The Journal Of Extra-corporeal Technology[JOURNAL]
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200 papers
Variability in triggers for mechanical left ventricular unloading in VA-ECMO: A literature search.
Calhoun A, Lee MH, Pisano DV … +2 more , Karavas A, Ortoleva J
J Extra Corpor Technol · 2025 Mar · PMID 40053855 · Full text
BACKGROUND: Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) is a means of supporting the lungs or the heart and lungs in patients with hemodynamic compromise that is refractory to conventional measures. VA-ECM...
BACKGROUND: Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) is a means of supporting the lungs or the heart and lungs in patients with hemodynamic compromise that is refractory to conventional measures. VA-ECMO is most commonly deployed in a percutaneous fashion with femoral arterial and venous access. While VA-ECMO, particularly in a femoral-femoral configuration, provides both hemodynamic and ventilatory support, it also causes increased afterload on the left ventricle (LV) which in turn may result in LV distension (LVD). LV thrombus formation, ventricular arrhythmias, pulmonary edema, and pulmonary hemorrhage are clinical manifestations of LVD. LV unloading is a means of preventing LVD and its sequelae. If less invasive methods fail to achieve adequate LV unloading, invasive mechanical methods are pursued such as intra-aortic balloon pump counter-pulsation, atrial septostomy, surgical venting, left atrial cannulation, and percutaneous transvalvular micro-axial pump placement. METHODS: We sought to review indicators of LVD, thresholds, and options for mechanical venting strategies. A Pubmed search was performed to identify current literature about LV unloading for VA ECMO. This was categorized and summarized to determine commonly reported thresholds for mechanical LV unloading. RESULTS: Multiple physiologic and radiographic indicators were reported without uniformity. Common indicators included increased pulmonary artery catheter pressures, decreased Aortic Line Pulse Pressure, as well as multiple Echocardiographic, and radiographic indicators. CONCLUSION: Although there has been significant interest in the topic, there is currently limited uniformity in thresholds for when to initiate and escalate mechanical LV unloading. While the method of LV unloading is an active area of investigation, the threshold for which to initiate invasive venting strategies is largely unexplored.
Development and validation of a checklist for cardiopulmonary bypass.
Assis Dos Reis Filho V, Aparecida Antonelli Novello K, Matias ML
J Extra Corpor Technol · 2025 Mar · PMID 40053854 · Full text
INTRODUCTION: Risk prevention protocols related to patient care have been developed to reduce the incidence of adverse events in health care services. Cardiopulmonary bypass (CPB) can trigger several complications, inclu...
INTRODUCTION: Risk prevention protocols related to patient care have been developed to reduce the incidence of adverse events in health care services. Cardiopulmonary bypass (CPB) can trigger several complications, including physiological problems, electrical, mechanical, and human failures, or defective components. In order to promote patient safety and the identification of failures before they can cause damage, it is necessary to the use of a checklist for all surgeries. OBJECTIVE: To prepare and validate a checklist for cardiopulmonary bypass. METHODOLOGY: A consensus validation methodology is applied in this study, in which the Delphi technique was structured for the instrument's development. Five perfusion experts, with at least five years of experience, had an active participation in this research. First, a questionnaire was structured, based on a comprehensive review of the relevant literature. Then, two rounds of assessments were conducted, allowing for the collection of experts' opinions. RESULTS: In the first moment, a 42-item list was prepared and sent to the five experts for analysis. Based on participant's responses, certain elements were accepted, excluded, and suggested. After that, a second 37-item list was assessed by the experts, resulting in all 37 items having an average assessment of ≥4 and a standard deviation ≤1.0 of acceptance. Based on these results, a 41-element checklist was developed, and these elements were considered crucial and relevant for the concerned analysis. CONCLUSION: The use of specific checklists for cardiopulmonary bypass comes into view as a highly proficient strategy, capable of promoting substantial improvements in the procedure safety and quality. The implementation and approval of this checklist should be considered.
Limiting the gamble: Risk and predictability for renal replacement therapy in patients receiving mechanical circulatory support★.
Gore K, Linder D, Martinez Duque JJ … +6 more , Wang J, Wester B, Otero T, Yockelson S, Ruiz AA, Nossaman BD
J Extra Corpor Technol · 2025 Mar · PMID 40053853 · Full text
BACKGROUND: Patients receiving mechanical circulatory support (MCS) frequently require renal replacement therapy (RRT). Examining risk factors for requiring RRT in patients receiving MCS may allow improved understanding...
