We present a case of acute respiratory distress syndrome (ARDS) secondary to COVID-19 who required venovenous extracorporeal membrane oxygenation (V-V ECMO). Initially, a right ventricular assist ...device (RVAD), the ProtekDuo with an oxygenator, was placed in an outside heart center and the patient was transferred to us for ECMO management. Due to severe hypoxia, the configuration was later modified, and a 25 Fr femoral drainage cannula was inserted for venous drainage only. The arterial return tubing was spliced and using a Y-connector, arterialized blood was returned through both limbs of the ProtekDuo resulting in a significantly increased oxygenation and flow.
The c2d Spitzer Legacy project obtained images and photometry with both IRAC and MIPS instruments for five large, nearby molecular clouds. Three of the clouds were also mapped in dust continuum ...emission at 1.1 mm, and optical spectroscopy has been obtained for some clouds. This paper combines information drawn from studies of individual clouds into a combined and updated statistical analysis of star-formation rates and efficiencies, numbers and lifetimes for spectral energy distribution (SED) classes, and clustering properties. Current star-formation efficiencies range from 3% to 6%; if star formation continues at current rates for 10 Myr, efficiencies could reach 15-30%. Star-formation rates and rates per unit area vary from cloud to cloud; taken together, the five clouds are producing about 260 M of stars per Myr. The star-formation surface density is more than an order of magnitude larger than would be predicted from the Kennicutt relation used in extragalactic studies, reflecting the fact that those relations apply to larger scales, where more diffuse matter is included in the gas surface density. Measured against the dense gas probed by the maps of dust continuum emission, the efficiencies are much higher, with stellar masses similar to masses of dense gas, and the current stock of dense cores would be exhausted in 1.8 Myr on average. Nonetheless, star formation is still slow compared to that expected in a free-fall time, even in the dense cores. The derived lifetime for the Class I phase is 0.54 Myr, considerably longer than some estimates. Similarly, the lifetime for the Class 0 SED class, 0.16 Myr, with the notable exception of the Ophiuchus cloud, is longer than early estimates. If photometry is corrected for estimated extinction before calculating class indicators, the lifetimes drop to 0.44 Myr for Class I and to 0.10 for Class 0. These lifetimes assume a continuous flow through the Class II phase and should be considered median lifetimes or half-lives. Star formation is highly concentrated to regions of high extinction, and the youngest objects are very strongly associated with dense cores. The great majority (90%) of young stars lie within loose clusters with at least 35 members and a stellar density of 1 M pc-3. Accretion at the sound speed from an isothermal sphere over the lifetime derived for the Class I phase could build a star of about 0.25 M , given an efficiency of 0.3. Building larger mass stars by using higher mass accretion rates could be problematic, as our data confirm and aggravate the 'luminosity problem' for protostars. At a given T bol, the values for L bol are mostly less than predicted by standard infall models and scatter over several orders of magnitude. These results strongly suggest that accretion is time variable, with prolonged periods of very low accretion. Based on a very simple model and this sample of sources, half the mass of a star would be accreted during only 7% of the Class I lifetime, as represented by the eight most luminous objects.
The ProtekDuo, single site dual lumen cannula can be used in a multitude of configurations. In the medical literature, the ProtekDuo is described as right ventricular assist device (RVAD), as left ...ventricular assist device (LVAD), as biventricular assist device (BiVAD) when combined with an Impella device or other LVAD’s, as double lumen drainage cannula on cardiopulmonary bypass (CPB), as RVAD with oxygenator, in veno-pulmonary (V-P) ECMO configuration, venovenous-pulmonary (VV-P) ECMO configuration with additional drainage cannula, and in veno-venopulmonary (V-VP) ECMO configuration as double lumen return cannula. Improvements in flow and oxygenation have been recognized in various settings and need further scientific evaluation. We summarized the above-mentioned configurations, technical aspects, and the present literature available for the ProtekDuo.
Coronary artery disease (CAD) is a leading cause of death and disability. Conventional non-invasive diagnostic modalities for the detection of stable CAD at rest are subject to significant ...limitations: low sensitivity, and personal expertise. We aimed to develop a reliable and time-cost efficient screening tool for the detection of coronary ischemia using machine learning.
