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Extracorporeal perfusion of organs has a wide range of clinical applications like prolonged vital storage of organs, isolated applications of drugs, bridging time to transplant, and free composite tissue transfer without anastomosis, but there are a limited number of experimental models on this topic.This study aimed to develop and evaluate a human extracorporeal free flap perfusion model using an extracorporeal membrane oxygenation device. Five patients undergoing esthetic abdominoplasty participated in this study. Deep inferior epigastric artery perforator flaps were obtained abdominoplasty flaps, which are normally medical waste, used in this model. Deep inferior epigastric artery perforator flaps were extracorporeally perfused with a mean of 6 days. The biochemical and pathological evaluations of the perfusions were discussed in the article.

Objectives: To determine whether mortality differs between roller and centrifugal pumps used during extracorporeal membrane oxygenation in infants weighing less than 10 kg., Design: Retrospective propensity-matched cohort study., Setting: All extracorporeal membrane oxygenation centers reporting to the Extracorporeal Life Support Organization., Patients: All patients less than 10 kg supported on extracorporeal membrane oxygenation during 2011-2016 within Extracorporeal Life Support Organization Registry., Interventions: Centrifugal and roller pump recipients were propensity matched (1:1) based on predicted probability of receiving a centrifugal pump using demographic variables, indication for extracorporeal membrane oxygenation, central versus peripheral cannulation, and pre-extracorporeal membrane oxygenation patient management., Measurements and Main Results: A total of 12,890 patients less than 10 kg were supported with extracorporeal membrane oxygenation within the Extracorporeal Life Support Organization registry during 2011-2016. Patients were propensity matched into a cohort of 8,366. Venoarterial and venovenous extracorporeal membrane oxygenation runs were propensity matched separately. The propensity-matched cohorts were similar except earlier year of extracorporeal membrane oxygenation (standardized mean difference, 0.49) in the roller pump group. Within the propensity-matched cohort, survival to discharge was lower in the centrifugal pump group (57% vs 59%; odds ratio, 0.91; 95% CI, 0.83-0.99; p = 0.04). Hemolytic, infectious, limb injury, mechanical, metabolic, neurologic, pulmonary, and renal complications were more frequent in the centrifugal pump group. Hemorrhagic complications were similar between groups. Hemolysis mediated the relationship between centrifugal pumps and mortality (indirect effect, 0.023; p < 0.001)., Conclusions: In this propensity score-matched cohort study of 8,366 extracorporeal membrane oxygenation recipients weighing less than 10 kg, those supported with centrifugal pumps had increased mortality and extracorporeal membrane oxygenation complications. Hemolysis was evaluated as a potential mediator of the relationship between centrifugal pump use and mortality and met criteria for full mediation.

Introduction: There is an increasing need for transport extracorporeal membrane oxygenation (ECMO) in thoracic transplantation. This study was performed to evaluate the safety and feasibility of transport ECMO in thoracic transplantation., Patients and Methods: A total of 24 patients referred from outside hospitals for ECMO treatment used our interhospital ECMO transport system from December 2011 to October 2018. We retrospectively analyzed the clinical data to evaluate the feasibility and safety of transport ECMO for thoracic transplantations., Results: The median transport distance was 34 km (interquartile range [IQR]: 29-45) and the median transport time was 38 minutes (IQR: 26-45). There were no adverse events during transit in any patient. ECMO weaning was possible in 19 patients (79%) and 13 patients (54%) were weaned from mechanical ventilation. Of these patients, only 14 (58%) underwent transplantation, of whom 8 received lung transplants (53%) and 6 received heart transplants (67%). Among the patients receiving transplants, intensive care unit discharge was possible in 9 patients (64%), and 8 patients (57%) were discharged home., Conclusions: Transport ECMO to the transplantation center is a useful strategy to rescue patients with cardiorespiratory failure who may require transplantation, providing an additional means of improving the chance of survival., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Veno-arterial extracorporeal membrane oxygenation can be vital to support patients in severe or rapidly progressing cardiogenic shock. In cases of left ventricular distension, left ventricular decompression during veno-arterial extracorporeal membrane oxygenation may be a crucial factor influencing the patient outcome. Application of a double lumen arterial cannula for a left ventricular unloading is an alternative, straightforward method for left ventricular decompression during extracorporeal membrane oxygenation in a veno-arterial configuration., Objectives: The purpose of this article is to use a mathematical model of the human adult cardiovascular system to analyze the left ventricular function of a patient in cardiogenic shock supported by veno-arterial extracorporeal membrane oxygenation with and without the application of left ventricular unloading using a novel double lumen arterial cannula., Methods: A lumped model of cardiovascular system hydraulics has been coupled with models of non-pulsatile veno-arterial extracorporeal membrane oxygenation, a standard venous cannula, and a drainage lumen of a double lumen arterial cannula. Cardiogenic shock has been induced by decreasing left ventricular contractility to 10% of baseline normal value., Results: The simulation results indicate that applying double lumen arterial cannula during veno-arterial extracorporeal membrane oxygenation is associated with reduction of left ventricular end-systolic volume, end-diastolic volume, end-systolic pressure, and end-diastolic pressure., Conclusions: A double lumen arterial cannula is a viable alternative less invasive method for left ventricular decompression during veno-arterial extracorporeal membrane oxygenation. However, to allow for satisfactory extracorporeal membrane oxygenation flow, the cannula design has to be revisited.

