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Thrombosis inside the membrane oxygenator ( MO) is a critical complication during venovenous extracorporeal membrane oxygenation ( ECMO). The aim of this study was to prove if thrombotic clots manifest within the MO when D-dimer levels are elevated over a long-term period. Heparin-coated polymethylpentene MOs ( n = 13) were exchanged due to high plasma D-dimer levels. Clot volume was calculated using multidetector computed tomography ( MDCT). Coagulation parameters and MO function were analyzed before and after MO exchange. Before MO exchange, D-dimer levels increased significantly in each patient (11.5 [6.5-15.5] mg/L to 35.0 [34-35] mg/L, P ≤ 0.001). High levels of D-dimers were tolerated for 1 to 6 days. Additionally, fibrinogen concentration ( n = 8) and platelet count decreased ( n = 8). Within 48 h after exchange, D-dimer levels decreased significantly ( n = 11, 12 [8-16] mg/L, P = 0.004). Fibrinogen concentration and platelet counts increased. Clots were found in all MOs in the inlet part of the device. Clot volume (16-106 cm3) did not correlate with MO support time but increased significantly when high D-dimer levels were accepted for >2 days. An increase or high levels of D-dimers in absence of other explaining pathology during ECMO therapy reflected coagulation activity within the MO. Evidence of clots within the MO at high D-dimer levels and decrease after exchange underline the relevance of D-dimer testing during ECMO treatment. Besides, surveillance of MOs during ongoing ECMO therapy will help to predict clot formation, and to avoid system-induced coagulation disorders as well as critical situations. [ABSTRACT FROM AUTHOR]

Clinical data on anticoagulation needs of modern extracorporeal membrane oxygenation ( ECMO) and its impact on coagulation are scarce. Therefore, we analyzed coagulation-related parameters, need for transfusion, and management of anticoagulation in adult patients with severe acute respiratory failure during treatment with either pumpless interventional lung assist ( iLA) or veno-venous ECMO ( vv-ECMO). Sixty-three patients treated with iLA and 192 patients treated with vv-ECMO at Regensburg University Hospital between January 2005 and May 2011 were analyzed. Data related to anticoagulation, transfusion, and coagulation parameters were collected prospectively by the Regensburg ECMO registry. Except for a higher, sequential organ failure assessment ( SOFA) score in the ECMO group (12 [9-15] vs. 11 [7-14], P = 0.007), a better oxygenation, and a lower dosage of vasopressors in the iLA patients, both groups had similar baseline characteristics. No difference was noted in terms of outcome and overall transfusion requirements. Factors of the plasmatic coagulation system were only marginally altered over time and did not differ between groups. Platelet counts in ECMO-treated patients, but not in those treated with iLA, dropped significantly during extracorporeal support. A more intense systemic anticoagulation with a mean activated partial thromboplastin time ( aPTT) > 53 s led to a higher need for transfusions compared with the group with a mean aPTT < 53 s, whereas the average durability of membrane oxygenators was not affected. Need for red blood cell ( RBC) transfusion was highest in patients with extrapulmonary sepsis (257 mL/day), and was significantly lower in primary pulmonary adult respiratory distress syndrome ( ARDS) (102 mL/day). Overall, 110 (0-274) mL RBC was transfused in the ECMO group versus 146 (41-227) mL in the iLA group per day on support. The impact of modern iLA and ECMO systems on coagulation allows comparatively safe long-term treatment of adult patients with acute respiratory failure. A moderate systemic anticoagulation seems to be sufficient. Importantly, platelets are more affected by vv-ECMO compared with pumpless iLA. [ABSTRACT FROM AUTHOR]

Extracorporeal membrane oxygenation ( ECMO) provides temporary life-saving support for pediatric patients with severe cardiac failure, but causes metabolic disturbances and altered nutritional requirements. However, few studies have addressed the optimal energy supply to meet the demand of these children, largely due to technical difficulties with their invasive nature. We have adapted respiratory mass spectrometry to continuously measure O2 consumption and CO 2 production in the gas exchange across the ECMO oxygenator, as well as that across the ventilator. This study aimed to assess energy expenditure ( EE) and respiratory quotient ( RQ) in children on ECMO. Five children (aged 0.3 to 36 months, median 20) were studied between Day 1 and Day 6 on ECMO. EE and RQ were measured in sequential fashion at the child's native lungs and ECMO oxygenator using respiratory mass spectrometry. Measurements were collected at 4-h intervals, with the means in 24 h representing the values of each day. Each child's caloric and protein intakes were recorded for each day. Between ECMO Days 1 and 6, there was a small but significant increase in EE from 40 to 46 kcal/kg/day ( P = 0.03). In comparison, the caloric intake significantly increased by twice as much as EE from 30 to 61 kcal/kg/day ( P = 0.017). As a result, RQ significantly increased from 0.6 to 1.0 ( P < 0.0001). Protein intake significantly increased during ECMO Days 1 to 6 from 0.5 to 1.5 g/kg/day ( P = 0.04). Respiratory mass spectrometry is feasible to provide a unique and safe technique to measure EE and RQ in patients on ECMO. Without this knowledge, inadequate feeding may occur. Further studies are warranted in a larger patient population to provide better information to guide clinical practice in this special group of critically ill children. [ABSTRACT FROM AUTHOR]

