ASAIO Journal最新文献

Mechanical cavopulmonary assist (CPA) remains challenging for failing Fontan circulation. This study aimed to evaluate the hemodynamic impact of partial CPA using a juvenile porcine model. Six pigs (30 kg) underwent the Fontan procedure using a handmade Y-shaped graft. Total CPA was established by assisting both superior vena cava (SVC) and inferior vena cava (IVC) flow to the pulmonary artery, whereas partial CPA assisted only IVC flow using a centrifugal pump. Cavopulmonary assist flow was set to 100%, 50%, or 25% of pre-Fontan cardiac output (CO). Hemodynamics at baseline, after total CPA, and after partial CPA were compared using paired t-tests. Total CPA with 100% CO support increased CO and reduced SVC and IVC pressures compared to baseline (CO, 1.03 vs. 2.36 L/min; SVC pressure, 16.3 vs. 9.5 mm Hg; IVC pressure, 17.3 vs. 9.3 mm Hg, p < 0.05 for all). Partial CPA with 25% CO support increased CO and decreased IVC pressure, though SVC pressure increased (CO, 1.03 vs. 1.52 L/min; SVC pressure, 16.3 vs. 20.5 mm Hg; IVC pressure, 17.3 vs. 11.5 mm Hg, p < 0.05 for all). Although total CPA achieved optimal hemodynamics, partial CPA with 25% CO flow was effective, suggesting a feasible, noninvasive solution for patients with failing Fontan physiology.

The impact of race on extracorporeal life support (ECLS) availability, morbidity, and mortality remains poorly defined. We sought to define the impact of race/ethnicity, sex, and location on ECLS outcomes, and identify potential disparities that remain intact using a modern, inclusive cohort of neonates receiving ECLS in the United States. Data were extracted from the Children's Hospital Association Pediatric Health Information System (PHIS) database on neonates who received ECLS from January 1, 2010-December 31, 2020. Both adjusted and unadjusted regression models were fitted to study the association between neonatal ECLS outcomes and covariates. During the study period, 6,695 neonates from 47 hospitals met the inclusion criteria. Non-Hispanic White neonates (45%), males (57%), and hospitals in the Southern region (32%) compromised the largest proportions of ECLS cases and cardiac disease (44%) was the most common indication for ECLS. Hospital region was associated with ECLS duration with hospitals in the Midwest (median 6 days) and West (6 days) having significantly shorter courses than those in the Northeast (7 days) and South (7 days) (p < 0.01). Associations between race/ethnicity, sex, hospital region, and mortality were detected. Non-Hispanic Black neonates (35% mortality), males (37%), and neonates in the Midwest region (34%) experienced lower ECLS mortality rates (all p < 0.05).

In patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock, red blood cell (RBC) transfusion is often necessary, but its impact on long-term mortality remains unclear. This multicenter retrospective cohort study aimed to assess the association between RBC transfusion and 1 year mortality in patients on VA-ECMO. Data were collected from two French intensive care units (ICUs) between January 1st, 2016, and December 31st, 2021. Adults with cardiogenic shock supported by VA-ECMO were included, while those under 18, with ECMO duration <24 hours, or cardiac arrest before or during implantation were excluded. Among 190 patients (71% male, median age 60 years), the median VA-ECMO duration was 8 days. One year mortality was 54%. Red blood cell transfusions were administered to 83% of patients, with a median of six packs. Multivariable analysis showed no significant association between RBC transfusion and 1 year mortality across various transfusion metrics, including transfusion status, total units, and daily packs (all p > 0.05). Subgroup analyses confirmed this consistent pattern. Although RBC transfusion is frequent in VA-ECMO-supported patients, this study found no significant association with 1 year survival. Given the risks of transfusion, a cautious approach is recommended. Further studies are needed to refine transfusion strategies for this high-risk population.

