The role of extracorporeal membrane oxygenation circulatory support in the ‘crash and burn’ patient

Ghodsizad, Ali; Koerner, Michael M.; Brehm, Christoph; El‐Banayosy, Aly

doi:10.1097/hco.0000000000000061

Cited by 63 publications

(93 citation statements)

References 11 publications

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“…Available data from other centers show that usually 10–60% of patients on VA‐ECMO develop severe LV distension, with the highest rates observed in neonates and children . Similar to other centers with low rates of severe LV distension , we also pursue aggressive prophylaxis of LV distension . Our approach includes close monitoring of PCWP and frequent cardiac ultrasound exams, diuretic therapy, or renal replacement therapy to correct fluid overload, and titration of inotropes to utilize residual left ventricular function.…”

Section: Discussionmentioning

confidence: 94%

Refractory Pulmonary Edema and Upper Body Hypoxemia During Veno‐Arterial Extracorporeal Membrane Oxygenation—A Case for Atrial Septostomy

et al. 2018

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Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides mechanical circulatory support for patients with advanced cardiogenic shock, facilitating myocardial recovery and limiting multi-organ failure. In patients with severely limited left ventricular ejection, peripheral VA-ECMO can further increase left ventricular and left atrial pressures (LAP). Failure to decompress the left heart under these circumstances can result in pulmonary edema and upper body hypoxemia, that is, myocardial and cerebral ischemia. Atrial septostomy can decrease LAP in these situations. However, the effects of atrial septostomy on upper body oxygenation remain unknown. After IRB approval, we identified 9 out of 242 adult VA-ECMO patients between January 2011 and June 2016 who also underwent atrial septostomy for refractory pulmonary edema/upper body hypoxemia. We analyzed LAP/pulmonary capillary wedge pressure (PCWP), right atrial pressures (RAPs), P O /F O ratios (blood samples from right radial artery), intrathoracic volume status, and resolution of pulmonary edema before and up to 48 h after septostomy. There were no procedure-related complications. Thirty-day survival was 44%. LAP/PCWP decreased by approximately 40% immediately following septostomy and remained so for at least 24 h. P O /F O ratios significantly increased from 0.49 (0.38-2.12) before to 5.35 (3.01-7.69) immediately after septostomy and continued so for 24 h, 6.6 (4.49-10.93). Radiographic measurements also indicated a significant improvement in thoracic intravascular volume status after atrial septostomy. Atrial septostomy reduces LAP and improves upper body oxygenation and intrathoracic vascular volume status in patients developing severe refractory pulmonary edema while undergoing peripheral VA-ECMO. Atrial septostomy therefore appears safe and suitable to reduce the risk of upper body ischemia under these circumstances.

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Section: Discussionmentioning

confidence: 94%

Refractory Pulmonary Edema and Upper Body Hypoxemia During Veno‐Arterial Extracorporeal Membrane Oxygenation—A Case for Atrial Septostomy

et al. 2018

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“…It is technically simple to implement requires no arterial cannulation and no pump. This may prove particularly useful in centers that do not have rapid access to advanced techniques such as ECMO ().…”

Section: Discussionmentioning

confidence: 99%

Rescue therapy for hypercapnia due to high PEEP mechanical ventilation in patients with ARDS and renal failure

et al. 2018

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Extracorporeal removal of carbon dioxide in patients experiencing severe hypercapnia due to lung protective mechanical ventilation was first described over four decades ago. There have been many devices developed and described in the interim, many of which require additional training, resources, and staff. This manuscript describes a readily available and relatively simple adjunct that can provide partial lung support in patients with acute respiratory distress syndrome complicated by severe hypercapnia and acute kidney injury requiring dialysis.

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“…There are no guidelines regarding sufficient cardiac recovery for primary weaning. El‐Banayosy and coworkers proposed a left ventricular ejection fraction of more than 30% and normal filling pressures of less than 18 mm Hg during pump stop as sufficient weaning criteria . However Loforte et al showed in their retrospective analysis that patients being weaned from ECLS with a left ventricular ejection fraction of less than 40% at weaning showed a 12‐month survival of less than 50% .…”

Section: Discussionmentioning

confidence: 99%

“…During the ECLS weaning, the cardiac function was evaluated by echocardiography and invasive hemodynamic measurements with a pulmonary artery catheter. An insufficient cardiac recovery was considered if left ventricular function was less than 30% and pulmonary wedge pressure and/or central venous pressure was higher than 18 mm Hg during pump stop phases .…”

Section: Methodsmentioning

confidence: 99%

Impella 5.0 as a Second‐Line Mechanical Circulatory Support Strategy After Extracorporeal Life Support

et al. 2016

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The catheter-based Impella 5.0 left ventricular assist device is a powerful and less invasive alternative for patients in cardiogenic shock. The use as second-line therapy in patients with precedent extracorporeal life support (ECLS) has not been described before now. We analyzed our experience of consecutive patients treated with this alternative strategy. From April 2014 to December 2014, eight patients had been implanted as a second-line option after ECLS support. The reason for the change from ECLS to Impella 5.0 was absence of cardiac recovery for primary weaning and complications of ECLS therapy. The mean time of ECLS support prior to Impella implantation was 12 ± 7 days. The implantation of the Impella 5.0/CP was technically successful in all patients, and the ECLS could be explanted in all eight patients who received Impella implantation as a second-line treatment. The second-line Impella 5.0 therapy resulted in two patients who turned into left ventricular assist device (LVAD) candidates, two primary weaning candidates, and four patients who died in the setting of sepsis or absent cardiac recovery and contraindications for durable LVAD therapy. Thereby, the overall hospital discharge survival as well as the 180-day survival was 50% for Impella 5.0 implantations as second-line procedure after ECLS. The latest follow-up survival of this second-line strategy after ECLS was three out of eight, as one patient died after 299 days of LVAD support due to sepsis. The use of Impella 5.0 constitutes a possible second-line therapeutic option for those patients who do not show cardiac recovery during prolonged ECLS support or suffer from complications of ECLS therapy. This treatment allows additional time for decisions regarding cardiac recovery or indication for durable LVAD therapy.

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The role of extracorporeal membrane oxygenation circulatory support in the ‘crash and burn’ patient

Cited by 63 publications

References 11 publications

Refractory Pulmonary Edema and Upper Body Hypoxemia During Veno‐Arterial Extracorporeal Membrane Oxygenation—A Case for Atrial Septostomy

Refractory Pulmonary Edema and Upper Body Hypoxemia During Veno‐Arterial Extracorporeal Membrane Oxygenation—A Case for Atrial Septostomy

Rescue therapy for hypercapnia due to high PEEP mechanical ventilation in patients with ARDS and renal failure

Impella 5.0 as a Second‐Line Mechanical Circulatory Support Strategy After Extracorporeal Life Support

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