EXTEND (EXTra-uterine Environment for Neonatal Development) is a novel system for supporting extremely premature infants that replicates in utero conditions by maintaining a sterile fluid environment and providing gas exchange via a pumpless arteriovenous oxygenator circuit connected to the umbilical vessels. Target gestational age (GA) for EXTEND support in human infants is 23-27 weeks, when immature lungs are most susceptible to injury in the setting of air ventilation. We previously demonstrated physiologic support of premature lambs cannulated at 105-117 days GA (lungs developmentally analogous to the 23-27 week GA human infant) for up to 28 days on EXTEND. In the present study, we sought to determine the technical feasibility of umbilical vessel cannulation in 85-96 days GA lambs delivered to EXTEND at weights equivalent to the 23-27 week GA human infant (500-850 g). Five preterm lambs were cannulated at 85-96 days GA (term 145 days) and supported on EXTEND for 4-7 days. All lambs underwent umbilical artery and umbilical vein cannulation. Circuit flows and pressures were monitored continuously, and blood gases were obtained at regular intervals for assessment of oxygen parameters. Systemic pH and lactate were measured at least once daily. Mean body weight at cannulation was 641 ± 71 g (range 480-850 g). All lambs were cannulated successfully (cannula size varied from 8 to 12 Fr), and mean survival on EXTEND was 140 ± 7 hours. Mean circuit flow was 213 ± 15 mL/kg*min, mean pH was 7.37 ± 0.01, and mean lactate was 1.6 ± 0.2 mmol/L. During the initial 120 hours after EXTEND cannulation, there were no significant differences between 85-96 days GA lambs and 105-117 days GA lambs in weight-adjusted circuit flows, oxygen delivery, pH, or lactate levels. This study demonstrates successful umbilical cord cannulation and adequate circuit flows and oxygen delivery in midgestation lambs size-matched to the 23-27 week GA human fetus, which represents an important step in the translation of EXTEND to clinical practice., (© 2019 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Extracorporeal membrane oxygenation (ECMO) is becoming more and more clinically important. The extracorporeal circuit for membrane oxygenation consists of a pump, a membrane oxygenator and large volume tubing. The ECMO device forms an additional compartment, which can absorb drugs with high lipophilia and protein binding. Thus, ECMO affects the volume of distribution and the clearance. As a consequence, the pharmacokinetic-pharmacodynamic (pk-pd) target parameters cannot be achieved. The selection of an appropriate substance and the mode of application, combined with therapeutic drug monitoring (TDM), can significantly improve the therapeutic outcome of critically ill patients.

Background: Extracorporeal carbon dioxide removal (ECCO 2 R) uses an extracorporeal circuit to directly remove carbon dioxide from the blood either in lieu of mechanical ventilation or in combination with it. While the potential benefits of the technology are leading to increasing use, there are very real risks associated with it. Several studies demonstrated major bleeding and clotting complications, often associated with hemolysis and poorer outcomes in patients receiving ECCO 2 R. A better understanding of the risks originating specifically from the rotary blood pump component of the circuit is urgently needed., Methods: High-resolution computational fluid dynamics was used to calculate the hemodynamics and hemocompatibility of three current rotary blood pumps for various pump flow rates., Results: The hydraulic efficiency dramatically decreases to 5-10% if operating at blood flow rates below 1 L/min, the pump internal flow recirculation rate increases 6-12-fold in these flow ranges, and adverse effects are increased due to multiple exposures to high shear stress. The deleterious consequences include a steep increase in hemolysis and destruction of platelets., Conclusions: The role of blood pumps in contributing to adverse effects at the lower blood flow rates used during ECCO 2 R is shown here to be significant. Current rotary blood pumps should be used with caution if operated at blood flow rates below 2 L/min, because of significant and high recirculation, shear stress, and hemolysis. There is a clear and urgent need to design dedicated blood pumps which are optimized for blood flow rates in the range of 0.5-1.5 L/min.

Effective strategies to optimize Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS 1) patients are in much need. A novel awake venous-arterial extracorporeal membrane oxygenation (aVA ECMO) allows for clinical assessments while temporarily supporting biventricular function and stabilizing end-organ functions. The aim of the study was to assess outcomes of patients with aVA ECMO support before durable left ventricular assist device (LVAD) implantation. We evaluated 83 patients who received durable LVAD in 2012-2015, of whom 19 received aVA ECMO support before durable LVAD. Kaplan-Meier and Cox proportional hazards analyses were conducted to assess post-LVAD survival. No complications were observed during the mean aVA ECMO support of 2.7 days. Unadjusted survival of aVA ECMO-supported patients and non-aVA ECMO INTERMACS 1 patients at 1 year were 84.2% and 66.7%, respectively (p = 0.15). Survival of aVA ECMO patients was comparable with that of non-aVA ECMO INTERMACS 2 cohort (84.2% vs. 80.8%) at 1 year. Multivariate analysis demonstrated a significant reduction in the risk of death in aVA ECMO group compared with INTERMACS 1 non-aVA ECMO group (hazard ratio [HR]: 0.17; p = 0.035). Awake venous-arterial (VA) ECMO allows bridge to next therapy and improves outcomes in INTERMACS category 1 patients with an effect comparable with downgrading the disease severity on the INTERMACS scale.

Background: Temporary mechanical circulatory support (MCS) devices provide hemodynamic assistance for shock refractory to pharmacological treatment. Most registries have focused on single devices or specific etiologies of shock, limiting data regarding overall practice patterns with temporary MCS in cardiac intensive care units., Methods: The CCCTN (Critical Care Cardiology Trials Network) is a multicenter network of tertiary CICUs in North America. Between September 2017 and September 2018, each center (n=16) contributed a 2-month snapshot of consecutive medical CICU admissions., Results: Of the 270 admissions using temporary MCS, 33% had acute myocardial infarction-related cardiogenic shock (CS), 31% had CS not related to acute myocardial infarction, 11% had mixed shock, and 22% had an indication other than shock. Among all 585 admissions with CS or mixed shock, 34% used temporary MCS during the CICU stay with substantial variation between centers (range: 17%-50%). The most common temporary MCS devices were intraaortic balloon pumps (72%), Impella (17%), and veno-arterial extracorporeal membrane oxygenation (11%), although intraaortic balloon pump use also varied between centers (range: 40%-100%). Patients managed with intraaortic balloon pump versus other forms of MCS (advanced MCS) had lower Sequential Organ Failure Assessment scores and less severe metabolic derangements. Illness severity was similar at high- versus low-MCS utilizing centers and at centers with more advanced MCS use., Conclusions: There is wide variation in the use of temporary MCS among patients with shock in tertiary CICUs. While hospital-level variation in temporary MCS device selection is not explained by differences in illness severity, patient-level variation appears to be related, at least in part, to illness severity.

