BackgroundThe rate, prognostic impacts, and predisposing factors of major vascular complications (MVCs) in patients underwent venoarterial extracorporeal membrane oxygenation (VA-ECMO) by surgical cut-down are poorly understood. The purpose of this study was to identify these parameters in adult VA-ECMO patients.MethodsAdult postcardiotomy cardiogenic shock (PCS) patients receiving VA-ECMO by femoral surgical cut-down cannulation from January 2004 to December 2015 were enrolled in this study. Patients were separated into two groups depending on the presence of MVCs. Multivariate logistic regression was performed to identify factors independently associated with MVCs.ResultsOf 432 patients with PCS treated with VA-ECMO, 252 patients (58.3%) were weaned off VA-ECMO and 153 patients (35.4%) survived to discharge. MVCs were seen in 72 patients (16.7%), including bleeding or hematoma in the cannulation site (8.6%), limb ischemia requiring fasciotomy (8.6%), femoral artery embolism (0.7%), and retroperitoneal bleeding (0.7%). The rate of survival to discharge was 16.7 and 39.2% in patients with or without MVCs, respectively (p < 0.001). Obesity, concomitant with intra-aortic balloon pump (IABP), Sequential Organ Failure Assessment (SOFA) score at 24 h post-ECMO, and hemostasis disorder were shown to be associated with MVCs. MVCs were an independent risk factor for in-hospital mortality by multivariate analysis (odds ratio 3.91; 95% confidence interval, 1.67–9.14; p = 0.013).ConclusionsMVCs are common and associated with higher in-hospital mortality among adult PCS patients receiving peripheral VA-ECMO support. The obesity, concomitant with IABP, SOFA score at 24 h post-ECMO, and hemostasis disorder were independent risk factor of MVCs.

BackgroundThe addition of an intra-aortic balloon pump (IABP) during peripheral venoarterial extracorporeal membrane oxygenation (VA ECMO) support has been shown to improve coronary bypass graft flows and cardiac function in refractory cardiogenic shock after cardiac surgery. The purpose of this study was to evaluate the impact of additional IABP support on the cerebral blood flow (CBF) in patients with peripheral VA ECMO following cardiac procedures.MethodsTwelve patients (mean age 60.40 ± 9.80 years) received VA ECMO combined with IABP support for postcardiotomy cardiogenic shock after coronary artery bypass grafting. The mean CBF in the bilateral middle cerebral arteries was measured with and without IABP counterpulsation by transcranial Doppler. The patients provided their control values. The mean CBF data were divided into two groups (pulsatile pressure greater than 10 mmHg, P group; pulsatile pressure less than 10 mmHg, N group) based on whether the patients experienced cardiac stun. The mean cerebral blood flow in VA ECMO (IABP turned off) alone and VA ECMO with IABP support were compared using the paired t test.ResultsAll of the patients were successfully weaned from VA ECMO, and eight patients survived to discharge. The addition of IABP to VA ECMO did not change the mean CBF (251.47 ± 79.28 ml/min vs. 251.30 ± 79.47 ml/min, P = 0.96). The mean CBF was higher in VA ECMO alone than in VA ECMO combined with IABP support in the N group (257.68 ± 97.21 ml/min vs. 239.47 ± 95.60, P = 0.00). The addition of IABP to VA ECMO support increased the mean CBF values significantly compared with VA ECMO alone (261.68 ± 82.45 ml/min vs. 244.43 ± 45.85 ml/min, P = 0.00) in the P group.ConclusionThese results demonstrate that an IABP significantly changes the CBF during peripheral VA ECMO, depending on the antegrade blood flow by spontaneous cardiac function. The addition of an IABP to VA ECMO support decreased the CBF during cardiac stun, and it increased CBF without cardiac stun.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an option for mechanical support for patients with postcardiotomy cardiogenic shock (PCS). However, the use of VA-ECMO in patients suffering from aortic disease with PCS has not been greatly reported. This is a retrospective review of adult patients undergoing aortic surgery who received VA-ECMO support to treat refractory PCS from August 2009 to May 2016. A total of 36 patients who underwent aortic surgery with VA-ECMO support for refractory PCS were included. Preoperative, perioperative, and postoperative variables were assessed and analyzed for possible correlation with in-hospital mortality. After a mean duration of 3.6 ± 2.9 days, 24 patients (67%) were weaned off VA-ECMO, and 18 patients (50%) were discharged from the hospital. The overall in-hospital mortality was 50%. The main cause of death was multiple organ dysfunction. The survivors had a lower level of preoperative creatine kinase-MB (CK-MB), a higher rate of antegrade cannulation, and a lower lactate level at 12 h, respectively. Relevant factors for in-hospital mortality were retrograde-flow cannulation (odds ratio [OR], 2.49), peak lactate levels greater than 20 mmol/L (OR, 5.0), and preoperative CK-MB greater than 100 IU/L (OR, 6.40). Antegrade cannulation may provide better perfusion and should be emphasized to improve outcomes. Additionally, levels of peak serum lactate and preoperative CK-MB may be relevant factors for in-hospital mortality in aortic patients with PCS.

