Effect of arterial oxygen partial pressure inflection point on Venoarterial extracorporeal membrane oxygenation for emergency cardiac support

Abstract Background Temporary circulatory support is a bridge between acute circulatory failure and definitive treatment or recovery. Currently, venoarterial extracorporeal membrane oxygenation (VA-ECMO) is considered to be one of the effective circulatory support methods, although cardiac function monitoring during the treatment still needs further investigation. Inflection point of arterial oxygen partial pressure (IPPaO2) may occur at an early stage in part of patients with a good prognosis after VA-ECMO treatment, and the relationship between time of IPPaO2 (tIPPaO2) and recovery of cardiac function or prognosis remains unclear. Methods To investigate this relationship, we retrospectively analyzed the clinical data of 71 patients with different conditions after treatment with VA-ECMO in the emergency center of Jiangsu Province Hospital between May 2015 and July 2020. Spearman’s correlation analysis was used for the correlation between tIPPaO2 and quantitative data, and ROC curve for the predictive effect of tIPPaO2 on the 28-day mortality. Results Thirty-five patients were admitted because of refractory cardiogenic shock (26 of 35 survived) and the remaining 36 patients due to cardiac arrest (13 of 36 survived). The overall survival rate was 54.9% (39 of 71 survived). Acute physiology and chronic health evaluation II, ECMO time, tIPPaO2, continuous renal replacement therapy time, mechanical ventilation time, and bleeding complications in the survival group were lower than those in the non-survival group, with length of stay, intensive care unit stay, and platelet levels were being higher. The tIPPaO2 was negatively correlated with ejection fraction, and the shorter tIPPaO2 resulted in a higher 28-day survival probability, higher predictive value for acute myocardial infarction and fulminant myocarditis. Conclusions Therefore, tIPPaO2 could be a reliable qualitative indicator of cardiac function in patients treated with VA-ECMO, which can reveal appropriate timing for adjusting VA-ECMO flow or weaning. Trial registration ChiCTR1900026105.

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Venoarterial extracorporeal membrane oxygenation as mechanical circulatory support in adult septic shock: a systematic review and meta-analysis with individual participant data meta-regression analysis

Critical Care ◽

10.1186/s13054-021-03668-5 ◽

2021 ◽

Vol 25 (1) ◽

Author(s):

Ryan Ruiyang Ling ◽

Kollengode Ramanathan ◽

Wynne Hsing Poon ◽

Chuen Seng Tan ◽

Nicolas Brechot ◽

...

Keyword(s):

Septic Shock ◽

Extracorporeal Membrane Oxygenation ◽

Mechanical Circulatory Support ◽

Meta Analysis ◽

Left Ventricular ◽

Adult Patients ◽

Circulatory Support ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Refractory Septic Shock ◽

Va Ecmo

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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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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Mechanical thrombectomy in acute ischemic stroke patients under venoarterial extracorporeal membrane oxygenation

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2019-015407 ◽

2019 ◽

Vol 12 (5) ◽

pp. 486-488

Author(s):

Loic Le Guennec ◽

Matthieu Schmidt ◽

Frédéric Clarençon ◽

Ahmed Mohamed Elhfnawy ◽

Flore Baronnet ◽

...

Keyword(s):

Ischemic Stroke ◽

Extracorporeal Membrane Oxygenation ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Adult Patients ◽

Circulatory Support ◽

Membrane Oxygenation ◽

Cerebrovascular Complication ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Va Ecmo

BackgroundUse of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in adult patients to treat refractory cardiogenic shock has increased in recent years, and ischemic stroke is the most frequent VA-ECMO-induced cerebrovascular complication. No adult case of mechanical thrombectomy (MT) has been reported.MethodsRetrospective observational study of hospital medical records of patients who received circulatory support with VA-ECMO with acute ischemic stroke treated with MT, from 2006 to 2018.ResultsTwo adult patients on VA-ECMO with acute ischemic stroke treated with MT were found. Both cases were successfully treated.ConclusionThese cases illustrate the feasibility of performing MT in adult patients on ECMO.

