Conventional versus restricted anti-Xa-guided heparin protocol in adult patients undergoing extracorporeal membrane oxygenation.

OBJECTIVE: The optimal intensity of anticoagulation for adult patients supported with extracorporeal membrane oxygenation (ECMO) remains uncertain. The objective of this study was to evaluate the effectiveness and safety of two anticoagulation protocols using conventional (0.3-0.7 IU/ml) versus restricted (0.2-0.5 IU/ml) anti-factor Xa (anti-Xa) targets for the management of unfractionated heparin (UFH) in adult ECMO patients. METHODS: This retrospective before-after cohort study compared two groups of ECMO patients who received UFH for at least 24-h from March 2016 to May 2019. The primary outcome was the composite rate of major bleeding or thrombotic events per ECMO day. Secondary outcomes included the mean amount of blood products transfused per ECMO day, the proportion of patients who were within the target anti-Xa at 24-h, the time to achieve target anti-Xa, and the number of heparin infusion adjustments to reach target anti-Xa. RESULTS: Forty-one patients were included in this analysis (conventional, n = 25; restricted, n = 16). There was no difference in the composite rate of major bleeding or thrombotic events per ECMO day (p = .090). The restricted group had lower rates of packed red blood cells (pRBC) transfusion per ECMO day (mean 1 ± 1 vs 3 ± 2 units, p = .003) and required fewer heparin infusion adjustments to reach the target (p = .007). There was no difference between the groups in the number of patients who achieved target anti-Xa at 24-h (p = .940). CONCLUSION: In adult ECMO patients, anticoagulation with a restricted anti-Xa target was associated with lower pRBC transfusions and did not provoke an excess of thrombotic events.

An unusual case of Darier disease complicated with a parasitic infestation.

A 40-year-old woman living in the countryside near Cali, Colombia, presented with exacerbation of papules located on her face and neck and an ulcer located on the left retroauricular area of 2 weeks' duration. She stated that her skin lesions appeared erratically, beginning at 13 years of age and that her father and daughter had similar skin lesions. Physical examination revealed multiple erythematous, hyperkeratotic papules, and yellowish brown crusts that coalesced to plaques located on symmetrical areas of the forehead, neck, and periauricular areas with excoriation and malodor (Figure 1a and 1b). There were flat-topped papules on the dorsal aspect of her hands. The fingernails exhibited subungual hyperkeratotic fragments, V-shaped notches at the free edges of some nails, distal onycholysis, and white longitudinal bands (Figure 1c). We also discovered a foul-smelling left retroauricular cavity, approximately 3 cm in length and 3 cm in depth, with multiple fly larvae inside of it (Figure 2). We made the diagnosis of retroauricular myiasis and obtained skin biopsy specimens from her forehead and scalp, to confirm the presumptive diagnosis of Darier disease.

Hemocompatibility-Related Adverse Events and Survival on Venoarterial Extracorporeal Life Support: An ELSO Registry Analysis.

OBJECTIVES: This study sought to determine the frequency, incidence rates over time, association with mortality, and potential risk factors for hemocompatibility-related adverse events (HRAEs) occurring during venoarterial-extracorporeal life support (VA-ECLS). BACKGROUND: HRAEs are common complications of VA-ECLS. Studies examining relevant clinical predictors and the association of HRAEs with survival are limited by small sample size and single-center setting. METHODS: We queried adult patients supported with VA-ECLS from 2010 to 2017 in the Extracorporeal Life Support Organization database to assess the impact of HRAEs on in-hospital mortality. RESULTS: Among 11,984 adults meeting study inclusion, 8,457 HRAEs occurred; 62.1% were bleeding events. The HRAE rate decreased significantly over the study period (p trend <0.001), but rates of medical bleeding and ischemic stroke remained stable. HRAEs had a cumulative association with mortality in adjusted analysis: 1 event, odds ratio (OR) of 1.43; 2 events, OR of 1.86; ≥3 events, OR of 3.27 (p < 0.001 for all). HRAEs most strongly associated with mortality were medical bleeding, including intracranial (OR: 7.71), pulmonary (OR: 3.08), and gastrointestinal (OR: 1.95) hemorrhage and ischemic stroke (OR: 2.31); p < 0.001 for all. Risk factors included the following: for bleeding: older age, lower pH, and female sex; for thrombosis: younger age, male sex, Asian race, and non-polymethylpentene oxygenator; and for both: time on ECLS, central cannulation, and renal failure. CONCLUSIONS: Although decreasing, HRAEs remain common during VA-ECLS and have a cumulative association with survival. Bleeding events are twice as common as thrombotic events, with a hierarchy of HRAEs influencing survival. Differential risk factors for bleeding and thrombotic complications exist and raise the possibility of a tailored approach to ECLS management.

Preimplant Phosphodiesterase-5 Inhibitor Use Is Associated With Higher Rates of Severe Early Right Heart Failure After Left Ventricular Assist Device Implantation.

Background Early right heart failure (RHF) occurs commonly in left ventricular assist device (LVAD) recipients, and increased right ventricular (RV) afterload may contribute. Selective pulmonary vasodilators, like phosphodiesterase-5 inhibitors (PDE5i), are used off-label to reduce RV afterload before LVAD implantation, but the association between preoperative PDE5i use and early RHF after LVAD is unknown. Methods and Results We analyzed adult patients from the INTERMACS registry (Interagency Registry for Mechanically Assisted Circulatory Support) who received a continuous flow LVAD after 2012. Patients on PDE5i were propensity-matched 1:1 to controls. The primary outcome was the incidence of severe early RHF, defined as the composite of death from RHF within 30 days, need for RV assist device support within 30 days, or use of inotropes beyond 14 days. Of 11 544 continuous flow LVAD recipients, 1199 (10.4%) received preoperative PDE5i. Compared to controls, patients on PDE5i had higher pulmonary artery systolic pressure (53.4 mm Hg versus 49.5 mm Hg) and pulmonary vascular resistance (2.6 WU versus 2.3 WU; P<0.001 for both). Before propensity matching, the incidence of severe early RHF was higher among patients on PDE5i than in controls (29.4% versus 23.1%; unadjusted odds ratio (OR), 1.32; 95% CI, 1.17-1.50). This association persisted after propensity matching (PDE5i, 28.9% versus control 23.7%; OR, 1.31; 95% CI, 1.09-1.57), driven by a higher incidence of prolonged inotropic support. Similar results were observed across a wide range of subgroups stratified by markers of pulmonary vascular disease and RV dysfunction. Conclusions Patients treated with preoperative PDE5i had markers of increased RV afterload and HF severity compared to unmatched controls. Even after propensity matching, patients receiving preimplant PDE5i therapy had higher rates of post-LVAD RHF.