ASAIO Journal最新文献

Cases of antepartum respiratory failure or cardiogenic shock treated successfully with extracorporeal life support (ECLS) with high rates of survival for both mother and fetus are well documented. In contrast, there is a paucity of literature on the outcomes of these neonates after delivery. We report a single-center retrospective study of all adult cases of antepartum ECLS from February 2015 to April 2023 with neonatal follow-up. Seven patients met inclusion criteria with a maternal age of 32.0 ± 5.5 years (median ± interquartile range [IQR]), primarily due to respiratory failure in six (86%) patients, with ECLS initiation at 27.0 ± 3.0 weeks gestation. All mothers and fetuses survived to delivery at a gestational age of 29.0 ± 4.5 weeks. All neonates survived to discharge home with the most common comorbidities being prematurity in seven (100%) patients and bronchopulmonary dysplasia in three (43%). In a follow-up period of 1.4 ± 1.2 years; four (57%) patients underwent formal neurodevelopmental testing and two (50%) had identified delays, both related to speech/language. These results suggest that children exposed to antenatal ECLS demonstrate high rates of survival without significant morbidity, but that follow-up for neurodevelopmental delays may be warranted.

Whether an anticoagulation strategy combining bivalirudin and aspirin during extracorporeal membrane oxygenation (ECMO) would prolong oxygenator use is unknown. No clear data exist on oxygenator life span during prolonged ECMO use. We evaluated 70 adult patients who received ECMO due to coronavirus disease 2019 (COVID-19)-associated acute respiratory distress syndrome for at least 7 days and who required no or at least one ECMO oxygenator replacement due to ECMO-circuit thrombosis. Anticoagulation parameters mainly included activated partial thromboplastin time (aPTT), with monitoring of international normalized ratio and platelet count. The main target aPTT was 45-60 seconds. The indication for oxygenator replacement was ECMO-circuit thrombosis. The mean ECMO duration was 41.8 ± 25.3 days. No oxygenator replacement was required in 48 patients (68.6%) during a mean of 34.9 ± 23.5 ECMO days (range 7-104). Twenty-two patients (31.4%) required 35 oxygenator replacements throughout a mean ECMO duration of 56.9 ± 22.8 days (range 19-102). The mean aPTT was similar throughout ECMO in the two groups. A higher percentage of out-of-target aPTT was associated with a shorter duration of oxygenator use. Bivalirudin plus aspirin may prove to be a more appropriate anticoagulation strategy during ECMO, resulting in more effective utilization of ECMO oxygenators.

This report presents a case series that introduces differential venous drainage (DVD) as an underrated complication arising from the hemodynamic impact of the extracorporeal life support (ECLS) circuit on a patient's native circulation. In this series, we examine how DVD can be recognized and distinguished, particularly as its presentation may initially resemble the more extensively reported differential oxygenation (DO), a hemodynamic phenomenon observed in peripheral veno-arterial extracorporeal membrane oxygenation (V-A ECMO). Differential oxygenation, also known as differential hypoxemia or "Harlequin Syndrome," manifests as an uneven distribution of oxygenated blood between the upper and lower body in patients on V-A ECMO. In contrast, DVD arises from DVD patterns within the circulation. Our analysis reveals cases where DVD produces symptoms similar to DO, highlighting its unique diagnostic and therapeutic challenges, its clinical significance, and its potential implications for patient outcomes. Additionally, we outline the various management strategies for both DO and DVD, underscoring the need for a deeper understanding of their respective impacts on clinical outcomes.

Despite progress in understanding and managing left ventricular assist device (LVAD) complications, outflow graft (OG) stenosis remains inadequately characterized. We described patients who underwent invasive percutaneous OG studies. We used a 10 and 14 mm OG three-dimensional (3D) reconstruction and computational fluid dynamics (CFD) analysis to examine the impact of OG stenosis on flow dynamics. Of the 21 LVAD patients who underwent invasive OG study (median age: 62.6 years, 81% male, 3 HeartMate 3 [HM3], 15 HeartWare [HVAD], and 3 HeartMate II [HMII]), 9 (43%) underwent OG stenting (0 HM3, 7 HVAD, and 2 HMII). Of these nine patients, two had stroke, and three expired post-OG intervention. Computational fluid dynamics analysis showed that with increasing degrees of OG stenosis, there was a rise in pressure gradient across the stenotic area, wall shear stress at the stenotic area, aortic wall shear stress, aortic root recirculation, and chaotic flow. These negative changes were more pronounced for the smaller OG. In conclusion, in our experience, the invasive hemodynamics study and OG stenting, when indicated, are safe and effective. Interestingly, the smaller OG diameter showed a worse hemodynamic response to stenosis. Further research on OG stenosis is needed to define best practices for this LVAD complication.

Hypothermic oxygenated perfusion (HOPE) is a promising method for donor heart preservation, but the hypothermic conditions reduce metabolic activity, making cardiac evaluation challenging, and necessitating prognostic biomarkers to monitor graft quality. This study aims to identify biomarkers during HOPE that predict cardiac function. Seven porcine slaughterhouse hearts underwent 4 hours of HOPE followed by 4 hours of normothermic machine perfusion (NMP) with continuous functional assessment, including measurements of cardiac output (CO), cardiac index (CI), coronary flow (CF), coronary flow index (CFI), left ventricular pressure (LVP), left atrial pressure (LAP), and mean aortic pressure (MAP). Perfusate samples collected at baseline and after 4 hours of HOPE were analyzed for damage markers. Correlations were found between ammonia and CI (r = 0.86), troponin I and CI (r = 0.79), and lactate and CFI (r = -0.81). Mitochondrial and nuclear cell-free DNA decreased during HOPE but did not correlate with function. Olink data indicated that tyrosine-protein kinase Yes (YES1) was negatively correlated with CI (r = -0.86), CF (r = -0.79), and CFI (r = -0.86). These findings suggest YES1, troponin I, ammonia, and lactate as potential prognostic biomarkers during HOPE that may predict cardiac function post-reperfusion, warranting further research to validate their translational potential.