Chronic systolic heart failure (HF) with acute decompensation can result in cardiogenic shock (CS) requiring short-term mechanical circulatory support. We sought to identify predictors of survival for acute decompensated HF (ADHF) patients requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Patients >18 years old treated at our institution with VA-ECMO from 2009 to 2018 for ADHF with CS were studied. Demographic, hemodynamic, and echocardiographic data were collected. The primary outcome was survival to discharge. Fifty-two patients received VA-ECMO for ADHF with CS; 24 (46.2%) survived. Seventeen (32.7%) had suffered cardiac arrest, and 37 (71.2%) were mechanically ventilated. Mean lactate was 4.33 ± 3.45 mmol/L, and patients were receiving 2.7 ± 1.2 vasopressor/inotropic infusions at ECMO initiation; these did not differ significantly between survivors and nonsurvivors. Pre-ECMO cardiac index was 1.84 ± 0.56L/min/m and 1.94 ± 0.63L/min/m in survivors and nonsurvivors, respectively (p = 0.57). In multivariable analysis, only diabetes mellitus (DM; OR, 13.25; CI, 1.42-123.40; p = 0.02) and mineralocorticoid receptor antagonist use (OR, 0.12; CI, 0.02-0.78; p = 0.03) were independent predictors of mortality. Nineteen (79.2%) survivors required durable ventricular assist device. Among ADHF patients receiving VA-ECMO, DM is a powerful predictor of outcomes while markers of clinical acuity including hemodynamics, vasopressor/inotrope use, and lactate are not. The vast majority of survivors required durable left-ventricular assist devices.

The objective of this study was to describe a single-center experience with neonatal and pediatric extracorporeal life support (ECLS) and compare patient-related outcomes with those of the Extracorporeal Life Support Organization (ELSO) Registry. A retrospective review of subject characteristics, outcomes, and complications of patients who received the ECLS at Penn State Health Children's Hospital (PSHCH) from 2000 to 2016 was performed. Fisher's exact test was used to compare the PSHCH outcomes and complications to the ELSO Registry report. Data from 118 patients were included. Survival to discontinuation of the ECLS was 70.3% and 65.2% to discharge/transfer. Following circuitry equipment changes, the survival to discharge/transfer improved for both neonatal (<29 days) and pediatric (29 days to <18 years) patients. The most common complications associated with ECLS were clinical seizures, intracranial hemorrhage, and culture-proven infection. ECLS for pulmonary support appeared to be associated with a higher risk of circuit thrombus and cannula problems. When compared to the ELSO Registry, low volume ECLS centers, like our institution, can have outcomes that are no different or statistically better as noted with neonatal and pediatric cardiac patients. Pediatric patients requiring pulmonary support appeared to experience more mechanical complications during ECLS suggesting the need for ongoing technological improvement., (© 2019 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Objective: Extracorporeal life support has traditionally been used as a supportive platform for patients with cardiopulmonary failure. Many of these patients require endovascular access for the performance of diagnostic or therapeutic procedures, and obtaining vascular access in these patients can be problematic. We sought to develop a novel system that allows the extracorporeal life support circuit to serve as an access point to the cardiovascular system., Methods: By using computer-aided design, modeling, and 3-dimensional printing, a novel adaptor that can be easily inserted and removed from an extracorporeal life support circuit was developed. A mock loop was used to measure flow and pressure at various pump speeds with insertion of guidewires and catheters through the adaptor. The ability of the system to enable performance of endovascular procedures in vivo was then tested in a porcine extracorporeal life support model., Results: By using a small arterial cannula (15F) at 3500 RPM and 3.2 LPM, 15% and 24% decrements in circuit flow were observed when a 0.035" guidewire and 5F angiography catheter, respectively, were passed through the adaptor (P < .001). However, when using a larger arterial cannula (23F) at 3500 RPM and 4.7 LPM, only 3% and 5% decrements in flow were observed (P < .001), respectively, with intermediate changes when using 17F to 21F cannulas. In vivo testing confirmed that this system enables the performance of a variety of endovascular procedures, including left ventriculography, aortic root and coronary angiography, and descending aortography., Conclusions: This novel system successfully enables endovascular access through an extracorporeal life support circuit. This technology may transform extracorporeal life support from a purely supportive strategy to a platform for endovascular intervention., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Clot formation within membrane oxygenators (MOs) remains a critical problem during extracorporeal membrane oxygenation (ECMO). The composition of the clots-in particular, the presence of von Willebrand factor (vWF)-may be an indicator for prevalent nonphysiological flow conditions, foreign body reactions, or coagulation abnormalities in critically ill patients. Mats of interwoven gas exchange fibers from randomly collected MOs (PLS, Maquet, Rastatt, Germany) of 21 patients were stained with antibodies (anti-vWF and anti-P-selectin) and counterstained with 4',6-diamidino-2-phenylindole. The extent of vWF-loading was correlated with patient and technical data. While 12 MOs showed low vWF-loadings, 9 MOs showed high vWF-loading with highest accumulations close to crossing points of adjacent gas fibers. The presence and the extent of vWF-fibers/"cobwebs," leukocytes, platelet-leukocyte aggregates (PLAs), and P-selectin-positive platelet aggregates were independent of the extent of vWF-loading. However, the highly loaded MOs were obtained from patients with a significantly elevated SOFA score, severe thrombocytopenia, and persistent liver dysfunction. The coagulation abnormalities of these critically ill patients may cause an accumulation of the highly thrombogenic and elongated high-molecular-weight vWF multimers in the plasma which will be trapped in the MOs during the ECMO therapy., (© 2019 The Authors. Artificial Organs published by Wiley Periodicals, Inc. on behalf of International Center for Artificial Organ and Transplantation (ICAOT).)

