ASAIO Journal最新文献

This referral center's prospective inception-cohort study from 1989 to 2000 (Era 1) and 2000 to 2022 (Era 2) included 232 consecutive children having neonatal respiratory extracorporeal membrane oxygenation (ECMO). Kindergarten-age outcomes determined in 137/139 (95.8%) survivors were Wechsler Preschool and Primary Scales of Intelligence, Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI), and sensorimotor disability, with optimal outcome defined as scores greater than or equal to 80 and without disability. In Era 2, there were fewer patients/year, fewer neonates with meconium aspiration syndrome, and more with sepsis, lethal disease, or "other" diagnoses. Era 2 also had higher rates of venoarterial cannulation, cannulation after the first week of life, and extracorporeal cardiopulmonary resuscitation. In survivors, there was a shift in Full-Scale Intelligence Quotient (FSIQ), Verbal IQ, Performance IQ, and VMI to the left of population norms, with scores less than 70 in 16-40% (expected in 2.27% of the normative population), disability in 53%, and optimal outcome in 38%. Era was not independently associated with mortality, optimal outcome, or FSIQ outcomes. Congenital Diaphragmatic Hernia (CDH) was independently associated with lower optimal outcome and FSIQ. Sensorineural hearing loss (bilateral, predominantly high-frequency, often progressive, and of delayed onset) was eliminated from Era 2, despite a concerning incidence of 40% in Era 1. Survival and neurocognitive outcomes after neonatal respiratory ECMO have not changed over 34 years.

Continuous-flow left ventricular assist devices (CF-LVADs) improve quality of life and survival in patients with advanced heart failure but are frequently complicated by gastrointestinal bleeding (GIB). Reduced pulsatile flow may induce mucosal hypoxia, upregulating factors such as hypoxia-inducible factor (HIF)-1α and triggering neo-angiogenesis, leading to the development of gastrointestinal angiodysplasias (GIADs), a common cause of GIB. Digoxin inhibits HIF-1α and may prevent GIAD development, although its impact on the incidence of GIB remains uncertain. This meta-analysis (PROSPERO ID: CRD42024626222) evaluated the association between digoxin use and GIB occurrence (primary outcome) in patients with CF-LVADs. Research articles including adults with CF-LVADs, comparing digoxin users versus nonusers were included. Overall, four studies were included (n = 14,917; age 55 ± 13 years, 21% female) with 2,742 patients in the digoxin group and 12,175 in the no-digoxin group. Continuous-flow left ventricular assist device was axial (HeartMate II) in 78% of cases and centrifugal (HeartMate 3/HeartWare) in 22%. Digoxin use was associated with a nonsignificant lower risk of GIB (hazard ratio [HR]: 0.70; 95% confidence interval [CI]: 0.49-1.01). However, regarding GIAD-related GIB, digoxin was associated with a significantly lower risk (HR: 0.33; 95% CI: 0.13-0.82). Among 14,917 patients with CF-LVADs, digoxin use was associated with a trend toward a lower risk of GIB and a lower risk of GIAD-related GIB.

International guidelines for the nutrition management of critically ill adults do not sufficiently cover the unique challenges and considerations of patients receiving extracorporeal membrane oxygenation (ECMO). The aim of the current guideline is to assess the literature informing nutrition provision and practice for patients receiving ECMO and provide clinicians with consensus-based recommendations to inform clinical practice. A group of international experts was convened by the Extracorporeal Life Support Organization (ELSO) to systematically develop consensus-based recommendations for nutrition therapy. Questions of interest were developed by the authors based on those included in guideline recommendations for general critically ill patients on key clinical areas of nutrition provision and practice during critical illness, but specific to the context of patients receiving ECMO. Following question development, a systematic review of the literature was undertaken, recommendations were developed accordingly, and blind voting was undertaken to determine consensus. Study quality was assessed using the National Institute for Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. A total of 31 publications informed the recommendations with no randomized controlled trials found. Sixteen consensus-based recommendations were formulated for 10 clinical questions, of which 11 reached "strong consensus" (100%) and five "consensus" (87.5%). A total of 26 studies were eligible for quality assessment with 24 (92.3%) rated "fair," 1 (3.8%) rated "good," and 1 (3.8%) rated "poor." There is limited high-level evidence to inform nutrition practice in adult patients receiving ECMO. However, these consensus recommendations have been developed using the available observational data, relevant studies of nutrition in general critically ill patients, and the clinical expertise of those working in high-volume ECMO centers and will help to guide nutrition practices in this patient group.

