ASAIO Journal最新文献

High-frequency oscillatory ventilation (HFOV) is used in neonates with hypoxic respiratory failure both as a primary mode and as a rescue mode of ventilation. It is unknown to what degree the use of HFOV provides a measurable benefit to infants with congenital diaphragmatic hernia (CDH) receiving extracorporeal life support (ECLS). We sought to determine whether pre-ECLS use of HFOV compared to conventional mechanical ventilation (CMV) was associated with differences in mortality. Neonates who underwent ECLS for CDH were identified within the Extracorporeal Life Support Organization (ELSO) Registry. Patients were categorized as those on HFOV versus on CMV immediately before initiating ECLS. Patients were matched 1:1 for severity based on pre-ECLS covariates using the propensity score (PS) for ventilator choice. There were 2,892 infants with an overall mortality of 47.3%. Conventional ventilation was used before ECLS in 677 (23.4%) and HFOV in 2,215 (76.6%). Of these, 1,354 infants were matched (1:1) based on ventilator choice (677 CMV and 677 HFOV). High-frequency oscillatory ventilation was associated with 49% higher odds of mortality based on 677 PS matched pairs (odds ratio [OR] = 1.492, 95% confidence interval [CI]: 1.200-1.856, p < 0.001). Patients who received pre-ECLS mechanical ventilation with HFOV were noted to have higher mortality in neonates with CDH compared to CMV.

Pediatric hemodialysis is a life-saving treatment for children with chronic kidney diseases. Central venous catheters (CVCs) are the most commonly used vascular access, despite being commonly subject to complications leading to inadequate hemodialysis and catheter replacement. The available CVCs feature various design elements reflecting ongoing efforts to achieve optimal performance. Computational fluid dynamics (CFD) can contribute to analyze the flow dynamics within the CVCs. The aim of this study is to investigate the design parameters that most influence the flow performance of CVCs. A design of experiment (DOE) was set up to assess the CFD of two CVC models of 6.5F and 8F size. Blood flow rates, shear stress, residence time, and platelet lysis index were evaluated. The results showed how the proximal side holes were the most influential geometrical features, influencing both the flow rates ( r > 0.64) and the shear stress of the CVCs (| r | > 0.5). At increased flow rate, the side holes were found to be competing with the tip in terms, especially, of residence time inside the CVC. The findings of this DOE show how CFD can contribute to understand the influence of design parameters and potentially guide the development of optimized pediatric-specific CVC models.

Blood compatibility, defined as a material's ability to maintain blood flow without inducing coagulation or hemolysis, was investigated through surface roughness optimization in blood pump flow channels. This study examines how machining parameters (depth of cut, cutting speed, feed per tooth, and cutting width) affect surface roughness using orthogonal experiments, revealing their descending order of influence. Blood compatibility tests comparing cellular damage and adhesion across varying surface roughness levels demonstrated that rougher titanium alloy surfaces significantly increased hemolysis rates and promoted platelet adhesion, accelerating thrombus formation. Genetic algorithm optimization identified optimal parameters: 80 m/min cutting speed, 0.2 mm depth of cut, 1.25 mm cutting width, and 0.02 mm/tooth feed. These parameters minimize surface roughness while maintaining machining efficiency, crucially enhancing blood pump performance by reducing thrombogenic risks. The established evaluation system and parameter optimization methodology provide practical guidance for manufacturing blood-contacting medical devices with improved hemocompatibility.

Bridging subtherapeutic international normalized ratios (INRs) in patients with left ventricular assist devices is not well studied and may cause harm. This retrospective, single-center, pre- and post-cohort study assessed whether a more conservative enoxaparin bridging protocol for patients with subtherapeutic INRs correlated with a reduction in major bleeding and thrombotic events in patients with HeartMate 3 devices. Eighty-two patients and 237 subtherapeutic episodes were included. The rate of the primary composite outcome was numerically lower in the post-group (5.7% vs . 1.5%, p = 0.075). The secondary composite outcome of major bleeding events or thrombotic events within 30 days was significantly reduced in the post-group (10.5% vs. 3.8%, p = 0.041). The rate of major bleeding events within 30 days was reduced in the post-group (10.5% vs. 3.0%, p = 0.019). In a subgroup of patients taking concomitant antiplatelet therapy, the primary composite outcome was significantly reduced in the post-group (5.1% vs. 0.0%, p = 0.044). Routine bridging of subtherapeutic INRs in patients with an HM3 device may be both unnecessary and harmful. A conservative bridging protocol may reduce major bleeding events without increasing the rate of thrombotic events among HM3 patients. Larger studies are necessary to confirm the results.