Extracorporeal membrane oxygenation is a modality of extracorporeal life support that allows for temporary support in pulmonary and/or cardiac failure refractory to conventional therapy. Since the first descriptions of extracorporeal membrane oxygenation, significant improvements have occurred in the device and the management of patients and, consequently, in the outcomes of critically ill patients during extracorporeal membrane oxygenation. Many important studies about the use of extracorporeal membrane oxygenation in patients with acute respiratory distress syndrome refractory to conventional clinical support, under in-hospital cardiac arrest and with cardiogenic refractory shock have been published in recent years. The objective of this literature review is to present the theoretical and practical aspects of extracorporeal membrane oxygenation support for respiratory and/or cardiac functions in critically ill patients.

Mortality from cardiogenic shock primarily in the setting of acute myocardial infarction is unchanged at approximately 50%, despite the availability of advanced ventricular assist devices. A description of currently available mechanical circulatory support (MCS) devices is provided with a suggested algorithm for therapy with different MCS devices in cardiogenic shock. In order to increase survival placement of these devices in cardiogenic shock prior to percutaneous coronary intervention of the infarct related artery is strongly recommended., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Pulseless ventricular tachycardia/ventricular fibrillation (VT/VF) is the initial rhythm in a third of in-hospital cardiac arrest patients. Mechanical circulatory support (MCS) device use remains poorly understood in this population., Methods: We conducted an observational analysis of temporal trends in the utilization of MCS in VT/VF IHCA between January 2008 and December 2014 utilizing the Nationwide Inpatient Sample (NIS) database. Using multivariable analysis, we assessed factors associated with MCS use and survival to discharge., Results: Among 151,628 hospitalizations with VT/VF IHCA, 14,981 (9.9%) received MCS. Intra-aortic balloon pump (IABP) was the most commonly used MCS (9.1%). From 2008 to 2014, there was significant increase in the utilization of MCS (8.7-11%; p trend  < 0.0001). On multivariable analysis, there was 12-fold increase and three-fold increase in the utilization of PVAD and ECMO respectively; however, there was no significant change in the use of IABP. Over the seven-year sample period, there was significant increase in the overall survival to hospital discharge (35.4-43.5%; p trend  < 0.0001). Survival to hospital discharge increased in both MCS and non-MCS groups., Conclusion: There was significant increase in utilization of MCS after VT/VF IHCA during the study period. IABP was the most commonly utilized MCS. The survival to hospital discharge increased in the overall study population including both MCS and non-MCS groups. Future studies are needed to identify patient population most likely to benefit from the use of MCS after VT/VF IHCA., (© 2019 Wiley Periodicals, Inc.)

Cardiogenic shock (CS) is associated with high morbidity and mortality despite recent advances in the temporary mechanical circulatory support (MCS) devices. The current utilization and outcomes of these MCS devices with or without vasopressors compared with conventional medical therapy (no-MCS) in CS remain poorly described. The study population was extracted from the 2014 Nationwide Readmissions Database using International Classification of Diseases, Ninth Revision, Clinical Modification codes for CS, temporary MCS devices, and vasopressor infusion. Study end points included in-hospital all-cause mortality, length of index hospital stay (LOS), the likelihood of receiving invasive treatment, postprocedural bleeding, vascular complications, total hospitalization charges, and discharge disposition. A total of 59,148 discharges with a diagnosis of CS were identified (age 67 years; 38.5% female). Temporary MCS devices were utilized in 22.7%. The use of these devices was associated with lower in-hospital all-cause mortality (33.0% vs 39.7%, p <0.01), increased likelihood of invasive therapy (75.7% vs 26.3%, p <0.01), and increased likelihood of being discharged home (24.8% vs 20.6%, p <0.01). However, the MCS group had longer LOS (16.9 vs 12.1 days, p <0.01), higher vascular complications (2.6% vs 1.4%, p <0.01), bleeding (31.2% vs 16.8%, p <0.01), and total hospitalization charges ($374,574 vs $182,045, p <0.01). In conclusion, the use of the temporary MCS devices for the treatment of CS was associated with lower mortality, increased the likelihood of receiving invasive treatment and the likelihood of being discharged home. However, it was associated with higher in-hospital complications, LOS, and hospitalization charges., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The objective of this study was to do an in vitro evaluation of venous line pressure using different venous line lengths and venous cannula sizes in pediatric venoarterial extracorporeal life support (VA-ECLS) and venovenous ECLS (VV-ECLS) circuits. The pediatric VA-ECLS circuit consisted of a Xenios i-cor diagonal pump, a Maquet Quadrox-i pediatric oxygenator, a Medtronic Biomedicus arterial cannula, a Biomedicus venous cannula, and 1/4″ ID arterial and venous tubing. The pediatric VV-ECLS circuit was similar, except it included a Maquet Avalon ELITE bi-caval dual lumen cannula. Circuits were primed with lactated Ringer's solution and packed red blood cells (hematocrit 40%). Trials were conducted at various flow rates (VA-ECLS: 250-1250 mL/min, VV-ECLS: 250-2000 mL/min) using different venous tubing lengths (2, 4, and 6 feet) and cannula sizes (VA-ECLS: A8Fr/V10Fr, A10Fr/V12Fr and A12Fr/V14Fr, VV-ECLS: 13Fr, 16Fr, 19Fr, 20Fr and 23Fr) at 36°C. Real-time pressure and flow data were recorded for analysis. The use of a small-caliber venous cannula significantly increased the venous line pressure in the 2 pediatric circuits (P < 0.01). Shorter venous tubing lengths significantly reduced the venous line pressure at high flow rates (P < 0.01). The VV-ECLS circuit had larger negative pre-pump pressure drops (7.2 to -102.2 mm Hg) when compared to the VA-ECLS circuit (0.7 to -60.7 mm Hg). Selecting an appropriate venous cannula and a shorter venous tubing when feasible may significantly reduce the pressure drop of the venous line in pediatric VA-ECLS and VV-ECLS circuits and improve venous drainage., (© 2019 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Ambulation while on extracorporeal membrane oxygenation (ECMO) is critical to facilitate native pulmonary recovery for patients with acute respiratory failure and is a prerequisite for listing for lung transplantation to achieve optimal outcomes. The development of a bicaval dual-lumen cannula capable of providing venovenous (VV) ECMO support via the internal jugular vein has greatly facilitated ambulation and rehabilitation programs. But cannula dislodgement is a serious concern with ambulation and rehabilitation, especially when minor cannula migration can significantly impact VV-ECMO flow. We review an optimal technique to secure dual-lumen cannula to facilitate early mobility, ambulation, and rehabilitation and prevent ECMO cannula dislodgement.