The catheter-based Impella 5.0 left ventricular assist device ( LVAD) is a powerful and less invasive alternative for patients in cardiogenic shock. The use of this device as a primary mechanical circulatory support strategy in INTERMACS II patients should be evaluated. From April 2014 to August 2014, eight Impella 5.0 devices were implanted in seven patients via the axillary artery access (six right and two left). We analyzed the outcome of the four patients in whom the Impella 5.0 device was implanted for the purpose of primary stabilization of cardiogenic shock ( INTERMACS II). The remaining three patients had a contraindication for a permanent LVAD and received the device for prolonged weaning from extracorporeal life support (ECLS) system. The implantation of the Impella 5.0 was technically successful in all patients and resulted in the stabilization of the clinical situation. All four patients could be bridged to a long-term device ( n = 3) or to cardiac recovery ( n = 1). In one patient, 2 days of ECLS support was necessary because of pump thrombosis after 31 days of Impella 5.0 support. One patient with bronchopneumonia had the Impella 5.0 exchanged from the right to the left axillary artery after 22 days of support because of the progressive loss of purge flow and the need for longer bridging to a permanent LVAD. The last patient was supported for giant-cell myocarditis for 22 days and bridged to cardiac recovery. All patients were transferred to the intensive care unit with the Impella device in place. In INTERMACS II situations, the implantation of the Impella 5.0 via the right or left axillary access allowed additional time for decision making. Early patient mobilization, including walking with the Impella device in place, optimized the conditions for either weaning or the implantation of a permanent LVAD. This novel technique of left axillary approach leads to more flexibility in the case of anatomical- or device-related contraindications to right-side access, or when the device needs to be exchanged while continuous support is necessary. [ABSTRACT FROM AUTHOR]

Central veno-arterial extracorporeal membrane oxygenation ( ECMO) is traditionally implanted using direct cannulation of the aorta and right atrium. We aim to summarize the outcome of patients who underwent perioperative central ECMO implantation using an alternative surgical approach, which allows sternum closure and does not require resternotomy at the time of explantation. We retrospectively reviewed patients who required veno-arterial ECMO support at our institution between January 2013 and July 2014. Inclusion criteria were patients undergoing central ECMO implantation using the above-mentioned implantation technique. Nine patients (65 ± 14 years) were supported using this technique. Four patients underwent coronary bypass surgery as a primary surgery and the other five patients had combined coronary and valve surgeries. The average duration of ECMO support was 9 ± 7 days (range 1-24 days). The dominant postoperative complication was renal failure, which occurred in eight patients (89%). In four patients (44%), the ECMO was successfully removed. Survival rate to discharge was 22%. In conclusion, this study showed the feasibility of this alternative ECMO implantation technique. No technical issues were encountered. Extended support duration and reducing resternotomy risks may be the main advantages of this technique compared with conventional ECMO implantation methods. [ABSTRACT FROM AUTHOR]

To evaluate the feasibility of implementing a cardiac assist system in a nonuniversity hospital we analyzed 18 consecutive patients treated with venoarterial membrane oxygenation. The system was used electively in 5/18 (27.8%) patients during high-risk interventions. Thirteen patients (72.2%) were treated in emergency situations. The extracorporal system could be initiated successfully in all patients. Periprocedural complications were hemolysis in 3/18 (16.7%), disseminated intravascular coagulation in 2/18 (11.1%), cerebral ischemia in 1/18 (5.6%), and local infection in 2/18 (11.1%) patients. None of these led to a discontinuation of the therapy. All electively treated patients were successfully weaned from the extracorporeal system. In 9/13 (69.2%) emergency patients the system was removed successfully. The 60-day survival rate of the emergency patients was 53.8% (7/13). Our experience confirms that an innovative extracorporeal circulatory support system can be implemented in a nonuniversity hospital at a tolerable risk and a low complication and high procedural success rate. [ABSTRACT FROM AUTHOR]

Severe acute heart failure requires immediate intensive care unit ( ICU) treatment, but prognosis and outcome of further treatment regimens largely depends on the preprocedural status of the patient. Especially, multiorgan failure including mechanical ventilation are unfavorable predictors of clinical outcome. Here, we report a strategy of immediate initiation of extracorporeal life support ( ECLS) in awake and spontaneously breathing patients with acute heart failure to achieve early multiorgan recovery and gain sufficient time for further treatment planning. Twenty-three patients with severe cardiac failure refractory to standard medical management underwent ECLS treatment, after first clinical signs of cardiac failure appeared to avoid mechanical ventilation. Hemodynamic parameters and renal and liver functions were monitored. Outcome at 1 and 6 months was determined. Patients 46.1 ± 15.5 years of age were placed on ECLS due to various underlying diagnosis: ischemic heart disease ( n = 6), dilatative cardiomyopathy ( n = 4), myocarditis ( n = 2), graft failure following heart transplantation ( n = 6), or other diseases ( n = 5). ECLS lasted 11.9 ± 12.9 days. Hemodynamic stabilization was achieved immediately after ECLS initiation. Vasopressors were reduced subsequently and the cardiac situation improved indicated by central venous saturation, which increased from 38.5 ± 11.3% before to 74.26 ± 8.4% ( P < 0.0001) 24 h after ECLS initiation. Similarly, serum lactate levels decreased from 4.7 ± 4.6 to 1.7 ± 1.51 mmol/L ( P = 0.003). Cumulative 30-day survival was 87.5%, and 6-month survival was 70.8%. In acute cardiac failure, early ECLS treatment is a safe, feasible treatment in awake patients allowing a gain of time for final decision. Moreover, this strategy avoids complications associated with sedation and mechanical ventilation and leads to recovery of secondary organ function, enabling destination therapy. [ABSTRACT FROM AUTHOR]