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Mechanical Circulatory Support to Treat Pulmonary Embolism: Venoarterial Extracorporeal Membrane Oxygenation and Right Ventricular Assist Devices

Texas Heart Institute Journal ◽

10.14503/thij-19-7025 ◽

2020 ◽

Vol 47 (3) ◽

pp. 202-206

Author(s):

Aneil Bhalla ◽

Robert Attaran

Keyword(s):

Pulmonary Embolism ◽

Extracorporeal Membrane Oxygenation ◽

Right Ventricular ◽

Mechanical Circulatory Support ◽

Massive Pulmonary Embolism ◽

Circulatory Support ◽

Ventricular Assist ◽

Membrane Oxygenation ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Va Ecmo

Mechanical circulatory support may help patients with massive pulmonary embolism who are not candidates for systemic thrombolysis, pulmonary embolectomy, or catheter-directed therapy, or in whom these established interventions have failed. Little published literature covers this topic, which led us to compare outcomes of patients whose massive pulmonary embolism was managed with the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) or a right ventricular assist device (RVAD). We searched the medical literature from January 1990 through September 2018 for reports of adults hospitalized for massive or high-risk pulmonary embolism complicated by hemodynamic instability, and who underwent VA-ECMO therapy or RVAD placement. Primary outcomes included weaning from mechanical circulatory support and discharge from the hospital. We found 16 reports that included 181 patients (164 VA-ECMO and 17 RVAD). All RVAD recipients were successfully weaned from support, as were 122 (74%) of the VA-ECMO patients. Sixteen (94%) of the RVAD patients were discharged from the hospital, as were 120 (73%) of the VA-ECMO patients. Of note, the 8 RVAD patients who had an Impella RP System were all weaned and discharged. For patients with massive pulmonary embolism who are not candidates for conventional interventions or whose conditions are refractory, mechanical circulatory support in the form of RVAD placement or ECMO may be considered. Larger comparative studies 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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Venoarterial Extracorporeal Membrane Oxygenation as Mechanical Circulatory Support in Adult Septic Shock: A Systematic Review and Meta-Analysis with Individual Participant Data Meta-Regression Analysis.

10.21203/rs.3.rs-507866/v1 ◽

2021 ◽

Author(s):

Ryan Ruiyang Ling ◽

Kollengode Ramanathan ◽

Wynne Hsing Poon ◽

Chuen Seng Tan ◽

Nicolas Brechot ◽

...

Keyword(s):

Septic Shock ◽

Extracorporeal Membrane Oxygenation ◽

Mechanical Circulatory Support ◽

Meta Analysis ◽

Left Ventricular ◽

Adult Patients ◽

Circulatory Support ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Refractory Septic Shock ◽

Va Ecmo

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 April 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%). Extracorporeal cardiopulmonary resuscitation was associated with reduced chances of survival (Risk ratio: 0.403, 95%CI: 0.197-0.826, p=0.01). 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 but 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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Veno-arterial extracorporeal membrane oxygenation with concomitant Impella versus concomitant intra-aortic-balloon-pump for cardiogenic shock

Perfusion ◽

10.1177/02676591211033947 ◽

2021 ◽

pp. 026765912110339

Author(s):

Shek-yin Au ◽

Ka-man Fong ◽

Chun-Fung Sunny Tsang ◽

Ka-Chun Alan Chan ◽

Chi Yuen Wong ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Mechanical Circulatory Support ◽

Primary Outcome ◽

Left Ventricular ◽

Circulatory Support ◽

Queen Elizabeth Hospital ◽

Intra Aortic Balloon Pump ◽

Membrane Oxygenation ◽

Significant Difference ◽

Va Ecmo

Introduction: The intra-aortic balloon pump (IABP) and Impella are left ventricular unloading devices with peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) in place and later serve as bridging therapy when VA-ECMO is terminated. We aimed to determine the potential differences in clinical outcomes and rate of complications between the two combinations of mechanical circulatory support. Methods: This was a retrospective, single institutional cohort study conducted in the intensive care unit (ICU) of Queen Elizabeth Hospital, Hong Kong. Inclusion criteria included all patients aged ⩾18 years, who had VA-ECMO support, and who had left ventricular unloading by either IABP or Impella between January 1, 2018 and October 31, 2020. Patients <18 years old, with central VA-ECMO, who did not require left ventricular unloading, or who underwent surgical venting procedures were excluded. The primary outcome was ECMO duration. Secondary outcomes included length of stay (LOS) in the ICU, hospital LOS, mortality, and complication rate. Results: Fifty-two patients with ECMO + IABP and 14 patients with ECMO + Impella were recruited. No statistically significant difference was observed in terms of ECMO duration (2.5 vs 4.6 days, p = 0.147), ICU LOS (7.7 vs 10.8 days, p = 0.367), and hospital LOS (14.8 vs 16.5 days, p = 0.556) between the two groups. No statistically significant difference was observed in the ECMO, ICU, and hospital mortalities between the two groups. Specific complications related to the ECMO and Impella combination were also noted. Conclusions: Impella was not shown to offer a statistically significant clinical benefit compared with IABP in conjunction with ECMO. Clinicians should be aware of the specific complications of using Impella.