BACKGROUND: Patients receiving mechanical circulatory support (MCS) frequently require renal replacement therapy (RRT). Examining risk factors for requiring RRT in patients receiving MCS may allow improved understanding of these comorbidities and enhance patient outcomes. METHODS: Following IRB approval, patient characteristics, comorbidities, and the need for RRT were studied in 129 patients who received MCS from January 2017 to October 2023. The clinical variables underwent machine learning to examine their relationships to the outcome of interest, the need for RRT. RESULTS: In this study, the incidence of RRT was 36% with a 95% confidence interval ranging from 29% to 44%. Following machine learning, patients with a history of immunologic therapy or having a pacemaker or internal cardiac defibrillator (ICD) were associated with the need for RRT (χ = 44, P = 0.0003). The c-index statistic for this model was 0.81. The anticoagulation therapy administered in these two groups was also analyzed. Patients in these two groups receiving unfractionated heparin were observed to have a higher incidence (44%) in the need for RRT. CONCLUSION: The incidence of RRT was high in this patient population. The novel associations in patients requiring MCS who have received prior immunologic therapy or have pre-existing pacemaker/ICDs suggest that an increased systemic inflammatory state exists that escalates the need for RRT. Unfractionated heparin appears to provide minimal protection from the need for RRT in patients requiring MCS. These findings suggest that other options for systemic anticoagulation in patients requiring MCS should be considered. Further investigation into how these background inflammatory conditions contribute to the need for RRT in patients requiring MCS is warranted.
Evaluating the need for magnesium administration following cardioplegic arrest with del Nido cardioplegia solution.
Whittaker Striker C, Reagor JA
J Extra Corpor Technol · 2025 Mar · PMID 40053852 · Full text
BACKGROUND: del Nido cardioplegia (dNC) solution is widely used in pediatric and congenital cardiac surgery. In 2014, Cincinnati Children's Hospital Medical Center (CCHMC) changed from Mee cardioplegic solution to dNC. S...
BACKGROUND: del Nido cardioplegia (dNC) solution is widely used in pediatric and congenital cardiac surgery. In 2014, Cincinnati Children's Hospital Medical Center (CCHMC) changed from Mee cardioplegic solution to dNC. Since Mee solution does not contain magnesium, magnesium was administrated post cross-clamp removal, at a dose of 25 mg/kg up to 1 g, to abate hypomagnesemia. This practice remained in place with the use of dNC. We postulated that patients may experience hypermagnesemia under this protocol. METHODS: To determine if exogenous magnesium is necessary post-clamp removal in our practice, a study examining serum magnesium levels during cardiopulmonary bypass (CPB) was completed from January 2022 through October 2023 (IRB #2021-0816). One hundred patients undergoing CPB with cross-clamp, ranging from infants to adults, were consented. Two magnesium samples were collected. Draw 1 (D1) was collected post cardioplegia administration and 30 min prior to cross-clamp removal. Draw 2 (D2) was collected post-cross-clamp removal and 10 ± 2 min following magnesium administration. RESULTS: Both samples demonstrated magnesium levels > 1.6 mg/dL or higher (normal magnesium range at CCHMC, 1.6-2.6 mg/dL). A Wilcoxon rank sum test demonstrated statistical significance for D1, comparing the number of samples that fell above 2.6 mg/dL vs. those that fell within the normal range (p < 0.001). D2 demonstrated values above the normal range for all but one sample, which does not satisfy the criteria of the Wilcoxon rank sum test for demonstrating significance (p = 0.089); however, ninety-nine samples displayed hypermagnesemia. CONCLUSION: This study demonstrates that exogenous magnesium administration may not be necessary in the setting of our practice at CCHMC and dNC cardioplegic arrest.
Pediatric cardiac patients with pulmonary hemorrhage supported on ECMO: An ELSO registry study.
Anton-Martin P, Young C, Sandhu H … +1 more , Vellore S
J Extra Corpor Technol · 2025 Mar · PMID 40053851 · Full text
BACKGROUND: Pulmonary Hemorrhage (PH) is a rare but potentially devastating condition and pediatric cardiac patients are at increased risk for. ECMO may be used to safely support these patients, but data is limited. METH...
