the coagulation profile and thrombin generation between patients supported with either VV and VA ECMO. A prospective cohort study of patients undergoing VA and VV ECMO at an Intensive care department of a university hospital and ECMO referral centre. In addition to routine coagulation testing and heparin monitoring per unit protocol, thromboelastography (TEG), multiplate aggregometry (MEA), calibrated automated thrombinography (CAT) and von-Willebrand’s activity (antigen and activity ratio) were sampled second-daily for 1 week, then weekly thereafter. VA patients had significantly lower platelets counts, fibrinogen, anti-thrombin and clot strength with higher d-dimer levels than VV patients, consistent with a more pronounced consumptive coagulopathy. Thrombin generation was higher in VA than VV patients, and the heparin dose required to suppress thrombin generation was lower in VA patients. There were no significant differences in total bleeding or thrombotic event rates between VV and VA patients when adjusted for days on extracorporeal support. VA patients received a lower median daily heparin dose 8500 IU [IQR 2500–24000] versus VV 28,800 IU [IQR 17,300–40,800.00]; < 0.001. Twenty-eight patients (72%) survived to hospital discharge; comprising 53% of VA patients and 77% of VV patients. Significant differences between the coagulation profiles of VA and VV patients exist, and anticoagulation strategies for patients of these modalities should be different. Further research into the development of tailored anticoagulation strategies that include the mode of ECMO support need to be completed.

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Veno-Arterial Extracorporeal Membrane Oxygenation for Patients Undergoing Acute Type A Aortic Dissection Surgery: A Six-Year Experience

Frontiers in Cardiovascular Medicine ◽

10.3389/fcvm.2021.652527 ◽

2021 ◽

Vol 8 ◽

Author(s):

Jun-yi Hou ◽

Chun-sheng Wang ◽

Hao Lai ◽

Yong-xin Sun ◽

Xin Li ◽

...

Keyword(s):

Aortic Dissection ◽

Extracorporeal Membrane Oxygenation ◽

Troponin T ◽

Type A ◽

Ecmo Support ◽

Acute Type ◽

Type A Aortic Dissection ◽

Membrane Oxygenation ◽

Creatine Kinase Mb ◽

Va Ecmo

Objectives: Acute type A aortic dissection (aTAAD) is usually lethal without emergency surgery. Although veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is widely used in patients with cardiogenic shock following cardiac surgery, VA-ECMO support following aTAAD surgery has not been well-described. Based on our 6-year experience, we aimed to retrospectively analyze risk factors, application and timing of VA-ECMO, and outcomes in aTAAD patients.Methods: In this retrospective, single-center study, we enrolled adult patients who underwent aTAAD surgery from January 2014 to December 2019 and were supported with VA-ECMO. Patients were divided into two groups according to whether or not they were successfully weaned from VA-ECMO. Preoperative, intraoperative and postoperative variables were assessed and analyzed. Outcomes of the patients were followed up until discharge.Results: Twenty-seven patients who received aTAAD surgery with VA-ECMO support were included in the study. Nine patients (33.3%) were successfully weaned from VA-ECMO. The median VA-ECMO support time and length of hospital stay in the successfully weaned group were significantly longer than in the group could not be successfully weaned (192 [111–327] vs. 55 [23–95] h, p < 0.01; 29 [18–40] vs. 4 [3–8] days, p < 0.01). Overall in-hospital mortality was 81.5%. The main causes of death were bleeding (37%), neurological complications (15%), and multiple organ dysfunction syndrome (15%). Preoperative levels of creatine kinase-MB (CK-MB) were lower in patients who were successfully weaned from VA-ECMO than in the failed group (14 [6–30] vs. 55 [28–138] U/L, p < 0.01). Postoperative peak levels of CK-MB, cardiac troponin T, lactate dehydrogenase, and lactate were significantly lower in the successful group than in the failed group.Conclusion: Postoperative VA-ECMO support was rarely used in aTAAD patients. Our study showed that VA-ECMO can be considered as a salvage treatment in aTAAD patients, despite the high rate of complications and mortality.

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Stroke During Extracorporeal Membrane Oxygenation: Timing, Risk Factors and Clinical Outcomes

10.21203/rs.3.rs-141344/v1 ◽

2021 ◽

Author(s):

Harim Kim ◽

Jeong Hoon Yang ◽

Chi Ryang Chung ◽

Kyeongman Jeon ◽

Gee Young Suh ◽

...

