BACKGROUND:The Impella device is a continuous axial flow pump which provides hemodynamic support by expelling blood into the aorta. The manufacturer recommends using dextrose-based heparin containing solutions as the default purge. As an alternative to anticoagulant solutions, a bicarbonate-based purge solution has been proposed with limited data substantiating adequate protection and durability.OBJECTIVE:To assess the impact of a bicarbonate-based purge solution on Impella pump thrombosis and bleeding outcomes.METHODS:Single-center, retrospective study of cardiogenic shock patients who received an Impella between December 2020 through September 2021. Patients were evaluated based on whether they received bicarbonate-based purge solutions or remained on heparin-based purge solutions. The primary outcome was the rate of Impella pump thrombosis, defined as multiple purge pressures greater than 800 mm Hg. Secondary outcomes included incidence of bleeding defined as a drop in Hgb of at least 2 g/dL along with use of blood products and supratherapeutic anticoagulation defined as an aPTT of greater than 70 seconds.RESULTS:Forty-three patients received bicarbonate-based purge solutions and 49 controls received heparin. The incidence of purge thrombosis by purge pressure threshold was similar between the two groups (16.3% vs 12.2%, P = 0.58). The rate of bleeding was lower with bicarbonate-based purge (27.9% vs 65.3%, P < 0.05) driven by a drop in Hgb of more than 2 g/dL. The rate of supratherapeutic anticoagulation was higher in the heparin arm (65.3% vs 27.9%, P < 0.05).CONCLUSION AND RELEVANCE:Nonanticoagulant purge alternatives offer the potential to reduce bleeding complications and laboratory monitoring burden while maintaining durability.

Anticoagulation during extracorporeal membrane oxygenation (ECMO) for Coronovirus Disease 2019 (COVID-19) can be performed by direct or indirect thrombin inhibitors but differences in outcomes with these agents are uncertain. A retrospective, multicenter study was conducted. All consecutive adult patients with COVID-19 placed on ECMO between March 1, 2020 and April 30, 2021 in participating centers, were included. Patients were divided in groups receiving either a direct thrombin inhibitor (DTI) or an indirect thrombin inhibitor such as unfractionated heparin (UFH). Overall, 455 patients with COVID-19 from 17 centers were placed on ECMO during the study period. Forty-four patients did not receive anticoagulation. Of the remaining 411 patients, DTI was used in 160 (39%) whereas 251 (61%) received UFH. At 90-days, in-hospital mortality was 50% (DTI) and 61% (UFH), adjusted hazard ratio: 0.81, 95% confidence interval (CI): 0.49–1.32. Deep vein thrombosis [adjusted odds ratio (aOR): 2.60, 95% CI: 0.90–6.65], ischemic (aOR: 1.58, 95% CI: 0.18–14.0), and hemorrhagic (aOR:1.22, 95% CI: 0.39–3.87) stroke were similar with DTI in comparison to UFH. Bleeding requiring transfusion was lower in patients receiving DTI (aOR: 0.40, 95% CI: 0.18–0.87). Anticoagulants that directly inhibit thrombin are associated with similar in-hospital mortality, stroke, and venous thrombosis and do not confer a higher risk of clinical bleeding in comparison to conventional heparin during ECMO for COVID-19.

Molineros, Cyrene1; Louzon, Patricia2; Ventura, Davide3; Ensor, Christopher3; Silvestri, Scott3; Cavarocchi, Nicholas3; DeOliveira, Brittany4 Author Information