BACKGROUND: Pulmonary Hemorrhage (PH) is a rare but potentially devastating condition and pediatric cardiac patients are at increased risk for. ECMO may be used to safely support these patients, but data is limited. METHODS: Observational retrospective cohort study from the ELSO registry database in pediatric cardiac patients from birth to 18 years old with PH supported on ECMO from January 2011 through December 2020. The objectives of the study were to characterize pediatric cardiac patients with PH before ECMO and to describe factors associated with improved survival. RESULTS: A total of 161 cardiac neonates and children with PH supported on ECMO were analyzed. Median age and weight were 40 days (IQR 7.3-452) and 4.06 kg (IQR 3-9.36), respectively. Congenital heart disease accounted for 77% of diagnoses. Survival to hospital discharge was 35.8%. Before ECMO cannulation, most patients were ventilated in conventional modes (79.7%), followed by high-frequency oscillatory (HFOV) ventilation (11%). There was a significantly higher use of HFOV pre-cannulation in survivors compared to non-survivors (24.4% vs 2.8%, p < 0.001). Multivariable logistic regression demonstrated that HFOV before ECMO (OR 28.44, p < 0.001) and the absence of hemorrhagic (OR 3.51, p 0.031) and renal (OR 3.50, p 0.027) complications were independent predictors for survival to hospital discharge. CONCLUSION: Utilization of HFOV before cannulation to ECMO seems to be associated with improved survival in pediatric cardiac patients with acute pulmonary hemorrhage. A prospective assessment of mechanical ventilation practices before ECMO may improve outcomes in this medically complex population.
Print copies, ads and perfusion education.
Wong RK
J Extra Corpor Technol · 2025 Mar · PMID 40053850 · Full text
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Traditional vs. modified Ringer lactate-based del Nido cardioplegia impacts on clinical outcomes in patients undergoing coronary artery bypass grafting: Results from a prospective, randomized, blinded trial.
Kachoueian N, Janghorban S, Gorjipour F … +5 more , Torkashvand M, Mahjoob MP, Aslani H, Mehrabanian M, Gorjipour F
J Extra Corpor Technol · 2024 Dec · PMID 39718017 · Full text
INTRODUCTION: Myocardial protection with cardioplegia is a crucial approach to mitigate myocardial damage during coronary bypass grafting surgery (CABG) with cardiopulmonary bypass (CPB). The major component of the del N...
INTRODUCTION: Myocardial protection with cardioplegia is a crucial approach to mitigate myocardial damage during coronary bypass grafting surgery (CABG) with cardiopulmonary bypass (CPB). The major component of the del Nido cardioplegia solution, Plasma-Lyte A, is difficult to obtain in Iran due to high cost. The objective of the current study was to study if the lactated Ringer's solution as the base for del Nido solution (LR DN) usage is a viable option as a substitute for Plasma-Lyte A in adult patients presenting for CABG surgery. STUDY DESIGN AND METHODS: The present prospective, randomized, blinded study was performed on 18-75-year-old patients ejection fraction (EF) > 35% undergoing CABG with CPB. Patients were randomly allocated to LR DN (modified del Nido cardioplegia) and PL DN (standard del Nido cardioplegia solution) groups. Serum level of cardiac troponin I (cTnI), the type and dosage of inotrope agents, EF, rate of arrhythmia after clamp removal and lactate level were measured and compared between patients of LR DN and PL DN groups. RESULTS: 109 patients were recruited. There were no statistically significant differences between groups for cardiopulmonary bypass times, cardiac enzymes, transfusion requirements, and arterial blood gases. There was no mortality for study patients. Postoperative serum levels of cTnI among patients in the LR DN group was significantly higher than patients of the PL DN group after ICU admission and 24 h post-ICU. Also, more patients needed epinephrine administration in the operating room in the LR DN group (29.8% vs. 11.5%; p: 0.019 vs. PL DN group). CONCLUSION: We concluded that the standard del Nido cardioplegia solution offers better myocardial protection compared with Ringer's lactate-based del Nido cardioplegia in adult patients undergoing CABG with CPB. We recommend using standard del Nido cardioplegia with a PL base for patients presenting for CABG surgery.
Failure to oxygenate during cardiopulmonary bypass; treatment options and intervention algorithm.
