Comparing in-patient extracorporeal cardiopulmonary resuscitation to standard cardiac treatment group of extracorporeal membrane oxygenation patients: 8 years of experience at a single institution.

INTRODUCTION: Post-cardiac arrest survivals remain low despite the effort of cardiopulmonary resuscitation. Utilization of extracorporeal membrane oxygenation during cardiopulmonary resuscitation (extracorporeal cardiopulmonary resuscitation) can provide immediate cardiovascular support and potentially improve outcomes of patients with cardiac arrest requiring cardiopulmonary resuscitation. There is renewed interest in the use of extracorporeal cardiopulmonary resuscitation due to improved outcomes over the years. METHODS: Extracorporeal membrane oxygenation data between 2010 and 2018 were reviewed. Patients with extracorporeal membrane oxygenation placed under cardiopulmonary resuscitation were identified, and demographics, extracorporeal membrane oxygenation survival, survival to discharge, and neurological recovery were retrospectively analyzed with institutional review board approval. RESULTS: Among 230 cases of extracorporeal membrane oxygenation, 34 (21 males and 13 females, age of 49 ± 13 years) underwent extracorporeal cardiopulmonary resuscitation. The mean duration of extracorporeal membrane oxygenation support after extracorporeal cardiopulmonary resuscitation was 8.3 ± 7.9 days. Extracorporeal membrane oxygenation mortality among extracorporeal cardiopulmonary resuscitation patients was 32% (11/34) and hospital survival was 38% (13/34), which are similar to standard cardiac extracorporeal membrane oxygenation (extracorporeal membrane oxygenation survival 62% and hospital survival 39% in cardiac extracorporeal membrane oxygenation). Among the extracorporeal membrane oxygenation death after extracorporeal cardiopulmonary resuscitation, the majority was due to neurological injury (73%, 8/11); 8/34 extracorporeal membrane oxygenation survival rate and 30-day survival rate were 63% and 25% in early half of study (2010-2014) and have improved to 70% and 60% in late half of study (2014-2018). CONCLUSION: Over years of experience with extracorporeal membrane oxygenation, the outcome of the extracorporeal cardiopulmonary resuscitation has been improving and appears to exceed those of traditional methods, despite limited sample size. Neurological complications still need to be addressed in order for survival and outcomes to improve.

Does acute kidney injury affect survival in adults with acute respiratory distress syndrome requiring extracorporeal membrane oxygenation?

INTRODUCTION: Patients who develop severe acute respiratory distress syndrome (ARDS) despite full medical management may require veno-venous extracorporeal membrane oxygenation (VV ECMO) to support respiratory function. Survival outcomes remain unclear in those who develop acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) during VV ECMO for isolated severe respiratory failure in adult populations. METHODS: A retrospective chart review (2010-2016) of patients who underwent VV ECMO for ARDS was conducted with university institutional review board (IRB) approval. Patients supported by veno-arterial ECMO were excluded. AKI was defined by acute renal failure receiving CRRT and the outcomes of patients on VV ECMO were compared between the AKI and non-AKI groups. RESULTS: We identified 54 ARDS patients supported by VV ECMO (mean ECMO days 12 ± 6.7) with 16 (30%) in the AKI group and 38 (70%) in the non-AKI group. No patient had previous renal failure and the serum creatinine was not significantly different between the two groups at the time of ECMO initiation. The AKI group showed a greater incidence of complications during ECMO, including liver failure (38% vs. 5%, p=0.002) and hemorrhage (94% vs. 45%, p=0.0008). ECMO survival of the AKI group (56% [9/16]) was inferior to the non-AKI group (87% [33/38], p=0.014). CONCLUSIONS: Our study demonstrated that VV ECMO successfully manages patients with severe isolated lung injury. However, once patients develop AKI during VV ECMO, they are likely to further develop multi-organ dysfunction, including hepatic and hematological complications, leading to inferior survival.

Arterial protocol including prophylactic distal perfusion catheter decreases limb ischemia complications in patients undergoing extracorporeal membrane oxygenation.