Recommendations concerning the management of hemoglobin levels and hematocrit in patients on extracorporeal membrane oxygenation ( ECMO) still advise maintenance of a normal hematocrit. In contrast, current transfusion guidelines for critically ill patients support restrictive transfusion practice. We report on a series of patients receiving venovenous ECMO (vv ECMO) for acute respiratory distress syndrome ( ARDS) treated according to the restrictive transfusion regimen recommended for critically ill patients. We retrospectively analyzed 18 patients receiving vv ECMO due to severe ARDS. Hemoglobin concentrations were kept between 7 and 9 g/d L with a transfusion trigger at 7 g/d L or when physiological transfusion triggers were apparent. We assessed baseline data, hospital mortality, time on ECMO, hemoglobin levels, hematocrit, quantities of packed red blood cells received, and lactate concentrations and compared survivors and nonsurvivors. The overall mortality of all patients on vv ECMO was 38.9%. Mean hemoglobin concentration over all patients and ECMO days was 8.30 ± 0.51 g/d L, and hematocrit was 0.25 ± 0.01, with no difference between survivors and nonsurvivors. Mean numbers of given PRBCs showed a trend towards higher quantities in the group of nonsurvivors, but the difference was not significant (1.97 ± 1.47 vs. 0.96 ± 0.76 units; P = 0.07). Mean lactate clearance from the first to the third day was 45.4 ± 28.3%, with no significant difference between survivors and nonsurvivors ( P = 0.19). In our cohort of patients treated with ECMO due to severe ARDS, the application of a restrictive transfusion protocol did not result in an increased mortality. Safety and feasibility of the application of a restrictive transfusion protocol in patients on ECMO must further be evaluated in randomized controlled trials. [ABSTRACT FROM AUTHOR]

The effects of extracorporeal membrane oxygenation ( ECMO) support on renal function in children with critical illness are unknown. The objective of this study was to investigate the impact of ECMO on renal function among children in different age groups. We performed a single-center retrospective observational study in critically ill children ≤18 years supported on ECMO for refractory cardiac or pulmonary failure (2006-2012). The patient population was divided into four age groups for the purpose of comparisons. The Acute Kidney Injury Network's ( AKIN's) validated, three-tiered staging system for acute kidney injury was used to categorize the degree of worsening renal function. Data on patient demographics, baseline characteristics, renal function parameters, dialysis, ultrafiltration, duration of mechanical cardiac support, and mortality were collected. Comparisons of baseline characteristics, duration of mechanical cardiac support, and renal function were made between the four age groups. During the study period, 311 patients qualified for inclusion, of whom 289 patients (94%) received venoarterial ( VA) ECMO, 12 (4%) received venovenous ( VV) ECMO, and 8 (3%) received both VV and VA ECMO. A total of 109 patients (36%) received ultrafiltration on ECMO, 58 (19%) received hemodialysis, and 51 (16%) received peritoneal dialysis. There was a steady and sustained improvement in renal function in all age groups during the ECMO run, with the maximum and longest-sustained improvement occurring in the oldest age group. Proportions of patients in different AKIN stages remained similar in the first 7 days after ECMO initiation. We demonstrate that renal dysfunction improves early after ECMO support. Irrespective of the underlying disease process or patient age, renal function improves in children with pulmonary or cardiac failure who are placed on ECMO. [ABSTRACT FROM AUTHOR]

We aimed to determine the effect of elective left heart decompression at the time of initiation of central venoarterial extracorporeal membrane oxygenation ( VA ECMO) on VA ECMO duration and clinical outcomes in children in a single tertiary ECMO referral center with a large pediatric population from a national referral center for pediatric cardiac surgery. We studied 51 episodes of VA ECMO in a historical cohort of 49 pediatric patients treated between the years 1990 and 2013 in the Paediatric Intensive Care Unit ( PICU) of the Royal Children's Hospital, Melbourne. The cases had a variety of diagnoses including congenital cardiac abnormalities, sepsis, myocarditis, and cardiomyopathy. Left heart decompression as an elective treatment or an emergency intervention for left heart distension was effectively achieved by a number of methods, including left atrial venting, blade atrial septostomy, and left ventricular cannulation. Elective left heart decompression was associated with a reduction in time on ECMO (128 h) when compared with emergency decompression (236 h) ( P = 0.013). Subgroup analysis showed that ECMO duration was greatest in noncardiac patients (elective 138 h, emergency 295 h; P = 0.02) and in patients who died despite both emergency decompression and ECMO (elective 133 h, emergency 354 h; P = 0.002). As the emergency cases had a lower pH, a higher PaCO2, and a lower oxygenation index and were treated with a higher mean airway pressure, positive end-expiratory pressure, and respiratory rate prior to receiving VA ECMO, we undertook multivariate linear regression modeling to show that only PaCO2 and the timing of left heart decompression were associated with ECMO duration. However, elective left heart decompression was not associated with a reduction in length of PICU stay, duration of mechanical ventilation, or duration of oxygen therapy. Elective left heart decompression was not associated with improved ECMO survival or survival to PICU discharge. Elective left heart decompression may reduce ECMO duration and has therefore the potential to reduce ECMO-related complications. A prospective, randomized controlled trial is indicated to study this intervention further. [ABSTRACT FROM AUTHOR]