Matte GS, Regan WL, Gadille SI … +3 more , Connor KR, Boyle SL, Fynn-Thompson FE
J Extra Corpor Technol · 2024 Dec · PMID 39705587 · Full text
Membrane oxygenator failure remains a concern for perfusion teams. Successful outcomes for this low-frequency, high-risk intervention are predicated on having written institutional protocols for both the oxygenator chang...
Membrane oxygenator failure remains a concern for perfusion teams. Successful outcomes for this low-frequency, high-risk intervention are predicated on having written institutional protocols for both the oxygenator change-out procedure as well as how often the procedure is practiced by staff perfusionists. A recent review of peer-reviewed journal articles, textbooks and online resources revealed a lack of a unified intervention algorithm for failure to oxygenate during cardiopulmonary bypass (CPB). While an oxygenator change-out procedure may still be considered the gold standard for a confirmed device failure, temporizing measures exist that, in select cases, can afford time to the clinical team and even obviate the need for an oxygenator change-out procedure. We now consider the venous piggyback technique sourcing blood from the venous limb of the circuit a first-line intervention to afford enhanced patient safety while the clinical team decides on required interventions when oxygenator failure presents during CPB.
Plasmapheresis for extracorporeal membrane oxygenation (ECMO)-induced hemolysis in infants.
Budhu G, Morris-Whyte K, Constantinescu AR
J Extra Corpor Technol · 2024 Dec · PMID 39705586 · Full text
BACKGROUND: Intravascular hemolysis is a known complication of extracorporeal membrane oxygenation (ECMO). Characterized by elevated plasma-free hemoglobin (PFH), intravascular hemolysis is associated with cytotoxic effe...
BACKGROUND: Intravascular hemolysis is a known complication of extracorporeal membrane oxygenation (ECMO). Characterized by elevated plasma-free hemoglobin (PFH), intravascular hemolysis is associated with cytotoxic effects leading to renal replacement therapy (RRT), longer ECMO runs, and mortality. Therapeutic plasma exchange (TPE) in tandem with ECMO was described as a therapy for various pathologic conditions, but there are no Extracorporeal Life Support Organization (ELSO) guidelines for the treatment of ECMO-induced hemolysis. We describe the use of TPE in the management of severe ECMO-induced hemolysis. METHODS: Two-term neonates receiving veno-arterial (VA) ECMO developed severe PFH, with peak values over 500 mg/dL. TPE was performed in tandem with the ECMO circuit. Packed red cells were used to prime the TPE circuit, and citrate anticoagulation was added to establish the interface, which could not be achieved with existing heparin in the ECMO circuit. Therapy was completed with saline solution as a decoy for citrate, to avoid hypocalcemia and intracranial bleeding. Plasma volume was replaced by fresh frozen plasma (FFP). RESULTS: In one patient PFH fell to 120 mg/dL, but rebounded to close to 500 mg/dL, only to stabilize between 210 and 300 mg/dL after the second TPE. He was liberated from ECMO, but could not survive a respiratory decompensation. The other patient's PFH improved to 360 mg/dL after one TPE and continued to decline to 120 mg/dL over the ensuing days. Despite that improvement, care was withdrawn. CONCLUSION: TPE is effective in decreasing the burden of PFH and is well tolerated in tandem with ECMO, and a database of infants with ECMO-induced hemolysis needs to be created to assess the current practice and establish clinical guidelines for its most appropriate therapy.
A technique avoiding cardioplegia delivery complications: a case using systemic hyperkalemia cardiopulmonary bypass combined with circulatory arrest.
Takeichi T, Morimoto Y, Yamada A … +1 more , Tanaka T
J Extra Corpor Technol · 2024 Dec · PMID 39705585 · Full text
We conducted a high-risk redo mitral valve replacement through a right mini-thoracotomy without rib spreading (redo-MICS MVR) under systemic hyperkalemia combined with circulatory arrest to circumvent complications assoc...
