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Introduction The incidence and management outcomes of COVID-19 patients with acute respiratory distress syndrome (ARDS) on veno-venous extracorporeal membrane oxygenation (V-V ECMO) requiring chest tubes are not well-described. This study sought to explore differences in tube thoracostomy rates and subsequent complications between patients with and without COVID-19 ARDS on V-V ECMO. Materials and Methods This study is a single institution, retrospective cohort study of patients with COVID-19 ARDS requiring V-V ECMO. The control cohort consisted of patients who required V-V ECMO for ARDS-related diagnoses from January 2018 to January 2021. The primary outcome was any complication following initial tube thoracostomy placement. Study approval was obtained from the Brooke Army Medical Center Institutional Review Board (C.2017.152d). Results Twenty-five COVID-19 patients and 38 controls were included. Demographic parameters did not differ between the groups. The incidence of pneumothorax was not significantly different between the two groups (44% COVID-19 vs. 22% control, OR 2.8, 95% CI 0.95–7.9, P  = 0.09). Patients with COVID-19 were as likely to receive tube thoracostomy as controls (36% vs. 24%, OR 1.8, 95% CI 0.55–5.7). Complications, however, were more likely to occur in the COVID-19 group (89% vs. 33%, OR 16, 95% CI, 1.6–201, P  = 0.0498). Conclusions Tube thoracostomy placement in COVID-19 patients with ARDS requiring V-V ECMO is common, as are complications following initial placement. Clinicians should anticipate the need for re-intervention in this patient population. Small-bore (14Fr and smaller) pigtail catheters appeared to be safe and efficacious in this setting, but further study on tube thoracostomy management in ECMO patients is needed. [ABSTRACT FROM AUTHOR]

Large mediastinal lipomas are rare. Complete surgical resection can be difficult due to the intricate anatomy in the mediastinum. We report the case of a 75-year-old man with worsened retrosternal pressure, decline in performance and syncope episodes. Computed tomography revealed a large retrocardiac low-attenuated mediastinal lesion measuring 10 × 8 cm, compressing the left atrium and pulmonary veins bilaterally. Surgical exploration was achieved through a right anterolateral thoracotomy with a successful en bloc resection without any intraoperative complications. The total operation time was 185 min with a total blood loss of <250 ml. Stand-by extracorporeal life support was present throughout the procedure, but its use was not required. The postoperative course was uneventful. The pathological examination revealed a mature mediastinal lipoma without any evidence of malignancy. In the 12-month control the patient was completely free of symptoms and in a good general condition. [ABSTRACT FROM AUTHOR]

Background Extracorporeal membrane oxygenation (ECMO) is a life-saving modality but has the potential to alter the pharmacokinetics (PK) of antimicrobials. Imipenem/cilastatin/relebactam is an antibiotic with utility in treating certain multi-drug resistant Gram-negative infections. Herein, we describe the population pharmacokinetics of imipenem and relebactam in critically ill patients supported on ECMO. Methods Patients with infection supported on ECMO received 4–6 doses of imipenem/cilastatin/relebactam per current prescribing information based on estimated creatinine clearance. Blood samples were collected following the final dose of the antibiotic. Concentrations were determined via LC–MS/MS. Population PK models were fit with and without covariates using Pmetrics. Monte Carlo simulations of 1000 patients assessed joint PTA of f AUC0–24/MIC ≥ 8 for relebactam, and ≥40% f T > MIC for imipenem for each approved dosing regimen. Results Seven patients supported on ECMO were included in PK analyses. A two-compartment model with creatinine clearance as a covariate on clearance for both imipenem and relebactam fitted the data best. The mean ± standard deviation parameters were: CL0, 15.21 ± 6.52 L/h; Vc, 10.13 ± 2.26 L; K12, 2.45 ± 1.16 h−1 and K21, 1.76 ± 0.49 h−1 for imipenem, and 6.95 ± 1.34 L/h, 9.81 ± 2.69 L, 2.43 ± 1.13 h−1 and 1.52 ± 0.67 h−1 for relebactam. Simulating each approved dose of imipenem/cilastatin/relebactam according to creatinine clearance yielded PTAs of ≥90% up to an MIC of 2 mg/L. Conclusions Imipenem/cilastatin/relebactam dosed according to package insert in patients supported on ECMO is predicted to achieve exposures sufficient to treat susceptible Gram-negative isolates, including Pseudomonas aeruginosa. [ABSTRACT FROM AUTHOR]

Objectives The use of extracorporeal membrane oxygenation (ECMO) may alter blood levels of several drugs, including antibiotics, leading to under dosing of these drugs and thus to potential treatment failure. No data exist on pharmacokinetics of new antimicrobial, in particular ceftazidime/avibactam. We therefore perform this study to evaluate ceftazidime/avibactam blood levels in ECMO patients and find factors associated with underdosing. Methods Retrospective observational study of patients on ECMO having received ceftazidime/avibactam and in whom trough blood levels of ceftazidime and avibactam were available. Main outcome measurement was the number of patients with ceftazidime and avibactam blood levels above predefined cut-off values, derived from the European Committee on Antimicrobial Susceptibility Testing (EUCAST) breakpoints for Enterobacteriaceae and Pseudomonas aeruginosa , namely 8 mg/L for ceftazidime and 4 mg/L for avibactam, and explored factors associated with underdosing. Results Twenty-three ceftazidime/avibactam trough levels were available in 14 ECMO patients, all of them having received veno-venous ECMO for SARS-CoV-2-associated pneumonia. Although ceftazidime levels were above 8 mg/L in all except one patient, nine (39%) of the avibactam dosages were below 4 mg/L. Increased renal clearance (creatinine clearance > 130 mL/min) was the main factor associated with under dosing, since 7 out of the 10 dosages below the predefined cut-offs were measured in patients with this condition. Conclusions In ECMO patients receiving ceftazidime/avibactam, ceftazidime and avibactam serum levels are above EUCAST breakpoints in most cases, justifying the use of normal dosing in ECMO patients. Increased renal clearance may lead to ceftazidime and avibactam under dosing. [ABSTRACT FROM AUTHOR]

Objective The aim of this study was to evaluate the prognostic impact of variables, including thrombocytopenia and the amount of platelet transfusion, for predicting survival in venoarterial extracorporeal membrane oxygenation (ECMO) recipients. Additionally, we aimed to identify the predictors of increased transfusion requirement during venoarterial ECMO support. Methods All patients who received venoarterial ECMO between December 2008 and March 2020 were retrospectively analyzed. Univariate and multivariate Cox regressions were used to evaluate in-hospital mortality according to variables including thrombocytopenia and daily average of platelet concentrate transfusion. Stepwise multiple linear regression analysis was used to identify independent predictors for transfusion requirements. Results Analysis of 218 patients demonstrated severe thrombocytopenia as an independent predictor of in-hospital mortality (hazard ratio = 2.840, 95% CI: 1.593-5.063, P <.001), along with age, pre-ECMO cardiac arrest, and pH. In contrast, the amount of platelet transfusion was not associated with in-hospital mortality. Multiple variables, including the type of indication for ECMO were associated with transfusion requirements. Conclusion Our findings identified severe thrombocytopenia as an independent prognostic factor of in-hospital mortality. However, daily average platelet transfusion was not associated with survival outcomes. Additionally, our study identified predictive variables of increased transfusion requirements. [ABSTRACT FROM AUTHOR]

Background Solid organ transplant recipients (SOTRs) are at higher risk for severe infection. However, the risk for severe COVID-19 and vaccine effectiveness among SOTRs remain unclear. Methods This retrospective study used a nationwide health care claims database and COVID-19 registry from the Republic of Korea (2020 to 2022). Adult SOTRs diagnosed with COVID-19 were matched with up to 4 non-SOTR COVID-19 patients by propensity score. Severe COVID-19 was defined as treatment with high-flow nasal cannulae, mechanical ventilation, or extracorporeal membrane oxygenation. Results Among 6783 SOTRs with COVID-19, severe COVID-19 was reported with the highest rate in lung transplant recipients (13.16%), followed by the heart (6.30%), kidney (3.90%), and liver (2.40%). SOTRs had a higher risk of severe COVID-19 compared to non-SOTRs, and lung transplant recipients showed the highest risk (adjusted odds ratio, 18.14; 95% confidence interval [CI], 8.53–38.58). Vaccine effectiveness against severe disease among SOTRs was 47% (95% CI, 18%–65%), 64% (95% CI, 49%–75%), and 64% (95% CI, 29%–81%) for 2, 3, and 4 doses, respectively. Conclusions SOTRs are at significantly higher risk for severe COVID-19 compared to non-SOTRs. Vaccination is effective in preventing the progression to severe COVID-19. Efforts should be made to improve vaccine uptake among SOTRs, while additional protective measures should be developed. [ABSTRACT FROM AUTHOR]