The impact of extracorporeal membrane oxygenation (ECMO) support on coronary blood flow and left ventricular unloading is still debated. This study aimed to further characterize the influence of ECMO on coronary artery blood flow and its ability to unload the left ventricle in a short-term model of acute cardiogenic shock. Seven anesthetized pigs were intubated and then underwent median sternotomy and cannulation for venoarterial (VA) ECMO. Flow in the left anterior descending (LAD) artery, left atrial pressure (LAP), left ventricular end-diastolic pressure (LVEDP), and mean arterial pressure (MAP) were measured before and after esmolol-induced cardiac dysfunction and after initiating VA-ECMO support. Induction of acute cardiogenic shock was associated with short-term increases in LAP from 8 ± 4 mmHg to 18 ± 14 mm Hg (P = 0.9) and LVEDP from 5 ± 2 mmHg to 13 ± 17 mm Hg (P = 0.9), and a decrease in MAP from 63 ± 16 mm Hg to 50 ± 24 mm Hg (P = 0.3). With VAECMO support, blood flow in the LAD increased from 28 ± 25 mL/min during acute unsupported cardiogenic shock to 67 ± 50 mL/min (P = 0.003), and LAP and LVEDP decreased to 8 + 5 mmHg (P = 0.7) and 5 ± 3 mmHg (P = 0.5), respectively. In this swine model of acute cardiogenic shock, VA-ECMO improved coronary blood flow and provided some degree of left ventricular unloading for the short duration of the study. [ABSTRACT FROM AUTHOR]

Blood contact with surfaces of the extracorporeal circuit provokes the activation of the coagulation system. To improve biocompatibility of the extracorporeal circuit without increasing the risk of bleeding, coatings of artificial surfaces were designed; many of them involve the use of heparin. Data in the literature show that heparin-induced thrombocytopenia is a major issue in the extracorporeal membrane oxygenation scenario, and no relevant benefits have been shown comparing heparin and no-heparin coating. [ABSTRACT FROM AUTHOR]

Patients with cardiogenic shock have a very high mortality. Here we report the first use of a percutaneous pulsatile cardiac assist device, based on a diagonal pump synchronized with the heart cycle by means of an electrocardiographic signal in adult pigs. Eight domestic pigs underwent mandatory ventilation. During sinus rhythm, there were no differences between pulsatile and nonpulsatile perfusion with regard to pulmonary artery pressure, pulmonary wedge pressure, central venous pressure, mean arterial pressure ( MAP), mean pulse pressure, and mean coronary artery flow ( CAF). After 2 min of complete cardiac arrest (ventricular fibrillation), circulatory support with the i-cor in venoarterial nonpulsatile extracorporeal membrane oxygenation ( ECMO) mode (3 L/min) restored systemic circulation, with an increase of MAP to 78.3 mm Hg and CAF to 5.27 mL/min. After changing from ECMO settings to pulsatile mode (3 L/min, 75 bpm, pulse amplitude range 3500 rpm), MAP did not change significantly (75.6 mm Hg); however, CAF increased to 8.45 mL/min. After changing back to nonpulsatile mode, MAP remained stable (83.6 mm Hg), but CAF decreased to 4.85 mL/min. Thereafter, pulsatile cardiac assist was established with a reduced blood flow of 2.5 L/min, and the pulse amplitude range was extended to 4500 rpm. Under these conditions, MAP remained stable (71.0 mm Hg), but CAF significantly increased to 15.2 mL/min ( P < 0.05). Percutaneous cardiac support using a venoarterial cardiac assist device equipped with a novel diagonal pump is able to restore and increase systemic and coronary circulation during ventricular fibrillation. Electrocardiographically triggered synchronized cardiac assist provides an additional increase of coronary artery flow. These promising results are to be confirmed in humans. [ABSTRACT FROM AUTHOR]

Extracorporeal membrane oxygenation ( ECMO) is a temporary mechanical circulatory assist method that offers circulatory as well as respiratory support efficiently via peripheral access; however, it is liable to complications. Limb ischemia is one of the notorious complications of ECMO but can be avoided utilizing a proper distal limb perfusion method. A retrospective study of patients undergoing peripheral venoarterial ( VA) ECMO for various reasons between June 2010 and December 2012 was performed. All patients were evaluated by our multidisciplinary team for suitability as candidates for ECMO. A peripheral VA- ECMO circuit was implanted via groin: inflow cannula in the femoral vein, an outflow cannula and distal-perfusion cannula, or an introducer sheath in the femoral artery. During the study period, 83 patients underwent various types of ECMO; 45 received peripheral VA- ECMO. Distal limb perfusion was achieved with an introducer sheath (6-8 Fr) in 13 cases and with a distal-perfusion cannula (10-12 Fr) in 32 cases. Nine (20%) patients developed signs of ischemia; five (11.2%) were treated conservatively, while four (8.8%) required surgical intervention. One patient required a below-knee amputation. The incidences of limb ischemia and limb ischemia requiring surgical intervention were significantly higher for the introducer sheath compared with the cannula (30.6 vs. 15.6% and 15.4 vs. 6.25%, respectively). Moreover, the patients supported on ECMO with a distal-perfusion cannula spent a significantly longer time on ECMO compared with the ones in whom an introducer sheath was used (11.9 ± 9.1 vs. 7.7 ± 4.3 days). The mean cannula size was significantly greater than the mean introducer sheath size (11.1 ± 1.3 vs. 7.0 ± 1.1 Fr). Use of a distal-perfusion cannula is a most reliable method of limb perfusion in peripheral VA- ECMO. The cannula can ensure adequate and smooth perfusion of the limb owing to its large caliber, its less turbulent flow, the ability it provides to monitor the flow, and the option to attach a side port. [ABSTRACT FROM AUTHOR]

The author reflects on the impact of the 2013-2014 influenza season on the patients that need extracorporeal membrane oxygenation (ECMO). He mentions that on the said period, more patients were put on veno-venous ECMO for respiratory failure while the early to middle-aged adults were considered to be hit the hardest. An overview on the assertion of the U.S. Centers for Disease Control and Prevention (CDC) that September through the end of April is the influenza season is offered.