OBJECTIVE: Venoarterial extracorporeal membrane oxygenation (ECMO) is a salvage therapy in patients with severe cardiopulmonary failure. Owing to the large size of the cannulas inserted via the femoral vessels (≤24-F) required for adequate oxygenation, this procedure could result in significant limb ischemic complications (10%-70%). This study evaluates the results of a distal limb perfusion arterial protocol designed to reduce associated complications. METHODS: We conducted a retrospective institutional review board-approved review of consecutive patients requiring ECMO via femoral cannulation (July 2010-January 2015). To prevent arterial ischemia, a distal perfusion catheter (DPC) was placed antegrade into the superficial femoral artery and connected to the ECMO circuit. Limb perfusion was monitored via near-infrared spectroscopy (NIRS) placed on both calves. Decannulation involved open repair, patch angioplasty, and femoral thrombectomy as needed. RESULTS: A total of 91 patients were placed on ECMO via femoral arterial cannula (16-F to 24-F) for a mean duration of 9 days (range, 1-40 days). A percutaneous DPC was inserted prophylactically at the time of cannulation in 55 of 91 patients, without subsequent ischemia. Of the remaining 36 patients without initial DPC placement, 12 (33% without DPC) developed ipsilateral limb ischemia related to arterial insufficiency, as detected by NIRS and clinical findings. In these patients, the placement of a DPC (n = 7) with or without a fasciotomy, or with a fasciotomy alone (n = 4), resulted in limb salvage; only one patient required subsequent amputation. After decannulation (n = 7), no patients had further evidence of limb ischemia. Risk factors for the development of limb ischemia identified by categorical analysis included lack of DPC at time of cannulation and ECMO cannula size of less than 20-Fr. There was a trend toward younger patient age. Overall ECMO survival rate was 42%, whereas survival in patients with limb ischemia was only 25%. CONCLUSIONS: Limb ischemia complications from ECMO may be decreased by prophylactic placement of an antegrade DPC. Without DPC, continuous monitoring using NIRS may identify limb ischemia, which can be treated subsequently with DPC and or fasciotomy.

Acute Myocardial Infarction Complicated by Cardiogenic Shock: An Algorithm-Based Extracorporeal Membrane Oxygenation Program Can Improve Clinical Outcomes.

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. 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 <90 mm Hg despite multiple inotropes, with or without intra-aortic balloon pump, lactic acidosis). Of 29 patients, 15 patients were treated before July 2010 (Group 1, old program), and 14 patients were treated after July 2010 (Group 2, new program). 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 two cases (13%) in Group 1 and four cases (29%) in Group 2. ECMO support was performed in one case (6.7%) in Group 1 and six cases (43%) in Group 2. The 30-day survival of Group 1 versus Group 2 was 40 versus 79% (P = 0.03), and 1-year survival rate was 20 versus 56% (P = 0.01). The survival rate for patients who underwent ECMO was 0% in Group 1 versus 83% in Group 2 (P = 0.09). In Group 2, the mean duration on ECMO was 9.8 ± 5.9 days. Of the six patients who required ECMO in Group 2, 100% were successfully weaned off ECMO or were bridged to ventricular assist device implantation. Initiation of an algorithm-based ECMO program improved the outcomes in patients with acute myocardial infarction complicated by cardiogenic shock.

Veno-Venous Extracorporeal Membrane Oxygenation (V V ECMO): Indications, Preprocedural Considerations, and Technique.

Veno-venous extracorporeal membrane oxygenation (V V ECMO) has been used for refractory respiratory failure. We describe the indications, technical aspects, and outcomes of placing V V ECMO in adults using a dual-lumen, single-cannula catheter.

Outcome of organs procured from donors on extracorporeal membrane oxygenation support: an analysis of kidney and liver allograft data.

INTRODUCTION: Extracorporeal membrane oxygenation has become rescue therapy for adults with overwhelming cardiac and/or respiratory failure. Not all patients are saved, creating a new cohort of potential organ donors. This study examines the outcomes of liver and kidney allografts procured from donors on extracorporeal membrane oxygenation (ECMO). METHODS: A retrospective review was conducted through the local organ procurement organization. Donors on ECMO prior to notification were classified into donation after brain death (DBD) and donation after cardiac death (DCD). We compared short-term outcome data against published standards. RESULTS: Between 1995 and 2012, 97 organs were procured from 41 donors supported on ECMO. There were 68 kidneys donated, 51 were transplanted and 17 discarded. Excluding extended criteria donors, 29 DBD and 13 DCD kidneys were transplanted from donors supported on ECMO. Delayed graft function occurred in 34% of DBD kidneys and 38% of DCD kidneys. Kidney allograft survival at one yr was 93%. Twenty-four livers were procured, nine discarded, and 15 transplanted. Ninety-three percent of liver transplant recipients were alive with graft function at one yr. CONCLUSIONS: Donation after brain death kidneys procured from donors on ECMO perform similarly to non-ECMO organs with regard to delayed graft function (DGF), one-yr graft survival and function. Livers from ECMO donors have a higher discard rate than non-ECMO donors, but function similarly at six months and one yr.