OBJECTIVES Patients after the Norwood procedure are prone to postoperative instability. Extracorporeal membrane oxygenation (ECMO) can help to overcome short-term organ failure. This retrospective single-centre study examines ECMO weaning, hospital discharge and long-term survival after ECMO therapy between Norwood and bidirectional Glenn palliation as well as risk factors for mortality. METHODS In our institution, over 450 Norwood procedures have been performed. Since the introduction of ECMO therapy, 306 Norwood operations took place between 2007 and 2022, involving ECMO in 59 cases before bidirectional Glenn. In 48.3% of cases, ECMO was initiated intraoperatively post-Norwood. Patient outcomes were tracked and mortality risk factors were analysed using uni- and multivariable testing. RESULTS ECMO therapy after Norwood (median duration: 5 days; range 0–17 days) saw 31.0% installed under CPR. Weaning was achieved in 46 children (78.0%), with 55.9% discharged home after a median of 45 (36–66) days. Late death occurred in 3 patients after 27, 234 and 1541 days. Currently, 30 children are in a median 4.8 year (3.4–7.7) follow-up. At the time of inquiry, 1 patient awaits bidirectional Glenn, 6 are at stage II palliation, Fontan was completed in 22 and 1 was lost to follow-up post-Norwood. Risk factor analysis revealed dialysis (P  < 0.001), cerebral lesions (P  = 0.026), longer ECMO duration (P  = 0.002), cardiac indication and lower body weight (P  = 0.038) as mortality-increasing factors. The 10-year mortality probability after ECMO therapy was 48.5% (95% CI 36.5–62.9%). CONCLUSIONS ECMO therapy in critically ill patients after the Norwood operation may significantly improve survival of a patient cohort otherwise forfeited and give the opportunity for successful future-stage operations. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES The aim of this study was to assess the early outcomes and risk factors of paediatric patients requiring extracorporeal membrane oxygenation after cardiac surgery (post-cardiotomy). METHODS Retrospective binational cohort study from the Australia and New Zealand Congenital Outcomes Registry for Surgery database. All patients younger than 18 years of age who underwent a paediatric cardiac surgical procedure from 1 January 2013 to 31 December 2021 and required post-cardiotomy extracorporeal membrane oxygenation (PC-ECMO) in the same hospital admission were included in the study. RESULTS Of the 12 290 patients included in the study, 376 patients required post-cardiotomy ECMO (3%). Amongst these patients, hospital mortality was 35.6% and two-thirds of patients experienced a major complication. Hypoplastic left heart syndrome was the most common diagnosis (17%). The Norwood procedure and modified Blalock–Taussig shunts had the highest incidence of requiring PC-ECMO (odds ratio of 10 and 6.8 respectively). Predictors of hospital mortality after PC-ECMO included single-ventricle physiology, intracranial haemorrhage and chylothorax. CONCLUSIONS In the current era, one-third of patients who required PC-ECMO after paediatric cardiac surgery in Australia and New Zealand did not survive to hospital discharge. The Norwood procedure and isolated modified Blalock–Taussig shunt had the highest incidence of requiring PC-ECMO. Patients undergoing the Norwood procedure had the highest mortality (48%). Two-thirds of patients on PC-ECMO developed a major complication. [ABSTRACT FROM AUTHOR]

Background Isavuconazole is first-line treatment of invasive aspergillosis. Therapeutic drug monitoring (TDM) is deemed not necessary, since most patients reached therapeutic levels (>1 mg/L) in large studies. Low levels were reported in some critically ill patients admitted to the ICU. The aim was to compare isavuconazole levels between critically ill and non-critically ill patients. Materials and methods Retrospective analysis of data from all patients treated with standard-dose isavuconazole between 1 January 2019 and 26 October 2022 was performed. The following data were collected: TDM results from the first 30 days of therapy; ward of admission; demographic and clinical characteristics; continuous renal replacement therapy; extracorporeal membrane oxygenation; and co-administered drugs. Results Seventy-two patients (median age 65 years) and 188 TDM measurements (mean number of samples per patient 2.6 ± 1.7) were included; 33 (45.8%) were ICU patients (3 also had haematological disorders); 39 (54.2%) were non-ICU patients, of whom 31 had haematological disorders. In all patients, the mean isavuconazole blood level was 3.33 ± 2.26 mg/L. Significantly lower levels were observed in the ICU versus the non-ICU population: mean 2.02 ± 1.22 versus 4.15 ± 2.31 mg/L (P  < 0.001). Significantly higher rates of subtherapeutic levels were observed in ICU patients compared with the non-ICU population: all determinations <2 mg/L in 33.3% versus 7.7%, and all determinations <1 mg/L in 12.1% versus 0%, respectively. Predictors of lower isavuconazole levels were admission to the ICU, BMI > 25 kg/m2, bilirubin > 1.2 mg/dL and the absence of haematological disorder. Conclusions ICU patients had significantly lower isavuconazole blood levels compared to non-ICU population. The TDM of isavuconazole for efficacy should be performed in ICU. [ABSTRACT FROM AUTHOR]

Objective The goal of this case report is to describe the process, challenges, and opportunities of implementing rehabilitation for individuals who were critically ill and required both mechanical ventilation (MV) and extracorporeal membrane oxygenation (ECMO) support following a coronavirus 2019 (COVID-19) infection in an academic medical center. Methods This administrative case report is set in a heart and vascular intensive care unit, a 35-bed critical care unit that provides services for patients with various complex cardiovascular surgical interventions, including transplantation. Patients were admitted to the heart and vascular intensive care unit with either COVID-19 acute respiratory distress syndrome or pulmonary fibrosis for consideration of bilateral orthotropic lung transplantation. The authors describe the process of establishing rehabilitation criteria for patients who, by previously established guidelines, would be considered too ill to engage in rehabilitation. Results The rehabilitation team, in coordination with an interprofessional team of critical care providers including physicians, respiratory care providers, perfusionists, and registered nurses, collaborated to implement a rehabilitation program for patients with critical COVID-19 being considered for bilateral orthotropic lung transplantation. This was accomplished by (1) reviewing previously published guidelines and practices; (2) developing an interdisciplinary framework for the consideration of rehabilitation treatment; and (3) implementing the framework for patients in our heart and vascular intensive care unit. Conclusion In response to the growing volume of patients admitted with critical COVID-19, the team initiated and developed an interprofessional framework and successfully provided rehabilitation services to patients who were critically ill. While resource-intensive, the process demonstrates that rehabilitation can be implemented on a case-by-case basis for select patients receiving extracorporeal membrane oxygenation and MV, who would previously have been considered too critically ill for rehabilitation services. Impact Rehabilitating patients with end-stage pulmonary disease on extracorporeal membrane oxygenation and MV support is challenging but feasible with appropriate interprofessional collaboration and knowledge sharing. [ABSTRACT FROM AUTHOR]

This case report details the management of a 79-year-old man who developed massive postoperative pneumothorax following redo coronary artery bypass grafting due to severe lung adhesions. We successfully treated the patient using veno-venous extracorporeal membrane oxygenation without femoral cannulation, allowing for early rehabilitation initiation. Veno-venous extracorporeal membrane oxygenation is a reasonable option for cases of severe respiratory failure due to pneumothorax with lung destruction caused by re-sternotomy during re-do cardiac surgery. [ABSTRACT FROM AUTHOR]

We describe bedside-to-bench immunological and genetic elucidation of defective pyroptosis attributable to novel caspase 4 defect mediating pathogen-triggered inflammatory programmed cell death, in the setting of severe pneumonia and abscess-forming melioidosis in an overtly healthy host failing to clear Burkholderia pseudomallei infection, and how targeted adjunctive biological therapy led to a successful outcome. [ABSTRACT FROM AUTHOR]

Introduction: Extracorporeal membrane oxygenation (ECMO) is typically used to provide mechanical perfusion and gas exchange to critically ill patients with cardiopulmonary failure. We present a case of a traumatic high transradial amputation in which the amputated limb was placed on ECMO to allow for limb perfusion during bony fixation and preparations and coordination of orthopedic and vascular soft tissue reconstructions. Materials and Methods: This is a descriptive single case report which underwent managment at a level 1 trauma center. Instutional review board (IRB) approval was obtained. Results: This case highlights many important factors of limb salvage. First, complex limb salvage requires a well-organized, pre-planned multi-disciplinary approach to optimize patient outcomes. Second, advancements in trauma resuscitation and reconstructive techniques over the past 20 years have drastically expanded the ability of treating surgeons to preserve limbs that would have otherwise been indicated for amputation. Lastly, which will be the focus of further discussion, ECMO and EP have a role in the limb salvage algorithm to extend current timing limitations for ischemia, allow for multidisciplinary planning, and prevent reperfusion injury with increasing literature to support its use. Conclusions: ECMO is an emerging technology that may have clinical utility for traumatic amputations, limb salvage, and free flap cases. In particular, it may extend current limitations of ischemia time and reduce the incidence of ischemia reperfusion injury in proximal amputation, thus expanding the current indications for proximal limb replantation. It is clear that developing a multi-disciplinary limb salvage team with standardized treatment protocols is paramount to optimize patient outcomes and allows limb salvage to be pursued in increasingly complex cases. [ABSTRACT FROM AUTHOR]