In today's era, given the worsening risk profiles of patients undergoing cardiac surgery, the increasing number of complex cardiac surgeries, and the increasing number of patients undergoing thoracic organ transplantation, short-term mechanical circulatory assist ( MCA) devices are indispensable. MCA devices are capable of supporting heart and lung function and have emerged as potentially lifesaving instruments, but may prove to be as hazardous as helpful due to their inherent tendency toward hemolysis, thromboembolism, and hemorrhage. Although MCA devices are being used regularly at some specialized centers, surgeries involving MCA are not as common as other routine cardiac surgeries, and even though professionals implanting and maintaining short-term MCAs are well acquainted with operating such devices, it is not uncommon to come across complications as a result of minor mistakes committed while dealing with them. Avoiding simple mistakes and taking proper precautions while implanting and maintaining these devices can prevent major catastrophes. We discuss commonly encountered problems and complications during the implantation and maintenance of short-term MCAs and offer reasonable and practical solutions. In addition, crucial issues such as anticoagulation, replacement of the device circuit, and management of the distal perfusion cannula are discussed. Continuous and efficient monitoring of the MCA device and the patient supported on MCA, together with anticipation and avoidance of complications, is key for successful short-term MCA support. [ABSTRACT FROM AUTHOR]

Molecular Adsorbent Recirculating System ( MARS) is a liver support system widely employed in the treatment of liver failure. The method is normally well tolerated. To develop a liver support system combining high efficiency and tolerability, we modified the MARS albumin circuit with the insertion of double adsorption units in parallel. Four patients have been treated with this modified method (high-efficiency MARS, HE MARS): two had very high serum bilirubin and two had very high total bile acids. After a single MARS session bilirubin was reduced more with HE MARS than standard MARS (from 27.6 to 52.3% in patient A and from 27.9 to 49.1% in patient B), and bile acid reduction increased from 40 to 59.8% in patient C and from 39.9 to 60% in patient D. The results of this preliminary investigation in only a very small number of patients do support the possibility of developing a liver support system that combines good tolerability and high efficacy. [ABSTRACT FROM AUTHOR]

Background and Objective: Coagulopathy is a common and serious problem in patients who received extracorporeal membrane oxygenation (ECMO), and this study evaluated whether the 2018 diffuse intravascular coagulation (DIC) score established by the International Society on Thrombosis and Hemostasis (ISTH) is associated with 90-day mortality in adult ECMO patients., Methods: A retrospective study analyzed data from adult patients receiving ECMO in our hospital from September 2018 to April 2021. Pre-ECMO DIC score and other variables were assessed and compared to predict 90-day mortality., Results: Among 103 eligible patients, 55.3% received V-V ECMO and 44.7% received V-A ECMO. The overall 90-day mortality for study patients was 54.4%, including 45.6% in the V-V group and 65.2% in the V-A group. Multiple logistic regression analysis showed that after adjusting for sex, sepsis, and APACHE II score, pre-ECMO DIC scores in the total and V-V group predicted 90-day mortality (odds ratio(OR): 1.419, 95% confidence interval (CI): 1.101-1.828; OR: 2.562; 95% CI: 1.452-4.520). Receiver operating characteristic (ROC) curves displayed that pre-ECMO DIC score of 4 in the total and V-V group was a good predictor of 90-day mortality (area under the curve [AUC] = 0.706, 95% CI: 0.606-0.806; AUC = 0.737, 95% CI: 0.604-0.870). Kaplan-Meier curves demonstrated the 90-day mortality of patients with pre-ECMO DIC score ≥ 4 in the total and V-V group was higher than that of patients with DIC score < 4 (hazard ratio [HR]: 2.821, 95% CI: 1.632-4.879; HR: 3.864, 95% CI: 1.660-8.992)., Conclusion: The pre-ECMO ISTH DIC score was associated with 90-day mortality in adult patients undergoing ECMO, particularly in the V-V ECMO group., (© 2022 International Center for Artificial Organ and Transplantation (ICAOT) and Wiley Periodicals LLC.)

Background: The hospital mortality of patients suffering from pulmonary failure requiring venovenous extracorporeal membrane oxygenation (V-V ECMO) or extracorporeal carbon dioxide removal (ECCO 2 R) is high. It is unclear whether outcome correlates with a hospital's annual procedural volume., Methods: Data on all V-V ECMO and ECCO 2 R cases treated from 2007 to 2019 were retrieved from the German Institute for Medical Documentation and Information. Comorbidities and outcomes were assessed by DRG, OPS, and ICD codes. The study population was divided into 5 groups depending on annual hospital V-V ECMO and ECCO 2 R volumes (<10 cases; 10-19 cases; 20-29 cases; 30-49 cases; ≥50 cases). Primary outcome was hospital mortality., Results: A total of 25 096 V-V ECMO and 3607 ECCO 2 R cases were analyzed. V-V ECMO hospitals increased from 89 in 2007 to 214 in 2019. Hospitals handling <10 cases annually increased especially (64 in 2007 to 149 in 2019). V-V ECMO cases rose from 807 in 2007 to 2597 in 2019. Over 50% of cases were treated in hospitals handling ≥30 cases annually. Hospital mortality was independent of the annual hospital procedural volume (55.3%; 61.3%; 59.8%; 60.2%; 56.3%, respectively, p = 0.287). We detected no differences when comparing hospitals handling <30 cases to those with ≥30 annually (p = 0.659). The numbers of ECCO 2 R hospitals and cases has dropped since 2011 (287 in 2007 to 48 in 2019). No correlation between annual hospital procedural volume and hospital mortality was identified (p = 0.914)., Conclusion: The number of hospitals treating patients requiring V-V ECMO and V-V ECMO cases rose from 2007 to 2019, while ECCO 2 R hospitals and their case numbers decreased. We detected no correlation between annual hospital V-V ECMO or ECCO 2 R volume and hospital mortality., (© 2022 The Authors. Artificial Organs published by International Center for Artificial Organ and Transplantation (ICAOT) and Wiley Periodicals LLC.)

