Search

Background: Stress cardiomyopathy (SCM) is an acute heart failure syndrome characterized by transient, usually reversible left ventricular systolic dysfunction with normal or enhanced basal compensatory wall motion abnormalities involving the left ventricular anterior septum and apex, resulting in a "ballooning" appearance. However, it has rarely been reported in patients undergoing spinal surgery. Case presentation: We report a case of severe stress cardiomyopathy in a scoliosis patient with pectus excavatum who underwent spinal corrective surgery. During the wake-up period, circulatory collapse occurred. After multidisciplinary consultation, the patient was diagnosed with stress cardiomyopathy. At last, she had a good prognosis after a series of treatments including ECMO. Conclusion: Stress cardiomyopathy is a reversible but uncommon condition. It can cause death if it is not diagnosed in time. Consequently, this report should improve the awareness of orthopedists and anesthesiologists for timely identification and management. For patients with potential risk factors, timely preoperative intervention should be performed to reduce the occurrence of stress cardiomyopathy. [ABSTRACT FROM AUTHOR]

In veno-arterial extracorporeal membrane oxygenation (VA-ECMO) treatment, the mixing zone is a key hemodynamic factor that determines the efficacy of the treatment. This study aimed to evaluate the applicability of a novel ultrasound technique called vector flow imaging (VFI) for visualizing complex flow patterns in an aorta phantom under VA-ECMO settings. VFI experiments were performed to image aortic hemodynamics under VA-ECMO treatment simulated in an anthropomorphic thoracic aorta phantom using a pulsatile pump (cardiac output: 2.7 L/min) and an ECMO pump with two different flow rates, 0.35 L/min and 1.0 L/min. The cardiac cycle of hemodynamics in the ascending aorta, aortic arch, and descending aorta was visualized, and the spatio-temporal dynamics of flow vectors were analyzed. VFI successfully visualized dynamic flow patterns in the aorta phantom. When the flow rate of the ECMO pump increased, ECMO flow was more dominant than cardiac output in the diastole phase, and the speed of cardiac output was suppressed in the systole phase. Vortex flow patterns were also detected in the ascending aorta and the arch under both ECMO flow rate conditions. The VFI technique may provide new insights into aortic hemodynamics and facilitates effective and safe VA-ECMO treatment. [ABSTRACT FROM AUTHOR]

Aims: Veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) with profound left ventricular (LV) failure is associated with inadequate LV emptying. To unload the LV, VA‐ECMO can be combined with Impella CP (ECMELLA). We hypothesized that ECMELLA improves cardiac energetics compared with VA‐ECMO in a porcine model of cardiogenic shock (CS). Methods and results: Land‐race pigs (weight 70 kg) were instrumented, including a LV conductance catheter and a carotid artery Doppler flow probe. CS was induced with embolization in the left main coronary artery. CS was defined as reduction of ≥50% in cardiac output or mixed oxygen saturation (SvO2) or a SvO2 < 30%. At CS VA‐ECMO was initiated and embolization was continued until arterial pulse pressure was <10 mmHg. At this point, Impella CP was placed in the ECMELLA arm. Support was maintained for 4 h. CS was induced in 15 pigs (VA‐ECMO n = 7, ECMELLA n = 8). At time of CS MAP was <45 mmHg in both groups, with no difference at 4 h (VA‐ECMO 64 mmHg ± 11 vs. ECMELLA 55 mmHg ± 21, P = 0.08). Carotid blood flow and arterial lactate increased from CS and was similar in VA‐ECMO and ECMELLA [239 mL/min ± 97 vs. 213 mL/min ± 133 (P = 0.6) and 5.2 ± 3.3 vs. 4.2 ± 2.9 mmol/ (P = 0.5)]. Pressure‐volume area (PVA) was significantly higher with VA‐ECMO compared with ECMELLA (9567 ± 1733 vs. 6921 ± 5036 mmHg × mL/min × 10−3, P = 0.014). Total diureses was found to be lower in VA‐ECMO compared with ECMELLA [248 mL (179–930) vs. 506 mL (418–2190); P = 0.005]. Conclusions: In a porcine model of CS, we found lower PVA, with the ECMELLA configuration compared with VA‐ECMO, indicating better cardiac energetics without compromising systemic perfusion. [ABSTRACT FROM AUTHOR]

Introduction: High-risk procedures in interventional cardiology include a wide spectrum of clinical and anatomical scenarios related to a higher periprocedural morbidity and mortality. The prophylactic use of short-term mechanical circulatory support (ST-MCS) may improve both the safety and efficacy of the intervention by leading to more stable procedural hemodynamics. However, the significant costs may limit its use in resource constrained settings. To overcome this limitation, we ideated a modified, low-cost, veno-arterial extracorporeal membrane oxygenator (V-A ECMO) setup. Methods: We conducted an observational prospective study including all patients undergoing a high-risk interventional cardiology procedure at our institution under prophylactic ST-MCS using a modified, low-cost version of V-A ECMO, where some components of the standard V-A ECMO circuit were replaced by supplies used for cardiac surgical cardiopulmonary bypass, achieving a cost reduction of 72%. We assessed in-hospital and mid-term outcomes, including procedural success, post-procedure complications and mortality. Results: Between March 2016 and December 2021, ten patients underwent high-risk IC procedures with prophylactic use of V-A ECMO. Isolated percutaneous intervention (PCI) was performed in six patients, isolated transcatheter aortic valve replacement (TAVR) in two, and a combined procedure (PCI + TAVR) in two. Mean ejection fraction was 34% (range 20–64%). Mean STS PROM was 16.2% (range 9.5–35.8%) and mean EuroScore was 23.7% (range 1.5–60%). The planned intervention was successfully performed in all cases. There were no reports of V-A ECMO malfunction. In nine patients the VA-ECMO was withdrawn immediately after the procedure but one patient required extended - 24 h - support with no significant issues. One patient experienced a periprocedural myocardial infarction and another developed a femoral pseudoaneurysm. In-hospital and 30-day survival were 100%, and 1-year survival was 80%. Conclusions: High-risk procedures in interventional cardiology can be successfully performed under prophylactic ST-MCS using a modified, low-cost V-A ECMO, suitable for limited-resource settings. [ABSTRACT FROM AUTHOR]

Aims Cardiogenic shock (CS) develops in up to 10% of patients with acute myocardial infarction (AMI) and carries a 50% risk of mortality. Despite the paucity of evidence regarding its benefits, venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used in clinical practice in patients with AMI in CS (AMI-CS). This review aims to provide an in-depth description of the four available randomized controlled trials to date designed to evaluate the benefit of VA-ECMO in patients with AMI-CS. Methods and results The literature search was conducted on PubMed, Google Scholar, and clinicaltrials.gov to identify the four relevant randomized control trials from years of inception to October 2023. Despite differences in patient selection, nuances in trial conduction, and variability in trial endpoints, all four trials (ECLS-SHOCK I, ECMO-CS, EUROSHOCK, and ECLS-SHOCK) failed to demonstrate a mortality benefit with the use of VA-ECMO in AMI-CS, with high rates of device-related complications. However, the outcome of these trials is nuanced by the limitations of each study that include small sample sizes, challenging patient selection, and high cross-over rates to the intervention group, and lack of use of left ventricular unloading strategies. Conclusion The presented literature of VA-ECMO in CS does not support its routine use in clinical practice. We have yet to identify which subset of patients would benefit most from this intervention. This review emphasizes the need for designing adequately powered trials to properly assess the role of VA-ECMO in AMI-CS, in order to build evidence for best practices. [ABSTRACT FROM AUTHOR]

