This study investigated the effects of red blood cell (RBC) storage time in a rabbit model of endotoxic shock by assessing lung injury, surfactant protein-A (SP-A) expression, oxidative stress markers, and cytokine level...This study investigated the effects of red blood cell (RBC) storage time in a rabbit model of endotoxic shock by assessing lung injury, surfactant protein-A (SP-A) expression, oxidative stress markers, and cytokine levels. Male New Zealand rabbits were divided into eight groups (n = 8): control, blood loss, endotoxin, blood loss + endotoxin, and four treatment groups receiving RBCs stored for 0, 7, 14, or 21 days. Following lipopolysaccharide injection, measurements were taken for interleukin (IL)-1β, IL-8, tumor necrosis factor-α, lung wet/dry weight ratio, malondialdehyde, superoxide dismutase, myeloperoxidase, nitric oxide synthase, and SP-A. Results showed that transfusion of RBCs, particularly those stored for longer durations, aggravated lung damage after endotoxin shock. Groups receiving RBCs stored for ≥14 days displayed significantly more severe lung edema, histopathological injury, and higher levels of oxidative stress markers compared with those receiving fresher (0 or 7 days) RBCs. Concurrently, antioxidant activity was diminished, and SP-A levels were significantly reduced. Notably, the proinflammatory cytokines IL-1β and IL-8 reached their highest concentrations in the group transfused with 21 day old RBCs. These findings suggest that for transfusion during endotoxic shock, RBCs stored for less than 14 days are preferable. https://links.lww.com/ASAIO/B918.
Neuromuscular blocking agent (NMB) utilization has been infrequently described in patients requiring extracorporeal membrane oxygenation (ECMO). The goal of this analysis was to evaluate NMB utilization at a high-volume...Neuromuscular blocking agent (NMB) utilization has been infrequently described in patients requiring extracorporeal membrane oxygenation (ECMO). The goal of this analysis was to evaluate NMB utilization at a high-volume ECMO center. This was a retrospective cohort study of patients who required ECMO at the Cleveland Clinic between January 2022 and December 2023. NMB utilization was collected, including the agent, dose, duration (if continuous infusion), and indication. Other clinical outcomes recorded included duration of ECMO support, evidence of neuromuscular dysfunction, and hospital mortality. In total, 329 patients were evaluated, and 280 patients were included. Nearly 50% of patients received NMB during their ECMO course. Most utilization was rocuronium bolus. Continuous infusion NMB was only used in 12%. Common indications for NMB were for bedside procedures (66%), hypoxemia (9%), and ECMO low flows (6%). When used for hypoxemia or ECMO low flows, administration of NMB was associated with an improvement in partial pressure of arterial oxygen (PaO 2 ) (64 vs . 105 mm Hg, p < 0.001) and ECMO flow (2.9 vs . 4.0 L/min, p = 0.016) at 1 hour, respectively. Evidence of neuromuscular dysfunction was documented in 6% of patients. Neuromuscular blocking agent use was needed in about half of patients on ECMO, but few patients required continuous NMB.
Extracorporeal life support (ECLS) technology has witnessed remarkable advancements during the last decades. However, further research and development of devices are required to increase, for example, performance-efficie...Extracorporeal life support (ECLS) technology has witnessed remarkable advancements during the last decades. However, further research and development of devices are required to increase, for example, performance-efficiency, hemocompatibility, and long-term stability. All novel devices, even in early research stages, must undergo rigorous testing and evaluation. Yet, these early evaluations are often conducted under nonstandardized conditions, resulting in data difficult to compare, interpret, or translate into clinical practice. Establishing well-defined, standardized in-vitro testing protocols for all ECLS components and devices would represent a major step forward. Such protocols would improve methodological consistency and ensure reproducibility across research groups. This document, developed by an international group of ECLS experts from all disciplines in which such components are designed, developed, and applied, provides clear recommendations and standardized criteria for device testing according to international norms. Adoption of these criteria including the ways of reporting results will foster a unified approach among scientists, engineers, clinicians, and the medical device industry. Ultimately, this common framework will facilitate data interpretation, improve comparability of study results between different groups, making the review of studies more straightforward, as not every aspect of testing requires additional review and discussion, certainly favoring decision-making in the development and application of ECLS technologies.