OBJECTIVES Infants awaiting paediatric heart transplantation (PHT) experience long waitlist duration and high mortality due to donor shortage. Using the United Network for Organ Sharing database, we explored if increasing donor–recipient weight ratio (DRWR) >2.0 (recommended cutoff) was associated with adverse outcomes. METHODS Between 2007 and 2020, 1392 infants received PHT. We divided cohort into 3 groups: A (DRWR ≤1.0, n  = 239, 17%), B (DRWR 1.0–2.0, n  = 947, 68%), C (DRWR >2.0, n  = 206, 15%). Group characteristics and PHT outcomes were analysed. RESULTS DRWR ranged between 0.5 and 4.1. Underlying pathology (congenital versus cardiomyopathy), gender, race, renal function and mechanical circulatory support were comparable between groups. Group C patients were more likely to be ventilated, to receive ABO blood group (ABO)-incompatible heart and to have longer donor ischaemic time. Waitlist duration was significantly shorter for group C (33 vs 50 days, P  < 0.1). Early outcomes for groups A, B and C were the following (respectively): operative death (6%, 4%, 3%, P  = 0.29), primary graft dysfunction (5%, 3%, 3%, P  = 0.30), renal failure (10%, 7%, 7%, P  = 0.42) and stroke (3%, 4%, 1%, P  = 0.36). The DRWR group was not associated with operative death in either congenital (odds ratio (OR) = 0.819, 95% confidence interval (CI) = 0.523–1.282) or cardiomyopathy (OR = 1.221, 95% CI = 0.780–1.912) patients and only significant factor was pre-PHT extracorporeal membrane oxygenation (OR = 4.400, 95% CI = 2.761–7.010). Additionally, survival at 1 year (87%, 87%, 85%, P  = 0.80) and 5 years (76%, 78%, 77%, P  = 0.80) was comparable between the DRWR groups. CONCLUSIONS Infants who received PHT with DRWR >2.0, up to 4.1, experienced shorter waitlist duration with no demonstrable increase in peri-transplant complications, operative or late mortality. Historic practice to avoid DRWR > 2.0 due to complications (e.g. hypertension-related stroke, graft dysfunction, death) is not currently supported in infants and stretching DRWR acceptance criteria would decrease PHT waitlist duration and potentially improve waitlist complications and mortality. [ABSTRACT FROM AUTHOR]

Background In critically ill patients with extracorporeal membrane oxygenation (ECMO) attainment of target concentration of isavuconazole is delayed using the routine loading dose. Objectives We investigated the influence of increasing the first loading dose of isavuconazole on plasma concentrations in critically ill patients treated with ECMO. Methods Fifteen patients were included in this study, and isavuconazole concentrations were measured at several timepoints starting 2 h after the first isavuconazole dose up to 168 h. By interim analysis of isavuconazole concentrations and meticulous screening for adverse events, the first loading dose was stepwise increased from 200 to 300 mg, and finally to 400 mg. Results Seven of 15 patients (47%) received standard isavuconazole loading dosage with 200 mg as the first dose, 3/15 (20%) received 300 mg, and 5/15 (33%) received 400 mg isavuconazole as the first dose, followed by subsequent standard dosing in all patients. In patients receiving 400 mg as the first dose all isavuconazole concentrations were significantly higher at timepoints up to the first 24 h, resulting in higher proportions of isavuconazole concentrations ≥1 mg/L compared with patients with other loading dosages. In timepoints ≥24 h after isavuconazole initiation all patient groups reached comparable plasma concentrations, regardless of the first loading dose regimen. We did not observe concentrations above ≥5 mg/L or any adverse events related to isavuconazole administration. Conclusions In critically ill patients with ECMO the 400 mg loading dose of isavuconazole resulted in immediate median isavuconazole plasma concentrations ≥1 mg/L and remained constant above this threshold after the first loading dose. [ABSTRACT FROM AUTHOR]

Pheochromocytomas are rare catecholamine-secreting neuroendocrine tumors. Their episodic nature is correlated with abrupt catecholamine release and clinical manifestations that mimic other vascular conditions, leading to delayed diagnosis and potentially life-threatening complications, such as acute myocarditis and pheochromocytoma crises. In this report, we described the case of fulminant adrenergic myocarditis-induced cardiogenic shock requiring extracorporeal membrane oxygenation support in a Vietnamese middle-aged man with a 5-year history of Brugada syndrome, hypertension, and previously undiagnosed pheochromocytoma. After stabilization, the patient was medically treated with a combination of α- and β-blockers before undergoing laparoscopic right adrenalectomy. [ABSTRACT FROM AUTHOR]

Background Fever and leukocytosis are 2 parameters commonly cited in clinical practice as indications to perform an infectious workup in patients receiving extracorporeal membrane oxygenation (ECMO), but their utility is unknown. Methods All patients who received ECMO between December 2014 and December 2020 with influenza or COVID-19 were included in this retrospective cohort study. Cultures were included if they were drawn from patients without signs of decompensation. Maximum temperature and white blood cell count were recorded on the day of culture collection. Workups with infections were compared with those that were negative. Results Of the 137 infectious workups in this 45-patient cohort, 86 (63%) were performed in patients with no signs of decompensation, totaling 165 cultures. These workups yielded 10 (12%) true infections. There were no differences in median (IQR) temperature (100.4 °F [100.2–100.8] vs 100.4 °F [99.3–100.9], P =.90) or white blood cell count (18.6 cells/mL [16.8–20.1] vs 16.7 cells/mL [12.8–22.3], P =.90) between those with and without infections. Conclusions In patients with influenza or COVID-19 who require ECMO, fever and leukocytosis were common indications for infectious workups, yet results were frequently negative. Despite their use in clinical practice, fever and leukocytosis are not reliable indicators of infection in patients who are hemodynamically stable and receiving ECMO. [ABSTRACT FROM AUTHOR]

Cardiac surgery performed on patients in cardiogenic shock is associated with a high mortality and morbidity. Preoperative Extra Corporeal Membrane Oxygenation (ECMO) in cardiogenic shock gives critically-ill patients a chance for surgical intervention and is associated with better surgical outcomes. We present a 29-year-old male who had a ventricular septal defect closure as a child and presented with multi-organ injuries following polytrauma. He was in cardiogenic shock despite maximal inotropic support. Transesophageal echocardiography demonstrated torrential tricuspid regurgitation (TR) from a flail tricuspid valve (TV) leaflet as the cause of cardiogenic shock. He was stabilized on Veno-Arterial ECMO and underwent reoperative cardiac surgery. Intra-operatively, the anterior leaflet of his TV and its papillary muscle was detached from the right ventricle. He had a successful tissue TV replacement. Early surgery was indicated to treat right ventricular failure due to torrential TR, but due to his restricting non-cardiac injuries, ECMO was successfully used as a short-term support strategy and as a bridge to definitive surgery. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Atrioventricular valve (AVV) replacements in patients with single-ventricle circulations pose significant surgical risks and are associated with high morbidity and mortality. METHODS From 1997 to 2021, 16 consecutive patients with functionally single-ventricle physiology underwent mechanical AVV replacement. Primary outcome was transplant-free survival. Secondary outcomes included major postoperative morbidity. RESULTS The median age of AVV replacement was 2 years old (interquartile range 0.6–3.8 years). All AVV replacements were performed with a St. Jude Medical mechanical valve, median 24 mm (range, 19–31mm). Extracorporeal membrane oxygenation (ECMO) was required in 4 patients. Operative mortality was 38% (6/16). There were 2 late deaths and 3 transplants. Transplant-free survival was 50% at 1 year, 37.5% at 5 years, and 22% at 10 years. Transplant-free survival was higher for patients with preserved ventricular function (P  = 0.01). Difference in transplant-free survival at 1 year was 75% vs 25%, at 5 years was 62.5% vs 12.5% and at 10 years was 57% vs 0%. Three (19%) patients had complete heart block requiring permanent pacemaker insertion. 6 of 13 patients (46%) patients reached Fontan completion (3 patients operated at/after Fontan). Significant bleeding events occurred in 8 patients (50%) with 3 patients suffering major cerebrovascular accidents. There were 6 events of valve thrombosis in 5 patients, resulting in 2 deaths and 2 heart transplants. CONCLUSIONS Mechanical valve replacement carries significant morbidity and mortality risk. While it successfully salvages about half of patients with preserved ventricular function, careful consideration of alternative options should be made before embarking upon mechanical valve replacement. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES The clinical profile and outcomes of patients with Coronavirus Disease 2019 (COVID-19) who require veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or veno-arterial-venous extracorporeal membrane oxygenation (VAV-ECMO) are poorly understood. We aimed to describe the characteristics and outcomes of these patients and to identify predictors of both favourable and unfavourable outcomes. METHODS ECMOSARS is a multicentre, prospective, nationwide French registry enrolling patients who require veno-venous extracorporeal membrane oxygenation (ECMO)/VA-ECMO in the context of COVID-19 infection (652 patients at 41 centres). We focused on 47 patients supported with VA- or VAV-ECMO for refractory cardiogenic shock. RESULTS The median age was 49. Fourteen percent of patients had a prior diagnosis of heart failure. The most common aetiologies of cardiogenic shock were acute pulmonary embolism (30%), myocarditis (28%) and acute coronary syndrome (4%). Extracorporeal cardiopulmonary resuscitation (E-CPR) occurred in 38%. In-hospital survival was 28% in the whole cohort, and 43% when E-CPR patients were excluded. ECMO cannulation was associated with significant improvements in pH and FiO2 on day 1, but non-survivors showed significantly more severe acidosis and higher FiO2 than survivors at this point (P  = 0.030 and P  = 0.006). Other factors associated with death were greater age (P  = 0.02), higher body mass index (P  = 0.03), E-CPR (P  = 0.001), non-myocarditis aetiology (P  = 0.02), higher serum lactates (P  = 0.004), epinephrine (but not noradrenaline) use before initiation of ECMO (P  = 0.003), haemorrhagic complications (P  = 0.001), greater transfusion requirements (P  = 0.001) and more severe Survival after Veno-Arterial ECMO (SAVE) and Sonographic Assessment of Intravascular Fluid Estimate (SAFE) scores (P  = 0.01 and P  = 0.03). CONCLUSIONS We report the largest focused analysis of VA- and VAV-ECMO recipients in COVID-19. Although relatively rare, the need for temporary mechanical circulatory support in these patients is associated with poor prognosis. However, VA-ECMO remains a viable solution to rescue carefully selected patients. We identified factors associated with poor prognosis and suggest that E-CPR is not a reasonable indication for VA-ECMO in this population. [ABSTRACT FROM AUTHOR]