Abstract Aims Veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) with profound left ventricular (LV) failure is associated with inadequate LV emptying. To unload the LV, VA‐ECMO can be combined with Impella CP (ECMELLA). We hypothesized that ECMELLA improves cardiac energetics compared with VA‐ECMO in a porcine model of cardiogenic shock (CS). Methods and results Land‐race pigs (weight 70 kg) were instrumented, including a LV conductance catheter and a carotid artery Doppler flow probe. CS was induced with embolization in the left main coronary artery. CS was defined as reduction of ≥50% in cardiac output or mixed oxygen saturation (SvO2) or a SvO2

With advancements in extracorporeal life support (ECLS) technologies, venoarterial extracorporeal membrane oxygenation (VA-ECMO) has emerged as a crucial cardiopulmonary support mechanism. This review explores the significance of VA-ECMO system configuration, cannulation strategies, and timing of initiation. Through an analysis of medication management strategies, complication management, and comprehensive preweaning assessments, it aims to establish a multidimensional evaluation framework to assist clinicians in making informed decisions regarding weaning from VA-ECMO, thereby ensuring the safe and effective transition of patients. [ABSTRACT FROM AUTHOR]

BACKGROUND: Clinical assessment and laboratory markers provide valuable information on tissue perfusion and enhance the optimalisation of management in the treatment of patients on extracorporeal membrane oxygenation (ECMO). The PCO2 gap is a reliable marker of cardiac output (CO) and perfusion. The aim of this study was to evaluate the PCO2 gap as a marker of tissue hypoperfusion and to compare it to lactate and SvO². METHODS: A single-center retrospective study on 131 adult cardiac patients who underwent ECMO implantation in the period between 2010 and 2021. Baseline characteristics, laboratory markers and mortality were analyzed. RESULTS: There was a statistically significant difference in the plasmatic levels of lactate, SvO2 and PCO2 gap between patients that survived and those who died post ECMO implantation (3.6±3.29 vs 7.15±7.38 mmol/l, p<0.001; 69.13±9 vs 67.38±10%, p<0.001; 7.65±2.93 vs 8.34±3.71, p<0.001 respectively). There was a statistically significant difference in PCO2 gap in the first 5 arterial blood gas (ABG) samples post ECMO implantation between patients that survived and those who died (9.08±4.79 vs 10.37±5.35, p<0.003). For SvO2, this difference was not statistically significant (69.82±11.91 vs 68.51±11.72, p<0.104). There was a statistically significant but low negative correlation between SvO2 and PCO2 gap post ECMO implantation (r = -0.354, p<0.001). CONCLUSION: The PCO2 gap is a valuable biomarker for monitoring tissue perfusion in patients on ECMO. It is associated with increased mortality and should be an integral part of clinical evaluation. [ABSTRACT FROM AUTHOR]

This review summarizes the current evidence regarding efficacy and safety of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in the setting of cardiogenic shock. Currently, there is evidence from 4 randomized controlled trials which all do not support a mortality benefit and increased complication rates by VA-ECMO. Based on current evidence, possible subgroups will be discussed and indications in selected very small patient groups be discussed. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Diagnosing FES is difficult and time‐consuming, and identify FES as an etiology of right ventricular volume overload for early diagnosis. Because FES is a reversible condition, even severe cases can be treated if the patient survives the acute phase. [ABSTRACT FROM AUTHOR]

In severe COVID-19-related respiratory failure, extracorporeal membrane oxygenation (ECMO) is a useful modality that is used to provide effective oxygenation and ventilation to the patient. This descriptive study aimed to investigate and compare the outcomes between COVID-19-infected patients and patients who were not infected and required ECMO support. A retrospective study was undertaken on a cohort of 82 adult patients ([Formula: see text]18-year-old) who required venoarterial (VA-ECMO) and venovenous (VV-ECMO) ECMO between January 2019 and December 2022 in a single academic center. Patients who were cannulated for COVID-19-related respiratory failure (C-group) were compared to patients who were cannulated for non-COVID etiologies (non-group). Patients were excluded if data were missing regarding cannulation, decannulation, presenting diagnosis, and survival status. Categorical data were reported as counts and percentages, and continuous data were reported as means with 95% confidence intervals. Out of the 82 included ECMO patients, 33 (40.2%) were cannulated for COVID-related reasons, and 49 (59.8%) were cannulated for reasons other than COVID-19 infection. Compared to the non-group, the C-group had a higher in-hospital (75.8% vs. 55.1%) and overall mortality rate (78.8% vs. 61.2%). The C-group also had an average hospital length of stay (LOS) of 46.6 ± 13.2 days and an average intensive care unit (ICU) LOS of 44.1 ± 13.3 days. The non-group had an average hospital LOS of 24.8 ± 6.6 days and an average ICU LOS of 20.8 ± 5.9 days. Subgroup analysis of patients only treated with VV-ECMO yielded a greater in-hospital mortality rate for the C-group compared to the non-group (75.0% vs. 42.1%). COVID-19-infected patients may experience different morbidity and mortality rates as well as clinical presentations compared to non-COVID-infected patients when requiring ECMO support.

ObjectiveVeno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a critical support technique for cardiac surgery patients. This study compares the outcomes of femoral artery cannulation vs. combined femoral and axillary artery cannulation in post-cardiotomy VA-ECMO patients. This study aimed to compare the clinical outcomes of critically ill patients post-cardiac surgery under VA-ECMO support using different cannulation strategies. Specifically, the focus was on the impact of femoral artery (FA) cannulation vs. combined femoral artery and axillary artery (FA+AA) cannulation on patient outcomes.MethodsThrough a retrospective analysis, we compared 51 adult patients who underwent cardiac surgery and received VA-ECMO support based on the cannulation strategy employed—FA cannulation in 27 cases vs. FA+AA cannulation in 24 cases.ResultsThe FA+AA group showed significant advantages over the FA group in terms of the incidence of chronic renal failure (CRF) (37.50% vs. 14.81%, p = 0.045), preoperative blood filtration requirement (37.50% vs. 11.11%, p = 0.016), decreased platelet count (82.67 ± 44.95 vs. 147.33 ± 108.79, p = 0.014), and elevated creatinine (Cr) levels (151.80 ± 60.73 vs. 110.26 ± 57.99, p = 0.041), although the two groups had similar 30-day mortality rates (FA group 40.74%, FA+AA group 33.33%). These findings underscore that a combined approach may offer more effective hemodynamic support and better clinical outcomes when selecting an ECMO cannulation strategy.ConclusionDespite the FA+AA group patients presenting with more preoperative risk factors, this group has exhibited lower rates of complications and faster recovery during ECMO treatment. While there has been no significant difference in 30-day mortality rates between the two cannulation strategies, the FA+AA approach may be more effective in reducing complications and improving limb ischemia. These findings highlight the importance of individualized treatment strategies and meticulous monitoring in managing post-cardiac surgery ECMO patients.