Diagnosing infections related to left ventricular assist devices (LVADs) is challenging due to poor accessibility and imaging artifacts, particularly when central components are involved. We investigated whether fluorine...Diagnosing infections related to left ventricular assist devices (LVADs) is challenging due to poor accessibility and imaging artifacts, particularly when central components are involved. We investigated whether fluorine-18 fluorodeoxyglucose ([ 18 F]FDG) positron emission tomography/computed tomography (PET/CT) improves the diagnosis of bloodstream infection (BSI) compared with clinical parameters alone. Sixty-one patients with suspected LVAD infection underwent PET/CT between 2016 and 2022. Fluorodeoxyglucose uptake at the LVAD exit site, driveline, inflow/outflow cannulas, and pump according to Deauville score (DS) and lymphadenopathy were assessed. C-reactive protein (CRP), body temperature, white blood cell count (WBC), and bloodstream infection (BSI) (positive blood cultures obtained within ±7 days) were documented. Overall, 52% of patients were BSI-positive; clinical parameters were not consistently correlated with DS. Sensitivity for detecting BSI was highest for CRP greater than 0.5 mg/dl (69%, 95% confidence interval [CI]: 50-84) and specificity for WBC (75%, 56-90). Positron emission tomography/computed tomography-based DS greater than or equal to 4 of peripheral components had less than 50% sensitivity and only modest specificity. Diagnostic performance was better for central components with the highest sensitivities for pump and outflow cannula (79%, 41-95; 77%, 56-91) and highest specificity for inflow cannula (85%, 55-98) in conjunction with positive lymphadenopathy (96%, 77-100). Combined with lymphadenopathy, PET/CT-based DS of central LVAD components outperforms standard clinical parameters in detecting LVAD-related BSI, thereby supporting an individualized therapeutic approach.
Postinfarction ventricular septal defects (VSDs) are a rare yet critical condition that can occur following a myocardial infarction. Initial management typically includes medical support and mechanical circulatory device...Postinfarction ventricular septal defects (VSDs) are a rare yet critical condition that can occur following a myocardial infarction. Initial management typically includes medical support and mechanical circulatory devices, such as extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pumps (IABP). However, the utility of Impella 5.5 in bridging postinfarct VSDs to surgical repair is an emerging new approach. This case report presents a 70 year old male with a postinfarct VSD and the successful use of Impella 5.5 to bridge him to surgical repair. After experiencing dyspnea and chest discomfort, the patient was diagnosed with a 100% occlusion of the left anterior descending artery, which was successfully treated with a drug-eluting stent. On re-admission for hemoptysis and shortness of breath, a ventricular septal rupture was identified, necessitating urgent surgical consultation. The patient was initially managed on an IABP and then converted to Impella 5.5. After stabilization of cardiogenic shock and improvement in the left-to-right shunt, he was taken to the operating room for repair. The VSD was closed using a single patch technique and an aneurysmectomy was performed. This case illustrates the potential utility of Impella 5.5 in managing postinfarct VSDs.
Moore EA, Han P, Shekar K
… +13 more, Ramanathan K, Riera Del Brio J, Puslecki M, Diaz R, Alfoudri H, Ramanan R, Sin SWC, Vercaemst L, Friedrich T, Roeleveld P, Said A, Alinier G, Zakhary B
These guidelines are intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing extracorporeal life supp...These guidelines are intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing extracorporeal life support (ECLS)/ECMO and describe what are believed to be useful and safe practice for ECLS and ECMO. The aim of clinical guidelines was to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgment, knowledge, and expertise. These guidelines do not take the place of physicians' and other health professionals' judgment in diagnosing and treatment of patients. These guidelines are not intended to and should not be interpreted as setting a standard of care or being deemed inclusive of all proper methods of care nor exclusive of other methods of care directed at obtaining the same results. The ultimate judgment must be made by the physician and other health professionals and the patient considering all the circumstances presented by the individual patient, and the known variability and biologic behavior of the clinical condition. These guidelines reflect the data at the time the guidelines were prepared; the results of subsequent studies or other information may cause revisions to the recommendations in these guidelines to be prudent to reflect new data, but ELSO is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through these guidelines.
Bonios MJ, Miliopoulos D, Tseliou E
… +9 more, Koliopoulou A, Ieromonachos K, Kogerakis N, Gkouziouta A, Kapelios CJ, Adamopoulos S, Miller D, Drakos SG, Chamogeorgakis T
Preoperative assessment for left ventricular assist device implantation (LVAD) of right ventricular (RV) failure risk in heart failure (HF) patients remains challenging. Hemodynamic, echocardiographic, and biochemical pa...Preoperative assessment for left ventricular assist device implantation (LVAD) of right ventricular (RV) failure risk in heart failure (HF) patients remains challenging. Hemodynamic, echocardiographic, and biochemical parameters are dynamic and can change during optimization. We aimed to determine whether RV interstitial fibrosis, a less dynamic parameter, is independent of conventional RV functional parameters. Nineteen patients with Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles I-III undergoing LVAD implantation were enrolled. Preoperative echocardiographic and hemodynamic data were collected. Myocardial tissue samples from the left ventricular apex and RV free wall were obtained to quantify interstitial fibrosis. The mean patient age was 40 ± 14 years. Left ventricular and RV interstitial fibrosis showed moderate correlation (r = 0.48, p = 0.04). All patients were on inotropic support and 17 were on intra-aortic balloon pump support at the time of implantation. Right ventricular fibrosis did not correlate with hemodynamic, echocardiographic, or biochemical markers of RV function. In advanced heart failure patients, RV interstitial fibrosis is independent of conventional RV functional parameters. It may serve as a less dynamic, complementary marker for assessing intrinsic RV functional reserve and prognosis. Further investigation is warranted.