Iatrogenic aortocoronary dissection (IACD) is a rare but potentially fatal complication of percutaneous coronary intervention or coronary angiography (CAG). In particular, if the condition of the patient is complicated by cardiogenic shock and right ventricular (RV) dysfunction, the mortality rate is high. Herein, we report the case of an 85-year-old woman with IACD who underwent elective CAG of the right coronary artery complicated with cardiogenic shock due to RV infarction. After prompt surgical repair and postoperative extracorporeal membrane oxygenation, the postoperative course was uneventful and the patient was discharged to a rehabilitation facility. [ABSTRACT FROM AUTHOR]

Mediastinal masses can be challenging to the surgical team and anesthetic considerations vary according to the location, pathology, surgical approach, and patient comorbidities. We report the case of a 21 cm symptomatic intrathoracic teratoma in a postpartum patient with a history of poliomyelitis. Significant challenges were presented for anesthetic induction, potential extracorporeal membrane oxygenation, and the use of neuraxial pain techniques and neuromuscular blockade. This case report demonstrates techniques to safely manage a patient with a large symptomatic mediastinal mass and potential neuromuscular disease. [ABSTRACT FROM AUTHOR]

Purpose The goal of this study was to evaluate the correlation of anti–factor Xa (anti-Xa) and activated partial thromboplastin time (aPTT) measures with heparin dosing in adult patients on extracorporeal membrane oxygenation (ECMO) support. Methods This was a retrospective cohort study evaluating adult patients managed on ECMO for at least 24 hours who received unfractionated heparin for systemic anticoagulation and were monitored per protocol using anti-Xa and/or aPTT coagulation assays. The primary outcome was the correlation between aPTT and anti-Xa measures. The secondary outcomes included, but were not limited to, the number of hemorrhagic and thrombotic events. Results Twenty-seven patients were included in this study. In the 227 events where both laboratory values were collected, a weak correlation was found between anti-Xa and aPTT (Spearman's correlation coefficient = 0.4, P = 0). In the 12 hemorrhagic events that occurred, aPTT was collected for only 10 events. Fifty percent of those events were associated with supratherapeutic aPTT, while none of the hemorrhagic events were associated with a supratherapeutic anti-Xa level. Two thrombotic events occurred, one of which had subtherapeutic anti-Xa and aPTT and the other of which had neither an anti-Xa nor aPTT measure on the day the event occurred. Conclusion In a population of patients on ECMO, many of whom had coronavirus disease 2019 (COVID-19), there was a weak association between aPTT and anti-Xa measures. Hemorrhagic evens were more common than thrombotic events; however, a relationship between these events and aPTT or anti-Xa levels was not determined. The applicability of these findings to an ECMO population without COVID-19 is unknown and will require further study. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Total ischaemic time (IT) is considered a limiting factor in lung transplantation. In this retrospective study, we investigate effects of IT and disease burden on outcomes after bilateral lung transplantation. METHODS A total of 1298 patients undergoing bilateral lung transplantation between January 2010 and May 2022 (follow-up 100%, median 54 months) were included. Pre-transplant diseases' severity (recipient body mass index, recipient age, previous lung transplantation, Tacrolimus immunosuppression, preoperative recipient extracorporeal membrane oxygenation support, lung volume reduction) for graft failure was individually calculated and—as IT—categorized. Vice versa adjusted Cox models were calculated. Considering competing risks, we assessed cumulative incidences of airway obstructive complications and chronic lung allograft dysfunction with death as competing risk factors for primary graft dysfunction were assessed by binary logistic regression. RESULTS Higher disease burden significantly accelerated chronic lung allograft dysfunction and death occurrence (P  < 0.001); IT did not. IT-adjusted disease burden strata showed 50% graft survival differences at 11 years after transplantation (range 24–74%), disease burden-adjusted IT strata 18% for all and 6% (54–60%) among those above 7 h. All significant primary graft dysfunction risk factors were diagnoses related, IT was not significantly important and odds ratios did not increase with IT. CONCLUSIONS The eventual graft survival disadvantage that results from an IT between 7 and at least 11 h is negligible in contrast to frequent recipients' disease-based risk levels. [ABSTRACT FROM AUTHOR]

Inhaled nitric oxide (iNO), a selective pulmonary vasodilator, is used as a therapeutic modality in infants with hypoxemic respiratory failure (HRF) associated with persistent pulmonary hypertension of the newborn (PPHN). iNO should ideally be initiated following echocardiographic confirmation of PPHN. Use of iNO is recommended in late preterm and term infants who develop HRF despite optimal oxygenation and ventilation strategies. However, routine iNO use in preterm infants on respiratory support is not recommended. iNO may be considered as a rescue modality in preterm infants with early-onset HRF when associated with prolonged rupture of membranes or oligohydramnios, or late-onset HRF in the context of bronchopulmonary dysplasia-associated pulmonary hypertension (PH) with severe right ventricular failure. A trial of iNO may also be considered for infants with congenital diaphragmatic hernia with persistent HRF despite optimal lung recruitment, and with echocardiographic evidence of supra-systemic PH and adequate left ventricular function. [ABSTRACT FROM AUTHOR]

We describe a 34-year-old soldier who sustained a blast injury in Syria resulting in tracheal 5 cm tracheal loss, cervical spine and cord injury with tetraplegia, multiple bilateral rib fractures, esophageal injury, traumatic brain injury, globe evisceration, and multiple extremity soft tissue and musculoskeletal injuries including a left tibia fracture with compartment syndrome. An emergent intubation of the transected trachea was performed in the field, and the patient was resuscitated with whole blood prehospital. During transport to the Role 2, the patient required cardiopulmonary resuscitation for cardiac arrest. On arrival, he underwent a resuscitative thoracotomy and received a massive transfusion exclusively with whole blood. A specialized critical care team transported the patient to the Role 3 hospital in Baghdad, and the DoD extracorporeal membrane oxygenation (ECMO) team was activated secondary to his unstable airway and severe hypoxia secondary to pulmonary blast injury. The casualty was cannulated in Baghdad approximately 40 hours after injury with bifemoral cannulae in a venovenous configuration. He was transported from Iraq to the U.S. Army Institute of Surgical Research Burn Center in San Antonio without issue. Extracorporeal membrane oxygenation support was successfully weaned, and he was decannulated on ECMO day 4. The early and en route use of venovenous ECMO allowed for maintenance of respiratory support during transport and bridge to operative management and demonstrates the feasibility of prolonged ECMO transport in critically ill combat casualties. [ABSTRACT FROM AUTHOR]

