Percutaneous Coronary Intervention (PCI) Strategies under Hemodynamic Support for Cardiogenic Shock: A Single-Center Experience with Two Patients

We describe two cases of profound cardiogenic shock complicating acute myocardial infarction (CSAMI) requiring mechanical circulatory support (MCS) with venoarterial extracorporeal membrane oxygenation (VA-ECMO) allowing complex, high-risk, and staged percutaneous interventions with successful decannulation but with unfortunate outcomes

Precannulation International Normalized Ratio is Independently Associated With Mortality in Veno-Arterial Extracorporeal Membrane Oxygenation

Objectives: To explore whether precannulation international normalized ratio (INR) is associated with in-hospital mortality in venoarterial extracorporeal membrane oxygenation (VA-ECMO) patients. Design: A retrospective, observational cohort study. Setting: A quaternary care academic medical center. Participants: Patients with cardiogenic shock on VA-ECMO for \u3e24 hours. Interventions: None, observational study. Measurements and Main Results: A total of 188 patients who were on VA-ECMO were included over three years. Patients were stratified into three groups based on their pre-ECMO INR: INR \u3c1.5, INR 1.5 to 1.8, and INR \u3e1.8. For all patients, demographics, comorbidities, and ECMO details were recorded. The study\u27s primary outcome was in-hospital mortality and secondary outcomes included major bleeding, minor bleeding, allogeneic transfusion, ischemic stroke, intracranial hemorrhage, acute renal failure, acute liver failure, gastrointestinal bleeding, intensive care unit and hospital lengths of stay. A multivariate logistic regression was used to determine whether precannulation INR was associated independently with in-hospital mortality. In-hospital mortality differed significantly by INR group (51.6% INR \u3e1.8 v 42.3% INR 1.5-1.8 v 24.3% INR \u3c1.5; p = 0.004). In a multivariate logistic regression model, precannulation INR \u3e1.8 was associated independently with an increased odds of mortality (odds ratio, 2.48; 95% confidence interval, 1.05-6.04) after controlling for sex, Survival after VA- ECMO score, and ECMO indication. An INR within 1.5 to 1.8 did not confer an increased mortality risk. Conclusions: An INR \u3e1.8 before VA-ECMO cannulation is associated independently with in-hospital mortality. Precannulation INR should be considered by clinicians so that ECMO resources can be better allocated and risks of organ failure and intracranial hemorrhage can be better understood

A descriptive evaluation of causes of death in venovenous extracorporeal membrane oxygenation

Veno-venous extracorporeal membrane oxygenation (VV ECMO) has become an important support modality for patients with acute respiratory failure refractory to optimal medical therapy, such as low tidal volume mechanical ventilator support, early paralytic infusion, and early prone positioning. The objective of this cohort study was to investigate the causes and timing of in-hospital mortality in patients on VV ECMO. All patients, excluding trauma and bridge to lung transplant, admitted 8/2014–6/2019 to a specialty ICU for VV ECMO were reviewed. Two hundred twenty-five patients were included. In-hospital mortality was 24.4% (n = 55). Most non-survivors (46/55, 84%) died prior to lung recovery and decannulation from VV ECMO. Most common cause of death (COD) for patients who died on VV ECMO was removal of life sustaining therapy (LST) in setting of multisystem organ failure (MSOF) (n = 24). Nine patients died a median of 9 days [6, 11] after decannulation. Most common COD in these patients was palliative withdrawal of LST due to poor prognosis (n = 3). Non-survivors were older and had worse predictive mortality scores than survivors. We found that death in patients supported with VV ECMO in our study most often occurs prior to decannulation and lung recovery. This study demonstrated that the most common cause of death in patients supported with VV ECMO was removal of LST due MSOF. Acute hemorrhage (systemic or intracranial) was not found to be a common cause of death in our patient population

Breathing Life Back into the Kidney-Continuous Renal Replacement Therapy and Veno-Venous Extracorporeal Membrane Oxygenation

