Acute myocardial infarction complicated by cardiogenic shock: an algorithm based ECMO program can improve clinical outcomes.

Objective: Extracorporeal membrane oxygenation (ECMO) in our institution resulted in near total mortality prior to the establishment of an algorithm-based program in July 2010. We hypothesized that an algorithm based ECMO program improves the outcome of patients with acute myocardial infarction complicated with cardiogenic shock. Methods: Between March 2003 and July 2013, 29 patients underwent emergent catheterization for acute myocardial infarction due to left main or proximal left anterior descending artery occlusion complicated with cardiogenic shock (defined as systolic blood pressure \u3c 90mmHg despite multiple inotropes, +- balloon pump, lactic acidosis). Of 29 patients, 15 patients were before July 2010 (Group 1, old program), 14 patients were after July 2010 (Group 2, new program). Results: There were no significant differences in the baseline characteristics, including age, sex, coronary risk factors and left ventricular ejection fraction, between the two groups. Cardiopulmonary resuscitation prior to ECMO was performed in 2 cases (13%) in Group 1 and 4 cases (29%) in Group 2. ECMO support was performed in 1 case (6.7%) in Group 1 and 6 cases (43%) in Group 2. The 30-day survival of Group 1 vs. Group 2 was 40% vs. 79% (p = 0.03), and one-year survival rate was 20% vs. 56% (p=0.01). The survival rate for patients who underwent ECMO was 0% in Group 1 vs. 83% in Group 2 (p = 0.09). In Group 2, the mean duration on ECMO was 9.8 ± 5.9 days. Of the 6 patients who required ECMO in Group 2, 100% were successfully weaned off ECMO or were bridged to ventricular assist device implantation. Conclusions: Initiation of an algorithm based ECMO program improved the outcomes in patients with acute myocardial infarction complicated by cardiogenic shock

The impact of a new ECMO program on clinical outcomes of patients with acute myocardial infarction complicated by cardiogenic shock.

Objective: To investigate if a new ECMO program will improve the outcome of patients who had acute myocardial infarction complicated with cardiogenic shock. Presented 24th Annual ELSO Conference. Philadelphia, PA. Sep 19-21, 2013

Management of Upper Aerodigestive Tract Bleeding in Patients on ECMO.

Introduction: Bleeding complications on Extracorporeal Membrane Oxygenation (ECMO) are often encountered. In a review of our own series, it was found that upper aero digestive tract bleeding was common and management was often difficult. We propose an algorithm to help manage upper aero digestive tract bleeding in the anticoagulated, ECMO patient. Hypothesis: Once an ECMO patient fails conservative management for upper aero digestive bleeding, more aggressive measures will prove successful, which will provide benefit to the patient. Methods: A retrospective chart review was performed of the patients who underwent venovenous or veno-arterial ECMO at our institution between July 2010 and July 2012. The patients that had upper aero digestive tract bleeding that required an Otolaryngology consultation were identified. They were further investigated to determine location of bleed and procedures performed to control the bleeding. Results: Among the 37 consecutive patients on ECMO, 11 (30%) had upper aero digestive tract bleeding events. Of these 11, 6 (55%) were secondary to an iatrogenic incident, such as placing a nasogastric tube or transesophageal echo probe. All 11 patients were treated at bedside with conservative management and 2 were treated in the operating room. 72.7 % of patients treated with conservative management required repeated procedures due to incomplete hemostasis, compared to 0% of patients once surgical intervention was complete. Conclusions: Approximately one third of the ECMO patients developed upper aero digestive tract bleeding. This bleeding should be controlled in a timely manner otherwise it may result in massive transfusions. Delaying intervention or conservative management may not be effective. We recommend surgical intervention if the initial conservative management failed and continued to bleed for more than 24-36 hours

Case Series on Veno - venous extracorporeal membrane oxygenation (VV-ECMO) as a bridge to complete recovery in influenza type A related refractory ARDS