Background: Idiopathic systemic capillary leak syndrome (ISCLS) is characterized by recurrent systemic capillary leakage and hypovolemic shock. Case presentation: We report a 59-year-old Caucasian man with ISCLS and persistent hypovolemic and cardiogenic shock after COVID-19 infection. Mechanical circulatory support was provided with veno-arterial extracorporeal membrane oxygenation and a microaxial pump. Massive fluid resuscitation was needed. Subsequent complications prolonged the intensive care treatment. Mechanical circulatory support was needed for 22 days. Cardiac function eventually fully recovered, and the patient survived without neurologic compromise. Conclusions: This case of severe ISCLS triggered by COVID-19 highlights that even the most severe hypovolemic and cardiogenic shock may be reversible in ISCLS.

BackgroundInsufficient ventricular unloading is a serious complication during veno-arterial extracorporeal membrane oxygenation (VA-ECMO) that has a crucial impact on patient outcomes. The existing conservative treatment options are limited, while mechanical decompression techniques are challenging and restricted in terms of their adoption and application. Two patients with cardiogenic shock experienced insufficient left ventricular unloading with no pulsatile contraction and aortic valve closure during VA-ECMO support. Gentle chest compression was applied to establish an active left ventricular drainage mechanism, which prevented the formation of intracardiac thrombi. No life-threatening complications or technical problems occurred. Therefore, gentle chest compression was established as an effective and safe method for treating insufficient left ventricular unloading in VA-ECMO patients.

Abstract Background ECPELLA, a combination of veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) and Impella, a percutaneous left ventricular (LV) assist device, has emerged as a novel therapeutic option in patients with severe cardiogenic shock (CS). Since multiple cardiovascular and pump factors influence the haemodynamic effects of ECPELLA, optimising ECPELLA management remains challenging. In this study, we conducted a comprehensive simulation study of ECPELLA haemodynamics. We also simulated global oxygen delivery (DO2) under ECPELLA in severe CS and acute respiratory failure as a first step to incorporate global DO2 into our developed cardiovascular simulation. Methods and results Both the systemic and pulmonary circulations were modelled using a 5-element resistance‒capacitance network. The four ventricles were represented by time-varying elastances with unidirectional valves. In the scenarios of severe LV dysfunction, biventricular dysfunction with normal pulmonary vascular resistance (PVR, 0.8 Wood units), and biventricular dysfunction with high PVR (6.0 Wood units), we compared the changes in haemodynamics, pressure–volume relationship (PV loop), and global DO2 under different VA-ECMO flows and Impella support levels. Results In the simulation, ECPELLA improved total systemic flow with a minimising biventricular pressure–volume loop, indicating biventricular unloading in normal PVR conditions. Meanwhile, increased Impella support level in high PVR conditions rendered the LV–PV loop smaller and induced LV suction in ECPELLA support conditions. The general trend of global DO2 was followed by the changes in total systemic flow. The addition of veno-venous ECMO (VV-ECMO) augmented the global DO2 increment under ECPELLA total support conditions. Conclusions The optimal ECPELLA support increased total systemic flow and achieved both biventricular unloading. The VV-ECMO effectively improves global DO2 in total ECPELLA support conditions.

Objectives: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) with concomitant percutaneous microaxial left ventricular assist device support is an emerging treatment modality for cardiogenic shock (CS). Survival outcomes by CS etiology with this support strategy have not been well described. Methods: This study was a retrospective, single-center analysis of patients with CS due to acute myocardial infarction (AMI-CS) or decompensated heart failure (ADHF-CS) supported with VA-ECMO with concomitant percutaneous microaxial left ventricular assist device support from December 2020 to January 2023. Results: A total of 44 patients were included (AMI-CS, n = 20, and ADHF-CS, n = 24). Patients with AMI-CS and ADHF-CS had similar survival at 90 days postdischarge (P = .267) with similar destinations after support (P = .220). Patients with AMI-CS initially supported with VA-ECMO were less likely to survive 90 days postdischarge (P = .038) when compared with other cohorts. Limb ischemia and acute kidney injury occurred more frequently in patients presenting with AMI-CS (P =.013; P = .030). Subanalysis of ADHF-CS patients into acute-on-chronic decompensated HF and de novo HF demonstrated no difference in survival or destination. Conclusions: VA-ECMO with concomitant percutaneous microaxial left ventricular assist device support can be used to successfully manage patients with CS. There is no difference in survival or destination for AMI-CS and ADHF-CS with this support strategy. AMI-CS patients with initial VA-ECMO support have increased mortality in comparison to other cohorts. Future multicenter studies are required to fully analyze the differences between AMI-CS and ADHF-CS with this support strategy.

Abstract Introduction Dilated cardiomyopathy (DCM) is characterized by the enlargement of the left ventricle or biventricular, accompanied by myocardial systolic dysfunction. Chlamydia psittacosis (CP) is a zoonotic pathogen, which can cause severe pneumonia, respiratory failure, and acute organ dysfunction. The deterioration of DCM caused by CP infection is extremely rare, and few cases of successful management were reported. Case presentation We reported a 67-year-old male patient with DCM and chronic heart failure. Who was admitted to ICU with severe pneumonia, acute hypoxemic respiratory failure, acute decompensated heart failure, arrhythmia, and cardiogenic shock. Mechanical ventilation (MV) and venous-arterial extracorporeal membrane oxygenation (VA-ECMO) were established for respiratory and circulatory support. Broncho alveolar lavage fluid(BALF)was collected for culture and metagenomics next-generation sequencing (mNGS) test. Repeated mNGS tests indicated the high possibility of CP pneumonia, thereafter, moxifloxacin and doxycycline were prescribed. After targeted antibiotics and organ support treatment, pneumonia, respiratory and circulatory failure were gradually resolved, patient was successfully weaned from MV and VA-ECMO. Finally, the patient was recovered and discharged alive. Conclusions Severe respiratory and circulatory failure caused by CP infection in DCM patients is a rare life-threatening clinical condition. Early accurate diagnosis, targeted antibiotic therapy, coupled with extracorporeal life support posed positive impact on the patient’s disease course and outcome.

Percutaneously placed veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is commonly used to support patients with refractory cardiac arrhythmias or arrest and worsening cardiogenic shock. Peripheral VA-ECMO by retrograde flow of blood in the aorta results in a significant increase in left ventricle (LV) afterload. A severely dysfunctional LV may be unable to overcome this afterload to open the aortic valve and unload itself. This may lead to LV distension, increased LV pressure, poor coronary blood circulation, increased left atrial pressures, pulmonary edema, and pulmonary hypertension. Moreover, it jeopardizes ventricular recovery, particularly in the presence of ischemia-induced myocardial impairment. Furthermore, if the aortic valve remains closed during the cardiac cycle, stasis of blood in the LV and aortic root may increase the risk of thrombus formation. These complications may preclude cardiac recovery and the patient from being a heart transplant candidate. In patients with cardiogenic shock, utilizing Impella with VA-ECMO, commonly referred to as ECPella, has consistently been shown to reduce mortality and improve outcomes. Patients who need prolonged ECPella support as a bridge to recovery or transplant may remain bed-bound since ambulation of patients with 2 mechanical circulatory support devices is challenging. We present the technique of ECPella placement through Y chimney graft anastomosis on the axillary artery for arterial cannula and Impella insertion and percutaneous cannulation of the right internal Jugular vein for venous cannula. This technique gives the ease of ambulation and decannulation of VA-ECMO under local anesthesia without requiring intubation or a trip to the operating room. [ABSTRACT FROM AUTHOR]

