ASAIO Journal最新文献

Extracorporeal membrane oxygenation (ECMO) utilization for primary pulmonary hypertension (PPHTN) remains controversial. This multicenter, retrospective analysis of the Extracorporeal Life Support Organization Registry evaluated 221 PPHTN patients placed on ECMO in 2000-2019. Survival by ECMO indications and cannulation strategies were compared with Kaplan-Meier analyses. ECMO mortality risk factors were analyzed using Cox proportional hazards regressions. The overall rate of survival to ECMO decannulation was 140/221 (63.3%), of which 112/140 (80.0%) survived to hospital discharge. Survival to decannulation increased between 2000-2009 (14/30, 46.7%) and 2010-2019 (126/191, 66.0%, p = 0.041) alongside survival to hospital discharge (9/30, 30.0% vs. 103/191, 53.9%, p = 0.015). Survival to decannulation was similar when patients were supported with either venovenous-ECMO (VV-ECMO; 39/54, 72.2%) or venoarterial-ECMO (VA-ECMO) for respiratory failure (43/71, 60.6%, p = 0.174), although VV-ECMO was associated with fewer complications (25/54, 46% vs. 25/71, 35%, respectively, p = 0.039) and increased survival to hospital discharge (34/54, 63.0% vs. 33/71, 46.5%, p = 0.067). The strongest independent predictor of ECMO morality was isolated vasopressor use before cannulation (hazard ratio [HR]: 3.37 [95% confidence interval {CI95%}: 1.16-9.81], p = 0.026). Extracorporeal membrane oxygenation mortality risk was lower among patients bridged-to-transplantation (HR: 0.37 [CI95%: 0.14-0.97], p = 0.043), and was inversely correlated with pre-ECMO pH (HR: 0.03 [CI95%: 0.00-0.49], p = 0.013). Extracorporeal membrane oxygenation use for PPHTN has grown alongside improved outcomes. Early ECMO initiation may improve outcomes in select individuals with PPHTN.

The Abiomed Impella 5.5 (Danvers, MA) is a temporary left ventricular assist device (LVAD) used to support patients during acute cardiogenic shock. It is a catheter-based micro-axial blood pump that is surgically implanted to provide up to 5.5 liters per minute (LPM) of cardiac augmentation. The pump is most frequently inserted through a right subclavicular incision to the axillary artery. Anticoagulation is used during the implant procedure and then maintained at a lower concentration during the duration of support. Inadequate anticoagulation can result in pump thrombosis with subsequent thromboembolization. Excess anticoagulation can result in surgical site bleeding and potential hematoma formation. This case series details three patients with a low-dose anticoagulation strategy. There were no adverse embolic or hemorrhagic events in the peri- or postoperative period.

To investigate the relationship between platelet counts within the first 24 hours of veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support and in-hospital mortality in postcardiotomy ECMO patients. Adult patients undergoing postcardiotomy V-A ECMO from 2017 to 2021 were included and divided into survivors and non-survivors. Logistic regression evaluated the association between the first-day platelet counts and in-hospital mortality. Spearman's correlation assessed the correlations between clinical factors and the platelet hourly % decrease within 24 hours of ECMO support. The study included 72 patients, with an in-hospital mortality of 51.4%. For every 10 ×109/L decrease in the lowest platelet count at 0-24, 0-12, and 12-24 hours of ECMO support, the odds of in-hospital mortality increased by 21.7% (adjusted odds ratios [aOR], 1.217; 95% confidence intervals [CI], 1.045-1.358), 20.6% (aOR, 1.206; 95% CI, 1.058-1.332), and 17.4% (aOR, 1.174; 95% CI, 1.034-1.294), respectively. Platelet hourly % decrease was positively correlated with peak lactate, alanine aminotransferase, D-dimer, fibrinogen degradation products, and ECMO flow rate variation. In postcardiotomy V-A ECMO patients, platelet counts within the first 24 hours of ECMO support are independently associated with higher in-hospital mortality. Potential factors related to decreasing rate of platelet count included thrombosis, ECMO flow fluctuation, tissue ischemia, and hypoxia.