Since its discovery in late 2019, severe acute respiratory syndrome coronavirus 2 has spread around the world, causing millions of deaths due to coronavirus disease 2019 (COVID-19). Numerous clinical and post-mortem investigations of COVID-19 cases have found myriad clinical and pathological manifestations of the disease. In this report, we present three autopsy cases in which, despite weaning from extracorporeal membrane oxygenation (ECMO), extensive intestinal epithelial shedding, probably due to ischemia, was followed by massive watery diarrhea and the spread of infection via the portal vein due to bacterial translocation, which resulted in cholangitis lenta. Thrombophilia was attributed to ECMO usage and COVID-19-related vascular endothelial damage. These cases provide instructive findings showing that the loss of the intestinal barrier may be the underlying cause of severe watery diarrhea and liver failure in COVID-19 patients, especially with ECMO usage. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Upper gastrointestinal bleeding (UGIB) is a common complication in adults treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock or cardiac arrest. We aimed to determine risk factors, prevalence and outcomes associated with VA-ECMO-associated UGIB in adult patients. METHODS: We conducted a retrospective cohort study (2014–2022) on consecutive VA-ECMO patients in the medical and infectious disease intensive care unit of Bichat-Claude Bernard University Hospital, Paris, France. UGIB was defined as (i) an overt bleeding (haematemesis, melena, haematochezia) or (ii) acute anaemia associated with a lesion diagnosed on upper gastrointestinal endoscopy. VA-ECMO-associated UGIB was defined as an UGIB occurring during VA-ECMO, or up to 10 days after decannulation in patients weaned off extracorporeal membrane oxygenation (ECMO). Cause-specific models were used to identify factors associated with UGIB and death, respectively. RESULTS: Among the 455 patients included, 48 (10%) were diagnosed with UGIB after a median of 12 [7; 23] days following ECMO cannulation. Mortality occurred in 36 (75%) patients with UGIB and 243 (60%) patients without. UGIB patients had longer intensive care unit stays (32 [19; 60] vs 18 [7; 37] days; P < 0.01), longer ECMO (14 [9; 18] vs 7 [4; 11] days; P < 0.01) and mechanical ventilation durations (21 [16; 36] vs 10 [5; 20] days; P < 0.01), as compared to non-UGIB patients. Ninety upper gastrointestinal endoscopies were performed, and the most frequent lesions detected were gastro-duodenal ulcers (n = 23, 26%), leading to 11/90 therapeutic procedures. By multivariable analysis, a history of peptic ulcer [cause-specific hazard ratio (CSHR) 2.93, 95% confidence interval (CI) [1.01; 8.51]], a dual antiplatelet therapy (CSHR 2.0, 95% CI [1.07; 3.72]) and extracorporeal cardiopulmonary resuscitation (CSHR 2.78, 95% CI [1.42; 5.45]) were independently associated with an increased risk of UGIB. CONCLUSIONS: In adult patients under VA-ECMO, a history of gastric ulcer, dual antiplatelet therapy and extracorporeal cardiopulmonary resuscitation were independently associated with an increased risk of UGIB. This study highlights the potential role of acute ischaemia–reperfusion injury in the pathophysiology of VA-ECMO-associated UGIB. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an emergency technique used in adult patients to treat refractory cardiogenic shock or refractory cardiac arrest [1]. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Haemorrhagic and thrombotic complications are known obstacles in extracorporeal life support (ECLS), and patients requiring post-cardiotomy (PC)-ECLS are particularly prone. The objective of this study was to characterize the incidence, type and clinical relevance of bleeding and thrombotic events in patients on PC-ECLS. METHODS: A total of 504 patients receiving PC-ECLS between 2000 and 2021 at a single centre were included in a retrospective analysis. Incidence and type of haemorrhagic and thrombotic complications in patients on PC-ECLS were assessed. Overall survival was compared, and perioperative risk factors for bleeding and thrombotic events were assessed by binary logistic regression. RESULTS: Of the 504 patients requiring PC-ECLS, 196 patients (38.9%) had 235 bleeding events [surgical site: n = 135 (26.8%); cannulation site: n = 68(13.4%); requiring surgical revision: n = 39 (7.7%); cannulation site change: n = 17 (3.4%); fatal cannulation site bleeding: n = 4(0.8%); intracranial haemorrhage: n = 11 (2.1%); gastrointestinal haemorrhage: n = 8 (1.6%); pulmonary haemorrhage: n = 8 (1.6%); and intra-abdominal/retroperitoneal haemorrhage: n = 5 (1%)]. Overall mortality was higher in patients with major bleeding complications than in patients without bleeding complications (P < 0.0001). A total of 74 patients (14.7%) had 84 thrombotic events [ischaemic stroke, n = 39 (7.7%); cannula/circuit thrombosis, n = 26 (5.2%); peripheral embolism, n = 11 (2.2%); device exchange for haemolysis, n = 8 (1.6%)]. Another 246 patients (48.8%) had at least 1 haemocompatibility-related adverse event. Preoperative dual antiplatelet therapy [adjusted odds ratio (OR): 1.83, 95% confidence interval (CI): 1.063–3.137] and ECLS duration (adjusted OR: 1.14, 95% CI: 1.086–1.197) were identified as independent risk factors for haemorrhage. Prior stroke/transient ischaemic attack (adjusted OR: 1.91, 95% CI: 1.08–3.83) and ECLS duration (adjusted OR: 1.09, 95% CI: 1.04–1.15) were identified as risk factors for thrombotic events. CONCLUSIONS: Bleeding complications in patients on ECLS are common and significantly impair survival. Nearly half of the patients were affected by any haemocompatibility-related event. Extracorporeal life support (ECLS) is an effective and valuable treatment option for patients in cardiogenic shock requiring temporary mechanical circulatory support. [ABSTRACT FROM AUTHOR]

Background Cloxacillin is the first-line treatment for methicillin-susceptible staphylococcal infective endocarditis (IE). The recommended dose is 12 g per day regardless of the patient characteristics, despite the importance of renal function on its pharmacokinetics. Objectives We sought to build a population pharmacokinetics model of continuous infusion cloxacillin in IE patients to evaluate the influence of multiple covariates and then develop a nomogram based on significant covariates for individual adaptation. Patients and methods We included patients of a local IE cohort who were treated with cloxacillin administered by continuous infusion, excluding those who received intermittent or continuous dialysis, extracorporeal membrane oxygenation or extracorporeal circulation. The population pharmacokinetic analysis was performed using Pmetrics. The influence of weight, ideal weight, height, body mass index, body surface area, glomerular filtration rate (GFR) calculated with the Chronic Kidney Disease Epidemiology Collaboration formula (both expressed in mL/min/1.73 m² and in mL/min) and serum protein level on cloxacillin pharmacokinetics was assessed. Accounting for relevant covariates, a dosing nomogram was developed to determine the optimal daily dose required to achieve a steady-state plasma concentration range of 20–50 mg/L with a probability ≥0.9. Results A total of 114 patients (331 plasma concentrations) were included. A one-compartment model including GFR expressed in mL/min as a covariate was chosen. Using the nomogram, achieving the cloxacillin concentration target requires a daily dose ranging from 3.5 to 13.1 g for a GFR ranging from 20 to 125 mL/min. Conclusions This work provided a practical tool for cloxacillin dose adjustment in IE according to renal function. [ABSTRACT FROM AUTHOR]

Background Accurate accounting of coronavirus disease 2019 (COVID-19) critical care outcomes has important implications for health care delivery. Research Question We aimed to determine critical care and organ support outcomes of intensive care unit (ICU) COVID-19 patients and whether they varied depending on the completeness of study follow-up or admission time period. Study Design and Methods We conducted a systematic review and meta-analysis of reports describing ICU, mechanical ventilation (MV), renal replacement therapy (RRT), and extracorporeal membrane oxygenation (ECMO) mortality. A search was conducted using PubMed, Embase, and Cochrane databases. We included English language observational studies of COVID-19 patients, reporting ICU admission, MV, and ICU case fatality, published from December 1, 2019 to December 31, 2020. We excluded reports of less than 5 ICU patients and pediatric populations. Study characteristics, patient demographics, and outcomes were extracted from each article. Subgroup meta-analyses were performed based on the admission end date and the completeness of data. Results Of 6,778 generated articles, 145 were retained for inclusion (n  = 60,357 patients). Case fatality rates across all studies were 34.0% (95% CI = 30.7%, 37.5%, P  < 0.001) for ICU deaths, 47.9% (95% CI = 41.6%, 54.2%, P  < 0.001) for MV deaths, 58.7% (95% CI = 50.0%, 67.2%, P  < 0.001) for RRT deaths, and 43.3% (95% CI = 31.4%, 55.4%, P  < 0.001) for extracorporeal membrane oxygenation deaths. There was no statistically significant difference in ICU and organ support outcomes between studies with complete follow-up versus studies without complete follow-up. Case fatality rates for ICU, MV, and RRT deaths were significantly higher in studies with patients admitted before April 31st 2020. Interpretation Coronavirus disease 2019 critical care outcomes have significantly improved since the start of the pandemic. Intensive care unit outcomes should be evaluated contextually (study quality, data completeness, and time) for the most accurate reporting and to effectively guide mortality predictions. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES In recent years, an increase in severe and even fatal outcomes related to oesophageal or airway button battery (BB) ingestion by infants and small children has been reported. Extensive tissue necrosis caused by lodged BB can lead to major complications, including tracheoesophageal fistula (TEF). In these instances, best treatment remains controversial. While small defects may warrant a conservative approach, surgery often remains inevitable in highly complex cases with large TEF. We present a series of small children that underwent successful surgical management by a multidisciplinary team in our institution. METHODS This is a retrospective analysis of n  = 4 patients <18 months undergoing TEF repair from 2018 to 2021. RESULTS Surgical repair under extracorporeal membrane oxygenation (ECMO) support was feasible in n  = 4 patients by reconstructing the trachea with decellularized aortic homografts that were buttressed with pedicled latissimus dorsi muscle flaps. While direct oesophageal repair was feasible in 1 patient, 3 required esophagogastrostomy and secondary repair. The procedure was completed successfully in all 4 children with no mortality and acceptable morbidity. CONCLUSIONS Tracheo-oesophageal repair after BB ingestion remains challenging and is associated with major morbidity. Bioprosthetic materials in conjunction with the interposition of vascularized tissue flaps between trachea and oesophagus appear to be a valid approach to manage severe cases. [ABSTRACT FROM AUTHOR]