Molecular oxygen is typically delivered to patients via oxygen inhalation or extracorporeal membrane oxygenation (ECMO), potentially resulting in systemic hyperoxia from liberal oxygen inhalation or localized hyperoxia in the lower body from peripheral venoarterial (VA) ECMO. Consequently, this exposes the gastrointestinal tract to excessive oxygen levels. Hyperoxia can trigger organ damage due to the overproduction of reactive oxygen species and is associated with increased mortality. The gut and gut microbiome play pivotal roles in critical illnesses and even small variations in oxygen levels can have a dramatic influence on the physiology and ecology of gut microbes. Here, we reviewed the emerging preclinical evidence which highlights how excessive inhaled oxygen can provoke diffuse villous damage, barrier dysfunction in the gut, and gut dysbiosis. The hallmark of this dysbiosis includes the expansion of oxygen-tolerant pathogens (e.g., Enterobacteriaceae) and the depletion of beneficial oxygen-intolerant microbes (e.g., Muribaculaceae). Furthermore, we discussed potential impact of oxygen on the gut in various underlying critical illnesses involving inspiratory oxygen and peripheral VA-ECMO. Currently, the available findings in this area are somewhat controversial, and a consensus has not yet to be reached. It appears that targeting near-physiological oxygenation levels may offer a means to avoid hyperoxia-induced gut injury and hypoxia-induced mesenteric ischemia. However, the optimal oxygenation target may vary depending on special clinical conditions, including acute hypoxia in adults and neonates, as well as particular patients undergoing gastrointestinal surgery or VA-ECMO support. Last, we outlined the current challenges and the need for future studies in this area. Insights into this vital ongoing research can assist clinicians in optimizing oxygenation for critically ill patients. [ABSTRACT FROM AUTHOR]

Background: ECPELLA, a combination of veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) and Impella, a percutaneous left ventricular (LV) assist device, has emerged as a novel therapeutic option in patients with severe cardiogenic shock (CS). Since multiple cardiovascular and pump factors influence the haemodynamic effects of ECPELLA, optimising ECPELLA management remains challenging. In this study, we conducted a comprehensive simulation study of ECPELLA haemodynamics. We also simulated global oxygen delivery (DO2) under ECPELLA in severe CS and acute respiratory failure as a first step to incorporate global DO2 into our developed cardiovascular simulation. Methods and results: Both the systemic and pulmonary circulations were modelled using a 5-element resistance‒capacitance network. The four ventricles were represented by time-varying elastances with unidirectional valves. In the scenarios of severe LV dysfunction, biventricular dysfunction with normal pulmonary vascular resistance (PVR, 0.8 Wood units), and biventricular dysfunction with high PVR (6.0 Wood units), we compared the changes in haemodynamics, pressure–volume relationship (PV loop), and global DO2 under different VA-ECMO flows and Impella support levels. Results: In the simulation, ECPELLA improved total systemic flow with a minimising biventricular pressure–volume loop, indicating biventricular unloading in normal PVR conditions. Meanwhile, increased Impella support level in high PVR conditions rendered the LV–PV loop smaller and induced LV suction in ECPELLA support conditions. The general trend of global DO2 was followed by the changes in total systemic flow. The addition of veno-venous ECMO (VV-ECMO) augmented the global DO2 increment under ECPELLA total support conditions. Conclusions: The optimal ECPELLA support increased total systemic flow and achieved both biventricular unloading. The VV-ECMO effectively improves global DO2 in total ECPELLA support conditions. [ABSTRACT FROM AUTHOR]

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) requires considerable human and financial resources. Few studies have focused on early mortality (ie, occurring within 72 hours after VA-ECMO implantation). The objective of this study was to establish a prognosis score—the IMPACT score (prediction of early mortality associated with VA-ECMO using preimplantation characteristics)—by determining the risk factors associated with early mortality. This was a retrospective and observational study. The study was conducted at a University hospital. This single-center retrospective study included 147 patients treated with VA-ECMO for cardiogenic shock between 2014 and 2021. The primary outcome was early mortality (ie, occurring within 72 hours after VA-ECMO implantation). Multivariate logistic regression was performed using a bootstrapping methodology to identify factors independently associated with early mortality. To construct the score, identified variables had points (pts) assigned corresponding to their odds ratio. A total of 147 patients were included in the study. Early mortality (<72 hours) was 26% (38 patients). Four variables were established: cardiac arrest (2 pts), lactate levels (3 pts), platelet count <100 g/L (4 pts), and renal-replacement therapy (5 pts). The IMPACT score had an area under the receiver operating characteristic curve of 0.78 (95% CI 0.86-0.70) to predict early mortality. In the authors' experience, 26% of patients treated with VA-ECMO presented early mortality. The IMPACT score is a reliable predictor of early mortality and may assist with VA-ECMO initiation decision-making. [ABSTRACT FROM AUTHOR]

Introduction: Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality. Despite decades of intensive research and several technological advancements, survival rates remain low. The integration of extracorporeal cardiopulmonary resuscitation (ECPR) has been recognized as a promising approach in refractory OHCA. However, evidence from recent randomized controlled trials yielded contradictory results, and the criteria for selecting eligible patients are still a subject of debate. Methods: This study is a retrospective analysis of refractory OHCA patients treated with ECPR. All adult patients who received ECPR, according to the hospital algorithm, from 2013 to 2021 were included. Two different algorithms were used during this period. A "permissive" algorithm was used from 2013 to mid-2016. Subsequently, a revised algorithm, more "restrictive", based on international guidelines, was implemented from mid-2016 to 2021. Key differences between the two algorithms included reducing the no-flow time from less than three minutes to zero minutes (implying that the cardiac arrests must occur in the presence of a witness with immediate CPR initiation), reducing low-flow duration from 100 to 60 min, and lowering the age limit from 65 to 55 years. The aim of this study is to compare these two algorithms (permissive (1) and restrictive (2)) to determine if the use of a restrictive algorithm was associated with higher survival rates. Results: A total of 48 patients were included in this study, with 23 treated under Algorithm 1 and 25 under Algorithm 2. A significant difference in survival rate was observed in favor of the restrictive algorithm (9% vs. 68%, p < 0.05). Moreover, significant differences emerged between algorithms regarding the no-flow time (0 (0–5) vs. 0 (0–0) minutes, p < 0.05). Survivors had a significantly shorter no-flow and low-flow time (0 (0–0) vs. 0 (0–3) minutes, p < 0.01 and 40 (31–53) vs. 60 (45–80) minutes, p < 0.05), respectively. Conclusion: The present study emphasizes that a stricter selection of OHCA patients improves survival rates in ECPR. [ABSTRACT FROM AUTHOR]

Introduction: Peripheral veno-arterial extracorporeal membrane oxygenation (VA ECMO) creates a retrograde flow along the aorta competing with the left ventricle (LV) in the so-called 'mixing zone' (MZ). Detecting it is essential to understand which of the LV or the ECMO flow perfuses the upper body – particularly the brain and the coronary arteries – in case of differential hypoxemia (DH). Methods: We described a mock circulation loop (MCL) that enabled experimental research on DH. We recreated the three clinical situations relevant to clinicians: where the brain is either totally perfused by the ECMO or the LV or both. In a second step, we used this model to investigate two scenarios to diagnose DH: (i) pulse pressure and (ii) thermodilution via injection of cold saline in the ECMO circuit. Results: The presented MCL was able to reproduce the three relevant mixing zones within the aortic arch, thus allowing to study DH. Pulse pressure was unable to detect location of the MZ. However, the thermodilution method was able to detect whether the brain was totally perfused by the ECMO or not. Conclusion: We validated an in-vitro differential hypoxemia model of cardiogenic shock supported by VA ECMO. This MCL could be used as an alternative to animal studies for research scenarios. [ABSTRACT FROM AUTHOR]

