ASAIO Journal最新文献

Heart transplantation (HT) is the definitive therapy for end-stage heart failure. Patients unwilling to receive blood product transfusions are often considered ineligible for HT due to the significant perioperative bleeding risk. "Bloodless" HT-that is, without use of blood product transfusions-provides the opportunity to extend this critical intervention to such patients. Here we describe our center's peri-transplant blood conservation protocol that supported successful bloodless HT in two patients unwilling to receive blood product transfusions. One of these patients represents the first described case of temporary mechanical circulatory support as a bridge to bloodless HT, which is of particular importance given the increasing use of such support before HT more broadly. Clinical management decisions and interventions that decreased blood loss, minimized bleeding risk, and stimulated erythropoiesis are highlighted. Utilization of similar strategies may allow for expansion of bloodless HT to centers that have previously not offered this therapy.

Bleeding is a major complication in patients on extracorporeal membrane oxygenation (ECMO). Acquired factor XIII (FXIII) deficiency develops during ECMO support; however, little is known about the effects of FXIII administration on bleeding ECMO outcomes. Our study aimed to evaluate the effect of FXIII concentrate on bleeding during ECMO and suggest an FXIII threshold level. Retrospective review of pediatric ECMO patients who received FXIII infusion. The International Society on Thrombosis and Hemostasis (ISTH) bleeding definition was used to classify bleeding as none (0), minor (1), clinically relevant non-major (2), and major (3). Factor XIII levels and bleeding scores were compared pre- and post-FXIII concentrate. Twenty patients received 27 infusions of FXIII. Factor XIII concentrate dosing was 37 ± 8 units/kg. Factor XIII levels increased from 41% (interquartile range [IQR]: 37-46) to 68% (IQR: 57-82), p value of less than 0.001. Bleeding severity improved after FXIII infusion; the mean ISTH bleeding score decreased from 2.0 ± 0.7 to 0.8 ± 0.9, p value of less than 0.001. Sixteen patients were successfully off ECMO and survived to discharge. Factor XIII administration was associated with improvement in bleeding severity when the initial FXIII level value was less than 50%. Pediatric ECMO patients with persistent bleeding should have FXIII levels measured and consideration of FXIII administration should be made at FXIII level value of less than 50%.

Fulminant myocarditis may present with rapidly progressive cardiogenic shock and biventricular failure. Although fulminant myocarditis often presents with global left ventricular (LV) failure, unusual right-ventricular-predominant forms can mimic inferior ST-elevation myocardial infarction (STEMI) and delay diagnosis. Mechanical circulatory support (MCS) is often required, and veno-arterial extracorporeal membrane oxygenation and Impella (EC-PELLA) has been used in select cases. However, guidance is limited regarding its role when recovery is uncertain. A previously well, 72 year old woman collapsed with complete heart block, inferior ST-elevation, and isolated right ventricular dysfunction-features that strongly suggested inferior STEMI, yet angiography was nonobstructive. Despite inotropes and mechanical ventilation, the patient deteriorated, prompting initiation of VA-ECMO. Progressive vasoplegia, end-organ failure, and pulmonary edema necessitated placement of an Impella CP device. Myocardial biopsy confirmed lymphocytic myocarditis. Despite maximal support; there was no LV recovery, and the patient developed multiorgan failure. After multidisciplinary review and family discussions, support was withdrawn. This case illustrates both the diagnostic pitfall of right-dominant fulminant myocarditis masquerading as STEMI and the escalating role of EC-PELLA when shock is refractory, while underscoring the challenge of determining futility in the absence of early recovery. We discuss hemodynamic goals, escalation strategy, and prognostic uncertainty, emphasizing the need for early collaborative decision-making frameworks.

Despite the increasing number of critically ill immunocompromised patients in intensive care unit, the outcome of different types of immunocompromised patients with respiratory failure managed with venovenous extracorporeal membrane oxygenation (VV ECMO) remains unclear. What is the overall mortality of immunocompromised patients with respiratory failure managed on VV ECMO compared to immunocompetent patients? Are there differences between different types of immunocompromised states? This is a systematic review and meta-analysis using MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials for studies of any design that reported outcomes of immunocompromised adult patients managed on VV ECMO for respiratory failure. A total of 13 studies were included. The pooled mortality among immunocompromised patients undergoing VV ECMO was 63% (95% confidence interval [CI]: 49-76%, I2 : 94.23%), which was significantly higher than immunocompetent patients (odds ratio [OR]: 2.57, 95% CI: 1.22-5.41, p = 0.03, I2 : 48.18%). Among immunocompromised subgroups, only patients with hematologic malignancy exhibited significantly higher mortality (OR: 5.78, 95% CI: 1.07-31.29, p = 0.05, I2 : 0.00%). Immunocompromised patients with acute respiratory failure treated with VV ECMO were associated with higher mortality compared to immunocompetent patients. Mortality varied by underlying cause of immunosuppression, emphasizing the need for careful, individualized patient selection.

