Incidence and predictors of ischemic cerebrovascular stroke among patients on extracorporeal membrane oxygenation support

Omar, Hesham R.; Mirsaeidi, Mehdi; Shumac, Jacob; Enten, Garrett; Mangar, Devanand; Camporesi, Enrico M.

doi:10.1016/j.jcrc.2015.11.009

Cited by 45 publications

(40 citation statements)

References 15 publications

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“…Multiple devices are used in current practice. Venoarterial‐extracorporeal membrane oxygenation (VA‐ECMO) and left ventricular assist device (LVAD) assist in blood perfusion and provide significant benefit for long‐term circulatory support 1,9 . Intra‐aortic balloon pumps (IABPs) are inserted directly into the aorta and use counterpulsion to increase cardiac output thereby reducing afterload 12 .…”

Section: Introductionmentioning

confidence: 99%

Assessing Cerebrovascular Hemodynamics Using Transcranial Doppler in Patients with Mechanical Circulatory Support Devices

Melmed

Schlick

Rinsky

et al. 2020

Journal of Neuroimaging

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BACKGROUND AND PURPOSE: Mechanical circulatory support (MCS) devices are commonly used in heart failure patients. These devices carry risk for presumably embolic and additionally hemorrhagic stroke. Alterations in blood flow play a key role in stroke pathophysiology, and we aimed to learn more about hemodynamic compromise. In this study, we used transcranial Doppler (TCD) ultrasound to define hemodynamics of commonly used nonpulsatile MCS devices, as well as pulsatile devices, with special attention to the total artificial heart (TAH). METHODS:From 2/2013 through 12/2016, we prospectively enrolled patients with MCS who underwent TCD imaging. We analyzed TCD parameters, including peak systolic velocity, end-diastolic velocity, pulsatility indices (PIs), and number of highintensity transient signals. Waveform morphologies were compared between various MCS devices. RESULTS: We performed 132 TCD studies in 86 MCS patients. Waveforms in patients supported by venoarterial-extracorporeal membrane oxygenation demonstrated continuous flow without clear systolic peaks with an average (±SD) PI of .43 (±.2). PIswere low in patients with continuous-flow left ventricular assist devices with a mean PI of .32 (±.13). Impella patients had morphologically distinct pulsatile waveforms and a higher mean PI of .65 (±.24). In intra-arterial balloon pump patients, mean PI was 1.01 (±.16) and diastolic upstrokes were pronounced. In TAH patients, mean middle cerebral artery velocity of 79.69 (±32.33) cm/seconds and PI of .74 (±.14) approached normal values. CONCLUSION: TCD can detect characteristic waveforms in patients supported by various MCS devices. These device-specific TCD patterns are recognizable and reproducible.

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Section: Introductionmentioning

confidence: 99%

Assessing Cerebrovascular Hemodynamics Using Transcranial Doppler in Patients with Mechanical Circulatory Support Devices

Melmed

Schlick

Rinsky

et al. 2020

Journal of Neuroimaging

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“…Cerebrovascular complications can be some of the most significant sources of morbidity and mortality in patients on VA‐ECMO, particularly in the pediatric literature where high rates of anoxic brain injury, spontaneous intracerebral hemorrhage, and ischemic strokes have been reported . Likewise, in adults, VA‐ECMO supports have also been associated with a considerable burden of ischemic strokes, anoxic brain injury, and cerebral hemorrhage, often unrelated to any embolic phenomena . There is currently very little known about the influence of cerebral blood flow (CBF) on neurologic outcomes and whether there is any impact on the basis of cannulation site.…”

Section: Introductionmentioning

confidence: 99%

Transcranial Doppler is an effective method in assessing cerebral blood flow patterns during peripheral venoarterial extracorporeal membrane oxygenation

Salna

Ikegami

Willey³

et al. 2019

J Card Surg

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Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) can be life-saving in refractory cardiogenic shock but carries a risk of neurologic complications such as stroke and hemorrhage. As little is known about the effects of different peripheral VA-ECMO cannulation sites on cerebral blood flow (CBF), transcranial Doppler (TCD) was used to determine whether the cannulation site affects CBF. Methods: Thirty-seven patients receiving VA-ECMO for cardiogenic shock via axillary or femoral artery cannulation were prospectively enrolled. Measured bilateral middle cerebral artery (MCA), mean flow velocities (MFV), and pulsatility indices (PI) were the primary outcomes and adverse neurologic events were secondary outcomes. Results: The median age was 58 years (IQR 51-66) with 26 (70%) males. Median VA-ECMO flow was 3.8 L/min (IQR 3.2-4.9) with mean arterial pressures of 80 mm Hg (IQR 75-86). Nineteen patients received right axillary artery cannulation while 18 underwent femoral cannulation. Compared with the femoral group, MFV was higher in the axillary group in the right MCA (46 cm/s [IQR 26-57] vs 27 [17-36], P = 0.03) and left (43 [IQR 35-60] vs 29 cm/s [16-48], P = 0.05). Axillary PI was significantly lower compared with the femoral group (right: 0.48 cm/s [0.25-0.65] vs 0.83 [0.66-0.93], P = 0.02; left: 0.41 cm/s [0.29-0.63] vs 1.02 [0.7-1.3], P = 0.004). One axillary patient experienced a stroke with deficits.Conclusions: TCD appears to be an effective tool for indirect monitoring of CBF in patients with ECMO with limited pulsatility. Axillary artery cannulation seems to provide higher cerebral flow rates without any difference in neurologic outcomes. Future studies may incorporate TCD into regulating ECMO flows to achieve physiologic CBF. K E Y W O R D S cardiogenic shock, extracorporeal membrane oxygenation, perfusion J Card Surg. 2019;34:447-452.wileyonlinelibrary.com/journal/jocs