PURPOSE:In 2020, ELSO published guidelines to assist providers with patient selection for ECMO in COVID ARDS.A BMI > 40 was listed as a relative contraindication for ECMO support without any supporting data in this specific patient population.Two major reports on ECMO patients from France and the ELSO database that included a total of 1118 patients with COVID ARDS, all with BMIs of <37, revealed mortality rates that ranged from 31%-37%.As a result of these publications and the ELSO guidelines mentioned above, multiple centers are using obesity as an exclusion factor for cannulation in COVID-19 patients.Our center in Central Florida used a modified patient eligibility criterion which allowed for patients with BMI >40 to be ECMO candidates.We aim to demonstrate the outcomes and feasibility of using ECMO in ARDS patients with extreme obesity METHODS: Data was collected from the ELSO database outlining outcomes of patients cannulated at Advent Health-Orlando for ECMO due to COVID ARDS between March 2020 -April 2021.The data included only patients with a BMI > 40.Data collected included age, length of stay, survival, discharge disposition, and expiration RESULTS:We have cannulated a total of 33 morbidly obese patients (BMI >40).19/33 (57%) have survived and transitioned to either home, long-term acute care facility, rehab, or original referring hospital.11/33 (33%) expired while on ECMO, 1/33 (3%) expired post-ECMO, resulting in an overall mortality of (12/33) 36%.The average LOS for all patients was 39.9 days.The survival group had an average LOS of 46.1 days.The average age for our cohort was 41 years CONCLUSIONS: It is our experience at Advent Health Orlando, that providing ECMO support to patients with BMI >40 has similar outcomes to patients who are not morbidly obese, our 59% survival rate compares to 60% in the ELSO historical database.Our 36% mortality rate compared to a range of 31-37% reported in the recent literature for COVID ARDS.Based on our results, we suggest that BMI > 40 be removed as a relative contraindication to ECMO.We also urge other centers to re-consider denying morbidly obese patients ECMO support based on the assumption that they may have a worse outcome than the rest of the population CLINICAL IMPLICATIONS: Based on our data, we demonstrate patients with COVID-19 ARDS with BMI > 40 benefited from ECMO support.In order to effectively ventilate morbidly obese patients, higher plateau pressures are required and may result in barotrauma and hemodynamic compromise.Supporting obese patients with ECMO to maintain protective lung settings can ultimately lead to better long-term outcomes.More data is needed to fully assess the survivability and overall quality of life in morbidly obese patients who are placed on ECMO, however, while this information is collected, we hope that the medical community will start offering the same opportunities to all patients regardless of weight DISCLOSURES: No relevant relationships by Nicholas Cavarocchi, source¼Web Response No relevant relationships by Sergio Ramirez, source¼Web

INTRODUCTION:Extracorporeal Membrane Oxygenation (ECMO) is a temporary therapy option for refractory cardiac or respiratory failure. Preliminary study suggests that ECMO aids in the recovery of end-organ function by maintaining systemic perfusion.METHODS:A retrospective IRB approved database research and chart review was performed on patients initiated on veno-arterial (VA-) ECMO between September 2010 and April 2019. End-organ injury markers were compared between the pre-ECMO period, defined as markers recorded before ECMO initiation, and the pre-decannulation period, defined as markers prior to ECMO decannulation. Data was expressed with mean ± standard deviation, or median [quartile 1, quartile 3] and compared between Pre-ECMO and per-decannulation period.RESULTS:Among the 159 VA-ECMO patients, 100 patients (63%) survived ECMO with mean ECMO duration 10 ± 7 days. Within the survival group, 78 patients (49%) weaned to recovery, and 22 patients (14%) weaned off to durable implantable devices. Compared to the pre-ECMO period, the pre-decannulation period significantly improved in pH (7.23 ± 0.19 vs. 7.40 ± 0.09; p < 0.001) and lactate (5.5 [2.3, 9.0] vs. 1.6 [0.9, 2.3]; p < 0.001), and serum creatinine (1.4 [1.1, 2.1] vs. 1.1 [0.8, 1.7]; p < 0.001). Significant changes were noted in ventilation parameters as well, such as FiO2 (100 [100, 100] vs. 50 [50, 50]; p < 0.001), PaO2 (88 [62, 135], 126 [87, 162]; p < 0.001) and PEEP (8.0 [5.0, 12.0] vs. 5.0 [5.0, 8.0]; p < 0.001).CONCLUSION:Maintaining perfusion with VA-ECMO utilization on indicated patients demonstrated improvements in end-organ functions. Survival rates of VA-ECMO patients were also optimistic.

The original version of this article unfortunately contained a mistake. The spelling of the Hitoshi Hirose name was incorrect. It was corrected in this erratum.

