Complex and High-Risk Percutaneous Intervention Assisted By Extracorporeal Membrane Oxygenation (ECMO)

The Challenges of Venoarterial ECMO for Postcardiotomy Shock

Extracorporeal Membrane Oxygenation: Opportunities for Expanding Nurses' Roles.

The Emerging Role of Bivalirudin for Therapeutic Anticoagulation in Patients With Coronavirus Disease 2019 Requiring Extracorporeal Membrane Oxygenation Support: Is It Time to Change the Routine Practice?

Outcome of extracorporeal membrane oxygenation support for complex high-risk elective percutaneous coronary interventions: A single-center experience

Funding Acknowledgements Type of funding sources: None. Background Despite the increase of extracorporeal membrane oxygenation (ECMO) employment around the globe over the last decades, studies describing the emergency use of venoarterial (VA)-ECMO in the cardiac catheterization laboratory (CCL) are scarce. Purpose The aim of this study was to describe the patient population that received ECMO in the CCL of a tertiary care center and the associated complications and outcomes. Methods In this single-center retrospective study we reviewed the baseline clinical and laboratory characteristics, indications and outcomes of adult patients, who received VA-ECMO between 2011 and 2019. Results In the given time period, ECMO use in the CCL increased drastically. Mean age of the 83 patients was 58.3 ± 12.5 years, 78.3% were male. From 2011 to 2018 ECMO-use in the CCL increased drastically. The most common indication for ECMO implantation was cardiac arrest (66%), followed by cardiogenic shock (12%), high-risk PCI (11%), and procedure-related complications (10%). While 30-day mortality in the total study population was 69%, it varied greatly depending on the underlying indication for ECMO therapy (cardiac arrest 78%, cardiogenic shock 20%, high-risk PCI 44%, procedure-related complications 88%). The most commonly occurring complications were acute kidney injury (20%) and cannula site bleeding (20%), followed by extremity complications (19%), sepsis (18%), major bleeding (10%) and stroke (8%). Of interest, patients receiving ECMO therapy after in-hospital cardiac arrest showed greater survival rates (28.2%) as compared to patients after out of hospital cardiac arrest (18.2%; p=0.045). High serum lactate levels (p=0.018) and low baseline pH values (p=0.001) at baseline were associated with a significantly increased 30-day mortality after ECMO implantation. Conclusion The emergency use of VA-ECMO in the CCL increased over the last years and was associated with a high 30-day mortality in our study population. Still, a >20% survival rate in the group of patients with refractory cardiac arrest, an otherwise futile situation, suggests that VA-ECMO implantation is reasonable in selected patients. As high admission serum lactate levels and the baseline pH are strong predictors of outcome, such parameters may be used to guide decision making.

Peripartum use of Extracorporeal Membrane Oxygenation (ECMO) in a Patient Suffering from COVID-19 Severe Acute Respiratory Distress Syndrome (ARDS): A Case Report

Practice patterns for extracorporeal membrane oxygenation (ECMO) use in newborns with Trisomy 21 (T21) have not been fully reported. The goals of this study were to 1) determine the incidence of ECMO use in T21 neonates; 2) identify clinical and demographic characteristics associated with ECMO use in this population; 3) describe outcomes of neonates with T21 supported with ECMO. This was a retrospective cohort study using the Pediatric Health Information System database (January 2000 to January 2014). Given the exploratory nature, only descriptive statistics were used. p < 0.05 was considered significant. Within 43 pediatric hospitals, the incidence of ECMO use in neonates with T21 was 2.3% (131/5,737). Neonates with T21 supported with ECMO were more likely to be admitted earlier; have higher birth weight, gestational age, and longer hospitalization; and have congenital diaphragmatic hernia or select cardiac anomalies versus those who did not require ECMO. T21 neonates supported with ECMO also had higher incidence of bronchopulmonary dysplasia, necrotizing enterocolitis, and mortality (unadjusted odds ratio 12.3 [95% confidence interval: 8.6-17.6]) compared with T21 neonates not exposed to ECMO. Compared with T21 neonates not requiring ECMO, those supported with ECMO had increased morbidity and mortality. Additional investigation on timing, indications, and risk/benefit profiles, for ECMO use in T21 neonates is needed.