We conducted a high-risk redo mitral valve replacement through a right mini-thoracotomy without rib spreading (redo-MICS MVR) under systemic hyperkalemia combined with circulatory arrest to circumvent complications associated with cardioplegia delivery. The patient, a 75-year-old man, had a predicted mortality rate of 20%. Initial antegrade cardioplegia successfully induced cardiac arrest, which was administered every 30 min. However, upon infusion of the second dose of cardioplegia, the aortic root pressure was approximately 20 mmHg. Despite multiple attempts to re-cross the clamp, the aortic root pressure did not improve. Consequently, retrograde cardioplegia was considered, but due to significant adhesion of the inferior vena cava, this approach was abandoned. Thus, the procedure was altered to utilize systemic hyperkalemia without aortic cross-clamping (ACC). Given the preoperative transesophageal echocardiography (TEE) diagnosis of mild aortic regurgitation, maintaining a clear surgical field was challenging, necessitating the combination of redo-MVR with circulatory arrest. This case exemplifies the successful management of cardioplegia delivery complications using systemic hyperkalemia and circulatory arrest, resulting in a favorable postoperative recovery for the patient.
High pressure excursion in a radial design oxygenator.
Svec A, Eadie T, D'Aloiso B … +1 more , Arlia P
J Extra Corpor Technol · 2024 Dec · PMID 39705584 · Full text
Oxygenator high-pressure (HPE) is a phenomenon that can occur during cardiopulmonary bypass (CPB) in which the oxygenator inlet pressure increases rapidly, thereby limiting flow. Most perfusionists globally do not use in...
Oxygenator high-pressure (HPE) is a phenomenon that can occur during cardiopulmonary bypass (CPB) in which the oxygenator inlet pressure increases rapidly, thereby limiting flow. Most perfusionists globally do not use inlet oxygenator pressure monitoring and therefore HPE is not often recognized. HPE may occur for various reasons, and it is not fully understood. Patient factors that put a patient at a higher risk of HPE are increased body surface area, blood type, and hematocrit count. Patient size, blood flow, and pressure drops of the oxygenator incorporated into the circuit can also increase the probability of an HPE occurring. This case study overviews our experience when dealing with an interesting case of HPE and the most up-to-date knowledge on appropriate steps to mitigate the effects on the patient.
Enhancing lung transplantation with ECMO: a comprehensive review of mechanisms, outcomes, and future considerations.
Pervaiz Butt S, Kakar V, Abdulaziz S … +18 more , Razzaq N, Saleem Y, Kumar A, Ashiq F, Ghisulal P, Thrush A, Malik S, Griffin M, Amir M, Khan U, Salim A, Zoumot Z, Mydin I, Aljabery Y, Bhatnagar G, Bayrak Y, Obeso A, Ahmed U
J Extra Corpor Technol · 2024 Dec · PMID 39705583 · Full text
BACKGROUND: Lung transplantation (LTx) is a critical intervention for patients with end-stage lung disease. However, challenges such as donor organ scarcity and post-transplant complications significantly affect its succ...
BACKGROUND: Lung transplantation (LTx) is a critical intervention for patients with end-stage lung disease. However, challenges such as donor organ scarcity and post-transplant complications significantly affect its success. Recent advancements in Extracorporeal Membrane Oxygenation (ECMO) have shown promise in improving the outcomes and expanding eligibility for LTx. METHODS: A comprehensive literature review was conducted, focusing on studies that explore the use of ECMO in lung transplantation. A thorough search of relevant studies on ECMO and LTx was conducted using multiple scholarly databases and relevant keywords, resulting in 73 studies that met the inclusion criteria. Sources included peer-reviewed journals and clinical trial results, with emphasis on articles captured recent advancements in ECMO technology and techniques. RESULTS: ECMO has been crucial in supporting patients before, during, and after LTx. It serves as a bridge to transplantation by maintaining pulmonary and circulatory stability in critically ill patients awaiting donor organs. ECMO also aids in the evaluation of marginal donor lungs and supports patients through acute post-transplant complications. Recent technological advancements have improved the safety and efficacy of ECMO, further solidifying its role in LTx. CONCLUSION: In conclusion, this review underscores ECMO's critical role in enhancing outcomes across all stages of lung transplantation. Its various configurations and strategies have shown promise in stabilizing critically ill patients and improving transplant success rates. Looking ahead, it's important to gather more information about the long-term outcomes and potential complications associated with ECMO use. More research and data collection will help us understand the benefits and risks better, leading to improved decision-making and patient care in this field.
Development of a professional advancement model for perfusionists.