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“…Neurological complications were the most frequently investigated (seven studies) (17)(18)(21)(22)(23)27,30) , followed by hemorrhagic (three studies) (24,29,32) , kidney (two studies) (26,31) , infectious (two studies) (20,25) , and mechanical (one study) (16) complications. Other complications were identified in the studies and were categorized as "other": formation of a lymphocele (one study) (33) , thrombocytopenia (one study) (19) , and thrombosis or pulmonary thromboembolism (one study) (34) .…”

Section: Sample/ecmo Modality Objective Findings/multivariate Analysimentioning

confidence: 99%

“…The frequent complications included: neurological (5.2%-15.1%) (17)(18)(21)(22)23,27,30) , bleeding (17%-80%) (24,29,32) , infection (21.4%-23.0%) (20,25) , kidney complications (48.8%-73%) (26,31) , lymphocele formation (16% in the total sample, in which 93.5% received heart transplants) (33) , thrombocytopenia (22%) (19) , and thrombosis or pulmonary thromboembolism (34) .…”

Section: Sample/ecmo Modality Objective Findings/multivariate Analysimentioning

confidence: 99%

“…Nineteen predictors were identified for neurological complications: age (17) , CA pre-ECMO (17)(18) , use of inotropes during ECMO (17) , post-ECMO hypoglycemia (17) , dialysis during ECMO (17)(18) , plasma free hemoglobin >50mg/dL, cardiac tamponade, disseminated intravascular coagulopathy, creatinine> 3mg/dL or creatinine between 1.5-3.0mg/dL (17) , hyperbilirubinemia during ECMO (18) , high level of pre-ECMO lactic acid (21)(22) , lower pre-ECMO serum hemoglobin level (22) , interval between CA and ECMO (22) , thrombocytopenia (23,27) , reduced creatinine clearance (23) , pre-admission antithrombotic therapy (27) , kidney insufficiency at ICU admission, and low pre-ECMO PaCO 2 (30) . For bleeding complications, high previous aPTT (≥70 sec), elevated APACHE III score, and post-surgery ECMO (24) were some of the predictors identified.…”

Section: Sample/ecmo Modality Objective Findings/multivariate Analysimentioning

confidence: 99%

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Predictors of complications associated with extracorporeal membrane oxygenation

Nakasato

Lopes

2020

Rev. Bras. Enferm.

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Objectives: to identify in the literature, the predictors of ECMO complications in adult patients. Methods: integrative review of literature, including articles in Portuguese, English and Spanish published from 2014 to 2018 in five databases. Included articles which analyzed the predictive factors of ECMO complications in adult patients using multivariate analysis. Results: a total of 1629 articles were identified, of which 19 were included. Nineteen predictors were identified for neurological complications (e.g., post-ECMO hypoglycemia), seven for bleeding complications (e.g., fungal pneumonia), four for infections complications (e.g., preoperative creatinine level), three for kidney complications (e.g., the length of ICU stay> 20 days) and a combination of factors for mechanical complications (e.g., median flow). Conclusions: different predictors were identified to ECMO complications. The knowledge of these predictors enables the individualized targeting of preventive interventions by multidisciplinary team for modifiable factors, as well as intensification of monitoring for early recognition of non-modifiable factors.

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Incidence and predictors of ischemic cerebrovascular stroke among patients on extracorporeal membrane oxygenation support

Cited by 45 publications

References 15 publications

Assessing Cerebrovascular Hemodynamics Using Transcranial Doppler in Patients with Mechanical Circulatory Support Devices

Assessing Cerebrovascular Hemodynamics Using Transcranial Doppler in Patients with Mechanical Circulatory Support Devices

Transcranial Doppler is an effective method in assessing cerebral blood flow patterns during peripheral venoarterial extracorporeal membrane oxygenation

Predictors of complications associated with extracorporeal membrane oxygenation

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