Bridging with low-molecular-weight heparin (LMWH) is recommended in continuous-flow left ventricular assist device (CF-LVAD) patients during subtherapeutic international normalized ratios (INRs). We aimed to assess the risk of adverse events during bridging in patients implanted at Leiden University Medical Center between 2010 and 2024. Incidence rates and hazard ratios of major bleeding, thromboembolic events, neurologic complications, and death with 95% confidence intervals (95% CI) were estimated by time-dependent Cox regression. Using a regression discontinuity design, we mimicked a trial by comparing patients during LMWH treatment due to a subtherapeutic INR to patients during INRs just in target range and no LMWH, considering INRs ±0.1, ±0.2, ±0.3, ±0.4, and ±0.5 around the lower INR target range. Ninety-two patients were included, with a median age of 63 years, 73 (79%) were male and 43 (47%) had Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) 3. Major bleeding rates were increased during bridging in all analyses. Bridging had 3.7-fold (95% CI, 1.6-8.7) increased major bleeding risk compared with no bridging considering INRs ±0.1, and 2.8-fold (95% CI, 1.4-5.5) considering INRs ±0.5. Thromboembolic events were infrequent and not different between the two groups. Neurologic complications occurred more frequently during bridging. Moreover, the risk of mortality was 25.0-fold (95% CI, 3.6-173.1) increased during versus no bridging. Therefore, bridging should be considered with caution in CF-LVAD patients.

Normothermic regional perfusion (NRP) is a strategy of postmortem reperfusion with warm oxygenated blood of a portion of the body applied in donors undergoing circulatory determination of death (DCDDs). Normothermic regional perfusion is aimed to shorten warm ischemic time, and to restore a near physiological environment throughout surgical recovery procedure. The regionalization of perfusion is aimed to prevent cerebral reperfusion, with an ethical and legal rationale. Endovascular occlusion of the aorta, accomplished inserting a balloon catheter through the femoral artery, is frequently implemented to provide the splanchnic regionalization required during abdominal NRP (A-NRP). As evidence accumulates, NRP is increasingly used, and extended criteria and older donors are increasingly enrolled in organ procurement programs. Vascular comorbidities, particularly age-related, or vascular anatomical anomalies could be identified in a growing number of donors. We describe a strategy of endovascular balloon occlusion through the axillary artery in controlled DCDDs undergoing A-NRP. Its invasiveness, effectiveness, and resource requirement are equivalent to the conventional approach. This procedure may represent a valuable alternative when femoral vessels could not be accessed for any clinical reason, avoiding the need to rush for surgical access to provide aortic cross-clamping, delaying NRP initiation and increasing warm ischemic time.

The clinical outcomes of patients with left ventricular assist devices (LVAD) have steadily improved, unveiling late right ventricular failure (RVF) and aortic regurgitation (AR) as drivers of long-term mortality. The continuous-flow LVAD physiology and the patient's pre-existing features predispose to these complications, recently labeled hemodynamic-related events (HDREs). We present the case of an LVAD carrier complicated by both late RVF and AR, in which a comprehensive hemodynamic and echo-guided ramp test was carried out. A step-by-step standardized ramp test protocol is described with a focus on the interpretation of longitudinal changes in hemodynamic and echocardiographic parameters at different LVAD speeds. We emphasize the clinical relevance of a dynamic evaluation to stage these complex hemodynamic scenarios and to guide individualized management. The ramp test was instrumental to unmask the relative contribution of several morphofunctional components as limiting factors to optimal hemodynamics at different LVAD speeds and identified RVF as the prevailing limiting factor, suggesting the futility of aortic valve replacement. We highlight the coexistence of AR and RVF as a hard conundrum to face, with an ominous clinical impact. An in-depth characterization of HDRE's natural history will be pivotal to build preventive and mitigation strategies to improve the durability of pump-patient continuum.

Superior vena cava drainage during venoarterial extracorporeal membrane oxygenation (ECMO) may reduce access insufficiency and differential oxygenation and is typically achieved via the femoral approach. Direct multistage jugular cannulation may be optimal. Despite its use at select centers, this approach is not well discussed in the literature. We present five percutaneous jugulo-femoral venoarterial ECMO initiations from our high-volume, intensivist-led service. Each case offers unique indication for direct SVC drainage in lieu of conventional femoral access. No injuries resulted from jugular cannulation, and ECMO therapy of up to 16 days proceeded in the absence of circuit or patient complications. Four patients survived to hospital discharge, while one was palliatively decannulated.