Background: Training is an essential aspect of providing high-quality treatment and ensuring patient safety in any medical practice. Because extracorporeal membrane oxygenation (ECMO) is a complicated operation with various elements, variables, and irregular situations, doctors must be experienced and knowledgeable about all conventional protocols and emergency procedures. The conventional simulation approach has a number of limitations. The approach is intrinsically costly since it relies on disposable medical equipment (i.e., oxygenators, heat exchangers, and pumps) that must be replaced regularly due to the damage caused by the liquid used to simulate blood. The oxygenator, which oxygenates the blood through a tailored membrane in ECMO, acts as a replacement for the patient's natural lung. For the context of simulation-based training (SBT) oxygenators are often expensive and cannot be recycled owing to contamination issues., Methods: Consequently, it is advised that the training process include a simulated version of oxygenators to optimize reusability and decrease training expenses. Toward this goal, this article demonstrates a mock oxygenator for ECMO SBT, designed to precisely replicate the real machine structure and operation., Results: The initial model was reproduced using 3D modeling and printing. Additionally, the mock oxygenator could mimic frequent events such as pump noise and clotting. Furthermore, the oxygenator is integrated with the modular ECMO simulator using cloud-based communication technology that goes in hand with the internet of things technology to provide remote control via an instructor tablet application., Conclusions: The final 3D modeled oxygenator body was tested and integrated with the other simulation modules at Hamad Medical Corporation with several participants to evaluate the effectiveness of the training session., (© 2022 The Authors. Artificial Organs published by International Center for Artificial Organ and Transplantation (ICAOT) and Wiley Periodicals LLC.)

Background: Extracorporeal membrane oxygenation (ECMO) has shown variable results in COVID-19 pneumonia however, some evidence supports benefit. Here we compare our institution's ECMO outcomes across multiple waves of the COVID-19 pandemic., Methods: All patients who received ECMO for COVID-19 between March 1, 2020, and March 1, 2021, were reviewed. Patients received venovenous (VV) or right ventricular assist device (RVAD/ECMO) ECMO. Early (March 1-July 6, 2020, Era 1) and late (July 7, 2020-March 1, 2021, Era 2) pandemic RVAD/ECMO patients were compared., Results: Fifty-four patients received ECMO of which 16 (29.6%) patients received VV ECMO and 38 (70.4%) RVAD/ECMO. Median age was 53.0 years, body mass index 36.1 kg/m 2 , 41.2% female, and 49% Caucasian. The most common pre-cannulation treatments included steroids (79.6%) and convalescent plasma (70.4%). Median time from admission to cannulation was 7.0 days. Median support time was 30.5 days (VV ECMO 35.0 days, RVAD/ECMO 26.0 days). In- hospital mortality was 42.6% (39.5% RVAD/ECMO, 50.0% VV ECMO). Significant morbidities included infection (80.8%), bleeding events (74.5%), and renal replacement therapy (30.8%). Cumulative mortality 120-days post-cannulation was 45.7% (VV ECMO 60.8%, RVAD/ECMO 40.0%). RVAD/ECMO Era 1 demonstrated a significantly lower cumulative mortality (16.2%) compared to Era 2 (60.4%). Competing risk analysis found age (HR 0.95, [95% CI 0.92, 0.98] p = 0.005) to be a protective factor for survival., Conclusion: ECMO support for COVID-19 is beneficial but carries significant morbidity. RVAD/ECMO support demonstrated consistent advantages in survival to VV-ECMO, but with declining efficacy across time during the COVID-19 pandemic., (© 2022 International Center for Artificial Organ and Transplantation (ICAOT) and Wiley Periodicals LLC.)

The risk of cardiac or lung failure after liver transplantation (LT) is significant. In rare cases, the usual intensive care techniques fail to maintain organ oxygenation with a risk of multiorgan dysfunction. Although extracorporeal membrane oxygenation (ECMO) is a difficult and risky procedure, it can be proposed as life-saving. Four children with either acute pulmonary (three) or cardiac (one) failure after LT, and the criteria that decided the use of ECMO (level of ventilation and results, dosage of inotropic drugs, cardiac ultrasound, blood lactate) were retrospectively reported. These patients, 1-11 years old, were treated with either veno-arterial (three) or veno-venous (one) ECMO. Two experienced a full recovery, with 3 and 6 years of follow-up. Two died of systemic inflammatory response syndrome (SIRS) due to ECMO, and relapse of heart failure due to the underlying disease. Although our patients' survival was only 50%, we showed that ECMO can be useful in children after LT. It should be considered before the development of irreversible multiorgan failure. [ABSTRACT FROM AUTHOR]

Several centers turn patients down for long-term ventricular assist devices (VADs) once they have received extracorporeal life support (ECLS) due to the expected poor outcome in these patients. The aim of this study was to identify survival predictors in this cohort of patients. Data of patients undergoing VAD support between January 2010 and November 2013 were retrospectively reviewed. Patients on ECLS support before implantation were considered eligible for inclusion. Outcome in survivors following long-term VAD support was compared with outcomes in nonsurvivors. Student's t-test and χ2-test were used as applicable. A total of 65 long-term VADs were implanted. The inclusion criteria were met by 24 patients. Eight patients did not survive the first 30 days. All preoperative characteristics were comparable between the two groups except for statistically higher Model for End-stage Liver Disease (MELD) score, bilirubin, white blood cell count, and blood urea nitrogen in nonsurvivors ( P = 0.002, 0.01, 0.01, and 0.003, respectively). Stepwise discriminant analysis revealed MELD score as the most important survival predictor. Based on this analysis, an outcome predictor formula was generated. The 30-day and 1-year survival rates were 67% and 54%, respectively. In this study, we were able to determine survival predictors in VAD patients with prior ECLS support. The outcome in these patients is limited and associated with higher postoperative complications, particularly right ventricular and respiratory failure. The pre-VAD MELD score is an important predictor of poor outcome. [ABSTRACT FROM AUTHOR]