In this study, we compare the clinical characteristics and courses of patients directly bridged to heart transplant with intraaortic balloon pump (IABP) versus Impella 5.5. We performed a retrospective cohort study of single-center institutional data including all adult patients at our institution bridged to transplant with either IABP or Impella 5.5 support between October 18, 2018, and May 31, 2023. Ninety-one heart transplant recipients were included in this study, of whom 54 (59%) were bridged on IABP and 37 (41%) were bridged on Impella 5.5. Patients supported with Impella 5.5 had comparable baseline characteristics compared to those bridged on IABP (all p > 0.05). However, Impella 5.5 patients had lower vasoactive inotropic scores during their temporary mechanical circulatory support (MCS) period than those bridged on IABP (all p < 0.05). Duration of MCS and post-transplant intensive care unit (ICU) length of stay were longer for Impella 5.5 patients (all p < 0.05), but rates of complications after transplant were comparable (all p > 0.05). Survival at 1 year post-transplant was significantly greater for the Impella 5.5 group (100% vs. 87%; p = 0.039). Given the increased use of MCS as a bridge to transplant, this project has important implications for preoperative management of waitlist patients.

The use of cardiac devices, including mechanical circulatory support (MCS), cardiac implantable electronic devices (CIEDs), and pacing wires, has increased and significantly improved survival in patients with severe cardiac failure. However, these devices are frequently associated with acute brain injuries (ABIs) including ischemic strokes, intracranial hemorrhages, seizures, and hypoxic-ischemic brain injury which contribute substantially to morbidity and mortality. Computed tomography (CT) and magnetic resonance imaging (MRI), the standard imaging modalities for ABI diagnosis, can pose significant challenges in this patient population due to the risks associated with patient transportation and the incompatibility of ferromagnetic components of certain cardiac devices with high magnetic field of the MRI. This review discusses the application of Ultralow-field portable MRI (ULF-pMRI), which operates at much lower magnetic field (0.064 T), with the potential to allow safe bedside imaging of critically ill patients. In this review, we detail the clinical studies and research findings defining the safety, feasibility, and diagnostic utility of ULF-pMRI in detecting ABI in the critically ill. We further discuss the potential broader applications of ULF-pMRI, as a standard diagnostic tool for neurocritical care in patients with cardiac devices. The integration of such technology into current practice promises to enhance diagnostic accuracy, improve patient outcomes, and optimize healthcare resources.

Thoracoabdominal normothermic regional perfusion (TA-NRP) is increasingly implemented in donation after circulatory determination of death (DCD). Thoracoabdominal normothermic regional perfusion allows thoracic and abdominal organs to be perfused with warm, oxygenated blood after declaration of death, interrupting ischemia. Evidence is accumulating supporting the use of TA-NRP to improve the outcome of grafts from DCD donors. Thoracoabdominal normothermic regional perfusion may restore and maintain a near-physiological environment during procurement. Moreover, during TA-NRP it is feasible to evaluate the heart in situ . Thoracoabdominal normothermic regional perfusion could be performed through different cannulation techniques, central or peripheral, and, with different extracorporeal circuits. The use of conventional cardiopulmonary bypass and extracorporeal life support (ECLS) devices equipped with open circuits has been described. We report the use of a fully mobile, closed ECLS circuit to implement TA-NRP. The procedure was successfully performed in a peripheral center without a cardiac surgery program through a percutaneous cannulation approach. This strategy resulted in combined heart, liver, and kidney recovery despite a significantly prolonged functional warm ischemia time. The feasibility of TA-NRP using modified but still closed fully mobile ECLS circuits could furtherly support the expansion of DCD programs, increasing the availability of heart for transplantation, and the quality of the grafts, improving recipients' outcome.