Background: While troponin is an established biomarker of cardiac injury, its prognostic significance in post-cardiotomy cardiogenic shock patients supported by venoarterial extracorporeal membrane oxygenation (PCCS–VA-ECMO) remains unclear. Objective: This study aimed to assess the correlation between early post-operative troponin T levels and both short-term and long-term mortality outcomes in this cohort. Methods: We evaluated 1457 troponin T measurements from 102 PCCS–VA-ECMO patients treated from 2013 to 2018 at a specialized cardio-surgical and transplantation center. Emphasis was placed on troponin concentrations at 24–48 h post-surgery, post-VA-ECMO implantation, and peak troponin levels in relation to VA-ECMO weaning, as well as 90-day and one-year mortality. Results: No significant association was observed between troponin T levels post-VA-ECMO implantation and 90-day mortality (median: 1338 ng/L for overall, 1529 ng/L for survivors vs. 1294 ng/L for non-survivors; p = 0.146) or between peak troponin levels and 90-day mortality (median: 3583 ng/L for overall, 3337 ng/L for survivors vs. 3666 ng/L for non-survivors; p = 0.709). Comprehensive multivariate models showed no correlation between troponin levels and various mortality endpoints. Notably, age, procedure urgency, type, LVEF pre-surgery, Euroscore II, prior cardiac arrest, and VA-ECMO duration were not linked with troponin release. Hemodiafiltration emerged as the strongest mortality risk factor [HR 2.4]. Conclusions: Isolated early Troponin T release and peak troponin T were not associated, while organ complications were linked with VA-ECMO weaning or short- and long-term prognosis. The results underscore the multi-organ implications of PCCS in determining survival. [ABSTRACT FROM AUTHOR]

Introduction: Dilated cardiomyopathy (DCM) is characterized by the enlargement of the left ventricle or biventricular, accompanied by myocardial systolic dysfunction. Chlamydia psittacosis (CP) is a zoonotic pathogen, which can cause severe pneumonia, respiratory failure, and acute organ dysfunction. The deterioration of DCM caused by CP infection is extremely rare, and few cases of successful management were reported. Case presentation: We reported a 67-year-old male patient with DCM and chronic heart failure. Who was admitted to ICU with severe pneumonia, acute hypoxemic respiratory failure, acute decompensated heart failure, arrhythmia, and cardiogenic shock. Mechanical ventilation (MV) and venous-arterial extracorporeal membrane oxygenation (VA-ECMO) were established for respiratory and circulatory support. Broncho alveolar lavage fluid(BALF)was collected for culture and metagenomics next-generation sequencing (mNGS) test. Repeated mNGS tests indicated the high possibility of CP pneumonia, thereafter, moxifloxacin and doxycycline were prescribed. After targeted antibiotics and organ support treatment, pneumonia, respiratory and circulatory failure were gradually resolved, patient was successfully weaned from MV and VA-ECMO. Finally, the patient was recovered and discharged alive. Conclusions: Severe respiratory and circulatory failure caused by CP infection in DCM patients is a rare life-threatening clinical condition. Early accurate diagnosis, targeted antibiotic therapy, coupled with extracorporeal life support posed positive impact on the patient's disease course and outcome. [ABSTRACT FROM AUTHOR]

Cardiogenic Shock represents a life-threatening condition characterized by high mortality and a spectrum of clinical presentations, complicating ~5%−10% of patients presenting with Acute Coronary Syndromes. Despite advances in interventional cardiology and emergency medicine, mortality rates remain extremely high and evidence concerning its management is scarce. Consequently, the decision making relies heavily on a single operator's experience. This comprehensive review aims to provide a thorough update on the latest proof regarding mechanical circulatory support devices of the left ventricle and examines the role of the classification scores on the selection of the appropriate patient and timing for the initiation of the device. The five necessary steps to a successful mechanical circulatory support device's insertion. The picture was made by Pixlr AI Image Generator.

Background The new heart allocation policy places veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO)‐supported heart transplant (HT) candidates at the highest priority status. Despite increasing evidence supporting left ventricular (LV) unloading during VA‐ECMO, the effect of LV unloading on transplant outcomes following bridging to HT with VA‐ECMO remains unknown. Methods and Results From October 18, 2018 to March 21, 2023, 624 patients on VA‐ECMO at the time of HT were identified in the United Network for Organ Sharing database and were divided into 2 groups: VA‐ECMO alone (N=384) versus VA‐ECMO with LV unloading (N=240). Subanalysis was performed in the LV unloading group: Impella (N=106) versus intra‐aortic balloon pump (N=134). Recipient age was younger in the VA‐ECMO alone group (48 versus 53 years, P=0.018), as was donor age (VA‐ECMO alone, 29 years versus LV unloading, 32 years, P=0.041). One‐year survival was comparable between groups (VA‐ECMO alone, 88.0±1.8% versus LV unloading, 90.4±2.1%; P=0.92). Multivariable Cox hazard model showed LV unloading was not associated with posttransplant mortality after HT (hazard ratio, 0.92; P=0.70). Different LV unloading methods had similar 1‐year survival (intra‐aortic balloon pump, 89.2±3.0% versus Impella, 92.4±2.8%; P=0.65). Posttransplant survival was comparable between different Impella versions (Impella 2.5, versus Impella CP, versus Impella 5.0, versus Impella 5.5). Conclusions Under the current allocation policy, LV unloading did not impact waitlist outcome and posttransplant survival in patients bridged to HT with VA‐ECMO, nor did mode of LV unloading. This highlights the importance of a tailored approach in HT candidates on VA‐ECMO, where routine LV unloading may not be universally necessary.

Key Clinical Message Diagnosing FES is difficult and time‐consuming, and identify FES as an etiology of right ventricular volume overload for early diagnosis. Because FES is a reversible condition, even severe cases can be treated if the patient survives the acute phase.

IntroductionThe presence of cerebral-cardiac syndrome, wherein brain diseases coincide with heart dysfunction, significantly impacts patient prognosis. In severe instances, circulatory failure may ensue, posing a life-threatening scenario necessitating immediate life support measures, particularly effective circulatory support methods. The application of extracorporeal membrane oxygenation (ECMO) is extensively employed as a valuable modality for delivering circulatory and respiratory support in the care of individuals experiencing life-threatening circulatory and respiratory failure. This approach facilitates a critical temporal window for subsequent interventions. Consequently, ECMO has emerged as a potentially effective life support modality for patients experiencing severe circulatory failure in the context of cerebral-cardiac syndrome. However, the existing literature on this field of study remains limited.Case descriptionIn this paper, we present a case study of a patient experiencing a critical cerebral-cardiac syndrome. The individual successfully underwent veno-arterial-ECMO (VA-ECMO) therapy, and the patient not only survived, but also received rehabilitation treatment, demonstrating its efficacy as a life support intervention.ConclusionVA-ECMO could potentially serve as an efficacious life support modality for individuals experiencing severe circulatory failure attributable to cerebral-cardiac syndrome.