Severe left ventricular (LV) dysfunction patients undergoing off-pump coronary artery bypass grafting (OPCAB) are often associated with a higher mortality. The efficacy and safety of the preoperative prophylactic intra-aortic balloon pump (IABP) insertion is not well established. 416 consecutive patients with severe LV dysfunction (ejection fraction ≤35%) undergoing isolated OPCAB were enrolled in a retrospective observational study. 191 patients was enrolled in the IABP group; the remaining 225 patients was in control group. A total of 129 pairs of patients were propensity-score matched. No significant differences in demographic and preoperative risk factors were found between the two groups. The postoperative 30-day mortality occurred more frequently in the control group compared with the IABP group (8.5% vs. 1.6%, p = 0.02). There was a significant reduction of low cardiac output syndrome in the IABP group compared with the control group (14% vs. 6.2%, p = 0.04). Prolonged mechanical ventilation (≥48 h) occurred more frequently in the control group (34.9% vs. 20.9%, p = 0.02). IABP also decreased the postoperative length of stay. Preoperative IABP was associated with a lower 30-day mortality, suggesting that it is effective in patients with severe LV dysfunction undergoing OPCAB.

The immature CD14CD16 monocytes might contribute to blood-circuit contact-induced acute lung injury by generating TNF-α-producing, mature monocytes. New strategies based on monocyte manipulation could be a promising therapeutic approach for minimising CPB-related lung injury.

From early May 2009, the novel influenza A (H1N1) pandemic affected mainland China. Of those infected, a small proportion of patients developed acute respiratory distress syndrome (ARDS) so rapidly and severely that conventional ventilation treatment was ineffective. As an alternative treatment, the effect of extracorporeal membrane oxygenation (ECMO) was evaluated. From November 2009 to January 2010, all patients suffering from influenza A (H1N1)-associated ARDS referred to Beijing Anzhen Hospital for treatment with ECMO were enrolled. We describe the characteristics, treatment, and outcomes of these patients at 1- and 3-month follow-up. Nine patients (four females; mean age, 31.2 [21-59] years) from four centers were enrolled. All females had a history of recent pregnancy or had recently given birth. Before ECMO, patients had severe respiratory failure despite advanced mechanical ventilatory support with a mean partial pressure of arterial oxygen/fraction of inspired oxygen of 52.9 ± 5.1 (45.0-63.8) mm Hg, positive end-expiratory pressure of 17.2 ± 4.2 cmH(2) O, and a Murray Lung Score of 3.6 (3.25-3.75). All nine patients were treated with veno-venous ECMO via percutaneous access. The mean duration of ECMO support was 436.6 ± 652.1 h (67.0-2160.0). At the end of 1-year follow-up, five patients (55.7%) were weaned from ECMO. Five patients (55.7%) survived to hospital discharge. Four patients (44.4%) died while undergoing ECMO. The mean length of intensive care unit and hospital stay was 4-204 days (median, 32) and 4-234 days (median, 38), respectively. There was no significant difference between survivors and nonsurvivors in the screened parameters. Use of ECMO for critically ill patients with 2009 influenza A (H1N1)-related ARDS is feasible and effective. However, this treatment is technically demanding. For success, careful selection of patients is crucial.

The urinary trypsin inhibitor (ulinastatin) is used in the clinic to prevent inflammatory responses in patients undergoing cardiopulmonary bypass (CPB); however, the anti-inflammatory mechanism is unclear. In the current study, we recruited 40 patients undergoing selective cardiac valve replacement surgery; and these patients were randomly divided into two groups (ulinastatin group [UG] and control group [CG]). We collected peripheral blood preoperatively, at the end of CPB, and postoperative days 1 and 3 and analyzed the kinetic changes in regulatory T (Treg) cell subsets. There was no statistically significant difference in the number of CD4(+) T cells between the two groups. The number of CD4(+)CD25(+) Treg cells, especially the suppressive activated Treg (aTreg) subset, was higher in the UG than the CG 1 and 3 days postoperatively. Thus, ulinastatin alleviated the inflammatory response during CPB by inducing the expansion of aTreg cells.

Background It has been widely accepted that monocytes are one of the central mediators contributing to inflammaging. However, it remains unclear whether aged monocytes, similar to aged T cells, have characteristics of hyperactivation and increased expression of co-inhibitory molecules. Methods Peripheral blood mononuclear cells (PBMCs) were isolated from young (21–40 years old), middle-aged (41–60 years old), and older human subjects (> 60 years old). Flow cytometry was used to monitor changes in the expression of surface molecules of monocyte subsets and cytokine-producing capacity. Results We observed increased tumor necrosis factor-α: TNF-α and decreased interleukin-6 (IL-6) production in monocytes from older adults compared with young and middle-aged adults. Older adults had a greater percentage of intermediate and non-classical monocyte subsets, along with increased levels of the immune activation markers human leukocyte antigen-DR (HLA-DR), and adhesion molecules cluster of differentiation molecule 11b (CD11b) and L-selectin (CD62L). Furthermore, we observed increased C–C motif chemokine receptor 2 (CCR2) expression on classical monocytes and decreased C-X3-C motif chemokine receptor 1 (CX3CR1) expression on non-classical monocytes in older adult subjects. The expression of co-inhibitory receptors was reduced on monocyte subsets in older adults. Conclusions Circulating monocytes in older adults exhibit increased expression of activation, adhesion, and migration markers, but decreased expression of co-inhibitory molecules.