BackgroundTrends in temporary mechanical circulatory support (tMCS) use with associated outcomes and cost in cardiogenic shock secondary to decompensated chronic heart failure (HF-CS) remains poorly understood. We describe trends in tMCS use, associated outcomes, and cost in HF-CS. MethodsWe included adults enrolled in a national insurance claims dataset with HF-CS who received intra-aortic balloon pump (IABP), Impella, or extracorporeal membrane oxygenation (ECMO) without acute coronary syndrome, or postcardiotomy shock. We identified predictors of device use, associated outcomes, and inflation-adjusted costs. ResultsWe studied 2722 HF-CS patients receiving tMCS: 1799 (66%) male, 1771 (65%) White, and 1836 (67%) with ischemic cardiomyopathy. Rate of tMCS use increased from 2010-2019. Impella use showed the largest increase (Δ+344%), followed by ECMO (Δ+112%). Patients receiving ECMO had a higher comorbidity burden, and patients receiving IABP were more likely to have valvular heart disease. Compared with IABP, 30-day mortality rate was no different for Impella (adjusted odds ratio, 1.24; 95% CI, 0.93-1.66) but was higher with ECMO (adjusted odds ratio, 3.08; 95% CI, 2.22-4.27). Adjusted hospitalization cost was highest for ECMO (median, $191,079 [IQR, $165,760-$239,373]), followed by Impella (median, $142,518 [IQR, $126,845-$179,938]), and IABP (median, $132,060 [IQR, $113,794-$160,244]). We observed a linear association between price standardized cost-quartile and complications, but not for 30-day mortality. ConclusionsThe use of Impella and ECMO is increasing with an associated cost increase. The use of ECMO coincided with higher 30-day mortality compared with IABP in HF-CS. These findings likely reflect increasing disease severity and evolving practice patterns rather than causation.

Only a small fraction of pediatric cardiac surgical patients are supported with extracorporeal membrane oxygenation following cardiac surgery, but extracorporeal membrane oxygenation use is more common among those undergoing higher complexity surgery. We evaluated extracorporeal membrane oxygenation metrics indexed to annual cardiac surgical volume to better understand extracorporeal membrane oxygenation use among U.S. cardiac surgical programs. Retrospective analysis SETTING:: Forty-three U.S. Children's Hospitals in the Pediatric Health Information System that performed cardiac surgery and used extracorporeal membrane oxygenation. All patients (< 19 yr) undergoing cardiac surgery during January 2003 to July 2014. None. Both extracorporeal membrane oxygenation use and surgical mortality were risk adjusted using Risk Adjustment for Congenital Heart Surgery 1. Extracorporeal membrane oxygenation metrics indexed to annual cardiac surgery cases were calculated for each hospital and the metric values divided into quintiles for comparison across hospitals. Among 131,786 cardiac surgical patients, 3,782 (2.9%) received extracorporeal membrane oxygenation. Median case mix adjusted rate of extracorporeal membrane oxygenation use was 2.8% (interquartile range, 1.6-3.4%). Median pediatric cardiac case mix adjusted surgical mortality was 3.5%. Extracorporeal membrane oxygenation-associated surgical mortality was 1.3% (interquartile range, 0.7-1.6%); without extracorporeal membrane oxygenation, median case mix adjusted surgical mortality would increase from 3.5% to 5.0%. Among patients who died, 36.7% (median) were supported with extracorporeal membrane oxygenation. The median reduction in case mix adjusted surgical mortality from extracorporeal membrane oxygenation surgical survival was 30.1%. The median extracorporeal membrane oxygenation free surgical survival was 95% (interquartile range, 94-96%). Centers with less than 150 annual surgical cases had significantly lower median extracorporeal membrane oxygenation use (0.78%) than centers with greater than 275 cases (≥ 2.8% extracorporeal membrane oxygenation use). Extracorporeal membrane oxygenation use and mortality varied within quintiles and across quintiles of center annual surgical case volume. Risk adjusted extracorporeal membrane oxygenation metrics indexed to annual surgical volume provide potential for benchmarking as well as a greater understanding of extracorporeal membrane oxygenation utilization, efficacy, and impact on cardiac surgery mortality.