Blakey AK
J Extra Corpor Technol · 2024 Dec · PMID 39705582 · Full text
BACKGROUND: Improvement in professional advancement opportunities may reduce turnover and improve retention for perfusionists. However, the current literature lacks examples of professional advancement models (PAMs) for...
BACKGROUND: Improvement in professional advancement opportunities may reduce turnover and improve retention for perfusionists. However, the current literature lacks examples of professional advancement models (PAMs) for perfusionists. METHODS: This review looks at examples from other healthcare fields to provide the rationale and develop a framework for such a model. RESULTS: The review results led to the development of a point-based PAM that included four levels: perfusionist I, II, III, and IV. Each level is associated with its own point requirement, experience level, and salary increase. Points can be acquired through four defined categories. CONCLUSION: Perfusion programs needing professional advancement can use these results as a foundation for implementing a PAM for perfusionists.
Determining the association of hyperoxia while on extracorporeal life support with mortality in neonates following Norwood operation.
Beshish AG, Aljiffry A, Xiang Y … +9 more , Evans S, Scheel A, Harriott A, Patel S, Amedi A, Harding A, Davis J, Shashidharan S, Kwiatkowski DM
J Extra Corpor Technol · 2024 Dec · PMID 39705581 · Full text
BACKGROUND: Patients requiring extracorporeal life support (ECLS) support post-Norwood operation constitute an extremely high-risk group. MATERIALS AND METHODS: We retrospectively aimed to evaluate the relationship of hy...
BACKGROUND: Patients requiring extracorporeal life support (ECLS) support post-Norwood operation constitute an extremely high-risk group. MATERIALS AND METHODS: We retrospectively aimed to evaluate the relationship of hyperoxia with mortality and other clinical outcomes in patients who required ECLS following Norwood operation between January/2010 and December/2020 in a large volume center. RESULTS: During the study period 65 patients required ECLS post-Norwood. Using receiver operating characteristic (ROC) curve analysis, mean PaO of 182 mmHg in the first 48-hour on ECLS was determined to have the optimal discriminatory ability for mortality (sensitivity 68%, specificity 70%). Of the 65 patients, 52% had PaO > 182 mmHg and were designated as hyperoxia group. Patients in the hyperoxia-group had longer cardiopulmonary bypass time (187 vs. 165 min, p = 0.023), shorter duration from CICU arrival to ECLS-cannulation (13.28 vs. 132.58 h, p = 0.003), higher serum lactate within 2-hours from ECLS-canulation (14.55 vs. 5.80, p = 0.01), higher ECLS flows in the first 4-hours (152.68 vs. 124.14, p = 0.006), and higher mortality (77% vs. 39%, p = 0.005). In the unadjusted-analysis, using a derived cut-point, patients in the hyperoxia-group had 5.15 higher odds of mortality (p = 0.003). However, this association was insignificant when adjusting for confounding variables (p = 0.104). Using a functional status scale, new morbidity (38% vs. 21%), and unfavorable outcomes (13% vs. 5%) were higher in the hyperoxia group. Despite being higher in the hyperoxia group, this did not reach statistical significance. CONCLUSION: Neonates with hyperoxia (PaO > 182 Torr) during the first 48-hour of ECLS post-Norwood operation had 5 times higher odds of mortality in the unadjusted analysis, however, this was insignificant when adjusting for confounding variables. Patients in the hyperoxia group had shorter duration from CICU arrival to ECLS-cannulation, higher serum lactate prior to ECLS-canulation, and higher ECLS flows in the first 4-hours, (p < 0.05). Multicenter evaluation of this modifiable risk factor is imperative to improve the care of this high-risk cohort.
Interaction of milrinone with extracorporeal life support.
Whelan AJ, Mim S, Hunt JP … +6 more , McKnite AM, Green DJ, Imburgia CE, Momper JD, Stitt G, Watt KM
J Extra Corpor Technol · 2024 Dec · PMID 39705580 · Full text
BACKGROUND: Milrinone is commonly prescribed to critically ill patients who need extracorporeal life support such as extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT). Currently,...