Venoarterial extracorporeal membrane oxygenation (VA ECMO) is an effective mechanical circulatory support for cardiopulmonary failure. Conventionally, an arterial cannula over 15 Fr is inserted for full circulatory support in peripheral VA ECMO. However, limited data are available regarding the impact of cannula size on clinical and procedural outcomes. Between January 2014 and April 2016, 165 patients underwent peripheral VA ECMO with femoral artery cannulation were enrolled in a single-center registry. We classified patients into two groups according to the arterial cannula's size: "small cannula group" (14-15 Fr, n = 87) and "large cannula group" (16-21 Fr, n = 78). We compared the clinical outcomes and procedural-related complications between the two groups. Neither the survival to discharge (51.7% in the small cannula group vs. 57.7% in the large cannula group; p = 0.44) nor the weaning success rate (70.1% vs. 64.1%; p = 0.41) was significantly different between the two groups. There was no significant difference in initial ECMO flow/body surface area between the two groups (1.86 ± 0.42 vs. 1.98 ± 0.49 L/min/m; p = 0.12) although small cannula group had a numerically low value. The small cannula group showed significantly shorter ECMO duration time (2.6 [0.7-5.2] vs. 4.0 [1.3-7.8] day; p < 0.01). Also, lower limb ischemia was significantly lower in the small cannula group (4.6% vs. 15.4%; p = 0.02). In peripheral VA ECMO, as compared with the large cannula strategy, the small arterial cannula strategy showed similar clinical outcomes and a decrease in lower limb ischemia.

B-mode ultrasound imaging guidance of cannulas can be compromised by noise, artifacts, and echogenicity that is not distinctive from that of surrounding anatomy. We have modified a venovenous extracorporeal membrane oxygenation cannula by embedding piezoelectric crystals into each of its 3 blood flow ports. Each vibrating crystal acoustically interacts with a Doppler imaging signal and produces an instantaneous color marker. The aim of this study was to compare identification of the extracorporeal membrane oxygenation cannula ports by B-mode imaging versus the color Doppler marker. Unlike B-mode imaging, the color Doppler marker identified the corresponding port even in highly challenging closed-chest scans in anesthetized pigs. The method could improve guidance accuracy of cannulas by ultrasound scans., (© 2018 by the American Institute of Ultrasound in Medicine.)

Background: Ventricular septal defect (VSD) is a lethal complication of acute myocardial infarction (AMI) and is often associated with cardiogenic shock. The optimal form of percutaneous mechanical circulatory support (MCS) for AMI-VSD is unknown., Methods and Results: We used a previously validated cardiovascular model to simulate AMI-VSD with parameters adjusted to replicate average hemodynamics reported in the literature, including a pulmonary-to-systemic blood flow ratio of 3.0. We then predicted effects of different types of percutaneous MCS (including intra-aortic balloon pumping, Impella, TandemHeart, and extracorporeal membrane oxygenation) on pressures and flows throughout the cardiovascular system. The simulation replicated all major hemodynamic parameters reported in the literature with AMI-VSD. Inotropes and vasopressors worsened left-to-right shunting, whereas vasodilators decreased shunting at the expense of worsening hypotension. All MCS devices increased forward blood flow and arterial pressure but other effects varied among devices. Impella 5.0 provided the greatest degree of pulmonary capillary wedge pressure reductions and decreased left-to-right shunting. Extracorporeal membrane oxygenation worsened pulmonary capillary wedge pressure and shunting, which could be improved by adding Impella or passive left ventricular vent. Pulmonary-to-systemic blood flow ratio could not be reduced below 2.0, and pulmonary flows remained high with all forms of MCS., Conclusions: Although no form of percutaneous MCS normalized hemodynamics in AMI-VSD, pulmonary capillary wedge pressure and shunting were worsened by extracorporeal membrane oxygenation and improved by Impella. Accordingly, based on hemodynamics alone, Impella provides the optimal form of support in AMI-VSD. However, other factors, including team experience, device availability, potential for tissue ingestion, and clinical characteristics, need to be considered when choosing a percutaneous MCS device for AMI-VSD.