Abstract Background and objectives Limb ischemia or compartment syndrome, requiring surgery, are some of the frequent cannula-related complications in patients supported with veno-arterial extracorporeal membrane oxygenation (VA-ECMO). The purpose of this exploratory study is to depict and evaluate the dynamic changes in the lower limb muscles with ultrasound shear wave elastography as marker for early lower limb ischemia. Methods Eleven patients with VA-ECMO after cardiac arrest were included in this study. Seven patients received distal perfusion cannula (DPC) after implantation of the VA-ECMO, whereas 4 had no DPC after VA-ECMO. Compartment syndrome was clinically excluded in all patients. Both lower limbs, e.g., with and without arterial cannula, were monitored with near-infrared spectroscopy (NIRS) for the oxygen saturation of the local tissue. We performed ultrasound shear wave elastrography (SWE) to assess dynamic changes of the medial gastrocnemius muscle at maximum passive muscle stretch (exercise) of both legs. Color-coded duplexsonography was conducted to examine the blood flow velocity of the popliteal artery of the lower limb. Results We found no difference between DPC and no DPC (p = 0.115) during use of VA-ECMO. However, we detected marked lower limb muscle perfusion deficits of cannulated (58.9 ± 13.5 kPa) vs. cannula-free limb (95.7 ± 27.9 kPa: p

Background: Veno-arterial extracorporeal membrane oxygenation (va-ECMO) can provide circulatory and respiratory support in patients with cardiogenic shock. The main aim of this work was to investigate the association of blood biomarkers with mortality in patients with myocardial infarction needing va-ECMO support. Methods: We retrospectively analyzed electronic medical charts from patients receiving va-ECMO support in the period from 2008 to 2021 at the Medical University Innsbruck, Department of Anesthesiology and Intensive Care Medicine. Results: Of 188 patients, 57% (108/188) survived to discharge, with hemorrhage (46%) and thrombosis (27%) as the most frequent adverse events. Procalcitonin levels were markedly higher in non-survivors compared with survivors during the observation period. The multivariable model identified higher blood levels of procalcitonin (HR 1.01, p = 0.002) as a laboratory parameter associated with a higher risk of mortality. Conclusions: In our study population of patients with myocardial infarction-associated cardiogenic shock, deceased patients had increased levels of inflammatory blood biomarkers throughout the whole study period. Increased procalcitonin levels have been associated with a higher risk of mortality. Future studies are needed to show the role of procalcitonin in patients receiving ECMO support. [ABSTRACT FROM AUTHOR]

Background and objectives: Limb ischemia or compartment syndrome, requiring surgery, are some of the frequent cannula-related complications in patients supported with veno-arterial extracorporeal membrane oxygenation (VA-ECMO). The purpose of this exploratory study is to depict and evaluate the dynamic changes in the lower limb muscles with ultrasound shear wave elastography as marker for early lower limb ischemia. Methods: Eleven patients with VA-ECMO after cardiac arrest were included in this study. Seven patients received distal perfusion cannula (DPC) after implantation of the VA-ECMO, whereas 4 had no DPC after VA-ECMO. Compartment syndrome was clinically excluded in all patients. Both lower limbs, e.g., with and without arterial cannula, were monitored with near-infrared spectroscopy (NIRS) for the oxygen saturation of the local tissue. We performed ultrasound shear wave elastrography (SWE) to assess dynamic changes of the medial gastrocnemius muscle at maximum passive muscle stretch (exercise) of both legs. Color-coded duplexsonography was conducted to examine the blood flow velocity of the popliteal artery of the lower limb. Results: We found no difference between DPC and no DPC (p = 0.115) during use of VA-ECMO. However, we detected marked lower limb muscle perfusion deficits of cannulated (58.9 ± 13.5 kPa) vs. cannula-free limb (95.7 ± 27.9 kPa: p < 0.001), applying SWE. No relationship was detected between NIRS measurements and SWE values (kPa) of both lower limbs. The mean peak systolic velocity of the popliteal artery at the cannulated side (30.0 ± 11.7 cm/s) was reduced compared to the non-cannulated side (39.3 ± 18.6 cm/s; p = 0.054). Conclusions: Regardless of DPC after implantation of VA-ECMO, the gastrocnemius muscles seem to lose function due to cannula-related microcirculatory deficits. Muscle function analysis via SWE combined with NIRS might offer a sensitive indicator for early onset leg ischemia during VA-ECMO-related arterial cannulation. [ABSTRACT FROM AUTHOR]

In 2018, the United Network for Organ Sharing (UNOS) modified their heart allocation policy to reduce waitlist mortality. The rates of simultaneous heart-kidney transplant (SHKT) have dramatically increased in recent years, despite increased rates of posttransplant renal failure in the new policy era. This study sought to investigate the impact of the new allocation system on waitlist and posttransplant outcomes of simultaneous heart-kidney transplantation. Adult patients listed for SHKT between 2012 and 2021 were included. Patients were cross-validated across both Thoracic and Kidney UNOS databases to confirm accurate listing and transplant data. Patients were stratified according to listing era. The Fine and Gray model was used to assess waitlist outcomes and posttransplant renal graft function. Kaplan-Meier analysis and Cox regression were used to compare posttransplant survival. A total of 2,588 patients were included, of whom 1,406 (54.1%) were listed between 2012 and 2018 (era 1) and 1,182 (45.9%) between 2019 and 2021 (era 2). Era 2 was associated with increased likelihood of transplant (adjusted Sub-hazard ratios (aSHR): 1.52; p < 0.01) and decreased waitlist mortality (aSHR: 0.63; p < 0.01). Posttransplant survival at 2 years was decreased in era 2 (78.8% vs 86.9%; p < 0.01). Undersized hearts (hazard ratio [HR]: 2.02; p < 0.01), use of extracorporeal membrane oxygenation (HR: 2.67; p < 0.1), and transplants performed following the policy change (HR: 1.45; p = 0.03) were associated with increased mortality. Actuarial survival (combined waitlist and posttransplant) was significantly lower in the modern era (71.6% vs 62.2%; p = 0.02). The allocation policy change has improved waitlist outcomes in patients listed for SHKT but potentially at the cost of worsened posttransplant outcomes. [ABSTRACT FROM AUTHOR]

Background: The management of complex groin wounds following VA‐ECMO after heart transplant (HT) is uncertain due to limited experience. Sartorius muscle flaps (SMF) have been used in vascular surgery for groin wound complications. However, their use in HT recipients with perioperative VA‐ECMO is unclear. This study aims to describe characteristics and outcomes of HT patients with groin complications after arterial decannulation for femoral VA‐ECMO. Methods: We retrospectively reviewed HT patients who underwent peri‐transplant femoral VA‐ECMO at our institution from April 2011 to February 2023. Patients were categorized into two groups based on the presence of cannulation‐related wound complications. Results: Among the 34 patients requiring VA‐ECMO peri‐transplant, 17 (50%) experienced complications at the cannulation site. Baseline characteristics including duration of VA‐ECMO support were comparable in both groups. Patients with complications presented mostly with open wounds (41.1%) after a median duration of 22 days post‐transplant. Concurrent groin infections were observed in 52.3% of patients, all caused by gram‐negative bacteria. Wound complications were managed with 12 (70.6%) undergoing SMF treatment and 5 (31.2%) receiving conventional therapy. Four SMF recipients had preemptive procedures for wound dehiscence, while eight underwent SMF for groin infections. Among the SMF group, 11 patients had favorable outcomes without recurrent complications, except for one patient who developed a groin infection with pseudoaneurysm formation. Conventional therapy with vacuum assisted closure (VAC) and antibiotics were utilized in four patients without infection and one patient with infection. Three patients required additional surgeries with favorable healing of the wound. Conclusion: Complications related to femoral VA‐ECMO are common in HT patients, with infection being the most frequent complication. SMFs can be a useful tool to prevent progression of infection and improve local healing. [ABSTRACT FROM AUTHOR]