Preparation and technical considerations for percutaneous cannulation for veno-arterial extracorporeal membrane oxygenation.

BACKGROUND: The most frequent limb complications from peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) are limb ischemia and localized bleeding. To minimize these risks, perfusion of the distal limb with peripheral percutaneous cannulation was done. TECHNIQUE: Percutaneous cannulation with a distal perfusion port was performed in all patients. During the VA-ECMO, distal limb perfusion was monitored using near-infrared spectroscopy to assess tissue oxygenation. At the decannulation, patch angioplasty was performed to prevent the development of narrowing of the artery at the cannulation site. CONCLUSIONS: Using our standard technique, we have not experienced any limb loss related to ischemia or bleeding.

Surgical treatment of infective endocarditis in patients undergoing chronic hemodialysis.

BACKGROUND AND AIM OF THE STUDY: Infective endocarditis (IE) is a devastating complication in patients undergoing chronic hemodialysis (HD). The study aim was to reveal the characteristics and outcomes of surgically managed IE in chronic HD patients. METHODS: Between April 1998 and August 2011, a total of 119 patients underwent surgery to treat IE. Of these patients, 16 were receiving chronic HD preoperatively. A comparison between non-HD patients (n = 103) and HD patients (n = 16) was conducted with regards to perioperative variables and postoperative morbidity and mortality. A survival analysis was performed using the Kaplan-Meier method. RESULTS: Preoperatively, a greater proportion of HD patients had diabetes mellitus than did non-HD patients (44% versus 16%, p = 0.015). Staphylococcus spp. (56%) and Enterococcus spp. (25%) were the predominant microorganisms in HD patients, while Staphylococcus spp. (37%) and Streptococcus spp. (21%) were predominant in non-HD patients. The most affected valve position was the aortic valve, followed by the mitral and the tricuspid in both groups. An annular reconstruction was performed in 56% of HD patients and in 30% of non-HD patients (p = 0.039). The HD patients had a higher incidence of perioperative use of intra-aortic balloon pump placement (25% versus 6.9%, p = 0.042), postoperative open-chest management (38% versus 9.8%, p = 0.009), and prolonged ventilation (63% versus 33%, p = 0.025). The operative mortality was 9.7% in non-HD patients and 38% in HD patients (p = 0.008). Survival at one year was 82% in the non-HD group and 34% in the HD group (p < 0.001). Multivariable analysis revealed that chronic HD is an independent predictor of operative and long-term mortality. CONCLUSION: The operative outcome after endocarditis in HD patients remains poor, and the importance of preventing endocarditis in chronic HD patients is further emphasized.

Cerebral and lower limb near-infrared spectroscopy in adults on extracorporeal membrane oxygenation.

Percutaneous femoral venoarterial (VA) or jugular venovenous (VV) extracorporeal membrane oxygenation (ECMO) can result in delivery of hypoxic blood to the brain, coronaries, and upper extremities. Additionally, VA-ECMO by percutaneous femoral artery cannulation may compromise perfusion to the lower limbs. Use of near-infrared spectroscopy (NIRS) detects regional ischemia and warns of impending hypoxic damage. We report the first known series with standardized monitoring of this parameter in adults on ECMO. This is an institutional review board-approved single institution retrospective review of patients with NIRS monitoring on ECMO from July 2010 until June 2011. Patients were analyzed for drops in NIRS tracings below 40 or >25% from baseline. VA-ECMO and VV-ECMO were initiated by percutaneous cannulation of the femoral vessels and the internal jugular vein, respectively. Sensors were placed on the patients' foreheads and on the lower limbs. NIRS tracings were recorded, analyzed, and correlated with clinical events. Twenty patients were analyzed (median age: 47.5 years): 17 patients were placed on VA-ECMO, and three patients on VV-ECMO. The median duration on ECMO was 7 days (range 2-26). One hundred percent of patients had a significant drop in bilateral cerebral oximetry tracings resulting in hemodynamic interventions, which involved increasing pressure, oxygenation, and/or ECMO flow. In 16 patients (80%), these interventions corrected the underlying ischemia. Four patients (20%) required further diagnostic intervention for persistent decreased bilateral and/or unilateral cerebral oximetry tracings, and were found to have a cerebrovascular accident (CVA). Six (30%) patients had persistent unilateral lower limb oximetry events, which resolved upon placement or replacement of a distal perfusion cannula. No patient was found to have either lower limb ischemia or a CVA with normal NIRS tracings. Use of NIRS with ECMO is important in detecting ischemic cerebral and peripheral vascular events. This allows for potential correction of the underlying process, thus preventing permanent ischemic damage.