Electrocardiogram (ECG)-synchronized pulsatile veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is a recent development in extracorporeal therapy for patients with severe cardiogenic shock. Although preclinical studies have shown benefits of pulsatile flow relative to continuous ECMO flow, none have explored the effects of the timing of ECMO pulses with respect to the cardiac cycle and its possible implications on ECMO complications. This study aimed to develop a computational fluid dynamics (CFD) model of V-A ECMO in a patient-specific human aorta and evaluate the effect of ECMO timing on cardiac unloading, surplus hemodynamic energy delivery, and mixing zone position. Using direct flow measurements from cardiogenic shock patients and an ECMO device, the model revealed that maximal left ventricular (LV) unloading occurred when the ECMO pulse was in early diastole (35-40% from LV peak systolic flow). Maximum surplus hemodynamic energy transmission to aortic branches occurred at 20% from LV peak systolic flow. This indicates a trade-off between heart afterload and hemodynamic energy delivery in selecting ECMO pulse timing. The mixing zone was primarily located in the aortic arch across timing configurations. Therefore, selecting ECMO pulse timing is crucial to maximizing the benefits of pulsatile flow in V-A ECMO treatment.

The impact of methylprednisolone (MP) on ventricular assist device (VAD)-associated inflammation in children and its association with outcomes remains unclear. We report this single-center retrospective study of children less than 21 years old supported with a VAD from February 2018 to December 2022. Methylprednisolone utilization, serial laboratory markers of hemolysis, inflammation, anticoagulation, and VAD adverse outcomes were analyzed. Sixty-eight patients (47% male, median age 3.2 years, 54% pulsatile flow) were included. Thirty-three patients (49%) received MP during VAD support, starting at a median 9 days post-implant (interquartile range [IQR]: 7-14), and for a median of 4 days (IQR: 3-5). Post-MP, there was a significant reduction in c-reactive protein (CRP) (12.4-3.2 mg/dl, p < 0.001) and fibrinogen (592-325 mg/dl, p < 0.001). Patients receiving MP had a higher daily rate of decline of fibrinogen (p = 0.024) and higher bivalirudin dose (p = 0.013) in the 2nd week post-implant. Methylprednisolone utilization was associated with higher proportion of stroke (p = 0.023), infection (p = 0.010), and pump thrombosis (p = 0.023). Methylprednisolone is used frequently during pediatric VAD support and reduces inflammatory markers. Infectious and thrombotic complications were more common in the cohort receiving MP, and larger studies are needed to investigate this further.

The 2021 Adult and Pediatric Anticoagulation Guidelines for patients on extracorporeal membrane oxygenation (ECMO) recommend a target partial thromboplastin time (PTT) between 60 and 85 seconds when unfractionated heparin (UFH) is administered as an anticoagulant. However, institutions may develop their own protocols in the absence of solid evidence regarding patient anticoagulation during ECMO support. We aimed to determine the association between maintenance anticoagulation with different PTT ranges among patients receiving UFH or no anticoagulation therapy and the occurrence of hemorrhagic complications in adults receiving ECMO support. We conducted a prospective cohort study that included 277 adults on ECMO support. Kaplan-Meier curves were used to compare the time-dependent risk of hemorrhagic events. The association was estimated using the hazard ratio, and the risk was estimated using the multivariate Cox proportional hazards model adjusted for covariates. The time-dependent risk of hemorrhagic events during ECMO support was 2.97-fold higher in patients with a PTT greater than 70 than in patients under no UFH therapy (95% confidence interval [CI]: 1.53-5.77; p = 0.001). An association was observed between target PTT and hemorrhagic complications, with the risk of hemorrhagic complications being higher when maintaining PTT values greater than 70 seconds during ECMO support.

Veno-pulmonary extracorporeal membrane oxygenation (VP ECMO) is an emerging mechanical support therapy for patients with right ventricular (RV) injury. This study aimed to assess the hemodynamic impact of VP ECMO using a mock circulatory loop (MCL) to simulate patients with varying levels of RV injury and pulmonary vascular resistance (PVR). Right ventricular injury was simulated by changing the end-systolic pressure-volume relationship (47.5-100% of healthy RV), in combination with different PVR states (100-600 dyne·s·cm-5). Veno-pulmonary extracorporeal membrane oxygenation was introduced into the MCL circuit from 0 to 5 L/min at 1 L/min intervals. We demonstrated that the effect of VP ECMO support on pulmonary and systemic hemodynamics may vary significantly depending on RV function and RV afterload. A common observation across all cases was that high ECMO flow rates increased mean pulmonary arterial and left atrial pressure and reduced pulmonary artery pulsatility significantly. The absolute value of these parameters depended highly on RV function and corresponding PVR state. The study highlights the importance of considering RV injury severity and corresponding afterload when using VP ECMO to maintain cardiorespiratory stability and prevent pulmonary vasculature damage or hemorrhage. Further research is needed to establish the safe and effective use of VP ECMO in managing cardiac or respiratory failure.