Background Cardiogenic shock is a rare adverse event of 5-fluorouracil (5-FU) administration. Because of its rare entity, little is known about epidemiologic and clinical features of 5-FU-induced cardiogenic shock, and recommendations about specific treatment are missing. Case summary We present a case of cardiogenic shock and ventricular arrhythmia due to 5-FU-induced toxic cardiomyopathy treated with vasopressor and inotropic drugs in combination with intra-aortic balloon pump. Because of persistent haemodynamic instability, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and Impella were implanted as a bridge to recovery. Systolic function recovered completely and the patient was weaned successfully. Discussion This case demonstrates toxic cardiomyopathy as a rare and potentially lethal cardiac adverse event of 5-FU administration. This case emphasizes the importance of mechanical support as bridging therapy to recovery of cardiac function. [ABSTRACT FROM AUTHOR]

Background Reverse takotsubo-like cardiomyopathy (rTCC) is a rare type of stress-induced cardiomyopathy associated with catecholamine surges. Reverse takotsubo-like cardiomyopathy is characterized by basal and mid-ventricular hypokinesis with apical sparing. Paragangliomas are catecholamine-secreting neuroendocrine tumours outside the adrenal gland that can cause palpitations, hypertension, and rarely cardiomyopathy. In cases of occult paraganglioma, catecholamine-induced rTCC can be rapidly reversed with adequate haemodynamic support. Case summary A 28-year-old woman with a history of cervical cancer, ovarian insufficiency, and preeclampsia presented to the emergency department with nausea, vomiting, and chest pain. The patient was initially tachycardic, tachypnoeic, and hypotensive. On exam, she was in distress with diffuse rales and cool extremities. Electrocardiogram showed sinus tachycardia to 147 b.p.m. and lateral ST depression in V4 and V5. Troponin was elevated to 13 563 ng/L. An echocardiogram showed severely reduced left ventricular ejection fraction (LVEF) with hypokinesis of the basal segments and apical sparing, identified as rTCC. Computed tomography of the abdomen showed a 3.6 × 2.7 cm right adrenal mass. The patient rapidly developed respiratory failure and was subsequently intubated, sedated, and initiated on vasopressors. In the setting of cardiogenic shock refractory to vasopressor support, the decision was made to cannulate for venoarterial extracorporeal membrane oxygenation (VA-ECMO). Plasma and urine metanephrines were elevated. After 5 days, the patient's LVEF recovered to her baseline, and the rTCC had resolved. The patient's hypertension was managed with gradual alpha-blockade, and she subsequently underwent successful adrenalectomy on Day 44. Discussion An occult paraganglioma should be considered when rTCC pattern is identified. The pathophysiology of paraganglioma-mediated catecholamine surges predisposing to rTCC is unclear. Potential mechanisms for rTCC include oestrogen deficiency, catecholamine cardiotoxicity, and coronary artery spasm. The VA-ECMO is an increasingly used modality to provide haemodynamic support to patients with refractory cardiogenic shock. [ABSTRACT FROM AUTHOR]

Background The present article describes three cases of patients in cardiogenic shock (CS) with previous cardiac surgery that made them initially inoperable. Perioperative support with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) improved haemodynamic status and results in these high-risk patients. Case summary Case 1 is a 57-year-old male morbidly obese with previous aortic valve replacement (AVR) who presented with chest pain and developed cardiac arrest. Cardiopulmonary resuscitation and femoral VA-ECMO were initiated. Three days later, a redo AVR was performed. Veno-arterial extracorporeal membrane oxygenation was maintained for 12 days, followed by 7 days of veno-venous ECMO for complete recovery. Case 2 features a 39-year-old male with two previous mitral valve replacements (MVRs). The first is due to papillary muscle rupture, and the second is due to endocarditis of the mitral prosthesis. He presented with CS and pulmonary oedema. Emergency surgery was performed and the patient was then placed in VA-ECMO. Weaning off was achieved 3 days after surgery. Case 3 is a 21-year-old female with a previous MVR due to rheumatic disease. She presented with CS, severe mitral prosthesis stenosis, and a pulmonary embolism. Femoral VA-ECMO was initiated, and one day later, she underwent a redo MVR operation. Extracorporeal membrane oxygenation was discontinued 4 days later. Discussion Dysfunctional prosthetic valves leading to CS may benefit from a redo cardiac operation supported by a perioperative VA-ECMO to optimize haemodynamic status. Despite the results from risk prediction scores, this approach has the potential to reduce operative mortality in initial inoperable patients and allow a definitive redo cardiac surgery. [ABSTRACT FROM AUTHOR]

Introduction: Based on extracorporeal circulation, targeted reperfusion strategies have been developed to improve survival and neurologic recovery in refractory cardiac arrest: Controlled Automated Reperfusion of the whoLe Body (CARL). Furthermore, animal and human cadaver studies have shown beneficial effects on cerebral pressure due to head elevation during conventional cardiopulmonary resuscitation. Our aim was to evaluate the impact of head elevation on survival, neurologic recovery and histopathologic outcome in addition to CARL in an animal model. Methods: After 20 min of ventricular fibrillation, 46 domestic pigs underwent CARL, including high, pulsatile extracorporeal blood flow, pH–stat acid–base management, priming with a colloid, mannitol and citrate, targeted oxygen, carbon dioxide and blood pressure management, rapid cooling and slow rewarming. N = 25 were head-up (HUP) during CARL, and N = 21 were supine (SUP). After weaning from ECC, the pigs were extubated and followed up in the animal care facility for up to seven days. Neuronal density was evaluated in neurohistopathology. Results: More animals in the HUP group survived and achieved a favorable neurological recovery, 21/25 (84%) versus 6/21 (29%) in the SUP group. Head positioning was an independent factor in neurologically favorable survival (p < 0.00012). Neurohistopathology showed no significant structural differences between HUP and SUP. Distinct, partly transient clinical neurologic deficits were blindness and ataxia. Conclusions: Head elevation during CARL after 20 min of cardiac arrest independently improved survival and neurologic outcome in pigs. Clinical follow-up revealed transient neurologic deficits potentially attributable to functions localized in the posterior perfusion area, whereas histopathologic findings did not show corresponding differences between the groups. A possible explanation of our findings may be venous congestion and edema as modifiable contributing factors of neurologic injury following prolonged cardiac arrest. [ABSTRACT FROM AUTHOR]