Background: Even with the use of extracorporeal membrane oxygenation (ECMO) in acute respiratory distress syndrome (ARDS), mortality remains high.Also, prognostication of patients with ARDS and ECMO is difficult.Cytokines are thought to be markers of inflammation in both ARDS and in ECMO, however, understanding is limited.We aimed to study the association of three serum cytokine levels with mortality in these patients with ARDS on ECMO.Methods: We performed a retrospective chart review of ARDS patients on ECMO between 2011 and 2017.Patients with serum TNF-α, IL-6 and IL-2 measured while on ECMO were included, with measurements recorded weekly up to a maximum of 4 measurements.A multivariable regression analysis was performed and generalizing estimating equations were used to analyze longitudinal trend of cytokines with mortality.Results: There were 47 patients with ARDS on ECMO, of which 31 (68.9%)survived at 30 days and 2 were lost to follow up.Initial IL-2 levels were found to be significantly higher among those who were alive compared to those who died at 30 days (2720 ± 2432 pg/ml vs. 1293 ± 693 pg/ml); p = 0.0460.At any given time, an increase in IL-2 was associated with a decrease in odds of death at 30 days (adjusted odds ratio 0.98, 95% confidence interval 0.97 -0.99, p = 0.08).There was no significant difference in average or initial levels of TNF-α and IL-6 among those who were alive vs. those who died at 30 days.There was no association between either of these cytokine levels with death while on ECMO.Conclusions: Higher levels of cytokine IL-2 were associated with

Background: Extracorporeal membrane oxygenation is an accepted therapy option for refractory cardiac or respiratory failure. The outcomes of cases initiated at non–extracorporeal membrane oxygenation centers and subsequently transported for management to an extracorporeal membrane oxygenation center require further investigation. Methods: Retrospective institutional review board–approved database research and chart reviews were performed on referrals for extracorporeal membrane oxygenation initially admitted to an outside non–extracorporeal membrane oxygenation center hospital (OSH) then transferred to our extracorporeal membrane oxygenation center (Thomas Jefferson University Hospital (TJUH)). Unstable patients were placed on extracorporeal membrane oxygenation at OSH (Group A) before transport, while others were initiated at our certified extracorporeal membrane oxygenation center (Group B) upon arrival. Group A was further subdivided into patients cannulated by OSH personnel (Group AOSH) or TJUH transport team (Group ATJUH). Outcomes and complications were compared between the different initiation sites and personnel. Results: A total of 108 patients were transferred from August 2010 to June 2018. The technical complication rate for all Group A patients was 33/49 (67%), while that of Group B was 24/59 (41%); p = 0.006. Within Group A, Group AOSH had a greater technical complication rate with 29/33 (88%) than Group ATJUH with 4/16 (25%); p < 0.001. extracorporeal membrane oxygenation survival rate was 34/49 (69%) in Group A and 43/59 (73%) in Group B; p = 0.690. The extracorporeal membrane oxygenation survival rate for Group AOSH and Group ATJUH was 21/33 (64%) and 13/16 (81%), respectively; p = 0.210. Conclusion: Promising extracorporeal membrane oxygenation survival rates were observed in transferred patients. The complication rates related to cannulation technique were significantly higher when patients were initiated at non–extracorporeal membrane oxygenation centers, especially when placed by personnel from non–extracorporeal membrane oxygenation centers.

Objective: The aim of this study is to review the impacts of aggressive placement of a distal perfusion catheter on the outcomes in patients supported with venoarterial extracorporeal membrane oxygenation via femoral cannulation. Methods: Analysis was performed with 143 consecutive femoral venoarterial extracorporeal membrane oxygenation cannulation. Patients were divided into two groups: the early period (October 2010 to December 2012, N = 47) where placement of a distal perfusion catheter was attempted percutaneously but not surgically and the late period (January 2013 to November 2018, N = 96) in which placement of distal perfusion catheter was aggressively utilized both percutaneously and surgically. The modification of venoarterial extracorporeal membrane oxygenation cannulation protocol for the late period involved (1) an immediate insertion of a distal perfusion catheter regardless of the size of femoral arterial cannula, (2) an open insertion of a distal perfusion catheter if percutaneous approach failed, and (3) when venoarterial extracorporeal membrane oxygenation cannulation was completed at a non-extracorporeal membrane oxygenation cannulation center, it was encouraged that they attempt insertion of a distal perfusion catheter at the time of cannulation. Results: In the late period, a distal perfusion catheter was placed in 96% (92/96) which was significantly increased from 66% (31/47) in the early period. Of these 92 patients in late period, nine patients (9.8%) required open direct insertion of a distal perfusion catheter. The incidence of lower limb ischemia (early vs. late period 26% vs 12%, P = 0.031) was significantly decreased in the late period. Logistic regression analyses showed that distal perfusion catheter placement was the only factor for preventing lower limb ischemia. Conclusion: Aggressive insertion of a distal perfusion catheter even utilizing surgical cut-down technique was shown to decrease the incidence of distal limb complications.