Obesity poses technical challenges during veno-venous extracorporeal membrane oxygenation (VV-ECMO) cannulation because of thick subcutaneous tissue and increased insertion resistance. While patient-related factors are w...Obesity poses technical challenges during veno-venous extracorporeal membrane oxygenation (VV-ECMO) cannulation because of thick subcutaneous tissue and increased insertion resistance. While patient-related factors are well recognized, the impact of cannula geometry and equipment design on cannulation success is less clearly described. We report a case of difficult VV-ECMO cannulation in a 68 year old obese man with severe respiratory failure due to acute asthma exacerbation. Despite adequate dilation and standard technique, advancement of a 24 Fr drainage cannula via the right internal jugular vein was unsuccessful, with fluoroscopic evidence of cannula deformation within soft tissue. A 23 Fr cannula was subsequently inserted smoothly under otherwise identical conditions. High-resolution digital microscopy was used to quantify cannula geometry, revealing a pronounced introducer-cannula diameter mismatch and steep taper angle in the failed cannula compared with the successfully inserted device. This case suggests that device-specific factors, including both cannula geometry and nominal French size, may collectively contribute to significant mechanical resistance during VV-ECMO cannulation, particularly in obese patients. Attention to cannula design, in addition to size, may help mitigate cannulation difficulties and improve procedural safety in anatomically challenging cases.
Despite increasing clinical interest in ambulatory extracorporeal membrane oxygenation (ECMO), its equipment is not optimally designed for portability. Blood pumps are too heavy for ambulation, as the lightest system on...Despite increasing clinical interest in ambulatory extracorporeal membrane oxygenation (ECMO), its equipment is not optimally designed for portability. Blood pumps are too heavy for ambulation, as the lightest system on the market weighs more than 10 kg. Recently, the authors have published a series of preclinical sheep studies that used ventricular assist devices (VAD) as part of the Pulmonary Assist System to improve portability of an extracorporeal life support technology. Here, data from those prior publications were used to evaluate a semi-empirical model that predicts the pressure-flow relationship in a VAD-pumped extracorporeal circuit. Three types of VAD pumps were evaluated in a single-site VV ECMO circuit in these prior studies. The semi-empirical model had an 11% ± 26% error in predicting achievable blood flow. Using this model, different circuit configuration scenarios were simulated to determine the range of operable flow. The highest flow from simulations was 3.76 L/min with a 30-French dual-lumen cannula, VAD, and a clinical oxygenator. The most sensitive parameter affecting flow was the cannula size. For long-term use, the oxygenator's thrombotic tendency would decrease the achievable flow over time. This semi-empirical model provides a simple framework to illustrate the relationship between circuit component selection, achievable blood flow, and oxygen transfer.
Patients receiving durable left ventricular assist device (dLVAD) support can experience device malfunction, cardiogenic shock, and/or incomplete unloading. Traditional guidance supports the use of emergent dLVAD exchang...Patients receiving durable left ventricular assist device (dLVAD) support can experience device malfunction, cardiogenic shock, and/or incomplete unloading. Traditional guidance supports the use of emergent dLVAD exchange or orthotopic heart transplantation (OHT). We challenge this paradigm with evidence from four cases at our institution. This case series highlights the use of a microaxial flow pump (mAFP; Impella 5.5; AbiomedM, Danvers, MA) in the setting of dLVAD malfunction as a bridge to decision. Use of the mAFP in four distinct cases improved end-organ perfusion and increased left ventricular unloading. Therefore, the patients were optimized before the final therapy was chosen. Success was seen in each case, with three undergoing a dLVAD exchange and the other an OHT. This initial evidence supports the role of mAFP as a rescue strategy for patients with malfunctioning dLVAD support. Use of mAFP also allows for potential patient mobilization. This approach may improve patient outcomes in selected cases compared with those that pursue direct and emergent dLVAD exchange.