Objective The primary objective of this observational study was to analyze the time to the first edge-of-bed (EOB) mobilization in adults who were critically ill with severe versus non-severe COVID-19 pneumonia. Secondary objectives included the description of early rehabilitation interventions and physical therapy delivery. Methods All adults with laboratory-confirmed COVID-19 requiring intensive care unit admission for ≥72 hours were included and divided according to their lowest PaO2/FiO2 ratio into severe (≤100 mmHg) or non-severe (>100 mmHg) COVID-19 pneumonia. Early rehabilitation interventions consisted of in-bed activities, EOB or out-of-bed mobilizations, standing, and walking. The Kaplan–Meier estimate and logistic regression were used to investigate the primary outcome time-to-EOB and factors associated with delayed mobilization. Results Among the 168 patients included in the study (mean age = 63 y [SD = 12 y]; Sequential Organ Failure Assessment = 11 [interquartile range = 9–14]), 77 (46%) were classified as non-severe, and 91 (54%) were classified as severe COVID-19 pneumonia. Median time-to-EOB was 3.9 days (95% CI = 2.3–5.5) with significant differences between subgroups (non-severe = 2.5 days [95% CI = 1.8–3.5]; severe = 7.2 days [95% CI = 5.7–8.8]). Extracorporeal membrane oxygenation use and high Sequential Organ Failure Assessment scores (adjusted effect = 13.7 days [95% CI = 10.1–17.4] and 0.3 days [95% CI = 0.1–0.6]) were significantly associated with delayed EOB mobilization. Physical therapy started within a median of 1.0 days (95% CI = 0.9–1.2) without subgroup differences. Conclusion This study shows that early rehabilitation and physical therapy within the recommended 72 hours during the COVID-19 pandemic could be maintained regardless of disease severity. In this cohort, the median time-to-EOB was fewer than 4 days, with disease severity and advanced organ support significantly delaying the time-to-EOB. Impact Early rehabilitation in the intensive care unit could be sustained in adults who are critically ill with COVID-19 pneumonia and can be implemented with existing protocols. Screening based on the PaO2/FiO2 ratio might reveal patients at risk and increased need for physical therapy. [ABSTRACT FROM AUTHOR]

Background Clinical differences between critical illness from influenza infection vs coronavirus disease 2019 (COVID-19) have not been well characterized in pediatric patients. Methods We compared demographics, clinical characteristics, and outcomes of US children (aged 8 months to 17 years) admitted to the intensive care or high-acuity unit with influenza or COVID-19. Using mixed-effects models, we assessed the odds of death or requiring life support for influenza vs COVID-19 after adjustment for age, sex, race and Hispanic origin, and underlying conditions including obesity. Results Children with influenza (n = 179) were younger than those with COVID-19 (n = 381; median, 5.2 years vs 13.8 years), less likely to be non-Hispanic Black (14.5% vs 27.6%) or Hispanic (24.0% vs 36.2%), and less likely to have ≥1 underlying condition (66.4% vs 78.5%) or be obese (21.4% vs 42.2%), and a shorter hospital stay (median, 5 days vs 7 days). They were similarly likely to require invasive mechanical ventilation (both 30.2%), vasopressor support (19.6% and 19.9%), or extracorporeal membrane oxygenation (2.2% and 2.9%). Four children with influenza (2.2%) and 11 children with COVID-19 (2.9%) died. The odds of death or requiring life support in children with influenza vs COVID-19 were similar (adjusted odds ratio, 1.30; 95% confidence interval,.78–2.15; P =.32). Conclusions Despite differences in demographics and clinical characteristics of children with influenza or COVID-19, the frequency of life-threatening complications was similar. Our findings highlight the importance of implementing prevention measures to reduce transmission and disease severity of influenza and COVID-19. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES To describe the use of ventricular assist devices (VAD) in children in Spain and to identify variables related to survival. METHODS This is an observational cohort study of all children younger than 18 years of age who underwent an initial implantation of a VAD at any of the 6 paediatric heart transplant centres from May 2006 to December 2020. Subjects were identified retrospectively from each hospital's database. RESULTS Paracorporeal VADs were implanted in 118 children [pulsatile (63%), continuous (30.5%) or both types (5.9%)]. Small children (<0.7 m2 of body surface area) comprised the majority of this cohort (63.3%). Overall, 67% survived to VAD explantation, and 64.9% survived to hospital discharge. Non-central nervous system haemorrhage (39%) and stroke (38.1%) were the most common complications. Body weight <5 kg, congenital heart disease, pre-implantation bilirubin >34 μmol/l and bridge to decision strategy were associated with a higher mortality at hospital discharge and in the long-term. Interagency registry for mechanically assisted circulatory support (INTERMACS) status 1 and cardiac arrest prior to VAD implantation were related to long-term mortality, whereas pre-implantation renal replacement therapy and extracorporeal membrane oxygenation were not related to mortality. CONCLUSIONS In Spain, 67% of the VAD-supported children have been bridged to heart transplantation or to recovery. Body weight lower than 5 kg, congenital heart disease diagnosis, cholestatic liver dysfunction, bridge to decision as VAD strategy, INTERMACS-1 status and cardiac arrest were pre-implantation variables related to mortality, whereas pre-implantation renal replacement therapy and extracorporeal membrane oxygenation were not. [ABSTRACT FROM AUTHOR]