Extracorporeal membrane oxygenation (ECMO) has been increasingly used in the treatment of refractory cardiac arrest and postarrest cardiogenic shock. We propose a technique for percutaneous decannulation of femoral venoarterial ECMO cannulas by using the MANTA vascular closure device, designed to close large-bore arteriotomies. This technique significantly simplifies the decannulation and might diminish the potential complications caused by the standard surgical removal., (Copyright © 2019 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Emergent implantation of temporary mechanical circulatory support using venoarterial ECMO (ECLS for extracorporeal Life Support) is increasingly adopted in various indications of acute circulatory failure refractory to optimal medical treatment. To implant such devices, but also to provide appropriate daily management, expertise and adapted technical platform are required. Organization, coordination and regulation of such program are not clearly established in our country. We propose a dedicated territorial organization to improve and facilitate management of these specific and most severe patients., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Introduction: Veno-arterial extracorporeal membrane oxygenation after heart surgery is a relatively common procedure. It is easily applicable but associated with a number of complications, including bloodstream infections. The aim of this study is to determine the current rate and the risk factors related to bloodstream infections acquired during post-cardiotomy veno-arterial extracorporeal membrane oxygenation., Methods: Single-center retrospective study. From the overall population receiving any kind of extracorporeal membrane oxygenation from March 2013 through December 2017, the post-cardiotomy patient population was extracted, with a final sample of 92 veno-arterial extracorporeal membrane oxygenations. The risk of developing bloodstream infections as a function of extracorporeal membrane oxygenation exposure was analyzed with appropriate statistical analyses, including a Kaplan-Meier analysis., Results: Overall, 14 (15.2%) patients developed a bloodstream infection during extracorporeal membrane oxygenation or within the first 48 h after extracorporeal membrane oxygenation removal. The total extracorporeal membrane oxygenation duration in the population was 567 days, and the incidence of bloodstream infections was 24.7 bloodstream infections/1000 extracorporeal membrane oxygenation days. There was a progressive increase in the cumulative hazard ratio during the first 7 days, reaching a value of 20% on day 7; from day 7 and day 15, the hazard ratio remained stable, with a second increase after day 15. The independent risk factors associated with bloodstream infections were adult age, pre-implantation serum total bilirubin level, and the amount of chest drain blood loss., Discussion: Infections acquired during veno-arterial extracorporeal membrane oxygenation are common. Identify the risk factors that may improve strategies for treatment and prevention.

Purpose: We describe the use of liposomal amphotericin B and amphotericin B deoxycholate in a critically ill patient with pulmonary blastomycosis receiving both venovenous extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT)., Summary: A 50-year-old African American man presented for dyspnea and cough and was noted to have blastomycosis on bronchoscopy. He developed respiratory failure and acute kidney injury, requiring mechanical ventilation, ECMO, and CRRT. After 4 days of liposomal amphotericin, the transmembrane pressure gradient on the membrane oxygenator increased dramatically without visualization of a clot, requiring a circuit exchange. A trough amphotericin B level taken the day before the exchange was undetectable for amphotericin B. After the circuit exchange, the patient was switched to amphotericin B deoxycholate. A subsequent trough level was 3.8 μg/mL. The patient improved and was able to be decannulated. However, he did require tracheostomy and long-term hemodialysis., Conclusion: In our case we believe that liposomal amphotericin B was significantly removed by ECMO and was responsible for the failure of the ECMO circuit. We would suggest amphotericin B deoxycholate be used in such patients preferentially and that serum levels of the drug be assessed when possible., (© American Society of Health-System Pharmacists 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Patients on extracorporeal membrane oxygenation are frequently in need for sedation. Use of propofol has been associated with impaired oxygenator function due to adsorption to the membrane as well as lipid load. The aim of our retrospective analysis was to compare two different sedation regimens containing either propofol or midazolam with respect to oxygenator running time., Methods: Midazolam was used in 73 patients whereas propofol was used in 49 patients, respectively. In the propofol group, veno-arterial-extracorporeal membrane oxygenation was used predominantly (84%), while veno-venous-extracorporeal membrane oxygenation was used more often in the midazolam group (64%)., Results: Oxygenator running time until first exchange was 7 days in both groups ( p = 0.759). No statistically significant differences could be observed between the subgroup of patients receiving lipid-free (n = 24) and lipid-containing (n = 31) parenteral nutrition, respectively. Laboratory parameters like triglycerides, free hemoglobin, fibrinogen, platelets, and activated partial thromboplastin time were not significantly different between both sedation regimens ( p = 0.462, p = 0.489, p = 0.960, p = 0.134, and p = 0.843) and were not associated with oxygenator running time., Conclusion: The use of propofol as sedative seems suitable in patients undergoing extracorporeal membrane oxygenation therapy.

Purpose: We assessed feasibility and safety of extracorporeal carbon dioxide removal (ECCO 2 R) to facilitate ultra-protective ventilation (V T 4 mL/kg and P PLAT  ≤ 25 cmH 2 O) in patients with moderate acute respiratory distress syndrome (ARDS)., Methods: Prospective multicenter international phase 2 study. Primary endpoint was the proportion of patients achieving ultra-protective ventilation with PaCO 2 not increasing more than 20% from baseline, and arterial pH > 7.30. Severe adverse events (SAE) and ECCO 2 R-related adverse events (ECCO 2 R-AE) were reported to an independent data and safety monitoring board. We used lower CO 2 extraction and higher CO 2 extraction devices (membrane lung cross-sectional area 0.59 vs. 1.30 m 2 ; flow 300-500 mL/min vs. 800-1000 mL/min, respectively)., Results: Ninety-five patients were enrolled. The proportion of patients who achieved ultra-protective settings by 8 h and 24 h was 78% (74 out of 95 patients; 95% confidence interval 68-89%) and 82% (78 out of 95 patients; 95% confidence interval 76-88%), respectively. ECCO 2 R was maintained for 5 [3-8] days. Six SAEs were reported; two of them were attributed to ECCO 2 R (brain hemorrhage and pneumothorax). ECCO 2 R-AEs were reported in 39% of the patients. A total of 69 patients (73%) were alive at day 28. Fifty-nine patients (62%) were alive at hospital discharge., Conclusions: Use of ECCO 2 R to facilitate ultra-protective ventilation was feasible. A randomized clinical trial is required to assess the overall benefits and harms. CLINICALTRIALS.GOV: NCT02282657.

