Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly adopted for the treatment of cardiogenic shock (CS). However, a marker of successful weaning remains largely unknown. Our ...hypothesis was that successful weaning is associated with sustained microcirculatory function during ECMO flow reduction. Therefore, we sought to test the usefulness of microcirculatory imaging in the same sublingual spot, using incident dark field (IDF) imaging in assessing successful weaning from VA-ECMO and compare IDF imaging with echocardiographic parameters.
Weaning was performed by decreasing the VA-ECMO flow to 50% (F
) from the baseline. The endpoint of the study was successful VA-ECMO explantation within 48 hours after weaning. The response of sublingual microcirculation to a weaning attempt (WA) was evaluated. Microcirculation was measured in one sublingual area (single spot (ss)) using CytoCam IDF imaging during WA. Total vessel density (TVDss) and perfused vessel density (PVDss) of the sublingual area were evaluated before and during 50% flow reduction (TVDss
, PVDss
) after a WA and compared to conventional echocardiographic parameters as indicators of the success or failure of the WA.
Patients (n = 13) aged 49 ± 18 years, who received VA-ECMO for the treatment of refractory CS due to pulmonary embolism (n = 5), post cardiotomy (n = 3), acute coronary syndrome (n = 2), myocarditis (n = 2) and drug intoxication (n = 1), were included. TVDss
(21.9 vs 12.9 mm/mm
, p = 0.001), PVDss
(19.7 vs 12.4 mm/mm
, p = 0.01) and aortic velocity-time integral (VTI) at 50% flow reduction (VTI
) were higher in patients successfully weaned vs not successfully weaned. The area under the curve (AUC) was 0.99 vs 0.93 vs 0.85 for TVDss
(small vessels) >12.2 mm/mm
, left ventricular ejection fraction (LVEF) >15% and aortic VTI >11 cm. Likewise, the AUC was 0.91 vs 0.93 vs 0.85 for the PVDss
(all vessels) >14.8 mm/mm
, LVEF >15% and aortic VTI >11 cm.
This study identified sublingual microcirculation as a novel potential marker for identifying successful weaning from VA-ECMO. Sustained values of TVDss
and PVDss
were found to be specific and sensitive indicators of successful weaning from VA-ECMO as compared to echocardiographic parameters.
In cardiac arrest, cerebral ischemia and reperfusion injury mainly determine the neurological outcome. The aim of this study was to investigate the relation between the course of cerebral oxygenation ...and regain of consciousness in patients treated with extracorporeal cardiopulmonary resuscitation (ECPR). We hypothesized that rapid cerebral oxygenation increase causes unfavorable outcomes.
This prospective observational study was conducted in three European hospitals. We included adult ECPR patients between October 2018 and March 2020, in whom cerebral regional oxygen saturation (rSO
) measurements were started minutes before ECPR initiation until 3 h after. The primary outcome was regain of consciousness, defined as following commands, analyzed using binary logistic regression.
The sample consisted of 26 ECPR patients (23% women, Age
46 years). We found no significant differences in rSO
values at baseline (49.1% versus 49.3% for regain versus no regain of consciousness). Mean cerebral rSO
values in the first 30 min after ECPR initiation were higher in patients who regained consciousness (38%) than in patients who did not regain consciousness (62%, odds ratio 1.23, 95% confidence interval 1.01-1.50).
Higher mean cerebral rSO
values in the first 30 min after initiation of ECPR were found in patients who regained consciousness.
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an effective technique for providing emergency mechanical circulatory support for patients with cardiogenic shock. VA-ECMO enables a ...rapid restoration of global systemic organ perfusion, but it has not been found to always show a parallel improvement in the microcirculation. We hypothesized in this study that the response of the microcirculation to the initiation of VA-ECMO might identify patients with increased chances of intensive care unit (ICU) survival.
Twenty-four patients were included in this study. Sublingual microcirculation measurements were performed using the CytoCam-IDF (incident dark field) imaging device. Microcirculatory measurements were performed at baseline, after VA-ECMO insertion (T1), 48-72 h after initiation of VA-ECMO (T2), 5-6 days after (T3), 9-10 days after (T4), and within 24 h of VA-ECMO removal.