Hybrid extracorporeal membrane oxygenation (ECMO), containing additional ECMO cannulations in addition to conventional ECMO, is increasingly used for the treatment of serious cardiopulmonary conditions. Patients initiating non-hybrid ECMO may transition to hybrid ECMO as their condition worsens. This study compared mortality rates between patients initially on hybrid ECMO and those who transitioned from non-hybrid to hybrid ECMO. We also examined complications related to hybrid ECMO, comparing them with those of non-hybrid ECMO. Data from PubMed, Embase, and Cochrane databases were analyzed using Peto odds ratios and 95% confidential intervals (CIs), with an additional safety comparison to the Extracorporeal Life Support Organization registry to overcome the small number of selected studies. A meta-analysis was performed using review manager. The mortality rate did not differ significantly between whether the hybrid ECMO was used initially or transitioned from non-hybrid ECMO during treatment. Renal-related complications were the most frequent in both hybrid and non-hybrid ECMO cases, with overall higher complication rates in hybrid ECMO. The study concludes that transitioning to hybrid ECMO during treatment does not increase mortality compared to starting with hybrid ECMO, but potential complications, especially with commodity conditions, should be considered. This study provides valuable guidance for clinicians choosing ECMO modalities in clinical practice.

Extracorporeal membrane oxygenation (ECMO) has been primarily used for respiratory and circulatory failure, but its airway-related use has not been investigated well. Tracheal procedures are a situation when ECMO could be used to support patients during anticipated difficult airway management. The Extracorporeal Life Support Organization registry was queried for adult patients treated with ECMO in 2010-2022 during the same admission with types of tracheal procedures. Tracheal procedures were divided into surgical procedure and bronchoscopic procedure groups, and the survival rate was analyzed for each procedural type. Two-hundred sixty-nine patients met the inclusion criteria (64 surgical procedures and 205 bronchoscopic procedures), and 173 (64.3%) patients survived to discharge. Among the surgical procedures, tracheal resection was most performed (30 patients; 46.9%) and was associated with a high survival rate to discharge (86.7%; p = 0.003) compared with airway reconstruction (57.1%) and airway injury repair (46.2%). In bronchoscopic procedure, tracheal stent had favorable survival (76.1%; p = 0.004), whereas tumor debulking was associated with poor prognosis (48.3%; p = 0.006). Hemorrhagic complications were seen in 70 (26.0%) patients and were associated with a worse survival rate (58.6%; p < 0.001). Among them, surgical site bleeding was seen in 35 (13.0%) patients and was also associated with worse survival (42.9%; p = 0.007).

Inflammatory mediators play a major role in the development and progression of acute kidney injury (AKI). Continuous renal replacement therapy (CRRT) removes these mediators from the blood using AN69-M, AN69-ST, and HF1400 filters to target low and middle-molecular weight molecules. We characterized the in vitro removal performance of each filter in a 72 hour simulated CRRT procedure. Urea clearance with AN69-M and AN69-ST remained stable (52.4 and 51.2 ml/minute, respectively) but decreased with HF1400 (47.0 ml/minute; p < 0.001). Vancomycin clearance remained stable for AN69 filters but decreased for HF1400. Interleukin (IL)-8 was removed primarily via adsorption with the AN69 filters (92.2 and 91.2 ml/minute for AN69-M and AN69-ST, respectively), but clearance was significantly lower with HF1400 (8.4 ml/minute). Tumor necrosis factor (TNF)-α clearance was higher with AN69-ST compared with AN69-M or HF1400 (10.3, 1.8, and 2.3 ml/minute, respectively). β2-microglobulin clearance was higher with both AN69-based filters. The hydrogel water repartition of AN69 filters was different, with a higher percentage of bound water in AN69-ST versus AN69-M (30.5% ± 0.2% and 19.3% ± 1.5%, respectively; p < 0.05). These results suggest that clearance profiles of CRRT filters differ according to their properties; further investigation is needed to translate this into clinical improvements.

Isolated acute right ventricular failure (aRVF) is associated with poor prognosis in different scenarios. In severe conditions, temporary mechanical cardiocirculatory support (tMCS) is required. PLACE is an international, retrospective, multicenter registry including 17 centers that investigated patients affected by isolated aRVF and treated with various types of tMCS from January 2000 to December 2020. The registry included 644 (69.6% males, mean age: 55 years) patients. The most frequent etiologies were post-left ventricular assist device implantation (LVAD) and postcardiotomy shock. These patients received mostly mechanical circulatory support (MCS) and veno-arterial extracorporeal membrane oxygenation. Mean tMCS duration was 9 days, weaning was achieved in 70.5% of the patients, and the major cause of death on support was multiorgan failure (50.5%). The mortality rate was 45 and 48.4% in-hospital and at 3 month follow-up, respectively. Multivariable logistic regression analysis identified age, aRVF due to acute pulmonary hypertension, bilirubin level, and oliguria or anuria at tMCS implantation as risk factors for in-hospital mortality. Conversely, aRVF after LVAD was found to be associated with a lower risk of early mortality. In-hospital and 3 months mortality occurred in less than half of the aRVF-supported subjects. Furthermore, several preimplant aspects such as age, organ function, and type of tMCS are independently associated with in-hospital and 3 month mortality.