Respiratory failure is a significant problem within the pediatric population. A means of respiratory support that readily allows ambulation could improve treatment. The Pittsburgh Pediatric Ambulatory Lung (P-PAL) is being developed as a wearable pediatric pump-lung for long-term respiratory support and has previously demonstrated positive benchtop results. This study aimed to evaluate acute (4-6 hours) in vivo P-PAL performance, as well as develop an optimal implant strategy for future long-term studies. The P-PAL was connected to healthy sheep (n = 6, 23-32 kg) via cannulation of the right atrium and pulmonary artery. Plasma-free hemoglobin (PfHb) and animal hemodynamics were measured throughout the study. Oxygen transfer rates were measured at blood flows of 1-2.5 L/min. All animals survived the complete study duration with no device exchanges. Flow limitation because of venous cannula occlusion occurred in trial 2 and was remedied via an altered cannulation approach. Blood exiting the P-PAL had 100% oxygen saturation with the exception of trial 4 during which inadequate device priming led to intrabundle clot formation. Plasma-free hemoglobin remained low (<20 mg/dl) for all trials. In conclusion, this study demonstrated successful performance of the P-PAL in an acute setting and established the necessary methods for future long-term evaluation.

Femoral cannulation is a minimally invasive method which is an alternative method for central cannulation. This review focuses on the parameters and features of the available peripheral cannulas. Nowadays there exist many peripheral cannulas in a variety of sizes, configurations and lengths to meet the specific needs of the patients. Modern cannulas are strong, thin-walled and one piece reinforced constructions. Furthermore, modern cannulas are manufactured from a biocompatible material and surface coatings are applied to the cannulas to reduce the activation of the clotting. When peripheral cannulas are applied, bleeding, thrombosis and hemolysis are the most common complications.

Adequate extracorporeal membrane oxygenation support in the adult requires cannulae permitting blood flows up to 6-8 L/minute. In accordance with Poiseuille's law, flow is proportional to the fourth power of cannula inner diameter and inversely proportional to its length. Poiseuille's law can be applied to obtain the pressure drop of an incompressible, Newtonian fluid (such as water) flowing in a cylindrical tube. However, as blood is a pseudoplastic non-Newtonian fluid, the validity of Poiseuille's law is questionable for prediction of cannula properties in clinical practice. Pressure-flow charts with non-Newtonian fluids, such as blood, are typically not provided by the manufacturers. A standardized laboratory test of return (arterial) cannulae for extracorporeal membrane oxygenation was performed. The aim was to determine pressure-flow data with human whole blood in addition to manufacturers' water tests to facilitate an appropriate choice of cannula for the desired flow range. In total, 14 cannulae from three manufacturers were tested. Data concerning design, characteristics, and performance were graphically presented for each tested cannula. Measured blood flows were in most cases 3-21% lower than those provided by manufacturers. This was most pronounced in the narrow cannulae (15-17 Fr) where the reduction ranged from 27% to 40% at low flows and 5-15% in the upper flow range. These differences were less apparent with increasing cannula diameter. There was a marked disparity between manufacturers. Based on the measured results, testing of cannulae including whole blood flows in a standardized bench test would be recommended.

The use of extracorporeal life support devices such as extracorporeal membrane oxygenation in adults requires cannulation of the patient's vessels with comparatively large diameter cannulae to allow circulation of large volumes of blood (>5 L/min). The cannula diameter and length are the major determinants for extracorporeal membrane oxygenation flow. Manufacturing companies present pressure-flow charts for the cannulae; however, these tests are performed with water. Aims of this study were 1. to investigate the specified pressure-flow charts obtained when using human blood as the circulating medium and 2. to support extracorporeal membrane oxygenation providers with pressure-flow data for correct choice of the cannula to reach an optimal flow with optimal hydrodynamic performance. Eighteen extracorporeal membrane oxygenation drainage cannulae, donated by the manufacturers (n = 6), were studied in a centrifugal pump driven mock loop. Pressure-flow properties and cannula features were described. The results showed that when blood with a hematocrit of 27% was used, the drainage pressure was consistently higher for a given flow (range 10%-350%) than when water was used (data from each respective manufacturer's product information). It is concluded that the information provided by manufacturers in line with regulatory guidelines does not correspond to clinical performance and therefore may not provide the best guidance for clinicians.

Sedatives are administered during extracorporeal membrane oxygenation (ECMO) therapy to ensure patient safety, reduce the metabolic rate and correct the oxygen supply-demand balance. However, the concentrations of sedatives can be decreased due to absorption into the circuit. This study examined factors affecting the absorption of a commonly used sedative, midazolam (MDZ). Using multiple ex vivo simulation models, three factors that may influence MDZ levels in the ECMO circuit were examined: polyvinyl chloride (PVC) tubing in the circuit, use of a membrane oxygenator in the circuit, and heparin coating of the circuit. We also assessed changes in drug concentration when MDZ was re-injected in a circuit. The MDZ level decreased to approximately 60% of the initial concentration in simulated circuits within the first 30 minutes. The strongest factor in this phenomenon was contact with the PVC tubing. Membrane oxygenator use tended to increase MDZ loss, whereas heparin circuit coating had no influence on MDZ absorption. Similar results were obtained when a second dose of MDZ was injected to the second-use circuits., Competing Interests: No potential conflict of interest relevant to this article was reported.

Introduction: Patients under the error-prone and complication-burdened extracorporeal membrane oxygenation (ECMO) are looked after by a highly trained, multidisciplinary team. Simulation-based training (SBT) affords ECMO centers the opportunity to equip practitioners with the technical dexterity required to manage emergencies. The aim of this article is to review ECMO SBT activities and technology followed by a novel solution to current challenges., Ecmo Simulation: The commonly-used simulation approach is easy-to-build as it requires a functioning ECMO machine and an altered circuit. Complications are simulated through manual circuit manipulations. However, scenario diversity is limited and often lacks physiological and/or mechanical authenticity. It is also expensive to continuously operate due to the consumption of highly specialized equipment., Technological Aid: Commercial extensions can be added to enable remote control and to automate circuit manipulation, but do not improve on the realism or cost-effectiveness., A Modular Ecmo Simulator: To address those drawbacks, we are developing a standalone modular ECMO simulator that employs affordable technology for high-fidelity simulation.