A malignant form of non-cardiogenic pulmonary edema (NCPE) that develops soon after the termination of cardiopulmonary bypass support during cardiac surgery is rarely encountered. It sometimes requires immediate management, including venovenous extracorporeal membrane oxygenation (VV-ECMO). In the first case, a 78-year-old female patient experienced fulminating NCPE after mitral valve plasty, which caused severe respiratory failure and hemodynamic instability due to a huge amount of sputum. In the second case, a 47-year-old male patient presented with right-sided unilateral pulmonary edema with a substantial amount of sputum after minimally invasive cardiac surgery for mitral valve repair. In both cases, VV-ECMO and aggressive fluid replacement were promptly initiated. The NCPE resolved on post-operative day 2, resulting in the successful termination of VV-ECMO. NCPE leads to lethal respiratory failure with multifactorial causes during cardiac surgery. However, as NCPE is potentially transient, immediate treatment comprising VV-ECMO and aggressive fluid replacement can improve clinical outcomes. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES In 2018, the United Network for Organ Sharing modified their heart allocation policy to reduce waitlist mortality and prioritize patients with the greatest acuity. Considering declining rates of combined heart-lung transplantation, this study sought to investigate the impact of the new allocation system on waitlist and post-transplant outcomes of patients listed for combined heart-lung transplantation. METHODS Adult patients listed for combined heart-lung transplant between 2012 and 2021 were included. Patients were stratified according to listing era. Competing risk regression was used to assess waitlist outcomes. Cox proportional hazards regression was used to establish risk factors for post-transplant mortality. RESULTS A total of 511 patients were included, of whom 295 (57.8%) were listed in era 1 and 216 (42.2%) in era 2. Era 2 was associated with increased likelihood of transplant (adjusted standard hazard ratio (aSHR): 1.60 [1.23–2.07]; P  < 0.01) and decreased waitlist mortality (aSHR: 0.43 [0.25–0.73]; P  < 0.01). Despite longer ischaemic times and increased use of preoperative veno-arterial extracorporeal membrane oxygenation (ECMO) in era 2, early post-transplant survival was equivalent. Predicted heart mass ratio <0.8 (Hazard ratio (HR); 3.24; P  = 0.01), ventilator support (HR: 3.83; P  < 0.01) and greater ischaemic times (HR: 1.80; P  < 0.01) independently predicted the mortality. Procedures at high centre volumes (HR: 0.36; P  = 0.04) were associated with decreased mortality. Use of ECMO was not predictive of mortality in the modern era. CONCLUSIONS The allocation policy change has led to improvements in waitlist outcomes in patients listed for heart-lung transplantation. Despite increased ischaemic times and use of ECMO, early post-transplant survival was equivalent. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES The use of extracorporeal life support for cardiogenic shock has significantly increased over the past decade. However, there are insufficient data for the presence of sex-associated outcomes differences. Our study assesses differences between male and female patients placed on venoarterial extracorporeal life support (VA-ECLS) for cardiogenic shock from an international database. METHODS This is a multicentre, retrospective study on 9888 adult patients on VA-ECLS for cardiogenic shock from the Extracorporeal Life Support Organization registry from 2011 to 2019. The 1:1 nearest neighbour propensity score matching was performed. The primary end point was in-hospital mortality. Secondary end points include bleeding, infection and other complications. RESULTS There were 6747 (68%) male patients and 3141 (32%) female patients. Male patients were more likely to have history of myocardial infarction, coronary artery disease, diabetes, chronic kidney disease and congestive heart failure. Female patients were more likely to be centrally cannulated. After propensity score matching, there was no difference seen in in-hospital mortality. In regards to complications, female patients were more likely to experience limb ischaemia, whereas males were more likely to receive renal replacement therapy and have longer hospital stays. Multivariable logistic regression confirmed sex was not independently associated with mortality. CONCLUSIONS There was no difference in-hospital mortality between male and female patients receiving VA-ECLS for cardiogenic shock. Female patients were more likely to have limb ischaemia as a complication. Varying cannulation approaches for female patients should be further investigated. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Extracorporeal membrane oxygenation (ECMO) support prior to ventricular assist device (VAD) therapy is frequently used for stabilizing INTERMACS 1 and 2 paediatric patients. Data regarding outcomes with this strategy is limited. METHODS Patient characteristics and outcomes post-VAD therapy with and without preop ECMO support were compared. Survival and risk factor analysis was performed for all patients and INTERMACS profile 1 subgroup. RESULTS Of 541 INTERMACS 1 and 2 patients enrolled in Paediatric Interagency Registry for Mechanical Circulatory Support registry, 391 received primary VAD implantation and ECMO prior to VAD therapy was utilized in 150 patients. Younger age (P  < 0.0001) and shock (P  < 0.0001) were more common in group 2, with lower survival at 1, 6 and 12 months compared to group 1 (P  < 0.0001). Freedom from infection (P  = 0.03) was higher in group 1. Freedom from stroke (P  = 0.7) was similar. Paracorporeal continuous flow devices led to poor survival in both groups 1 and 2 (P  = 0.4). Implantable continuous flow (P  < 0.0001) and paracorporeal pulsatile devices (P  = 0.007) had better survival in primary VAD group. INTERMACS profile 1, lower weight, hepatic dysfunction, renal failure, paracorporeal continuous and percutaneous devices were associated with higher mortality. Preop ECMO therapy was not associated with higher mortality (P  = 0.12). Survival of INTERMACS profile 1 patient was similar at 1, 6 and 12 months in both groups (P  = 0.1). CONCLUSIONS INTERMACS profile 1, lower weight, hepatic dysfunction, renal failure and use of paracorporeal continuous flow or percutaneous assist devices are associated with a higher postoperative mortality. Preop ECMO therapy however is not independently associated with higher postop mortality. [ABSTRACT FROM AUTHOR]

Background Burkholderia cepacia complex is a group of potential nosocomial pathogens often linked to contaminated water. We report on a cluster of 8 B. cepacia complex infections in cardiothoracic intensive care unit patients, which were attributed to contaminated extracorporeal membrane oxygenation (ECMO) water heaters. Methods In December 2020, we identified an increase in B. cepacia complex infections in the cardiothoracic intensive care unit at Brigham and Women's Hospital. We sought commonalities, sequenced isolates, obtained environmental specimens, and enacted mitigation measures. Results Whole-genome sequencing of 13 B. cepacia complex clinical specimens between November 2020 and February 2021 identified 6 clonally related isolates, speciated as Burkholderia contaminans. All 6 occurred in patients on ECMO. Microbiology review identified 2 additional B. contaminans cases from June 2020 that may have also been cluster related, including 1 in a patient receiving ECMO. All 8 definite or probable cluster cases required treatment; 3 patients died, and 3 experienced recurrent infections. After ECMO was identified as the major commonality, all 9 of the hospital's ECMO water heaters were cultured, and B. contaminans grew in all cultures. Cultures from air sampled adjacent to the water heaters were negative. Water heater touch screens were culture positive for B. contaminans, and the sink drain in the ECMO heater reprocessing room also grew clonal B. contaminans. Observations of reprocessing revealed opportunities for cross-contamination between devices through splashing from the contaminated sink. The cluster was aborted by removing all water heaters from clinical service. Conclusions We identified a cluster of 8 B. cepacia complex infections associated with contaminated ECMO water heaters. This cluster underscores the potential risks associated with water-based ECMO heaters and, more broadly, water-based care for vulnerable patients. [ABSTRACT FROM AUTHOR]

Postoperative hemodynamic support with an Impella 5.0 was effective in a man who underwent lung lobectomy for lung cancer and cardiogenic shock. A 75-year-old man presented to hospital with an abnormal chest shadow on radiography. After thorough examination, the patient was diagnosed with lung cancer, and left lower lobectomy was performed. On the 2nd postoperative day, the patient experienced cardiac arrest because of a sudden drop in saturation of percutaneous oxygen. After a third defibrillation, his heartbeat resumed, and he was intubated and placed on a ventilator. Coronary angiography revealed acute coronary syndrome and the patient fell into a state of shock, which required venoarterial extracorporeal membrane oxygenation (VA-ECMO) support. Nevertheless, the circulatory dynamics are unstable, and Impella 5.0 was introduced. VA-ECMO and the Impella 5.0 were discontinued on the 6th and 8th postoperative days, respectively. The patient was eventually transferred to a nearby facility for further rehabilitation 109 days later. [ABSTRACT FROM AUTHOR]

Cardiac tamponade is a known life-threatening complication of extracorporeal membrane oxygenation (ECMO), often secondary to hemopericardium from major vascular or cardiac perforation. We present the unique case of a neonate with a milky pericardial effusion causing tamponade after ECMO cannulation, managed successfully with pericardial window. Understanding ECMO physiology and its effect on the classic presentation of tamponade is critical and can prevent delays in diagnosis. While hemopericardium is most commonly seen in these cases, findings of a non-bloody, milky effusion should prompt further workup for infection, chylopericardium or total parenteral nutrition-associated pericardial effusion, as the appropriate management can mitigate immediate and potential long-term sequelae. [ABSTRACT FROM AUTHOR]

The article describes a case of a female patient with severe granulomatosis with polyangiitis. Topics mentioned include the management of the patient with daratumumab, the clinical features of the autoimmune serology, the key symptoms of the disease, the effect of rituximab, and the use of extracorporeal membrane oxygenation therapy.

A study published in the European Journal of Cardio-Thoracic Surgery examined the use of extracorporeal life support (ECLS) in patients with infarct-related cardiogenic shock. The study found that ECLS did not reduce short-term mortality and was associated with more serious complications. However, the study had some potential weaknesses, including the involvement of multiple centers with varying levels of expertise and the inclusion of resuscitated patients who may have contributed to the negative outcomes. The study also raised questions about the diagnosis of cardiogenic shock and the management of ECLS therapy. The authors suggest that the results may be compromised due to these issues and emphasize the need for standardized protocols and guidelines in ECLS therapy. Additionally, they express concern that the use of ECLS may decline, similar to the decline in the use of the intra-aortic balloon pump, despite its potential benefits in certain patient populations. [Extracted from the article]