Cardiogenic Shock Requiring Extracorporeal Membrane Oxygenation Support in a Patient with Panhypopituitarism: A Case Report.

We present a 58-year-old female with a past history of a pituitary adenoma resected two years prior to admission who developed polymorphic ventricular tachycardia and cardiogenic shock requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO). We noted that the patient had stopped taking all of her medications six months prior to presentation. An extensive workup revealed acute panhypopituitarism with secondary hypothyroidism, secondary adrenal insufficiency, and central diabetes insipidus. She was immediately initiated on thyroid and adrenal hormone replacement therapy as well as fluid replacement. Within five days of her medical treatment, the patient's cardiac function improved and she was successfully weaned from VA-ECMO and subsequently discharged home with appropriate hormone replacement therapy.

Shunting of Oxygenated Blood to the Venous System in the Avalon® Cannula on Venovenous Extracorporeal Membrane Oxygenation with High-frequency Oscillatory Ventilation.

High-frequency oscillatory ventilation (HFOV) may assist in the prevention of volutrauma for high-risk patients with acute respiratory distress syndrome (ARDS) during venovenous extracorporeal membrane oxygenation (VV ECMO). In combined VV ECMO and HFOV, we noted that increased intrathoracic pressure contributed to shunt formation in the dual-lumen Avalon® cannula (Maquet, Rastatt, Germany). A 51-year-old female with ARDS secondary to aspiration pneumonia was placed on VV ECMO using a single Avalon cannula. By ECMO Day 16, she became unable to ventilate due to elevated peak airway pressures, even with low tidal volume ventilation and an otherwise stable VV ECMO course. HFOV was introduced to minimize ventilator-induced lung injury. Shortly after HFOV started, the patient desaturated, and consequently, the fraction of inspired oxygen (FiO2) was increased to 100%. We noted that a flash of bright red, oxygenated blood was flowing retrograde in the Avalon cannula at the same rate as the beat of the oscillator, while the patient's ECMO flow rate, arterial blood gas, and blood pressure all remained stable. The ECMO flow was increased above 5.5 L/min and the resolution of the retrograde shunt through the Avalon cannula was immediately observed.  Concurrent use of HFOV with VV ECMO using an Avalon cannula may result in a shunt that becomes visible with arterial O2 saturations nearing 100%. Due to pressure differences between the venous and arterial lumens of the Avalon cannula, increasing the ECMO flow rate appeared to decrease this shunting effect caused by elevated intrathoracic pressure.

Is hemodynamic transesophageal echocardiography needed for patients with left ventricular assist device?

BACKGROUND: Interventions in patients with a left ventricular assist device (LVAD) in the intensive care unit (ICU) are typically performed based on the results of conventional monitoring, such as vital signs and Swan-Ganz catheter (SGC) and LVAD parameters. These variables might not always accurately reflect a patient's cardiac function, volume status, and interventricular septal configuration, however. To assess the accuracy of standard monitoring, we performed routine continuous hemodynamic transesophageal echocardiography (hTEE) to evaluate cardiac function, volume status, and septal position. METHODS: Between 2011 and 2015, 93 HeartMate II LVADs were implanted. The study group comprised 30 patients with an SGC in place who were monitored routinely by hTEE in the ICU every 1 to 3 hours until extubation. A total of 147 hTEE studies were analyzed retrospectively to observe differences between conventional monitoring and hTEE. RESULTS: Among the 30 patients studied, 26 (87%) had at least 1 disagreement between conventional monitoring and hTEE findings. In 22 patients (73%), at least 1 of the hTEE studies was abnormal whereas conventional parameters were normal. Abnormal hTEE findings included a shift in the interventricular septum in 19 patients (63%), abnormal ventricular volume status in 22 patients (73%), and right ventricular failure in 9 patients (30%). Based on conventional monitoring, none of the patients required an LVAD speed change, whereas hTEE showed that 14 patients (47%) needed an LVAD speed adjustment. CONCLUSIONS: Conventional monitoring in the ICU might not provide an accurate representation of cardiac function, ventricular volume status, or septal position in patients with LVAD. Continuous monitoring with hTEE in patients with an LVAD may help guide optimal intervention in the ICU setting during the early postoperative period.