Clinical outcomes for patients with severe acute respiratory failure caused by different variants of the coronavirus disease 2019 (COVID-19) supported with extracorporeal membrane oxygenation (ECMO) are incompletely understood. Clinical characteristics, pre-ECMO management, and hospital mortality at 90 days for adults with COVID-19 who received venovenous ECMO (VV-ECMO) at North American centers during waves predominated by Delta (August 16 to December 12, 2021) and Omicron (January 31 to May 31, 2022) severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants were compared in a competing risks framework. One thousand seven hundred and sixty-six patients (1,580 Delta, 186 Omicron) received VV-ECMO for COVID-19 during the Delta- and Omicron-predominant waves in North American centers. In the unadjusted competing risks model, no significant difference was observed in risk of hospital mortality at 90 days between patients during the Delta- versus Omicron-predominant wave (subhazard ratio [sHR], 0.94; 95% confidence interval [CI], 0.74-1.19), but patients supported with VV-ECMO during the Omicron-predominant wave had a significantly lower adjusted risk of hospital mortality at 90 days (subhazard ratio, 0.71; 95% CI, 0.51-0.99). Patients receiving VV-ECMO during the Omicron-predominant wave had a similar unadjusted risk of hospital mortality at 90 days, but a significantly lower adjusted risk of hospital mortality at 90 days than those receiving VV-ECMO during the Delta-predominant wave.

During the coronavirus 2019 (COVID-19) pandemic, children suffered severe lung injury resulting in acute respiratory distress syndrome requiring support with extracorporeal membrane oxygenation (ECMO). In this case series, we described our center's experience employing a rehabilitation-focused ECMO strategy including extubation during ECMO support in four pediatric patients with acute COVID-19 pneumonia hospitalized from September 2021 to January 2022. All four patients tolerated extubation within 30 days of ECMO initiation and achieved mobility while on ECMO support. Duration of ECMO support was 35-152 days and hospital lengths of stay were 52-167 days. Three of four patients survived. Two of three survivors had normal functional status at discharge except for ongoing respiratory support. The third survivor had significant motor deficits due to critical illness polyneuropathy and was supported with daytime oxygen and nocturnal noninvasive support. Overall, these patients demonstrated good outcomes and tolerance of a rehabilitation-focused ECMO strategy.

Despite high mortality rates, pediatric extracorporeal membrane oxygenation (ECMO) redeployments are frequently discussed in everyday clinical care. We aim to investigate predictors of mortality in those patients. Clinical data from a single pediatric center were retrospectively analyzed. Patients with multiple ECMO runs between 2010 and 2023 were included. A total of 70 (13%) patients required multiple ECMO runs. Of those, 56 (80%) died before discharge; late mortality was 89% at a median of 1.6 (1.0-3.9) years. A total of 47 (67%) patients had neurologic findings. Only one (1%) survivor had a normal neurodevelopmental follow-up. Duration of the first ECMO run (odds ratio [OR]: 2.63, 1.08-7.96), total duration on ECMO (OR: 4.72, 1.29-23.54), neurologic findings at any time (OR: 7.94, 1.46-43.24), need for renal replacement therapy (OR: 4.79, 1.06-25.58), and lactate values correlated with late mortality. All 19 (27%) patients with neurologic findings before the second run died. The frequency of multiple-run ECMOs increased within the study period. Outcomes in pediatric patients with multiple ECMO runs are disheartening. Given all patients in our cohort with neurological findings before the second ECMO run died, neurological findings should be taken into consideration when determining the utility of further ECMO support.

There is insufficient data on the outcomes of donation after circulatory death (DCD) multiorgan transplant that includes heart. The primary objective of this study is to compare the overall survival outcomes of DCD and donation after brain death (DBD) multiorgan transplants. We identified all heart transplant patients from 2019 to June of 2023 using the United Network for Organ Sharing (UNOS) Database who also received an additional organ (kidney, liver, and lungs). A total of 1,844 DBD and 91 DCD multiorgan transplants occurred within the study period, the majority being combined heart-kidney transplantation. More patients were listed at a higher status in the DBD group ( p < 0.05) and were in the intensive care unit (ICU) before transplant ( p < 0.05). Despite the higher ischemia time in the DCD group ( p < 0.05), the overall unmatched survival did not differ between the two groups ( p < 0.05). Within the heart-kidney transplants, the overall survival between DBD and DCD heart-kidney transplants did not differ in either unmatched or matched groups (unmatched p = 0.5, matched p = 0.5). In conclusion, the data on the outcomes of DCD multiorgan transplants are limited. Still, our analysis of the currently available data suggests that the overall survival is comparable in the DCD multiorgan transplants.