Roller pumps are commonly used in circulatory assist devices to deliver blood, but the inherent high mechanical stresses (especially wall shear stress) may cause considerable damage to cells. Conventional experimental approaches to evaluate and reduce device-induced cell damage require considerable effort and resources. In this work, we describe the use of a new computational fluid dynamics method to more effectively study roller pump systems. A generalized parametric model for the fluid field in a typical roller pump system is presented first, and analytical formulations of the moving boundary are then derived. Based on the model and formulations, the dynamic geometry and mesh of the fluid field can be updated automatically according to the time-dependent roller positions. The described method successfully simulated the pulsing flow generated by the pump, offering a convenient way to visualize the inherent flow pattern and to assess shear-induced cell damage. Moreover, the highly reconfigurable model and the semiautomated simulation process extend the usefulness of the presented method to a wider range of applications. Comparison studies were conducted, and valuable indications about the detailed effects of structural parameters and operational conditions on the produced wall shear stress were obtained. Given the good consistency between the simulated results and the existing experimental data, the presented method displays promising potential to more effectively guide the development of improved roller pump systems which produce less mechanical damage to cells. [ABSTRACT FROM AUTHOR]

Veno-arterial extracorporeal membrane oxygenation ( ECMO) may be implanted using peripheral ECMO ( pECMO) or central ECMO ( cECMO) cannulation techniques. The aim of this study was to compare the outcome between these two cannulation techniques. A retrospective study was performed at Düsseldorf University Hospital from October 2009 through June 2011. Inclusion criteria were patients with veno-arterial ECMO support ≥24 h. Various pre- and postimplantation variables were investigated including postimplantation hemodynamic and ECMO parameters, oxygenation/ventilation parameters at 3, 6, 12, 24, 48, 72 h, as well as renal and liver function tests at first and third postoperative days following implantation. Outcome data of patients receiving pECMO were compared with those who received cECMO. The inclusion criteria were met by 37 patients (25 pECMO and 12 cECMO). There were no significant differences in baseline characteristics between these two groups except for younger age in pECMO patients ( P = 0.005). All postimplantation variables were comparable between the two groups except for higher PO2 and lower PCO2 values at the 3rd hour postimplantation in patients with pECMO ( P = 0.007 and 0.01, respectively). Eleven (44%) of the pECMO patients required re-exploration for bleeding versus 100% of patients with cECMO ( P = 0.01). Ischemic leg complication was observed in four pECMO and three cECMO patients. Thirty-day mortality in patients with pECMO and cECMO was 60% versus 67%, respectively ( P = 1.00). In this study, no particular oxygenation/ventilation, hemodymanic, or end-organ function advantage was observed with either cannulation technique. However, more bleeding and resternotomy complications were observed in cECMO patients. [ABSTRACT FROM AUTHOR]

Two centrifugal pumps, the Rota Flow ( Maquet, Jostra Medizintechnik AG, Hirrlingen, Germany) and Levitronix Centri Mag ( Levitronix LCC, Waltham, MA, USA), used in central or peripheral veno-arterial extracorporeal membrane oxygenation ( ECMO) support systems have been investigated, in terms of double-center experience, as treatment for patients with refractory cardiogenic shock ( CS). Between January 2006 and December 2012, 228 consecutive adult patients were supported on Rota Flow ( n = 213) or Centri Mag ( n = 15) ECMO, at our institutions (155 men; age 58.3 ± 10.5 years, range: 19-84 years). Indications for support were: failure to wean from cardiopulmonary bypass in the setting of postcardiotomy ( n = 118) and primary donor graft failure ( n = 37); postacute myocardial infarction CS ( n = 27); acute myocarditis ( n = 6); and CS on chronic heart failure ( n = 40). A peripheral ECMO setting was established in 126 (55.2%) patients while it was established centrally in 102 (44.7%). Overall mean support time was 10.9 ± 9.7 days (range: 1-43 days). Eighty-four (36.8%) patients died on ECMO. Overall success rate, in terms of survival on ECMO ( n = 144), weaning from mechanical support ( n = 107; 46.9%), bridge to mid-long-term ventricular assist device ( n = 6; 2.6%), and bridge to heart transplantation ( n = 31; 13.5%), was 63.1%. One hundred twenty-two (53.5%) patients were successfully discharged. Stepwise logistic regression identified blood lactate level and MB isoenzyme of creatine kinase ( CK-MB) relative index at 72 h after ECMO initiation, and number of packed red blood cells ( PRBCs) transfused on ECMO as significant predictors of mortality on ECMO ( P = 0.010, odds ratio [ OR] = 2.94; 95% confidence interval [ CI] = 1.10-3.14; P = 0.010, OR = 2.82, 95% CI = 1.014-3.721; and P = 0.011, OR = 2.69; 95% CI = 1.06-4.16, respectively). Central ECMO population had significantly higher rate of continuous veno-venous hemofiltration need and bleeding requiring surgery events compared with the peripheral ECMO setting population. No significant differences were seen by comparing the Rota Flow and Centri Mag populations in terms of device performance. At follow-up, persistent heart failure with left ventricle ejection fraction ( LVEF) ≤40% was a risk factor after hospital discharge. Patients with a poor hemodynamic status may benefit from rapid central or peripheral insertion of ECMO. The blood lactate level, CK-MB relative index, and PRBCs transfused should be strictly monitored during ECMO support. In addition, early ventricular assist device placement or urgent listing for heart transplant should be considered in patients with persistent impaired LVEF after ECMO. [ABSTRACT FROM AUTHOR]