Introduction to Extracorporeal Membrane Oxygenation.

Renewed interest in extracorporeal membrane oxygenation (ECMO) support of critically ill patients has led to a large expansion of its use across the world. This article reviews the long history of ECMO and introduces the early pioneers. The idea of team planning and team work is introduced in this article. There is an emphasis on understanding that ECMO care varies across institutions but is slowly growing to more uniform protocols.

Extracorporeal membrane oxygenation with multiple-organ failure: Can molecular adsorbent recirculating system therapy improve survival?

BACKGROUND: Liver dialysis, molecular adsorbent recirculating system (MARS) particularly, has been used in liver failure to bridge to transplantation. We expanded the indication for MARS to patients with acute shock liver failure and cardiopulmonary failure on extracorporeal membrane oxygenation (ECMO), aiming to improve survival to wean from ECMO. METHODS: Retrospective chart analysis of patients on ECMO between 2010 and 2015 found 28 patients who met the criteria for acute liver failure, diagnosed by hyperbilirubinemia (total bilirubin ≥10 mg/dl) or by elevated transaminase (alanine transaminase >1,000 IU/liter). Of these patients, 14 underwent MARS treatment (Group M), and 14 were supported with optimal medical treatment without MARS (Group C). Patient characteristics, liver function, and survival were compared between groups. RESULTS: Demographics, clinical risk factors, and pre-ECMO laboratory data were identical between the groups. MARS was used continuously for 8 days ± 9 in Group M. Total bilirubin, alanine transaminase, and international normalized ratio were improved significantly in Group M. There were no MARS-related complications. Survival to wean from ECMO for Group M was 64% (9/14) vs 21% (3/14) for Group C (p = 0.02). Mortality related to worsening liver dysfunction during ECMO was 40% (2/5 deaths) in Group M and 100% (11/11 deaths) in Group C (p = 0.004). The 30-day survival after ECMO was 43% (6/14) in Group M and 14% (2/14) in Group C (p = 0.09). CONCLUSIONS: MARS therapy in patients on ECMO safely accelerated recovery of liver function and improved survival to wean from ECMO, without increasing complications.

Issues in the Intensive Care Unit for Patients with Extracorporeal Membrane Oxygenation.

The care of patients on extracorporeal corporeal oxygenation support takes a coordinated effort among the team of nurses, midlevel providers, perfusionists, respiratory therapists, pharmacists, and physicians. Attention on the details of the circuitry and its interactions with the patient, the resolution of the disease process and the ongoing plan of care, and unique issues in the intensive care unit are crucial for success.

Clinical Significance of Spontaneous Echo Contrast on Extracorporeal Membrane Oxygenation.

BACKGROUND: Spontaneous echo contrast (SEC) is known to be a predisposition to thromboembolism and cerebrovascular accident. The aim of this study was to investigate the risk factors and the consequences of SEC in patients who were placed on venoarterial extracorporeal membrane oxygenation (VA-ECMO) because of cardiogenic shock. METHODS: Between January 2011 and December 2014, 98 patients underwent the insertion of VA-ECMO because of cardiogenic shock in our institution. Transthoracic and transesophageal echocardiography was performed and interpreted by National Board of Echocardiography certified cardiologists. Patients were divided into 2 groups based on the presence or absence of SEC. Clinical data, echocardiographic measurements, and outcomes were compared between the 2 groups. RESULTS: Of the 98 patients, 22 patients (22%) had SEC on echocardiography. Patients in the SEC group had a lower ejection fraction (8.0% versus 29%; p < 0.001), a lower pulsatility index (defined by [systolic blood pressure - diastolic blood pressure]/mean blood pressure) while receiving ECMO (0.13 ± 0.14 versus 0.26 ± 0.22; p = 0.009). The SEC group had a higher rate of intracardiac thrombus (46% versus 13%; p = 0.002) and stroke (36% versus 7.9%; p = 0.002). On univariate analysis, intracardiac thrombus, SEC, and low pulsatility were significant risk factors for the development of stroke. On multivariate analysis, SEC was the only independent risk factor for stroke. CONCLUSIONS: SEC on VA-ECMO resulted in an increased risk of intracardiac thrombus and stroke. Maintaining pulsatility while the patient is on ECMO may result in a decreased chance of developing SEC and stroke.