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Urgent coronary artery bypass graft surgery supported by veno-arterial extracorporeal membrane oxygenation: a report of two cases

Perfusion ◽

10.1177/02676591211008139 ◽

2021 ◽

pp. 026765912110081

Author(s):

Tamer Abdalghafoor ◽

Bassam Shoman ◽

Amr Salah Omar ◽

Yasser Shouman ◽

Abdulwahid Almulla

Keyword(s):

Coronary Artery ◽

Extracorporeal Membrane Oxygenation ◽

Coronary Artery Bypass ◽

Artery Bypass ◽

Bypass Graft ◽

Circulatory Support ◽

Membrane Oxygenation ◽

Cardiac Procedures ◽

Risk Patients ◽

Va Ecmo

Mechanical circulatory support (MCS) devices, especially veno-arterial extracorporeal membrane oxygenation (VA-ECMO) devices, are increasingly used to shore complex cardiac procedures in high-risk patients. We are reporting two cases where patients underwent coronary artery bypass grafting (CABG) under support of VA-ECMO in the setting of cardiogenic shock complicating acute myocardial infarction. The patients had different courses, but both survived the initial insult and were weaned successively from VA-ECMO. Our report indicates that VA-ECMO can be used instead of the cardiopulmonary bypass machine (CPB) to support the circulation during CABG surgery in patients with complex coronary anatomy and unstable haemodynamics. Future studies focusing on the long-term outcomes of such patients will probably help to establish the optimal management of this type of patients.

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Risk factors of acute renal injury and in-hospital mortality in adult patients with postcardiotomy cardiogenic shock requiring veno-arterial extracorporeal membrane oxygenation: utility of MELD-XI score

Perfusion ◽

10.1177/02676591211006619 ◽

2021 ◽

pp. 026765912110066

Author(s):

Xiaochen Ding ◽

Haixiu Xie ◽

Feng Yang ◽

Liangshan Wang ◽

Xiaotong Hou

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Hospital Mortality ◽

Cardiogenic Shock ◽

Sofa Score ◽

Adult Patients ◽

Left Ventricular Ejection ◽

Survival Group ◽

Membrane Oxygenation ◽

Va Ecmo ◽

Postcardiotomy Cardiogenic Shock

Background: The suitability of model for end-stage liver disease excluding international normalized ratio (MELD-XI) score to predict the incidence of acute kidney injury (AKI) and in-hospital mortality in adult patients with postcardiotomy cardiogenic shock (PCS) requiring venoarterial extracorporeal membrane oxygenation (VA ECMO) remains uncertain. This study was performed to explore whether the MELD-XI score has the association with the incidence of AKI and in-hospital mortality in these patients. Methods: Adult patients with PCS requiring VA ECMO from January 2012 to December 2017 were enrolled and first classified into AKI group ( n = 151) versus no-AKI group ( n = 132), then classified into survival group ( n = 143) versus no-survival group ( n = 140). Multivariate logistic regressions were performed to identify factors independently associated with AKI and mortality. Baseline data were defined as the first measurement available. Results: Of 283 patients, the incidence of AKI was 53.36%. The in-hospital mortality rates were 63.58% and 33.33% in patients with and without AKI (p < 0.0001). Baseline MELD-XI score, baseline serum total bilirubin (T-Bil), baseline blood urea nitrogen (BUN), baseline left ventricular ejection fraction (LVEF), sequential organ failure assessment (SOFA) score, and lactate level at ECMO initiation were shown to be associated with the AKI. Vasoactive-inotropic score (VIS) and SOFA score at ECMO initiation as well as renal failure requiring renal replacement therapy (RRT) were shown to be associated with in-hospital mortality. Conclusions: The baseline MELD-XI score, baseline BUN, baseline T-Bil, baseline LVEF, SOFA score and lactate at the initiation of ECMO were associated with AKI. AKI, SOFA score, and VIS at the initiation of ECMO were associated with in-hospital mortality, whereas MELD-XI score was not found to be associated with in-hospital mortality. A specific MELD-XI score as a threshold, as well as its sensitivity and specificity, needs to be confirmed in further studies.

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