Extracorporeal membrane oxygenation ( ECMO) therapy can result in systemic immune inflammation and trigger a hemolytic response, both of which can lead to oxidative stress injury. However, currently, there are few studies about whether ECMO can lead to oxidative stress injury. The objective of this study was to determine the effect of ECMO therapy on systemic oxidative stress. Twelve pigs were randomly divided into control and ECMO treatment groups. Blood samples were collected at −1, 0, 2, 6, 12, and 24 h during ECMO therapy in order to measure the levels of various oxidative stress markers in plasma. All animals included in the study were euthanized after 24 h of ECMO treatment. Malondialdehyde ( MDA) was used as a marker of oxidation, and superoxide dismutase ( SOD), glutathione ( GSH), and total antioxidant capacity ( T- AOC) were used as indices for antioxidant activity. The plasma levels of each molecule were similar when measured at −1 and 0 h ( P > 0.05). In the control group, MDA, SOD, GSH, and T- AOC remained relatively constant throughout the study period. However, when ECMO was administered for 2 h, plasma levels of MDA increased significantly; conversely, levels of SOD, GSH, and T- AOC decreased. Maximum MDA levels and minimal SOD, GSH, and T- AOC levels were observed after 6 h of ECMO treatment. MDA and SOD levels had returned to baseline at 24 h. At this time-point, levels of MDA and T- AOC in samples from the right frontal cortex and jejunum differed significantly between the control and ECMO treatment groups. These results show that early ECMO treatment can induce significant oxidative stress injury in plasma. However, in the latter stage of the treatment, the oxidative stress injury can be repaired gradually. ECMO treatment can also result in mild oxidative stress injury in the jejunum and brain tissue. [ABSTRACT FROM AUTHOR]

Membrane oxygenator ( MO) failure is a known hazard during venovenous extracorporeal membrane oxygenation (v-v ECMO) therapy. Knowledge about technical and performance details of different ECMO systems ( Maquet, Rastatt, Germany; Medos, Stolberg, Germany; Sorin, Modena, Italy) licensed for adults with acute lung failure might improve their handling. This retrospective study comprises 186 adult patients ( Regensburg ECMO Registry) treated with v-v ECMO. Flow dynamic data were used to analyze the performance of different blood pumps, cannula types, and MOs to maintain an adequate blood flow (1-5 L/min). Usage of the Medos ECMO system in critically ill patients required a higher pump speed and generated a higher pressure drop across the MO ( dpMO), however, without an increase in free plasma hemoglobin. The dpMO depended on the type of MO and increased with blood flow as expected. Type-specific normal values are reported. A distinct increase in dpMO above normal values within 1 day required an immediate MO exchange. This was an infrequent technical complication (3%). Finally, pressure-flow performance of single dual-lumen cannulas (27 Fr) was comparable with small single-lumen cannulas (15 Fr), without an increased risk of technical-induced hemolysis. Despite different performances, all current commercially available adult v-v ECMO systems produce adequate blood flow without an increased risk in technical-induced hemolysis. Familiarity with the specific properties of individual systems allows early detection of technical complications. Additionally, the choice of an adequate cannula requires a closer consideration of the individual patient situation. [ABSTRACT FROM AUTHOR]

Pulmonary changes in veno-venous extracorporeal membrane oxygenation ( VV- ECMO) are rarely determined. We compared the contribution of VV- ECMO and cannulation based on the observation of pulmonary inflammatory reaction and parenchymal construction in a porcine model of low tidal volume ( VT) ventilation. We also evaluated the effect of adding continuous renal replacement therapy ( CRRT) to the ECMO circuit, because CRRT is known to reduce systemic cytokine release induced by VV- ECMO. A total of 18 pigs undergoing low- VT ventilation were randomly divided into three groups (group 1, cannulation; group 2, VV- ECMO; group 3, VV- ECMO + CRRT) and studied for 24 h. Hemodynamic and ventilation parameters were recorded. We assessed plasma and alveolar cytokines, expression of pulmonary inflammatory genes, histopathological grading, and ultrastructural changes of the lungs. During the process, inspiratory volume increased and Pa O2 decreased in group 1. Systemic tumor necrosis factor-α ( TNF-α) and interleukin 6 ( IL-6) levels increased at 2 h in group 2 and partly decreased in group 3. At 24 h, the levels of bronchoalveolar lavage fluid, TNF-α, and IL-6 in group 2 were remarkably higher than those in groups 1 and 3. Pulmonary mRNA expression of cytokines did not differ between the groups. We observed an increased score of pulmonary pathological findings in pro-inflammatory cell infiltration and interstitial thickening of the lungs in group 2. The epithelium of the blood-air barrier after VV- ECMO was swollen. In group 3, the pulmonary parenchyma and blood-air barrier were well preserved. We concluded that in a porcine model of low- VT ventilation, both VV- ECMO and VV- ECMO in combination with CRRT provided adequate oxygenation and carbon dioxide removal. Compared with VV- ECMO alone, VV- ECMO in combination with CRRT better preserved the lung parenchyma by eliminating systemic cytokines. [ABSTRACT FROM AUTHOR]

The authors reflect on the selection of a pump for extracorporeal membrane oxygenation (ECMO) in the U.S. The authors mention that the analysis of the performance of the pump must be regarded especially in terms of creating hemolysis. They add that the ROTAFLOW pump is designed for open heart surgery in the operating room.