Quality of Life and Mid-Term Survival of Patients Bridged with Extracorporeal Membrane Oxygenation to Left Ventricular Assist Device.

Insertion of a left ventricular assist device (LVAD) improves survival and quality of life (QOL) in patients with class IV heart failure failing medical management. However, QOL and survival of patients bridged to LVAD with extracorporeal membrane oxygenation (ECMO) is unknown. Between July 2008 and June 2014, 213 patients underwent insertion of HeartMate II LVAD at two VAD centers without a bridge with a temporary VAD. Extracorporeal membrane oxygenation was used as a bridge before LVAD insertion in 22 Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) 1 patients (ECMO-VAD group). No bridge was used in 21 INTERMACS 1 patients and 170 INTERMACS 2-4 patients (primary LVAD group). Survival was compared between the ECMO-VAD group and INTERMACS 1 patients who underwent a primary LVAD insertion (INTERMACS 1 group). Quality of life was compared between the ECMO-VAD group and the primary LVAD group as a whole. The in-hospital mortality of the ECMO-VAD and INTERMACS1 groups was 23% and 14%, respectively (P = 0.38). The postimplant QOL scores of the ECMO-VAD group were not different compared with the primary LVAD group. Although the ECMO-VAD group consists of critically ill patients, the QOL and survival after discharge were not significantly different compared with patients who were not bridged with ECMO.

Systemic inflammatory response syndrome (SIRS) after extracorporeal membrane oxygenation (ECMO): Incidence, risks and survivals.

INTRODUCTION: Systemic inflammatory response syndrome (SIRS) is frequently observed after extracorporeal membrane oxygenation (ECMO) decannulation; however, these issues have not been investigated well in the past. METHODS: Retrospective chart review was performed to identify post-ECMO SIRS phenomenon, defined by exhibiting 2/3 of the following criteria: fever, leukocytosis, and escalation of vasopressors. The patients were divided into 2 groups: patients with documented infections (Group I) and patients with true SIRS (Group TS) without any evidence of infection. Survival and pre-, intra- and post-ECMO risk factors were analyzed. RESULTS: Among 62 ECMO survivors, 37 (60%) patients developed the post-ECMO SIRS phenomenon, including Group I (n = 22) and Group TS (n = 15). The 30-day survival rate of Group I and TS was 77% and 100%, respectively (p = 0.047), although risk factors were identical. CONCLUSIONS: SIRS phenomenon after ECMO decannulation commonly occurs. Differentiating between the similar clinical presentations of SIRS and infection is important and will impact clinical outcomes.

Ventilator strategies for VV ECMO management with concomitant tracheal injury and H1N1 influenza.

Tracheal injury is a rare but highly morbid complication of endotracheal intubation. Recent reviews have advocated conservative management of these injuries without operative intervention. Extracorporeal membrane oxygenation may be a useful tool in non-operative management of tracheal injury in the setting of severe respiratory failure and need for prolonged intubation. We present a morbidly obese 33 year-old-female with H1N1 influenza pneumonia complicated by acute respiratory distress syndrome and bacterial super-infection who sustained a post-intubation tracheal injury. Concomitant tracheal injury and acute lung injury pose a difficult ventilation dilemma. This patient was successfully managed by venovenous extracorporeal membrane oxygenation, high frequency oscillator ventilation, proning position and tube thoracostomy. The venovenous extracorporeal membrane oxygenation and ventilator management were essential for this patient's recovery.

Atrial septal defect and myocardial infarct.

The etiology for an acute myocardial infarction with normal coronary arteriography should rule in and rule out the presence of an atrial septal defect. Acute increases in left to right shunting with an atrial septal defect may lead to episodes of myocardial necrosis and right ventricular dysfunction. This case report describes such a scenario.