BACKGROUND: Milrinone is commonly prescribed to critically ill patients who need extracorporeal life support such as extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT). Currently, the effect of ECMO and CRRT on the disposition of milrinone is unknown. METHODS: Ex vivo ECMO and CRRT circuits were primed with human blood and then dosed with milrinone to study drug extraction by the circuits. Milrinone percent recovery over time was calculated to determine circuit component interaction with milrinone. RESULTS: Milrinone did not exhibit measurable interactions with the ECMO circuit, however, CRRT cleared 99% of milrinone from the experimental circuit within the first 2 hours. CONCLUSION: Milrinone dosing adjustments are likely required in patients who are supported with CRRT while dosing adjustments for ECMO based on these ex-vivo results are likely unnecessary. These results will help improve the safety and efficacy of milrinone in patients requiring ECMO and CRRT. Due to the limitations of ex-vivo experiments, future studies of milrinone exposure with ECLS should include patient circuit interactions as well as the physiology of critical illness.
Outcomes of Del Nido and hyperkalemic blood cardioplegia in adult cardiac surgery with prolonged aortic cross-clamp times★.
Szpytma M, Gimpel D, Ross J … +5 more , Newland RF, Crouch G, Rice GD, Bennetts JS, Baker RA
J Extra Corpor Technol · 2024 Dec · PMID 39705579 · Full text
BACKGROUND: The utility and uptake of Del Nido cardioplegia in adult cardiac surgery is rapidly increasing. Cases with prolonged aortic cross-clamp times necessitate multi-dosing however an understanding of safe ischaemi...
BACKGROUND: The utility and uptake of Del Nido cardioplegia in adult cardiac surgery is rapidly increasing. Cases with prolonged aortic cross-clamp times necessitate multi-dosing however an understanding of safe ischaemic times and definitive guidelines in this domain are lacking. Therefore, this study aimed to assess the safety and efficacy of our DNC strategy by comparing post-operative troponin profiles and clinical outcomes between Del Nido and hyperkalaemic cardioplegia for cases with aortic cross-clamp times of greater than 90 min. METHODS: A single-centre, retrospective cohort study at Flinders Medical Centre and Flinders Private Hospital of patients undergoing composite cardiac surgery with a cross-clamp time longer than 90 min. Data was prospectively collected from the Flinders Cardiac Surgery Registry from June 2014 to December 2022. A propensity-matched (1:1) analysis was performed comparing patients receiving Del Nido cardioplegia (n = 194) to those receiving hyperkalemic blood cardioplegia (n = 194). The primary outcome was the postoperative troponin release profile with clinical events reported as secondary outcomes. RESULTS: There was no difference in the peak or median troponin at 6, 12 and 72 h nor the number of patients with positive troponin profiles postoperatively between cohorts. There was no difference in clinical outcomes between groups with aortic cross-clamp times of 90 min which remained true in sensitivity analysis extending out to 120 min. The Del Nido cohort received less cardioplegia volume (p < 0.001) and were more likely to return to spontaneous rhythm (p < 0.002). CONCLUSION: Del Nido cardioplegia for anticipated aortic cross-clamp times of greater than 90 min provided equivocal post-operative troponin profiles and clinical outcomes compared to multidose hyperkalemic blood cardioplegia.
The potential benefits of monitoring oxygen delivery in relation to OERi and VCO during normothermic regional perfusion in DCD donors.
Condello I
J Extra Corpor Technol · 2024 Dec · PMID 39705578 · Full text
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Heparin resistance management during cardiac surgery: a literature review and future directions.
Butt SP, Kakar V, Kumar A … +12 more , Razzaq N, Saleem Y, Ali B, Raposo N, Ashiq F, Ghori A, Anderson P, Srivatav N, Aljabery Y, Abdulaziz S, Darr U, Bhatnagar G
J Extra Corpor Technol · 2024 Sep · PMID 39303137 · Full text
INTRODUCTION: Heparin, a commonly used anticoagulant in cardiac surgery, binds to antithrombin III (ATIII) to prevent clot formation. However, heparin resistance (HR) can complicate surgical procedures, leading to increa...