Introduction: Influenza A sequelae range from mild symptoms to acute respiratory distress syndrome (ARDS), which can be refractory to conventional ventilator therapy. We present a case series of three non-H1N1 Influenza patients with ARDS, who completely recovered after VV-ECMO. Case Presentation: In January and February 2013, we experienced three cases of Influenza A induced ARDS that failed conventional ARDS ventilator therapy. All three patients presented with typical flu-like symptoms, which deteriorated over several days, requiring intubation. They were all treated with oseltamivir. They had bilateral chest infiltrates on chest x-rays. After a few days of failing conventional treatment these patients were placed on VV-ECMO using Avalon Dual Lumen catheters. Presented 24th Annual ELSO Conference

Two-vessel off-pump coronary artery bypass grafting by left thoracotomy in a complex redo case

Introduction: The left thoracotomy approach is an alternative technique for coronary revascularization to avoid complications associated with re-sternotomy, such as injury to patent grafts, right ventricle, aorta, during re-sternotomy. Situations such as calcification of the ascending aorta and previous mediastinitis favor the use of the left thoracotomy approach. Revascularization of the circumflex territory via a lateral thoracotomy has been reported previously. However, reports of revascularization of the LAD combined with circumflex artery territory via left thoracotomy approach are rare. We successfully performed an off-pump CABG by left thoracotomy in a complex redo case to revascularize the LAD and obtuse marginal branch (OM) in an 83 year-old-man who had CABG and AVR in the past with a heavily calcified ascending aorta. Case Report: 83-year-old caucasian male History of CABG 20 years ago, redo CABG in the following year due to graft failure, and an AVR with a mechanical valve 12 years ago, and multiple coronary interventions. Presented with unstable angina. Echo showed normal LV function Due to his history of early stent re-stenosis and location of the disease, he was considered not suitable for repeat PCI. CT Scan showed severe calcification of the ascending aorta (left), and mild disease on the descending aorta. Presented at Chest 2013. Chicago IL.October 26-31, 2013

An old problem with a new therapy: gastrointestinal bleeding in ventricular assist device patients and deep overtube-assisted enteroscopy.

Conventional algorithms for diagnosis and treatment of gastrointestinal bleeding (GIB) in patients with nonpulsatile ventricular assist devices (VADs) may take days to perform while patients require transfusions. We developed a new algorithm based on deep overtube-assisted enteroscopy (DOAE) to facilitate a rapid diagnosis and treatment. From 2004 to 2012, 84 patients who underwent VAD placement in our institution, were evaluated for episodes of GIB. Our new algorithm for the management of GIB using DOAE was evaluated by dividing the episodes into three groups: group A (traditional management without enteroscopy), group B (traditional management with enteroscopy performed \u3e24 hours after presentation), and group C (new management algorithm with enteroscopy performedpresentation). Gastrointestinal bleeding was observed in 14 (17%) of our study patients for a total of 45 individual episodes of which 28 met our criteria for subanalysis. Forty-one (84%) lesions were confined to the upper gastrointestinal tract with more than 91% of these lesions being arteriovenous malformations. Average number of transfusions in groups A, B, and C were 4.1, 6.3, and 1.3, respectively (p = 0.001). The number of days to treatment was significantly shorter in group C than group B (0.4 vs. 5.3 days, p = 0.0002). Our new algorithm for the management of GIB using DOAE targets the most common locations of bleeding found in this patient population. When performed early, DOAE has the potential to decrease the need for transfusions and allow for an early diagnosis of GIB in VAD recipients

A cost reducing ECMO model: a single institutional experience.