INTRODUCTION:Post-cardiac arrest survivals remain low despite the effort of cardiopulmonary resuscitation. Utilization of extracorporeal membrane oxygenation during cardiopulmonary resuscitation (extracorporeal cardiopulmonary resuscitation) can provide immediate cardiovascular support and potentially improve outcomes of patients with cardiac arrest requiring cardiopulmonary resuscitation. There is renewed interest in the use of extracorporeal cardiopulmonary resuscitation due to improved outcomes over the years.METHODS:Extracorporeal membrane oxygenation data between 2010 and 2018 were reviewed. Patients with extracorporeal membrane oxygenation placed under cardiopulmonary resuscitation were identified, and demographics, extracorporeal membrane oxygenation survival, survival to discharge, and neurological recovery were retrospectively analyzed with institutional review board approval.RESULTS:Among 230 cases of extracorporeal membrane oxygenation, 34 (21 males and 13 females, age of 49 ± 13 years) underwent extracorporeal cardiopulmonary resuscitation. The mean duration of extracorporeal membrane oxygenation support after extracorporeal cardiopulmonary resuscitation was 8.3 ± 7.9 days. Extracorporeal membrane oxygenation mortality among extracorporeal cardiopulmonary resuscitation patients was 32% (11/34) and hospital survival was 38% (13/34), which are similar to standard cardiac extracorporeal membrane oxygenation (extracorporeal membrane oxygenation survival 62% and hospital survival 39% in cardiac extracorporeal membrane oxygenation). Among the extracorporeal membrane oxygenation death after extracorporeal cardiopulmonary resuscitation, the majority was due to neurological injury (73%, 8/11); 8/34 extracorporeal membrane oxygenation survival rate and 30-day survival rate were 63% and 25% in early half of study (2010-2014) and have improved to 70% and 60% in late half of study (2014-2018).CONCLUSION:Over years of experience with extracorporeal membrane oxygenation, the outcome of the extracorporeal cardiopulmonary resuscitation has been improving and appears to exceed those of traditional methods, despite limited sample size. Neurological complications still need to be addressed in order for survival and outcomes to improve.

The original version of this article unfortunately contained a mistake. The spelling of the Hitoshi Hirose name was incorrect. It was corrected in this erratum.

Purpose Post-cardiac arrest outcomes like survival to discharge and neurological recovery remain low despite improved medical care and technology. Nationally, traditional methods show that <50% survive traditional cardiopulmonary resuscitation (CPR) with <20% surviving until discharge. E-CPR can provide immediate cardiovascular support when traditional methods fail. There is renewed interest into the use of E-CPR due to improved outcomes. Methods Between 2010 and 2018, a total of 230 ECMO procedures were performed at our institution and 34 cases had E-CPR after traditional measures were inadequate. Patient demographics, ECMO survival, survival to discharge, and neurological recovery were retrospectively analyzed with IRB approval. Results Of the 34 patients who received E-CPR, there were 21 males and 13 females, with a mean age of 49 ± 13 years. The mean duration of ECMO support was 8.3 ± 7.9 days. The indications (#) for E-CPR in these patients were: acute myocardial infarction (15), malignant arrhythmia (6), myocarditis (2), acute pulmonary emboli (2), hypothermia (2), post-cardiotomy failure (2), and others (5). 11 of 34 (32%) patients died during ECMO from: anoxic brain injury (4), stroke (4), withdrawn care (2), and bowel necrosis (1). Additionally, 10 patients died after ECMO decannulation due to anoxic brain injury (5), sepsis (3), ventricular fibrillation (1), withdrawn care (1). E-CPR survival to discharge overall was 13/34 (38%) with full neurological recovery in all patients. ECMO survival rate and 30-days survival rate was improved from (63%, 15/24 and 25%, 6/24) early half of study (2010-2014) to (70%, 7/10 and 60%, 6/10) in late half of study (2014-2018). Among patients with anoxic brain injury that expired during E-CPR, 2/4 (50%) provided multiple organ procurement. Conclusion Over years of experience with ECMO, the outcome of the E-CPR has been improving and appears to exceed those of traditional methods, despite limited sample size. Multiple organ procurement appears to provide a minor added benefit. Neurological complications still need to be addressed in order for survival and outcomes to improve.