Of the 24 patients included in the study population, 15 survived and 9 died while on VA-ECMO. There was no significant difference between the systemic global hemodynamic variables at initiation of VA-ECMO between the survivors and non-survivors. There was, however, a significant difference in the microcirculatory parameters of both small and large vessels at all time points between the survivors and non-survivors. Perfused vessel density (PVD) at baseline (survivor versus non-survivor, 19.21 versus 13.78 mm/mm
, p = 0.001) was able to predict ICU survival on initiation of VA-ECMO; the area under the receiver operating characteristic curve (ROC) was 0.908 (95 % confidence interval 0.772-1.0).
PVD of the sublingual microcirculation at initiation of VA-ECMO can be used to predict ICU mortality in patients with cardiogenic shock.
Cardiac arrest (CA) due to pulmonary embolism (PE) is associated with low survival rates and poor neurological outcomes. We examined whether Extracorporeal Cardiopulmonary Resuscitation (ECPR) ...improves the outcomes of patients who suffer from CA due to massive PE.
We retrospectively included 39 CA patients with proven or strongly suspected PE in two hospitals in the Netherlands, in a ‘before/after’-design. 20 of these patients were treated with Conventional Cardiopulmonary Resuscitation (CCPR) and 19 patients with ECPR.
The main outcomes of this study were ICU survival and favourable neurological outcome, defined as Cerebral Performance Category (CPC) score 1–2. The ICU survival rate in CCPR patients was 5% compared to 26% in ECPR patients (p<0.01). Survival with favourable neurological outcome was present in 0/20 (0%) CCPR patients compared to 4/19 (21%) of the ECPR patients (p<0.05).
ECPR seems a promising treatment for cardiac arrest patients due to (suspected) massive pulmonary embolism compared to conventional CPR, though outcomes remain poor.
Mortality after veno-arterial extracorporeal membrane oxygenation (VA-ECMO) implantation remains a major problem in patients with cardiogenic shock. Our objective was to assess the utility of the ...SOFA score in combination with markers of right ventricular (RV) dysfunction in predicting mortality in the ICU.
Data were retrospectively obtained from all adult patients (n=103) who were treated with VA-ECMO between November 2004 and January 2016. The primary outcome of this study was ICU mortality after VA-ECMO implantation. Using the clinical, demographic and echocardiographic data, we developed a novel mortality risk score, the SOFA-RV score, which combine RV-function to the SOFA score at the time of VA-ECMO implantation.
Out of 103 patients, 37 (36%) died in the ICU. The median duration of VA-ECMO support was 7 days IQR 4-11, mean age 49 ± 16 years, and 54% were male. SOFA-RV score has an AUC of 0.70, and was significantly better than SOFA alone (AUC of 0.57) in predicting ICU mortality. In addition, SAVE and MELD scores were not able to predict ICU mortality.
Adding RV-function to the existing SOFA score improves significantly the prediction of ICU mortality in patients on VA-ECMO. Dedicated evaluation of RV function in patients with VA-ECMO is therefore recommended.
•This is the largest echocardiography-based prediction model after VA-ECMO.•One out of three patients did not survive ICU after VA-ECMO.•Three out of four non-survivors in the ICU had biventricular failure.•Adding RV function on echocardiography to the existing SOFA score improves significantly the prediction of ICU mortality.•Dedicated evaluation of the right ventricular function in patients with VA-ECMO is highly recommended.
Survival following cardiac arrest (CA) remains poor after conventional cardiopulmonary resuscitation (CCPR) (6-26%), and the outcomes after extracorporeal cardiopulmonary resuscitation (ECPR) are ...often inconsistent. Poor survival is a consequence of CA, low-flow states during CCPR, multi-organ injury, insufficient monitoring, and delayed treatment of the causative condition. We developed a new strategy to address these issues.
This all-comers, multicenter, prospective observational study (69 patients with in- and out-of-hospital CA (IHCA and OHCA) after prolonged refractory CCPR) focused on extracorporeal cardiopulmonary support, comprehensive monitoring, multi-organ repair, and the potential for out-of-hospital cannulation and treatment.