Background: Cardiogenic shock (CS) exhibits high (~50%) in-hospital mortality. The recently published Extracorporeal life Support in Cardiogenic Shock (ECLS-SHOCK) trial demonstrated the neutral effects of the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) on all-cause death, as well as on all secondary outcomes in subjects presenting with myocardial-infarction (MI)-related CS. Here, we compared ECLS-SHOCK eligibility criteria with a real-world cohort of CS patients. Methods and Results: ECLS-SHOCK eligibility criteria were applied to a prospective single-center CS registry (the PREPARE CS registry) consisting of 557 patients who were consecutively admitted to the catheterization laboratory (cath lab) of the Medical University of Graz, Austria, due to CS (SCAI C-E). Overall use of mechanical circulatory support (MCS) in this cohort was 19%. Sixty-nine percent of the entire cohort had MI-related CS, 38% of whom would have met ECLS-SHOCK eligibility criteria, thus representing only 27% of the PREPARE CS registry. Exclusion from the ECLS-SHOCK trial was based on patients with initial lactate values below 3 mmol/L (n = 168; 43.6%), aged over 80 years (n = 65; 16.9%), and with a duration of cardiopulmonary resuscitation (CPR) exceeding 45 min (n = 22; 5.7%). The 30-day mortality of patients of the PREPARE CS registry who met the ECLS-SHOCK eligibility criteria was 57.0%, compared to 48.4% of patients in the ECLS-SHOCK trial. The patients' baseline characteristics, however, differed considerably with respect to type of infarction, age, and gender. Conclusions: In a real-world cohort of patients with MI-related CS, only 38% of patients met the eligibility criteria of the ECLS-SHOCK trial. Thus, the impact of the use of VA-ECMO on outcome parameters in MI-related CS, as observed in the ECLS-SHOCK trial, may differ in a more heterogeneous real-world CS population of the PREPARE CS registry. [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]

BackgroundPulmonary embolism is a condition of right cardiac dysfunction due to pulmonary circulation obstruction. Malignant tumor-induced pulmonary embolism, which has a poor therapeutic outcome and a significant impact on hemodynamics, is the cause of sudden death in patients with malignant tumors.Case descriptionA 38-year-old female patient, who had a medical history of right renal hamartoma, and right renal space-occupying lesion, was admitted to the hospital. During the procedure to resect the right renal malignancy, the blood pressure and end-tidal carbon dioxide level dropped, and a potential pulmonary embolism was considered as a possibility. After inferior vena cava embolectomy, the hemodynamics in the patient remained unstable. The successful establishment of venoarterial extracorporeal membrane oxygenation (VA-ECMO) resulted in the stabilization of her hemodynamics and ventilation. On Day 2 of VA-ECMO support, her respiration and hemodynamics were relatively stable, and ECMO assistance was successfully terminated following the “pump-controlled retrograde trial off (PCRTO)” test on Day 6. The patient improved gradually after the procedure and was discharged from the hospital after 22 days.ConclusionVA-ECMO can be used as a transitional resuscitation technique for patients with massive pulmonary embolism. It is critical for the perfusion of vital organs and can assist with surgical or interventional treatment, lower right heart pressure, and hemodynamic stability. VA-ECMO has a significant impact on patient prognosis and can reduce the mortality rate.

Background Venoarterial extracorporeal membrane oxygenation (VA‐ECMO) is increasingly used for patients with cardiogenic shock. Although Impella or intra‐aortic balloon pump (IABP) is frequently used for left ventricular unloading (LVU) during VA‐ECMO treatment, there are limited data on comparative outcomes. We compared outcomes of Impella and IABP for LVU during VA‐ECMO. Methods and Results Using the Nationwide Readmissions Database between 2016 and 2020, we analyzed outcomes in 3 groups of patients with cardiogenic shock requiring VA‐ECMO based on LVU strategies: extracorporeal membrane oxygenation (ECMO) only, ECMO with IABP, and ECMO with Impella. Of 15 980 patients on VA‐ECMO, IABP and Impella were used in 19.4% and 16.4%, respectively. The proportion of patients receiving Impella significantly increased from 2016 to 2020 (6.5% versus 25.8%; P‐trend

IntroductionThe use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in extracorporeal cardiopulmonary resuscitation (ECPR) in selected patients after out-of-hospital cardiac arrest (OHCA) is an established method if return of spontaneous circulation cannot be achieved. Automated chest compression devices (ACCD) facilitate transportation of patients under ongoing CPR and might improve outcome. We thus sought to evaluate prognostic influence of mechanical CPR using ACCD in patients presenting with OHCA treated with ECPR including VA-ECMO.MethodsWe retrospectively analyzed data of 171 consecutive patients treated for OHCA using ECPR in our cardiac arrest center from the years 2016 to 2022. A Cox proportional hazards model was used to identify characteristics related with survival.ResultsOf the 171 analyzed patients (84% male, mean age 56 years), 12% survived the initial hospitalization with favorable neurological outcome. The primary reason for OHCA was an acute coronary event (72%) followed by primary arrhythmia (9%) and non-ischemic cardiogenic shock (6.7%). In most cases, the collapse was witnessed (83%) and bystander CPR was performed (83%). The median time from collapse to VA-ECMO was 81 min (Q1: 69 min, Q3: 98 min). No survival benefit was seen for patients resuscitated using ACCD. Patients in whom an ACCD was used presented with overall longer times from collapse to ECMO than those who were resuscitated manually [83 min (Q1: 70 min, Q3: 98 min) vs. 69 min (Q1: 57 min, Q3: 84 min), p = 0.004].ConclusionNo overall survival benefit of the use of ACCD before ECPR is established was found, possibly due to longer overall CPR duration. This may arguably be because of the limited availability of ACCD in pre-clinical paramedic service at the time of observation. Increasing the availability of these devices might thus improve treatment of OHCA, presumably by providing efficient CPR during transportation and transfer.

IntroductionVenoarterial extracorporeal membrane oxygenation (ECMO) is a rescue therapy that can stabilize patients with hemodynamic compromise. Indications continue to evolve, including drug overdose. However, the indication merely for vasoplegic shock following drug overdose is controversial.Case summaryWe report a case of a 57-year-old male with high-risk idiopathic pulmonary arterial hypertension treated with upfront triple combination therapy (sildenafil, bosentan, and intravenous treprostinil infusion via subcutaneous abdominal implantable pump). In one of the refills of the drug reservoir, accidental administration of 1 months's supply of treprostinil (200 mg) into the subcutaneous tissue occurred, causing refractory vasoplegic shock. He required urgent VA-ECMO for 96 h, surviving to discharge 28 days later.DiscussionTreprostinil poisoning is rare due to its less frequent use but is life-threatening. ECMO may be considered in vasoplegic shock due to overdose of vasodilatory medication. It allows organ perfusion to be maintained, with the knowledge that recovery is as rapid as drug elimination.

IntroductionThe use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in extracorporeal cardiopulmonary resuscitation (eCPR) has emerged as a treatment option for selected patients who are experiencing refractory cardiac arrest (CA). In the light of increasing availability, the analyses of outcome-relevant predisposing characteristics are of growing importance. We evaluated the prognostic influence of gender in patients presenting with out-of-hospital cardiac arrest (OHCA) treated with eCPR.MethodsWe retrospectively analysed the data of 377 consecutive patients treated for OHCA using eCPR in our cardiac arrest centre from January 2016 to December 2022. The primary outcome was defined as the survival of patients until they were discharged from the hospital, with a favourable neurological outcome [cerebral performance category (CPC) score of ≤2]. Statistical analyses were performed using baseline comparison, survival analysis, and multivariable analyses.ResultsOut of the 377 patients included in the study, 69 (21%) were female. Female patients showed a lower prevalence rate of pre-existing coronary artery disease (48% vs. 75%, p