Keyword(s):

Risk Factors ◽

Extracorporeal Membrane Oxygenation ◽

Brain Injuries ◽

Medical Center ◽

Ecmo Support ◽

Membrane Oxygenation ◽

Significant Difference ◽

Stroke Group ◽

Va Ecmo ◽

Vv Ecmo

Abstract Background Among various complications of extracorporeal membrane oxygenation (ECMO), stroke continues to be a major factor that worsens the clinical outcome because it is associated with mortality and adverse neurologic outcomes. Appropriate risk evaluation, screening, and management of neurologic injury under ECMO support has not yet been established and requires further investigation. Thus, this study analyzes the stroke related risk factors and outcomes in order to determine the appropriate intervention to minimize neurologic sequalae while on ECMO. Method Total 1039 patients who underwent ECMO from January 2012 to September 2019 at the Samsung Medical Center were reviewed and 759 subjects were selected for the analysis. The exclusion criteria were age < 18y, failure of successful ECMO initiation, multiple ECMO runs, underlying severe brain injury, and incomplete medical records. Multivariate analysis was performed to identify the risk factors of strokes on ECMO support using cox proportional hazard regression. In order to analyze the timing of stroke after ECMO initiation, the Mann–Whitney U test and Kruskal–Wallis rank sum test were performed.Results Among The overall incidence of stroke was 5.1% (n = 39) without a significant difference between venoarterial (VA) and venovenous(VV) ECMO (5.3% and 4.8%, respectively, p = 0.480). Independent risk factors for stroke were intraaortic balloon pump (IABP, p = 0.0008) and a history of stroke (p = 0.0354). Most hypoxic brain injuries were found in the VA ECMO (93.3%), and 54.5% of intracranial hemorrhage were in the VV ECMO. Most patients with strokes (61.5%) were diagnosed within 72hours after ECMO initiation. The time taken for stroke event from the time of ECMO insertion was shorter in the VA ECMO than in the VV ECMO (median 1.5 vs. 3 days). The stroke group had a higher mortality rate than the non-stroke group (64.1% and 44.7%, respectively, p = 0.014). Conclusion Concurrent ECMO and IABP use may increase the incidence of stroke during ECMO support. Evaluation for stroke that includes CT within 72 hours of ECMO insertion may enable early diagnosis, allowing timely intervention.

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Massive aspiration syndrome: a possible indication for “emergent” veno-venous extracorporeal membrane oxygenation?: a case report

Journal of Medical Case Reports ◽

10.1186/s13256-021-03050-7 ◽

2021 ◽

Vol 15 (1) ◽

Author(s):

Emiliano Gamberini ◽

Venerino Poletti ◽

Emanuele Russo ◽

Alessandro Circelli ◽

Marco Benni ◽

...

Keyword(s):

Respiratory Failure ◽

Extracorporeal Membrane Oxygenation ◽

White Male ◽

Ecmo Support ◽

Circulatory Support ◽

Lung Protective Ventilation ◽

Emergency Setting ◽

Membrane Oxygenation ◽

Va Ecmo ◽

Vv Ecmo

Abstract Background Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is usually performed in cases of severe respiratory failure in which conventional and advanced mechanical ventilation strategies are ineffective in achieving true lung-protective ventilation, thus triggering ventilatory-induced lung injury. If circulatory failure coexists, veno-arterial ECMO (VA-ECMO) may be preferred over VV-ECMO because of its potential for circulatory support. In VA-ECMO, the respiratory contribution is less effective and the complication rate is higher than in the VV configuration. Case presentation The authors present a case in which VV-ECMO was performed in an emergency setting to treat a 68-year-old White male patient who experienced acute respiratory failure after massive aspiration. Despite intubation and intensive care unit admission, multiple organ failure occurred suddenly, thus prompting referral to a level-1 trauma center with an ECMO facility. The patient’s condition slowly improved with VV-ECMO support along with standard treatment for hemodynamic impairment. VV-ECMO was discontinued on day 8. The patient was extubated on day 14 and discharged home fully recovered 34 days after the event. Conclusions Attention was focused on the decision to initiate VV-ECMO support even in the presence of severe hemodynamic derangement, although VA-ECMO could have provided better hemodynamic support but less effective respiratory support.

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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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