Bivalirudin is a direct thrombin inhibitor that inhibits both circulating thrombin and fibrin-bound thrombin, giving it the ability to not only prevent thrombus extension, but also more directly facilitate clot resolution than heparin. Although still not yet the standard of care, bivalirudin has become more frequently used for anticoagulation in patients on mechanical circulatory support. In patients who develop large or critically localized thrombosis, requiring catheter-directed therapy, alteplase remains the drug of choice. Here we describe three cases of children, all of whom were on mechanical circulatory support, who required catheter-directed thrombolysis. In each case, direct bivalirudin delivery through a lysis catheter was associated with rapid resolution of thrombosis. Although study of more patients is needed to truly assess safety and efficacy, this series demonstrates that bivalirudin may be an effective drug for thrombolysis and should be considered in patients who have experienced bleeding or other complications from catheter-directed alteplase infusion.

Extracorporeal membrane oxygenation (ECMO) provides critical cardiac support, but predicting outcomes remains a challenge. We enrolled 1,748 adult venoarterial (VA)-ECMO patients at the National Taiwan University Hospital between 2010 and 2021. The overall mortality rate was 68.2%. Machine learning with the random survival forest (RSF) model demonstrated superior prediction for in-hospital mortality (area under the curve [AUC]: 0.953, 95% confidence interval (CI): 0.925-0.981), outperforming the Sequential Organ Failure Assessment (SOFA; 0.753 [0.689-0.817]), Acute Physiology and Chronic Health Evaluation (APACHE) II (0.737 [0.672-0.802]), Survival after Venoarterial ECMO (SAVE; 0.624 [0.551-0.697]), ENCOURAGE (0.675 [0.606-0.743]), and Simplified Acute Physiology Score (SAPS) III (0.604 [0.533-0.675]) scores. Failure to achieve 25% clearance at 8 hours and 50% at 16 hours significantly increased mortality risk (HR: 1.65, 95% CI: 1.27-2.14, p < 0.001; HR: 1.25, 95% CI: 1.02-1.54, p = 0.035). Based on the RSF-derived variable importance, the RESCUE-24 Score was developed, assigning points for lactic acid clearance (10 for <50% at 16 hours, 6 for <25% at 8 hours), SvO 2 <75% (3 points), oliguria <500 ml (2 points), and age ≥60 years (2 points). Patients were classified into low risk (0-2), medium risk (3-20), and high risk (≥21). The medium- and high-risk groups exhibited significantly higher in-hospital mortality compared with the low-risk group (HR: 1.93 [1.46-2.55] and 5.47 [4.07-7.35], p < 0.002, respectively). Kaplan-Meier analysis confirmed that improved lactic acid clearance at 8 and 16 hours was associated with better survival (log-rank p < 0.001). The three groups of the RESCUE-24 Score also showed significant survival differences (log-rank p < 0.001). In conclusion, machine learning can help identify high-risk populations for tailored management. Achieving optimal lactic acid clearance within 24 hours is crucial for improving survival outcomes.

Extracorporeal membrane oxygenation (ECMO) supports severe cardiorespiratory failure but carries a significant bleeding risk. This systematic review aims to report bleeding definitions in studies involving neonates and children treated with ECMO and to determine how heterogeneity in bleeding definition affects bleeding prevalence. We conducted a meta-analysis including all studies from database inception until April 26, 2024. We evaluated the description of bleeding definitions and the reported prevalence of bleeding on ECMO. Of 6,482 screened studies, 169 were included (n = 154,046 subjects). There were 69 distinct bleeding definitions; intracranial hemorrhage (n = 42 studies) and the Extracorporeal Life Support Organization (ELSO) definition (n = 35 studies) were the most common bleeding definitions. The need for intervention, including transfusions, was included in bleeding definitions in 57% of the studies. The overall pooled prevalence of bleeding was 33%. Excluding studies that reported solely intracranial bleeding, the pooled prevalence of bleeding was 41% in studies using the ELSO definition and 39% in studies using other definitions, with high heterogeneity. Variations in bleeding definitions may account for the variability in the reported prevalence of bleeding in children on ECMO. Furthermore, variability in clinical practices regarding interventions to control bleeding may affect estimates of the prevalence of bleeding.