Ultrasound has become indispensable in the management of patients supported with extracorporeal membrane oxygenation (ECMO), enabling rapid diagnosis, procedural guidance, physiologic monitoring, and informed decision-making across the entire ECMO continuum. This review, conducted under the auspices of the Extracorporeal Life Support Organization (ELSO), provides evidence-based recommendations for the use of ultrasound in adult, pediatric, and neonatal ECMO patients. An international, multidisciplinary panel of experts with dual expertise in ECMO and ultrasound, representing all ELSO chapters, convened to define the scope and structure of the review. A comprehensive literature review identified 133 relevant publications informing recommendations. The review addresses training and competency requirements, choice of ultrasound modalities, and the role of ultrasound before ECMO initiation, during cannulation, throughout ECMO support, for troubleshooting complications, and during ECMO weaning and post-decannulation care. Pre-ECMO ultrasound is emphasized for assessment of cardiopulmonary function, vascular anatomy, and identification of contraindications or reversible conditions. Real-time ultrasound guidance is recommended for cannulation to reduce complications and confirm optimal cannula positioning. During ECMO, echocardiography and extracardiac ultrasound are central to monitoring cardiac function, cannula position, ventricular loading conditions, pulmonary pathology, neurological complications, and vascular integrity. Ultrasound-based strategies for diagnosing hypoxemia, recirculation, tamponade, ventricular distension, and limb ischemia are detailed. Finally, ultrasound plays a critical role in assessing readiness for ECMO liberation and identifying post-ECMO complications. This review highlights the pervasive role of ultrasound as a core competency in ECMO care and provides a practical framework to support safe, effective, and standardized ultrasound use across diverse ECMO programs worldwide.

The Extracorporeal Life Support Organization (ELSO) Registry is used by a variety of stakeholders to improve patient and institutional care quality, support research and device regulation, monitor practice patterns, and share best practices. To achieve these goals, Registry data must be accurate and reliable. In this article, we review the process of ELSO Registry data collection, assess data completeness and integrity, and report on the current status of the data. While accuracy is generally high, it can vary, leaving room for further improvement. Understanding the quality of the data is essential for using it effectively.

Shear-induced platelet activation and receptor shedding in mechanical circulatory support (MCS) paradoxically increase risks of thrombosis and bleeding. Although flow cytometry commonly assesses platelet activation and receptor expression, correlations with structural changes remain poorly defined. Recent studies emphasize the role of the marginal band (MB) in platelet morphological transitions during activation. This study investigated MB alteration in shear-induced activated platelets and its relationship with flow cytometric markers. Human blood was circulated in a circulatory loop with an MCS device for 4 hours. Under three operating conditions from 75 to 350 mm Hg pressure head, platelet activation (PAC-1 and P-selectin) and glycoprotein (GP) receptor shedding (GPIbα, GPVI, GPIIb/IIIa) were quantified by flow cytometry, and the MB collapse state was microscopically examined and classified. Results demonstrated that platelet activation, receptor shedding, and MB collapse progressively increased with increasing pressure head in the loop. Marginal band collapse correlated strongly with platelet activation, but less with platelet receptor shedding. Marginal band collapse varied significantly among the population of activated platelets, highlighting the complex, heterogeneous response of platelets to shear stresses generated in the loop. The study suggested that the MB collapse can be used as an effective assay to examine platelet activation caused by MCS devices.

Aortic root thrombosis is a rare but potentially fatal complication associated with left ventricular assist device usage, potentially causing myocardial infarction and right heart failure. A patient with aortic root thrombosis causing left main trunk occlusion early following HeartMate 3 implantation was successfully treated with surgical thrombectomy and a novel outflow graft-aortic root bypass. A 59 year old man with dilated cardiomyopathy and deteriorating heart failure underwent HeartMate 3 implantation and aortic valve repair for advanced circulatory support. Chest pain and reduced left ventricular assist device flow were noted on postoperative day 6. Left coronary cusp thrombosis occluded the left main trunk, causing myocardial infarction. Following emergency percutaneous coronary intervention, surgical thrombectomy was performed, accompanied by an outflow graft-aortic root bypass using a saphenous vein graft to relieve blood stasis in the aortic root for recurrence prevention. Postoperative computed tomography indicated graft patency and no thrombus recurrence. Computational fluid dynamics analysis showed altered flow velocity and wall shear stress within the aortic root, suggesting thrombosis prevention by the bypass. This case highlights a potential role of outflow graft-aortic bypass for recurrent aortic root thrombosis prevention. Additional studies are required to assess effects on clinical outcomes.