INTRODUCTION: Heparin, a commonly used anticoagulant in cardiac surgery, binds to antithrombin III (ATIII) to prevent clot formation. However, heparin resistance (HR) can complicate surgical procedures, leading to increased thromboembolic risks and bleeding complications. Proper diagnosis and management of HR are essential for optimizing surgical outcomes. METHODOLOGY: Diagnosis of HR involves assessing activated clotting time (ACT) and HR assays. Management strategies were identified through a comprehensive review of the literature, including studies exploring heparin dosage adjustments, antithrombin supplementation, and alternative anticoagulants in cardiac surgery patients with HR. A thorough search of relevant studies on HR was conducted using multiple scholarly databases and relevant keywords, resulting in 59 studies that met the inclusion criteria. DISCUSSION: HR occurs when patients do not respond adequately to heparin therapy, requiring higher doses or alternative anticoagulants. Mechanisms of HR include AT III deficiency, PF4 interference, and accelerated heparin clearance. Diagnosis involves assessing ACT and HR assays. HR in cardiac surgery can lead to thromboembolic events, increased bleeding, prolonged hospital stays, and elevated healthcare costs. Management strategies include adjusting heparin dosage, supplementing antithrombin levels, and considering alternative anticoagulants. Multidisciplinary management of HR involves collaboration among various specialities. Strategies include additional heparin doses, fresh frozen plasma (FFP) administration, and antithrombin concentrate supplementation. Emerging alternatives to heparin, such as direct thrombin inhibitors and nafamostat mesilate, are also being explored. CONCLUSION: Optimizing the management of HR is crucial for improving surgical outcomes and reducing complications in cardiac surgery patients. Multidisciplinary approaches and emerging anticoagulation strategies hold promise for addressing this challenge effectively.
Effects of cardiac rehabilitation in patients with ventricular assist devices: a scoping review.
Portuguez Jaramillo NE, Ceron AP, Piñeros Álvarez JL … +2 more , Giron Ruiz E, Castro Gómez C
J Extra Corpor Technol · 2024 Sep · PMID 39303136 · Full text
INTRODUCTION: Ventricular assist devices represent a treatment option for patients with advanced heart failure, offering control over various haemodynamic variables. Similarly, the prescription of exercise within a cardi...
INTRODUCTION: Ventricular assist devices represent a treatment option for patients with advanced heart failure, offering control over various haemodynamic variables. Similarly, the prescription of exercise within a cardiac rehabilitation programme for heart failure patients is recommended to reduce symptoms, and hospitalisations, improve cardiorespiratory fitness, and increase exercise tolerance. Therefore, exercise prescription can impact those with ventricular assist devices. Given the limited evidence on exercise-based cardiac rehabilitation programmes for this population, this review aims to describe the most commonly used strategies and their health benefits when physical exercise is included in a cardiac rehabilitation programme for patients with ventricular assist devices. MATERIALS AND METHODS: An exploratory review was conducted through searches in the databases: PubMed, SCOPUS, PeDro, and ScienceDirect. The search was limited to studies published between 2013 and 2023. Filters were applied independently by title, abstract, and full text. The included articles were analysed based on the description of the types of cardiac rehabilitation strategies used in patients with ventricular assist devices. RESULTS: Seven articles were included. Each programme employed a cardiopulmonary exercise test before prescribing physical exercise. The most commonly used strategy was aerobic exercise, predominantly high-intensity interval training (HIIT) with intensities close to 90% of peak VO, followed by continuous moderate-intensity exercise. Limb strength exercises were included in three programmes. CONCLUSIONS: The analysed literature suggests that cardiac rehabilitation in patients with ventricular assist devices is safe and can provide benefits in cardiorespiratory fitness and exercise tolerance. High-intensity interval training is identified as an appropriate strategy for achieving results, offering short-term improvements.
Cardiopulmonary bypass in a pediatric patient with factor XII deficiency.
Fenske JM, Tinius Juliani J, Herrington C
J Extra Corpor Technol · 2024 Sep · PMID 39303135 · Full text
The safe use of cardiopulmonary bypass (CPB) relies upon the ability to administer, monitor, and reverse anticoagulation. Although rare, the factor XII deficient patient creates a challenge for the perfusionist due to re...
The safe use of cardiopulmonary bypass (CPB) relies upon the ability to administer, monitor, and reverse anticoagulation. Although rare, the factor XII deficient patient creates a challenge for the perfusionist due to resultant complications in monitoring anticoagulation. There have been proposed strategies to aid in monitoring anticoagulation in factor XII deficient patients, however, documentation of successful monitoring during CPB is infrequent. With the use of the Hemochron Signature Elite and ACT + cartridges, CPB in a factor XII deficient 8-month-old was completed with predictable and reliable anticoagulation monitoring. This case report explores the current suggestions for factor XII deficiency management with CPB.
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