Background: Extracorporeal membrane oxygenation (ECMO) has improved outcomes in patients with cardiogenic shock (CS). Recent data and guidelines have recommended the use of venous-arterial (VA) ECMO in patients who have been successfully resuscitated from cardiac arrest (ROSC) to ameliorate the effects of post-resuscitation myocardial dysfunction. Use of ECMO often involves taking a patient to the operating room delaying the onset of care. We hypothesized that utilization of the Maquet Cardiohelp, a portable miniaturized ECMO system, in the cardiac catheterization laboratory (CCL), would increase use of ECMO for cardiac arrest patients. Methods: Cardiohelp (CH) ECMO was acquired in March 2012 by our tertiary care university hospital. We performed a retrospective analysis comparing the patients who received CH ECMO from March 2012 until June 2012 to those that received Centrimag (CM), a traditional ECMO circuit, in the in the 6 months prior to March 2012. Results: All patients were treated with femoral VA ECMO with antegrade perfusion distal via a percutaneous catheter in the superficial femoral artery. Overall, more patients were treated with CH compared to CM. Compared to patients who received CM, CH patients were more likely to have been referred for ECMO after ROSC from cardiac arrest and were more likely to have been transferred directly from the Emergency Department (ED). CM patients were slightly younger and were referred for ECMO treatment primarily due to cardiogenic shock (SBP3 pressors). 30 day survival was similar in both groups and there were no cases of stroke or limb ischemia. Conclusions: Use of the portable CH ECMO system with CCL initiation is associated with increased utilization of ECMO and particularly for the treatment of ED ROSC patients. This may be due to the portability of the device and existing relationships between the CCL and the ED. Rapid utilization of ECMO for these patients may lead to improved clinical outcomes.

The use of extracorporeal membrane oxygenation (ECMO) in cardiac surgery has been established in cases of postcardiotomy cardiogenic shock, which is refractory to conventional therapy with inotropes and intra-aortic balloon pulsation support. We sought to examine the literature in a systematic review manner on the outcomes of using ECMO postcardiac surgery. A comprehensive electronic literature search was done to identify all the articles that have discussed the use of ECMO postcardiac surgery. The keywords and medical subject headings terms were used to identify the relevant articles. Studies have been screened according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The identified studies have been summarized in each relevant section of this study. Cardiogenic shock postcardiac surgery can benefit from ECMO to varying degrees and the survival for this; otherwise, fatal condition has been shown to be improving through the use of ECMO. However, the decision and timing to initiate ECMO therapy remains selective and is dependent on a range of factors such as patient factor, clinician's judgment, meaning there is no consistent and solid ground regarding the timing of ECMO initiation. Current evidence suggests that the circulatory support provided by ECMO improves survival rates for postcardiac surgery cardiogenic shock patients who are refractory to inotropic management, without such ECMO support patient mortality rates would be much greater.