The purpose of this study was to evaluate the incidence of continuous renal replacement therapy (CRRT) in patients supported with veno-venous extracorporeal membrane oxygenation (VV ECMO). Secondary outcomes included mortality and the need for hemodialysis on hospital discharge. We performed a retrospective cohort study of all patients admitted to a specialty unit on VV ECMO between August 2014 and August 2018. Trauma and bridge to lung transplant patients were excluded. Demographics, comorbidities, pre-ECMO, ECMO, and renal replacement therapy outcome data were collected and analyzed with parametric and nonparametric statistics as appropriate. One hundred eighty-seven patients were enrolled. Median age was 45 (32, 55) years; precannulation pH, 7.21 (7.12, 7.30); PaO2/FiO2 ratio, 69 (56, 86); respiratory ECMO survival prediction score, 3 (0, 5); sequential organ failure assessment score, 12 (10, 14); and creatinine, 1.45 (0.93, 2.35) mg/dL. Overall survival to hospital discharge was 74.6%. Ninety-four (50.3%) patients had CRRT while on VV ECMO. Median time on CRRT was 14 (7, 21) days with 59 (61.4%) of these patients surviving to hospital discharge. Four (6.8%) patients, none with documented preexisting renal disease, required hemodialysis on discharge. CRRT patients had a statistically higher precannulation sequential organ failure assessment score, creatinine, total bilirubin and lower precannulation pH, respiratory ECMO survival prediction score, and platelet count compared with non-CRRT patients. Survival was 61.4% vs. 88.1% (p \u3c 0.001). More than half of our patients received CRRT while on VV ECMO. CRRT was used in a more critically ill patient population and was associated with higher in-hospital mortality. However, for patients who survived to hospital discharge, the majority have full renal recovery

A Retrospective Study of Infection in Patients Requiring Extracorporeal Membrane Oxygenation Support

Background: Healthcare-associated infections (HAIs) in critically ill patients are a serious public health problem. Extracorporeal membrane oxygenation (ECMO) has been used increasingly for patients with severe cardiac or respiratory failure, but it may increase HAI risk. The goal of our study was to characterize HAIs in ECMO patients at an ECMO referral center. Methods: This institutional review board–approved study identified all consecutive adult ECMO patients admitted to the cardiac surgery intensive care unit (CSICU) between January 1, 2015, and December 31, 2017. Demographic data, diagnosis, ECMO cannulation technique, and survival were collected. Urinary tract infection, pneumonia, and bacteremia incidence during ECMO and within 3 months of decannulation were collected. Outcomes of patients with HAIs were compared with noninfected patients, the CSICU infection incidence, and overall Extracorporeal Life Support Organization survival data. Results: There were 288 ECMO patients and 3396 CSICU admissions during this period. Survival was 72.3% for venoarterial ECMO, 85.3% for venovenous ECMO, and 57.1% for multimodality or veno-arteriovenous ECMO, with discharge survival of 60.2%, 72.0%, and 28.6%, respectively. Bacteremia incidence while cannulated was 6.8% for venoarterial ECMO and 9.3% for venovenous ECMO. Bacteremia occurred in 22 of 288 (7.6%) ECMO patients, compared with 48 of 3109 (1.5%) in non-ECMO CSICU patients, which was statistically significant (P \u3c .002). Bacteremia and pneumonia were associated with decreased VA-ECMO survival, with prolonged overall requirements for ECMO support. Conclusions: Nosocomial ECMO infections are significantly higher than in other CSICU patients. Infection risk remains significant even after decannulation. Infection is associated with increased mortality and longer duration of ECMO support. Further efforts are needed to determine HAI reduction strategies in this high-risk patient population

Intoxication and overdose should not preclude veno-venous extracorporeal membrane oxygenation

Introduction: Acute intoxication (AI) related morbidity and mortality are increasing in the United States. For patients with severe respiratory failure in the setting of an acute ingestion, veno-venous extracorporeal membrane oxygenation (VV ECMO) can provide salvage therapy. The purpose of this study was to evaluate outcomes in patients with overdose-related need for VV ECMO. Methods: We performed a retrospective review of all patients admitted to a specialty VV ECMO unit between August 2014 and August 2018. Patients were stratified by those whose indication for VV ECMO was directly related to an acute ingestion (alcohol, illicit drug, or prescription drug overdose) and those with unrelated diagnoses. Demographics, pre-cannulation clinical characteristics, ECMO parameters, and outcomes data was collected and analyzed with parametric and non-parametric statistics as indicated. Results: 189 patients were enrolled with 27 (14%) diagnosed with AI. Patients requiring VV ECMO for an AI were younger, had lower median BMI and PaO2/FiO2, and higher RESP scores than non-AI patients (p = 0.002, 0.01, 0.03 and 0.01). There was no difference in pre-cannulation pH, lactate, or SOFA scores between the two groups (p = 0.24, 0.5, 0.6). There was no difference in survival to discharge (p = 0.95). Among survivors, there was no difference in ECMO time or hospital stay (p = 0.24, 0.07). Conclusion: We demonstrate no survival difference for patients with and without an AI-related need for VV ECMO. AI patients should be supported with VV ECMO when traditional therapies fail despite potential stigma against acceptance on referral