The clinical tolerance of extracorporeal membrane oxygenation (ECMO) membrane changes in acute respiratory distress syndrome (ARDS) patients under veno-venous ECMO (VV-ECMO) has not been reported. The aim of this study was to describe the tolerance of membrane change. Patients requiring VV-ECMO were retrospectively included between March 2020 and May 2022. In case of membrane dysfunction or an increase in hemolysis markers or an alteration in gas exchange, a membrane change was performed. The primary outcome was a composite measure defined as the occurrence of at least one of the following events within 1 hour of membrane change: severe hypoxemia, hemodynamic collapse, bradycardia, arrhythmia, cardiac arrest, and death. During the study period, 70 patients required a VV-ECMO, 29 (41%) of whom died. Thirty-two patients required a membrane change for a total of 56 changes. The primary outcome occurred for 33 (59%) changes. Arterial desaturation <80% occurred for all complicated membrane changes and cardiac arrest concerned nine changes (16%). Low tidal volume (V T ), respiratory system compliance (Crs), PaO 2 , and high ECMO blood flow (Q ECMO ) were associated with poor tolerance of membrane change. Threshold values of 130 ml for V T , 9.3 cm H 2 O for Crs, 72 mm Hg for PaO 2 , and 3.65 L/minute for Q ECMO best determined the risk of poor tolerance of membrane change.

We assessed the prognostic potential of Galectin-3 in a sample of 159 heart failure patients who received a left ventricular assist device (LVAD) implant from 2012 to 2020. Clinical outcomes included hemodynamic data, right heart failure (RHF), hemocompatibility-related adverse events (HRAEs), and mortality. Galectin-3 was compounded into Michigan-RVF and EUROMACS-RHF risk scores and compared to the noncompounded risk scores. Right heart failure was significantly correlated with Galectin ( p = 0.004) on a continuous spectrum. Inotrope duration was significantly correlated to Galectin-3 (interquartile range [IQR]: 7.58-8.65, p < 0.001) along with INTERMACS score (IQR: 2.14-1.90, p < 0.001). Intensive care unit length of stay (median 8 days, p = 0.02), blood urea nitrogen ( p < 0.001), creatinine ( p < 0.001), and pulmonary artery pulsatility index ( p = 0.05) were also significantly correlated with Galectin-3. In our c-statistic analysis, the predictive value for RHF improved when Galectin-3 was included for both the Michigan-RVF (0.80-0.86) and EUROMACS-RHF (0.77-0.82) risk scores. When elevated over a binary cutoff of 18.2 ng/ml, Galectin-3 significantly correlated with HRAEs ( p = 0.014) and mortality ( p = 0.031). Galectin-3 shows great promise as a predictive biomarker in patients implanted with durable LVADs. In addition to significant correlation with key clinical outcomes, Galectin-3 enhanced the Michigan-RVF and EUROMACS-RHF risk scores in predicting progression to RHF.

The development of right heart failure (RHF) in patients with advanced heart failure following left ventricular assist device (LVAD) implantation remains difficult to predict. We proposed a novel composite hemodynamic index-the right ventricular-arterial compliance index (RVACi), derived from pulmonary artery pulse pressure (PAPP), ejection time (ET), heart rate (HR), and cardiac output (CO), with and expressed as mm Hg·s/L. We then conducted a retrospective, single-center analysis comparing the predictive value of RVACi for the development of RHF or unplanned right ventricular (RV) mechanical circulatory support following LVAD implantation against existing hemodynamic indices. One hundred patients were enrolled after screening 232 patients over a 10 year period, with 74 patients having complete hemodynamic data for RVACi calculation. There was good correlation between pulmonary arterial capacitance ( R ² = 0.48) and pulmonary vascular resistance ( R ² = 0.63) with RVACi, but not RV stroke work index or pulmonary artery pulsatility index. Reduced baseline RVACi (52 ± 23 vs . 92 ± 55 mm Hg·s/L; p = 0.02) was the strongest hemodynamic predictor of unplanned RV mechanical circulatory support requirement in patients following LVAD insertion. Composite pulsatile hemodynamic indices including RVACi may provide additional insight over existing hemodynamic indices for the prediction of RHF and need for RV mechanical circulatory support.