Bivalirudin, a direct thrombin inhibitor, is increasingly used as an alternative to heparin in pediatric mechanical circulatory support (MCS) and has resulted in improved stroke-free survival in children supported by par...Bivalirudin, a direct thrombin inhibitor, is increasingly used as an alternative to heparin in pediatric mechanical circulatory support (MCS) and has resulted in improved stroke-free survival in children supported by paracorporeal pulsatile devices. However, for those supported by implanted continuous-flow devices, such as HeartMate 3, significant practice variation exists in agents used as early intravenous anticoagulation. Leveraging ACTION VAD registry data, we sought to compare early hemocompatibility-related adverse events (<14 days) in pediatric HeartMate 3 patients on bivalirudin versus heparin (unfractionated heparin [UFH]). A total of 234 patients, aged under 25 years, with a median age of 15 years and a median weight of 60 kg, at the time of HeartMate 3 implant, were included in the study cohort. Of these, 100 (42.7%) received bivalirudin as initial intravenous anticoagulation agent and 134 (57.2%) received UFH. With data censored at change of agent, there was no significant difference between the groups for freedom from stroke (96.9% vs. 96.3%, p = 0.77) or bleeding (94.8% vs. 89.9% %, p = 0.21), but time to transition to oral anticoagulation was longer for the bivalirudin group. Survival at 1 year after implant was also not different between groups. These data suggest that bivalirudin is a reasonable alternative to UFH for early thromboprophylaxis after HeartMate 3 implantation.
The impact of acute liver dysfunction and chronic liver disease on adult patients receiving extracorporeal membrane oxygenation (ECMO) support remains unclear. To investigate this, we performed a retrospective analysis o...The impact of acute liver dysfunction and chronic liver disease on adult patients receiving extracorporeal membrane oxygenation (ECMO) support remains unclear. To investigate this, we performed a retrospective analysis of the Extracorporeal Life Support Organization (ELSO) Registry using data from 2012 to 2023. We used generalized linear regression models (GLMs) to examine the associations between acute liver dysfunction, chronic liver disease, and survival to hospital discharge. A total of 4,915 ECMO runs were included in the analysis. Survival to hospital discharge was 34% for patients with acute liver dysfunction compared to 42% for those with chronic liver disease. Compared to patients with acute liver dysfunction, those with chronic liver disease were more likely to survive (~29% more likely). Increased age (odds ratio [OR] per year: 0.97, 95% confidence interval [CI] = 0.97-0.98, p < 0.001) and low bicarbonate levels (OR per unit: 0.79, 95% CI = 0.67-0.93, p = 0.005) were associated with lower odds of survival. There was no difference in ECMO-related complications based on liver dysfunction acuity. Patients with acute liver dysfunction and chronic liver disease both have unique challenges during ECMO; however, acute liver dysfunction appears to be disproportionately associated with poor outcomes. Further studies are needed to fully understand the impact of liver dysfunction on ECMO survival.
HeartMate III (HM3) pump failure due to intrapump obstruction from biodebris or thrombosis is an uncommon but life-threatening condition. Here, we describe a case of HM3 failure from biodebris occluding the inflow cannul...HeartMate III (HM3) pump failure due to intrapump obstruction from biodebris or thrombosis is an uncommon but life-threatening condition. Here, we describe a case of HM3 failure from biodebris occluding the inflow cannula and pump interior 11 months after initial implant.
Nurmykhametova Z, Kaliyev R, Medressova A
… +9 more, Lesbekov T, Faizov L, Goncharov A, Aripov M, Tanaliyev N, Ibraimov B, Usseyeva M, Zuparov Y, Pya Y
The ex situ heart perfusion technique is noninferior to the standard of care static cold preservation in heart transplantation. It has enabled the expansion of donor criteria and provides reconditioning or treatment as w...The ex situ heart perfusion technique is noninferior to the standard of care static cold preservation in heart transplantation. It has enabled the expansion of donor criteria and provides reconditioning or treatment as well as diagnostic approaches. Angiography during ex situ heart perfusion is anecdotal but may be useful to evaluating anatomy and somehow coronary physiology on the beating donor heart. The aim of this study was to assess the efficacy and safety of coronary investigation of the beating heart during normothermic ex situ heart perfusion using our institution's unique system. Five domestic adult pigs (90-95 kg, 1-1.5 years of age) were included in the study. After cardiectomy, the pig hearts were connected to the ex situ device, and ex situ angiography and intravascular ultrasound were performed. Cineangiographic images were obtained in different orientations by rotating the C-arm around the heart to find the best angiographic projections for the coronary arteries to be visualized. The results of our study support ex situ coronary arteries evaluation during the normothermic ex situ heart perfusion as a reliable, safe procedure that can be successfully carried out when necessary. The intravascular ultrasound can be used as an adjunctive technology for creating a full picture of the coronary arteries' anatomy.