Veno-arterial extracorporeal membrane oxygenation (ECMO) is established therapy for short-term circulatory support for children with life-treating cardiorespiratory dysfunction. In children with congenital heart disease (CHD), ECMO is commonly used to support patients with post-cardiotomy shock or complications including intractable arrhythmias, cardiac arrest, and acute respiratory failure. Cannulation configurations include central, when the right atrium and aorta are utilized in patients with recent sternotomy, or peripheral, when cannulation of the neck or femoral vessels are used in non-operative patients. ECMO can be used to support any form of cardiac disease, including univentricular palliated circulation. Although veno-arterial ECMO is commonly used to support children with CHD, veno-venous ECMO has been used in selected patients with hypoxemia or ventilatory failure in the presence of good cardiac function. ECMO use and outcomes in the CHD population are mainly informed by single-center studies and reports from collated registry data. Significant knowledge gaps remain, including optimal patient selection, timing of ECMO deployment, duration of support, anti-coagulation, complications, and the impact of these factors on short- and long-term outcomes. This report, therefore, aims to present a comprehensive overview of the available literature informing patient selection, ECMO management, and in-hospital and early post-discharge outcomes in pediatric patients treated with ECMO for post-cardiotomy cardiorespiratory failure.

Background: Neurological complications are aleading cause of death in patients on extracorporeal membrane oxygenation(ECMO). Cerebral oxygen saturation monitoring by near infrared spectroscopy (NIRS)may predict neurological injury in ECMO patients. Methods: NIRS was performed routinely on ECMOpatients. Data recording clinical neurological signs and head computedtomography (CT) findings were retrospectively collected from medical records.Patients who underwent CT scans were grouped into those with neurological signsand NIRS event (Group A), neurological signs without NIRS event (Group B), NIRSevent without neurological signs (Group C), and no neurological sign or NIRSevent (Group D). NIRS event was defined as an acute, sustained decreasecompared to baseline NIRS value. The incidence and location of neurologicalinjury by CT was evaluated in each group, and the groups were further dividedbased on clinical neurological sign. Results: A total of 73 patients {groups A[14], B [40], C [0], D [19]} had completed NIRS documentation and 28 patientshad CT scans confirming neurological injuries [12 patients (86%) in A, 13patients (33%) in B, and 3 patients (16%) in D, P=0.006]. Among comatosepatients in both group A and B, the sensitivity and specificity in NIRSdetecting neurological injury were 59% and 93%, respectively. The sensitivityand specificity of NIRS in detecting neurological injury in the frontal temporaldistribution was 81.8% and 78.6% respectively. Conclusions: ECMO patients that developedneurological signs with NIRS event correlated with clinical neurological injuryand this was particularly apparent among comatose patients. NIRS was able todetect acute neurological disturbances within expected distributions.

We present a 58-year-old female with a past history of a pituitary adenoma resected two years prior to admission who developed polymorphic ventricular tachycardia and cardiogenic shock requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO). We noted that the patient had stopped taking all of her medications six months prior to presentation. An extensive workup revealed acute panhypopituitarism with secondary hypothyroidism, secondary adrenal insufficiency, and central diabetes insipidus. She was immediately initiated on thyroid and adrenal hormone replacement therapy as well as fluid replacement. Within five days of her medical treatment, the patient’s cardiac function improved and she was successfully weaned from VA-ECMO and subsequently discharged home with appropriate hormone replacement therapy.

Cardiogenic shock, cardiac arrest, acute respiratory failure, or a combination of such events, are all potential complications after cardiac surgery which lead to high mortality. Use of extracorporeal temporary cardio-circulatory and respiratory support for progressive clinical deterioration can facilitate bridging the patient to recovery or to more durable support. Over the last decade, extracorporeal membrane oxygenation (ECMO) has emerged as the preferred temporary artificial support system in such circumstances. Many factors have contributed to widespread ECMO use, including the relative ease of implantation, effectiveness, versatility, low cost relative to alternative devices, and potential for full, not just partial circulatory support. While there have been numerous publications detailing the short and midterm outcomes of ECMO support, specific reports about post-cardiotomy ECMO (PC-ECMO), are limited, single-center experiences. Etiology of cardiorespiratory failure leading to ECMO implantation, associated ECMO complications, and overall patient outcomes may be unique to the PC-ECMO population. Despite the rise in PC-ECMO use over the past decade, short-term survival has not improved. This report, therefore, aims to present a comprehensive overview of the literature with respect to the prevalence of ECMO use, patient characteristics, ECMO management, and in-hospital and early post-discharge patient outcomes for those treated for post-cardiotomy heart, lung, or heart-lung failure. (C) 2019 International Society for Heart and Lung Transplantation. All rights reserved.