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2019. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2019 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901 .

Introduction: Extracorporeal membrane oxygenation (ECMO) training programs employ real ECMO components, causing them to be extremely expensive while offering little realism in terms of blood oxygenation and pressure. To overcome those limitations, we are developing a standalone modular ECMO simulator that reproduces ECMO's visual, audio and haptic cues using affordable mechanisms. We present a central component of this simulator, capable of visually reproducing blood oxygenation color change using thermochromism., Methods: Our simulated ECMO circuit consists of two physically distant modules, responsible for adding and withdrawing heat from a thermochromic fluid. This manipulation of heat creates a temperature difference between the fluid in the drainage line and the fluid in the return line of the circuit and, hence, a color difference., Results: Thermochromic ink mixed with concentrated dyes was used to create a recipe for a realistic and affordable blood-colored fluid. The implemented "ECMO circuit" reproduced blood's oxygenation and deoxygenation color difference or lack thereof. The heat control circuit costs 300 USD to build and the thermochromic fluid costs 40 USD/L. During a ten-hour in situ demonstration, nineteen ECMO specialists rated the fidelity of the oxygenated and deoxygenated "blood" and the color contrast between them as highly realistic., Conclusions: Using low-cost yet high-fidelity simulation mechanisms, we implemented the central subsystem of our modular ECMO simulator, which creates the look and feel of an ECMO circuit without using an actual one.

Objective: To evaluate risk factors for hemolysis in pediatric extracorporeal life support., Design: Retrospective, single-center study., Setting: Pediatric intensive care unit., Patients: Two hundred thirty-six children who received extracorporeal membrane oxygenation., Interventions: None., Measurements and Main Results: Risk factors for hemolysis were retrospectively analyzed from a single center in a total of 236 neonatal and pediatric patients who received extracorporeal membrane oxygenation support (ECMO). There was no difference in the incidence of hemolysis between centrifugal (127 patients) and roller head (109 patients) pump type or between venoarterial and venovenous ECMO. High hemoglobin (Hb) was found to be an independent risk factor for hemolysis in both pump types. The Hb level >12 g/dL was significant in the roller group and the Hb level >13 g/dL was significant in the centrifugal group for the development of hemolysis for the cumulative ECMO run. The presence of high Hb levels on any given day increased the risk of hemolysis for that day of the ECMO run regardless of ECMO pump type. Higher revolutions per minute (RPMs) and higher inlet pressures on any given day increased the risk for the development of hemolysis in the centrifugal pump. Lower inlet venous pressures and RPMs were not associated with hemolysis in the roller group., Conclusions: An Hb level greater than 13 g/dL was associated with an increased risk of hemolysis, and a high Hb on a given day was associated with a significantly higher risk of hemolysis on the same day. Higher RPMs and lower inlet venous pressures were associated with an increased risk of hemolysis in the centrifugal pump only.

Extracorporeal membrane oxygenation (ECMO) is used for cardiopulmonary dysfunction. Hepatopulmonary syndrome (HPS) occurs in the setting of liver failure and may cause hypoxemia. Previous reports have described the use of ECMO for HPS after liver transplant. Our patient is a 19-month-old female with biliary atresia, an interrupted inferior vena cava, and HPS on 8 liters per minute of high-flow oxygen. Following liver transplantation, her postoperative course was complicated by severe hypoxemia requiring ECMO. Due to her interrupted inferior vena cava, our standard bi-caval cannula could not be used. Hence, a 16-French double lumen venovenous right internal jugular to right atrial cannula was used to provide extracorporeal life support. She was decannulated after 17 days, remained intubated for 2 days, and weaned to room air over the next 3 weeks. This is the third pediatric liver transplant patient supported with ECMO identified in the literature, and the youngest and smallest of those reported. This approach to cannulation is unique because of the use of a double lumen venovenous cannula for HPS in a child, selected due to complex anatomy. Posttransplant ECMO may provide pediatric patients with HPS and posttransplant hypoxemia a period of support for their pulmonary remodeling and recovery from HPS.

In recent years, there have been substantial advancements in the development of different technologies for extracorporeal membrane oxygenation (ECMO) for in-hospital and out of hospital applications. However the effectiveness of these devices is not clearly known. The objective of this study was to evaluate the cost-effectiveness of Cardiohelp compared to other portable ECMO devices. In this systematic review, we searched Medline (via Ovid), Embase, Pubmed, Cochrane Library, SCOPUS, CRD and NICE. Articles were assessed by two independent reviewers for eligibility and quality of the evidence. Studies which compared Cardiohelp to other ECMO devices were included. Seven out of 1316 publication were included in this review, three of them were clinical trials and four were observational studies. The majority of the studies had limited quality. According to the measures of safety, Cardiohelp had safer technological features, but on the other hand, was more complex to use. Considering the effectiveness, Cardiohelp was not statistically different from other technologies. Cardiohelp showed slightly better performance than Centrimag in terms of cost per patient and cost-effectiveness. However, when clinical criteria were used to select the patients with good prognosis to administer the ECMO, incremental cost utility ratios (ICURs) for both Cardiohelp and Centrimag were below the level of willingness-to-pay threshold. According to the measures of safety and effectiveness, ECMO with Cardiohelp was not considerably different from other evaluated technologies. Moreover, ECMO with Cardiohelp or Centrimag can be considered cost-effective, provided that the patients are selected carefully in terms of neurological outcomes.