Background Information on the severity of coronavirus disease 2019 (COVID-19) attributable to the Delta variant in the United States among pregnant people is limited. We assessed the risk for severe COVID-19 by pregnancy status in the period of Delta variant predominance compared with the pre-Delta period. Methods Laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections among symptomatic women of reproductive age (WRA) were assessed. We calculated adjusted risk ratios for severe disease including intensive care unit (ICU) admission, receipt of invasive ventilation or extracorporeal membrane oxygenation (ECMO), and death comparing the pre-Delta period (1 January 2020–26 June 2021) and the Delta period (27 June 2021–25 December 2021) for pregnant and nonpregnant WRA. Results Compared with the pre-Delta period, the risk of ICU admission during the Delta period was 41% higher (adjusted risk ratio [aRR], 1.41 [95% confidence interval {CI}, 1.17–1.69]) for pregnant WRA and 9% higher (aRR, 1.09 [95% CI, 1.00–1.18]) for nonpregnant WRA. The risk of invasive ventilation or ECMO was higher for pregnant (aRR, 1.83 [95% CI, 1.26–2.65]) and nonpregnant (aRR, 1.34 [95% CI, 1.17–1.54]) WRA in the Delta period. During the Delta period, the risk of death was 3.33 (95% CI, 2.48–4.46) times the risk in the pre-Delta period among pregnant WRA and 1.62 (95% CI, 1.49–1.77) among nonpregnant WRA. Conclusions Compared with the pre-Delta period, pregnant and nonpregnant WRA were at increased risk for severe COVID-19 in the Delta period. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Approximately 10% of lung transplant recipients have had previous cardiothoracic surgery. We sought to determine if previous surgery affects outcomes after lung transplant at a national level. METHODS The United Network for Organ Sharing database was analysed from 2005 to 2019 to include adult patients who underwent lung transplant who had previous cardiac surgery and previous thoracic surgery. T -test and chi-squared analysis were used to compare perioperative outcomes. Long-term survival comparison was performed using the Kaplan–Meier method in an unadjusted and propensity-matched analysis. RESULTS Out of 24 784 lung transplants, 691 (2.7%) had previous cardiac surgery and 1321 (6.5%) had previous thoracic surgery. Operative mortality was worse in previous cardiac surgery [42 (6.1%)] versus no previous cardiac surgery [740 (3.1%), P  < 0.001] and in previous thoracic surgery [65 (4.9%)] versus no previous thoracic surgery [717 (3.1%), P  < 0.001]. The previous thoracic surgery group had more primary graft failure and treated rejection during the first-year post-transplant. There was no difference in stroke, dialysis, intubation and extracorporeal membrane oxygenation at 72 h. Long-term survival was significantly worse for lung transplant patients who had undergone previous cardiac surgery (median 3.8 vs 6.3 years, P  < 0.001) due to an increase in cardiovascular deaths (P  = 0.008) and malignancy (P  = 0.043). However, there was no difference in previous thoracic surgery (median 6.6 vs 6.1 years, P  = 0.337). CONCLUSIONS Previous cardiac surgery prior to lung transplant results in worse survival related to cardiovascular death and malignancies. Previous thoracic surgery worsens perioperative outcomes but does not affect long-term survival. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Extracorporeal membrane oxygenation (ECMO) support for elective cardiothoracic surgery is well established. In contrast, there are not much data regarding the usefulness and outcome of ECMO in non-elective major lung resections for infectious lung abscess. METHODS All patients undergoing non-elective major lung surgery for infectious lung abscess at 5 centres in Germany, UK and Spain were enrolled in a prospective database. Malignant disorders and intrathoracic complications of other procedures were excluded. RESULTS There were 127 patients. The median age was 59 years (interquartile range 18.75). The mean Charlson index of comorbidity was 2.83 (standard deviation 2.57). Surgical procedures were lobectomy (89), pneumectomy (20) and segmentectomy (18). ECMO was used for 10 patients (pneumectomy 2, lobectomy 8) and several more received pre-ECMO treatment. Mortality was 17/127. Intraoperatively no ECMO-associated complications were encountered. EMCO [1/10 vs 16/117; odds ratio (OR): 0.70, 95% confidence interval (CI) 0.08–5.91, P = 0.74] and the extent of pulmonary resection were not associated with higher mortality. Preoperative sepsis (OR: 17.84, 95% CI 2.29–139.28, P < 0.01), preoperative air leak (OR: 13.12, 95% CI 4.10–42.07, P < 0.001), acute renal failure (OR: 7.00, 95% CI 2.19–22.43, P < 0.01) and Charlson index of comorbidity ≥ 3 (OR: 10.83, 95% CI 2.36–49.71, P < 0.01) were associated with significantly higher mortality. CONCLUSIONS The application of ECMO is widening the possibilities for successful surgical management of infectious, non-malignant lung abscesses. Particularly, patients with marginal functional operability benefit from the availability and readiness to use ECMO. Mortality is determined by the burden of pre-existent comorbidity, severe sepsis and septic shock. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Traditionally, patients on bridge-to-transplant extracorporeal membrane oxygenation were kept sedated and intubated. However, awake bridging strategies have evolved during recent years. This study aims to elaborate differences in physical activity and postoperative outcomes after lung transplantation (LTx), depending on bridging strategy and duration. METHODS Bridged patients receiving LTx between March 2013 and April 2021 were analysed. Awake bridging was defined as a Richmond Agitation-Sedation Scale score of ≥−1 until 24 h before transplantation. Patients were grouped in awake and sedated cohorts. RESULTS A total of 88 patients (35 awake, 53 sedated bridging) were included. After LTx, mobilization to standing position was achieved earlier in awake bridged patients (7 vs 15 days, P < 0.001). Postoperative ventilation time (247 vs 88 h, P  = 0.005) and intensive care unit stay (30 vs 16 days, P  = 0.004) were longer in the sedated cohort. Awake patients with bridging duration >6 days showed shorter postoperative ventilation time (108 vs 383 h, P  = 0.003), less intensive care unit days (23 vs 36, P  = 0.003) and earlier mobilization to standing position (9 vs 17 days, P < 0.001). In contrast, postoperative ventilation time and days in intensive care unit in patients with bridge-to-transplant duration ≤6 days were comparable between cohorts. Mobilization to standing position was achieved faster in the awake (≤6 days) bridged cohort (5 vs 9 days, P  = 0.024). CONCLUSIONS Despite the complex management of bridged patients, excellent survival rates after LTx can be achieved. Especially in patients with more than 1 week on extracorporeal membrane oxygenation, awake bridging concepts are associated with significantly faster recovery. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES We sought to investigate the impact of early postoperative low arterial oxygen saturation on mortality and morbidity after bidirectional cavopulmonary shunt (BCPS). METHODS The medical records of all patients who underwent BCPS between 2013 and 2018 were reviewed. RESULTS A total of 164 patients were included in this study. Forty-seven patients underwent reintervention during hospital stay at median 7 days after BCPS. Before reintervention, 30 patients were intubated or had SpO2 of <75%. All re-interventions for Glenn pathway obstruction and 4 out of 5 venovenous coil embolization resulted in hospital discharge, while high mortality was observed after other re-interventions (atrioventricular valve surgery, thrombolysis, systemic ventricular outflow obstruction relief, extracorporeal membrane oxygenation implantation and diaphragmatic plication). Additional aortopulmonary shunt with pulmonary artery discontinuation was performed in 8 patients who showed severe cyanosis with median SpO2 of 59% under maximal ventilation support. In the univariable Cox regression analysis, the associated factors for mortality before total cavopulmonary connection were reduced ventricular function [hazard ratio (HR) 6.89, 95% confidence interval (CI) 1.76–26.9, P -value 0.006], greater than moderate atrioventricular valve regurgitation (HR 5.89, 95% CI 1.70–20.4, P -value 0.005), SpO2 1 h after extubation (HR 0.87, 95% CI 0.80–0.96, P -value 0.004) and mean pulmonary artery pressure 1 h after extubation (HR 1.14, 95% CI 1.02–1.26, P -value 0.016). CONCLUSIONS After BCPS, unacceptable cyanosis persisted with various aetiologies. Low arterial oxygen saturation within 1 h after extubation is significantly associated with high mortality after BCPS. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Despite improvements in the surgical management of the hypoplastic left heart syndrome and its variant, the Norwood procedure is still associated with substantial mortality and morbidity and extracorporeal membrane oxygenation support is required in some patients. METHODS We reviewed patients with the Norwood procedure between 2007 and 2019. The primary end point of the study was mortality during extracorporeal membrane oxygenation. Secondary end points included morbidity, bidirectional cavopulmonary shunt and Fontan completion. RESULTS Of the 257 patients in whom the Norwood procedure was performed, mechanical support was required in 41 patients (16%). Indications for extracorporeal membrane oxygenation were low cardiac output (n = 16, 39%), hypoxaemia (n = 12, 29%) and inability to wean from cardiopulmonary bypass (n = 9, 22%). The median age at extracorporeal membrane oxygenation was 10.9 days (interquartile range, 7.9–21.2) and veno-arterial support was required in 37 patients (90.2%). Weaning from extracorporeal membrane oxygenation was achieved in 61% (n = 25). Survival to hospital discharge and 1-year survival was 34.6% (standard deviation: 17.1) and 25.7% (standard deviation: 7), respectively. Bidirectional cavopulmonary shunt was performed in 24% (n = 10) and Fontan completion in 7% (n = 3). Preoperative moderate or greater atrioventricular valve regurgitation was independently associated with mechanical support. Implantation of extracorporeal membrane oxygenation in the paediatric catheter laboratory was identified as an independent risk factor for mortality. CONCLUSIONS Moderate or greater atrioventricular valve regurgitation is an independent risk factor for mechanical support after the Norwood procedure. Mechanical support is associated with substantial in-hospital mortality; however, successful Fontan completion was accomplished in some patients. [ABSTRACT FROM AUTHOR]