CATASTROPHIC PULMONARY EMBOLISM SUCCESSFULLY TREATED WITH EXTRACORPOREAL MEMBRANE OXYGENATION

Research evaluating outcomes in critically ill patients with acute respiratory and cardiac failure supported with extracorporeal membrane oxygenation has increased significantly. The objective was to identify a core set of outcomes that are essential to include in all clinical research evaluating the use of either venoarterial or venovenous extracorporeal membrane oxygenation in critically ill patients, particularly regarding safety and adverse events. A three-round modified Delphi process. Patients, caregivers, multidisciplinary clinicians, researchers, industry partners, and research funders were included. Participants represented key extracorporeal membrane oxygenation organizations, including the Extracorporeal Life Support Organization, the International Extracorporeal Membrane Oxygenation Network, clinicians from high volume extracorporeal membrane oxygenation centers, and extracorporeal membrane oxygenation researchers or former extracorporeal membrane oxygenation patients from five continents. We used recommended standards for the development of a core outcome set. Outcome measures identified from systematic reviews of the literature and from qualitative studies of survivors were mapped to the domains identified by the Core Outcome Measures in Effectiveness Trials initiative separately for venovenous extracorporeal membrane oxygenation and venoarterial extracorporeal membrane oxygenation. Participant response rates were 40 of 47 (85%), 35 of 37 (95%), and 64 of 69 (93%) for survey rounds 1, 2, and 3, respectively, with participants representing 10 different countries on five continents. After the third round survey, 8 outcome measures met consensus for both venovenous extracorporeal membrane oxygenation and venoarterial extracorporeal membrane oxygenation. This study identified core outcomes to assess in all research evaluating the use of extracorporeal membrane oxygenation, including adverse events specific to this intervention, permitting standardization of outcome reporting for the first time. Identifying appropriate measurement instruments to evaluate these outcomes is an important next step to enable synthesis of extracorporeal membrane oxygenation research.

Background: Despite advances in extracorporeal membrane oxygenation (ECMO) for cardiogenic shock (CS), little is known about gender-based differences in its utilization and clinical outcomes. We aimed to assess whether gender influences ECMO use and outcomes in CS using Nationwide Inpatient Sample (NIS) Database. Methods: We conducted a retrospective cohort study using the Nationwide Inpatient Sample (NIS, 2016–2020), identifying adults (≥18 years) hospitalized with cardiogenic shock. ECMO use was identified using ICD-10-PCS codes. Survey-weighted logistic and linear regression models were used to assess gender differences in ECMO utilization, in-hospital mortality, length of stay (LOS), hospitalization costs, and major complications. Models adjusted for demographics, comorbidities (Elixhauser index), and hospital characteristics. Results: Among 13,005 patients receiving ECMO for CS, only 33.9% were female. Female patients were significantly less likely to receive ECMO (adjusted OR 0.89; 95% CI 0.82–0.97; p = 0.011). Female ECMO recipients were younger than males (mean age 47.7 vs. 52.8 years; p &lt; 0.001). There was no significant difference in in-hospital mortality by gender (aOR 1.12; 95% CI 0.92–1.35; p = 0.258). Length of stay was similar between genders (23.6 days), with a non-significant trend toward shorter LOS in females (β = –2.25; p = 0.071). Adjusted total hospital charges were significantly lower in females (β = –$95,269; p = 0.017) (Figure 1). Notably, complication rates varied by gender. Females had significantly lower adjusted odds of requiring dialysis (aOR 0.77; 95% CI 0.63–0.95; p = 0.013), developing acute kidney injury (aOR 0.71; 95% CI 0.57–0.88; p = 0.002), arrhythmias (aOR 0.67; 95% CI 0.56–0.80; p &lt; 0.001), and acute myocardial infarction (aOR 0.75; 95% CI 0.61–0.92; p = 0.007). However, female patients had higher adjusted odds of developing pericardial complications (aOR 1.35; 95% CI 1.04–1.74; p = 0.022) and pulmonary embolism (aOR 1.68; 95% CI 1.25–2.26; p = 0.001) (Figure 2). Conclusions: Women were less likely to receive ECMO for cardiogenic shock and tended to be younger at the time of receiving it. While in-hospital mortality and length of stay did not differ by gender, females had significantly lower hospital charges and distinct complication patterns. These findings highlight potential gender-based disparities in ECMO utilization and underscore the need for further investigation to ensure equitable access and outcomes.

The Case for Prolonged ECMO for COVID-19 ARDS as a Bridge to Recovery or Lung Transplantation.