During extracorporeal membrane oxygenation (ECMO) management, early recognition and intervention are essential in cases of membrane oxygenator (MO) oxygenation failure. However, because the MO oxygen transfer (O2 transfer) capacity is influenced by various factors, clear evaluation criteria are lacking. Theoretical O2 transfer values provided by manufacturers are commonly used to assess MO performance; however, these values are presented only under standardized conditions. In this study, to develop an O2 transfer model for real-world ECMO settings, we conducted perfusion experiments using bovine blood under various venous blood compositions (hemoglobin concentration and oxygen saturation) and operational conditions (blood flow and fraction of delivered oxygen). Although substantial variability was observed in the relationships between O2 transfer and individual parameters, partial correlation analysis revealed significant associations with all factors, underscoring the need to incorporate them into the model. A multilayer feedforward neural network was employed to construct the model, achieving a high coefficient of determination (R2 = 0.992), demonstrating excellent predictive performance. The proposed O2 transfer model provides a framework for evaluating the oxygenation performance of MO under diverse ECMO conditions. By enabling comparison with real-time clinical data, it has the potential to support clinical decision-making and enhance the safety of ECMO management.

Use of veno-venous (VV) extracorporeal membrane oxygenation (ECMO) to manage pediatric refractory respiratory failure has significantly increased in the last decade, however, when severe cardiac dysfunction develops or gas exchange remains impaired, conversion to other forms of bypass becomes essential. This retrospective study aims to evaluate the incidence, outcomes, and predictive factors for VV ECMO conversion in pediatric patients with refractory respiratory failure. Among the 5,162 pediatric patients in the Extracorporeal Life Support Organization (ELSO) Registry received VV ECMO between 2014 and 2024; among these, 421 (8.1%) were converted to veno-arterial (VA) or alternative configurations. The conversion group reported significantly higher in-hospital mortality (51.1% vs. 26.7%, p < 0.001) and higher incidence of complications during ECMO. Both the duration of ECMO support (13 [interquartile range {IQR}: 5; 27] vs. 8 [IQR: 4; 15] days; p < 0.001) and the duration of hospital stay (39 [18-73] vs. 32 [17-57] days, p = 0.007) were significantly longer in the conversion group. Higher levels of pre-ECMO lactate (odds ratio [OR]: 1.056 [95% confidence interval {CI}: 0.999-1.112], p < 0.042) were associated with a higher risk of conversion. This study suggests that the correct selection of the ECMO mode may improve survival and that VV ECMO should not be considered in patients presenting before ECMO deployment both low mean arterial pressure and high lactate levels.

Patients with advanced heart failure or cardiogenic shock often require a mechanical circulatory support device (MCSD) before heart transplantation (HT). While extracorporeal membrane oxygenation (ECMO) is commonly used for emergent stabilization, transitioning to alternative MCSDs may optimize patients before transplant. Prior studies suggest worse outcomes with ECMO alone. We examined post-HT outcomes in patients bridged from ECMO to other MCSDs. We used the United Network for Organ Sharing (UNOS)/Organ Procurement & Transplantation Network (OPTN) database to identify adults (age ≥18) undergoing HT between 2018 and 2024 who required ECMO at listing. Patients were grouped as ECMO only or ECMO transitioned to left ventricular assist device (LVAD), right ventricular assist device (RVAD), biventricular assist device (BiVAD), or total artificial heart (TAH). Survival was assessed by Kaplan-Meier curves and Cox regression models; outcomes were compared across groups. Of 749 patients, 527 (70%) were supported with ECMO alone. Survival at 30 days, 1 year, and 5 years was similar between ECMO-only and ECMO-to-MCSD (p = 0.46) and across MCSD subtypes (p = 0.96). Right ventricular assist device patients had lower 1 and 5 year survival than ECMO-only (p = 0.004). Rates of rejection, stroke, dialysis, and pacemaker use were similar. Hospital stay was shorter in ECMO-to-MCSD (p = 0.019). Bridging from ECMO to HT using alternative MCSDs is not associated with worse survival or clinical outcomes. Transitioning may offer comparable results with reduced hospital stays.