Background: The demand for ECMO support has grown. Its provision remains limited due to several factors (high cost, complicated technology, lack of expertise) which increase healthcare cost. Our goal was to assess if an ICU run ECMO model (without continuous bedside perfusion) would decrease costs while maintaining patient safety and outcomes. Method: We performed a retrospective review that analyzed the cost and safety benefits of a newly implemented ICU-run ECMO unit from 2011-2012. The program consisted of a dedicated ICU involving multidisciplinary providers (ICU RN, mid-level providers and intensivists). In year one, we introduced an education platform, new technology and dedicated space. In year two, the multidisciplinary providers (MDPs) adopted continuous bedside perfusion support. New management algorithms designating MDPs as first responders were established. The primary end point included total cost, while the secondary end points were the RN ratios and patients’ safety. We compared these parameters with the previous model. Results: During the study period, 75 patients were placed on ECMO (mean days: 10). The total hospital expenditure for the previous ECMO model was $623,070 compared to$302,328 respectively, showing a 46.8% decrease in cost. This cost decrease was attributed to a decreased utilization of perfusionist services and the introduction of longer lasting and more efficient ECMO technology. We did not find any significant changes in RN ratios or any differences in outcomes related to ICU safety events. Conclusion: We demonstrated that the ICU run ECMO model managed to lower hospital cost by reducing the cost of continuous bedside perfusion support with no loss in safety or outcomes. Presented at ASAIO’s 59th Annual Conference. Chicago, IL. June 12-15, 2013

We came, we saw, we cannulated?

Introduction: Despite advances in management of patients with severe acute respiratory distress syndrome (ARDS), mortality due to ARDS still remains high. In patients with refractory gas-exchange abnormalities, extracorporeal membrane oxygenation (ECMO) is considered as salvage therapy that aims to decrease ventilator induced lung injury and provide lung rest. injury and provide lung rest. Methods: We conducted a retrospective study of patients diagnosed with ARDS from October 2010 to September 2012. The aim of the study was to describe the population of patients placed on ECMO for ARDS in our institution. All patients placed on ARDSnet protocol were identified in the electronic patient record. Demographic, laboratory and ventilator data was extracted. Specifically mode of ventilation, use of rescue modalities (which included inhaled epoprostenol, skeletal muscle paralytics and/or use of airway pressure release ventilation (APRV)), Murray score, Oxygenation Index (OI), Alveolar-arterial gradient (A-a) and PaO2/FiO2 ratio (P/F) were tabulated. Survival to hospital discharge was recorded. Results: We identified a total of 149 patients. Of these 87 were managed per ARDSnet protocol, 48 received rescue modalities, and 14 patients were placed on ECMO in addition to rescue therapy after a mean interval of 72 hours. Six of 14 patients were placed on veno-arterial ECMO and the rest on veno-venous ECMO. Table 1 shows the baseline characteristics of these patients. Table 2 depicts the etiology of ARDS among our patient population. Mortality was higher in the ARDS group treated with rescue modalities (other than ECMO) compared to the group placed on ECMO as additional rescue therapy (77% vs. 50%; p = 0.3243). The ECMO group had a survival advantage despite higher A-a gradient, PaO2/Fio2 ratio, Oxygenation Index and Murray Score in the ECMO group (Table 1). Conclusion: Patients with ARDS placed on ECMO had an absolute reduction in mortality of 27% when compared to other rescue modalities. However this did not reach statistical significance due to the small sample size. We believe that ECMO is an important rescue modality in the right clinical setting. Treating physicians should consider ECMO as a treatment modality for severe ARDS patients

Left ventricular thrombus found in a patient with ARDS and stress-induced cardiomyopathy requiring veno-arterial ECMO.

Presentation: 68 year-old male with a history of acute leukemia with complete remission after bone marrow transplant 4 months ago, coronary disease s/p LAD stents about 14 years ago with no chronic anti-platelet medication, and repeated episode of DVT despite appropriate anti-coagulation, presented with viral pneumonia (rhinovirus)

MRSA sepsis and acute respiratory distress syndrome during veno-arterial extracorporeal membrane oxygenation (ECMO).

Presentation: A 39 year old female African American presented with respiratory distress two days after ERCP for pancreatitis. The patient quickly deteriorated, required intubation, and developed severe hypotension requiring vasopressors. VA-ECMO was initiated for ARDS and SIRS due to on-going pancreatitis. Pre ECMO ABG: PH 7.01, PaCO2 70, PaO2 70 with FiO2 100% with PEEP 15 Profound hypotension, required 2 pressors Preliminary results of cultures were negative at the time of ECMO placement. Presented 24th Annual ELSO Conference. Philadelphia, PA. Sep 19-21, 2013