We developed a supervised artificial intelligence algorithm combined with a five lead vectorcardiography (VCG) approach (i.e. Cardisiography, CSG) for the diagnosis of CAD. Using vectorcardiography, the excitation process of the heart can be described as a three-dimensional signal. A diagnosis can be received, by first, calculating specific physical parameters from the signal, and subsequently, analyzing them with a machine learning algorithm containing neuronal networks. In this multi-center analysis, the primary evaluated outcome was the accuracy of the CSG Diagnosis System, validated by a five-fold nested cross-validation in comparison to angiographic findings as the gold standard. Individuals with 1, 2, or 3- vessel disease were defined as being affected.
Of the 595 patients, 62·0% (n = 369) had 1, 2 or 3- vessel disease identified by coronary angiography. CSG identified a CAD at rest with a sensitivity of 90·2 ± 4·2% for female patients (male: 97·2 ± 3·1%), specificity of 74·4 ± 9·8% (male: 76·1 ± 8·5%), and overall accuracy of 82·5 ± 6·4% (male: 90·7 ± 3·3%).
These findings demonstrate that supervised artificial intelligence-enabled vectorcardiography can overcome limitations of conventional non-invasive diagnostic modalities for the detection of coronary ischemia at rest and is capable as a highly valid screening tool.
PURPOSE OF REVIEWIn advanced cardiogenic shock, early mechanical circulatory support may prevent multiorgan failure and death. In this article, we are describing our experience with extracorporeal ...membrane oxygenation (ECMO) application.
RECENT FINDINGSVenoarterial ECMO has been used successfully as a therapeutic option for patients with advanced cardiogenic shock and cardiac arrest.
SUMMARYIn this review, based on the daily routine of the Hershey group using ECMO for therapy of advanced cardiogenic shock, the application of ECMO is described. The aim is to share our hands-on experience during emergent implantation and to contribute to the knowledge within the field of mechanical circulatory support.
Several articles have discussed the weaning process for venoarterial extracorporeal membrane oxygenation; however, there is no published report to outline a standardized approach for weaning a ...patient from venovenous extracorporeal membrane oxygenation (ECMO). This complex process requires an organized approach and a thorough understanding of ventilator management and ECMO physiology. The purpose of this article is to describe the venovenous ECMO weaning protocol used at our institution as well as provide a review of the literature.
Background
Patients with combined circulatory shock and respiratory failure may benefit from veno‐arteriovenous (V‐AV) extracorporeal membrane oxygenation support (ECMO). We report our center’s ...experience with V‐AV ECMO and propose an algorithm to help identify patients that may benefit from early V‐AV ECMO support.
Methods
Clinical data were extracted from electronic medical records between November 1, 2016 and November 1, 2019.
Results
Out of a total of 369 patients placed on extracorporeal life support (ECLS), we identified a total of 26 patients who underwent hybrid ECMO placement. Three patients were excluded from our analysis due to veno‐venoarterial extracorporeal membrane oxygenation (V‐VA ECMO) configuration, therefore 23 patients were included in our analysis. The median age was 53 (range 25–73) years. Hybrid ECMO support was instituted most commonly for differential hypoxemia in patients on venoarterial (V‐A) ECMO support, and cardiogenic shock in patients who were initially started on venovenous (V‐V) ECMO. The initial ECMO cannulation was V‐A in 12 patients, V‐V in 8 patients, and directly V‐AV in 3 patients. Nine out of 23 patients were successfully decannulated (39.1%) and survived until hospital discharge. The main ECMO‐related complications included bleeding (n = 10), circuit exchange either due to hemolysis or oxygenator failure (n = 4), ECMO cannula site infection (n = 2), deep venous thrombosis (n = 2), and death during ECMO cannula exchange (n = 1).
Conclusions
V‐AV ECMO represents a rescue strategy in critically ill patients with combined respiratory failure and cardio‐circulatory shock.
Out of 369 patients placed on extracorporeal life support between November 1, 2016 and November 1, 2019, we identified a total of 23 patients who underwent V‐AV ECMO placement. The initial ECMO cannulation was V‐A in 12 patients, V‐V in 8 patients and V‐AV in 3 patients. Nine out of 23 patients were successfully decannulated (39.1%) and survived to hospital discharge. In conclusion, V‐AV ECMO represents a rescue strategy in critically ill patients with combined respiratory failure and cardio‐circulatory shock. ECMO, extracorporeal membrane oxygenation; V‐A, venoarterial; V‐AV, veno‐arteriovenous; V‐V, venovenous; V‐VA, veno‐venoarterial.
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