The overall survival rate at hospital discharge was 42.0%, and a favorable neurological outcome (CPC 1+2) at 90 days was achieved for 79.3% of survivors (CPC 1+2 survival 33%). IHCA survival was very favorable (51.7%), as was CPC 1+2 survival at 90 days (41%). Survival of OHCA patients was 35% and CPC 1+2 survival at 90 days was 28%. The subgroup of OHCA patients with pre-hospital cannulation showed a superior survival rate of 57.1%.
This new strategy focusing on repairing damage to multiple organs appears to improve outcomes after CA, and these findings should provide a sound basis for further research in this area.
Methods: Multivariate logistic regression analysis was performed to investigate predictors of ICU mortality in all patients on VA-ECMO between 2004 and 2015 in our tertiary referral hospital.
Summary
Over the past decades donor and recipient characteristics and medical management of heart transplantation (HT) patients have changed markedly. We studied the impact of these changes on ...long‐term clinical outcome. Data of all consecutive HT recipients in our center have been collected prospectively. Cohort A (n = 353) was defined as the adult pts transplanted between 1984 and 1999 and was compared with cohort B (n = 227) transplanted between 2000 and 2013. Compared with cohort A, recipients in cohort B had older donors (mean age 29 vs. 43 years, donors aged >50 year: 2% vs. 33%, respectively). Survival at 1 and 10 years in cohort A vs. B was 89% vs. 86% and 53% vs. 68%, respectively (P = 0.02). Cohort B pts were treated more often with tacrolimus‐based immunosuppression (77% vs. 22%; P = <0.0001) and early statins post‐HT (88% vs. 18%; P = 0.0001), while renal function was better conserved at 5 and 10 years (P = 0.001 and 0.02). Multivariate analysis showed significant reduction in 10‐year mortality with tacrolimus‐based immunosuppression (HR 0.27 and 95% CI 0.17–0.42), hypertension post‐HT (HR 0.5, 95% CI 0.36–0.72), and revascularization (HR 0.28, 95% CI 0.15–0.52). In spite of the use of much older donors, the long‐term outcome after HT has improved considerably in the last decade, probably due to the introduction of newer treatment modalities.
Results: The study population consisted 13 patients in cardiogenic shock due to pulmonary embolism (n=4; 31%) and postcardiac surgery patients (n=3; 23%) and various etiologies in the rest of the ...patients, 11 (85%) male and median age 55 23-80.
Bleeding is a common complication following left ventricular assist device (LVAD) implantation. The goal of this study was to investigate the incidence, predictors and clinical outcome of early ...bleeding events in patients after LVAD implantation.
A total of 83 patients (age 50 ± 13 years, 76% men) had an LVAD implanted 77% HeartMate II, 19% HeartMate 3 (Abbott, Chicago, IL, USA) over a period of 11 years. Patients were included consecutively. An early bleeding event was defined as the need for thoracic surgical re-exploration or transfusion with >4 units of packed red blood cells before discharge.
Overall, 39 (47%) patients (age 50 ± 14 years, 77% men) experienced an early bleeding event median time 6 days (interquartile range 1-9 days). Furthermore, 10 (26%) of these patients had ≥2 bleeding events. Twelve of the 14 (92%) patients with venoarterial extracorporeal membrane oxygenation (ECMO) support before LVAD implantation experienced an early bleeding event versus 27 of the 69 (39%) patients without ECMO support (P < 0.001). No difference was found in early bleeding rates between HeartMate II and HeartMate 3. Predictors for early bleeding events were lower pre- and postimplant platelet counts and ECMO support preimplantation. After multivariable adjustment, early bleeding events were associated with ECMO support preimplantation (odds ratio 6.3, 95% confidence interval 1.2-32.4; P = 0.03) and thrombocytopenia (<150 × 109/l) postimplant (odds ratio 5.9, 95% confidence interval 1.9-18.7; P = 0.002). Patients who experienced an early bleeding event had a significantly worse 90-day survival rate compared to patients who did not (79% vs 96%, P = 0.03).
An early bleeding event needing surgical exploration is highly prevalent after LVAD implantation, especially in patients bridged with ECMO and with pre- and postimplant thrombocytopenia.
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