Single center utilization and post-transplant outcomes of thoracoabdominal normothermic regional perfusion deceased cardiac donor organs.

INTRODUCTION: Thoracoabdominal normothermic regional perfusion (TA-NRP) following cardiac death is an emerging multivisceral organ procurement technique. Recent national studies on outcomes of presumptive TA-NRP-procured organs are limited by potential misclassification since TA-NRP is not differentiated from donation after cardiac death (DCD) in registry data. METHODS: We studied 22 donors whose designees consented to TA-NRP and organ procurement performed at our institution between January 20, 2020 and July 3, 2022. We identified these donors in SRTR to describe organ utilization and recipient outcomes and compared them to recipients of traditional DCD (tDCD) and donation after brain death (DBD) organs during the same timeframe. RESULTS: All 22 donors progressed to cardiac arrest and underwent TA-NRP followed by heart, lung, kidney, and/or liver procurement. Median donor age was 41 years, 55% had anoxic brain injury, 45% were hypertensive, 0% were diabetic, and median kidney donor profile index was 40%. TA-NRP utilization was high across all organ types (88%-100%), with a higher percentage of kidneys procured via TA-NRP compared to tDCD (88% vs. 72%, p = .02). Recipient and graft survival ranged from 89% to 100% and were comparable to tDCD and DBD recipients (p ≥ .2). Delayed graft function was lower for kidneys procured from TA-NRP compared to tDCD donors (27% vs. 44%, p = .045). CONCLUSION: Procurement from TA-NRP donors yielded high organ utilization, with outcomes comparable to tDCD and DBD recipients across organ types. Further large-scale study of TA-NRP donors, facilitated by its capture in the national registry, will be critical to fully understand its impact as an organ procurement technique.

Spinal Cord Infarction With Prolonged Femoral Venoarterial Extracorporeal Membrane Oxygenation.

OBJECTIVES: There have been sporadic reports of ischemic spinal cord injury (SCI) during venoarterial extracorporeal membrane oxygenation (VA-ECMO) support. The authors observed a troubling pattern of this catastrophic complication and evaluated the potential mechanisms of SCI related to ECMO. DESIGN: This study was a case series. SETTING: This study was performed at a single institution in a University setting. PARTICIPANTS: Patients requiring prolonged VA-ECMO were included. INTERVENTIONS: No interventions were done. This was an observational study. MEASUREMENTS AND MAIN RESULTS: Four hypotheses of etiology were considered: (1) hypercoagulable state/thromboembolism, (2) regional hypoxia/hypocarbia, (3) hyperperfusion and spinal cord edema, and (4) mechanical coverage of spinal arteries. The SCI involved the lower thoracic (T7-T12 level) spinal cord to the cauda equina in all patients. Seven out of 132 (5.3%) patients with prolonged VA-ECMO support developed SCI. The median time from ECMO cannulation to SCI was 7 (range: 6-17) days.There was no evidence of embolic SCI or extended regional hypoxia or hypocarbia. A unilateral, internal iliac artery was covered by the arterial cannula in 6/7 86%) patients, but flow into the internal iliac was demonstrated on imaging in all available patients. The median total flow (ECMO + intrinsic cardiac output) was 8.5 L/min (LPM), and indexed flow was 4.1 LPM/m2. The median central venous oxygen saturation was 88%, and intracranial pressure was measured at 30 mmHg in one patient, suggestive of hyperperfusion and spinal cord edema. CONCLUSIONS: An SCI is a serious complication of extended peripheral VA-ECMO support. Its etiology remains uncertain, but the authors' preliminary data suggested that spinal cord edema from hyperperfusion or venous congestion could contribute.

Multimodal opioid-sparing pain management after lung transplantation and the impact of liposomal bupivacaine intercostal nerve block.

Opioid analgesics are commonly used post-lung transplant, but have many side effects and are associated with worse outcomes. We conducted a retrospective review of all lung transplant recipients who were treated with a multimodal opioid-sparing pain protocol. The use of liposomal bupivacaine intercostal nerve block was variable due to hospital restrictions. The primary objective was to describe opioid requirements and patient-reported pain scores early post-lung transplant and to assess the impact of intraoperative liposomal bupivacaine intercostal nerve block. We treated 64 lung transplant recipients with our protocol. Opioid utilization decreased to a mean of 43 milligram oral morphine equivalents by postoperative day 4. Median pain scores peaked at 4 on postoperative day 1 and decreased thereafter. Only three patients were discharged home with opioids, all of whom were taking opioid agonist therapy pre-transplant for opioid use disorder. Patients who received liposomal bupivacaine intercostal nerve block in the operating room had a significant reduction in opioid consumption over postoperative day 1 through 4 (228 mg vs. 517 mg, P= .032). A multimodal opioid-sparing pain management protocol is feasible and resulted in weaning of opioids prior to hospital discharge.

Bedside angiography of distal perfusion catheter for veno-arterial extracorporeal membrane oxygenation.

BACKGROUND: The aim of this study was to evaluate the ipsilateral lower extremity (ILE) outcomes of patients who underwent bedside angiography via the distal perfusion catheter while on femoral veno-arterial extracorporeal membrane oxygenation (VA ECMO). METHODS: This is a retrospective analysis of all patients placed on VA ECMO at a single center from January 2017 to December 2019 who underwent bedside angiography via the distal perfusion catheter. RESULTS: Twenty-four patients underwent bedside angiography via the distal perfusion catheter after being placed on VA ECMO. A vasodilator was directly administered in three patients for suspected spasm. One patient had distal thrombus and underwent thrombectomy and fasciotomy. One patient had a dislodged catheter and underwent thrombectomy, fasciotomy, and replacement of the catheter. One patient had severe ILE ischemia, however was not intervened upon due to critical acuity. Finally, one patient had inadvertent placement in the saphenous vein and had a new catheter placed in the SFA. No patients underwent amputation. Ultimately, 21 patients (87.5%) had no ILE compromise at the end their ECMO course. Survival to decannulation was 66.7% (n = 16). CONCLUSIONS: Bedside angiography of the distal perfusion catheter is feasible and can be a useful adjunct in informing the need for further intervention to the ILE. CLASSIFICATIONS: extracorporeal membrane oxygenation, ischemia.

Percutaneous Dilational Tracheostomy for Coronavirus Disease 2019 Patients Requiring Mechanical Ventilation.

OBJECTIVES: To assess the impact of percutaneous dilational tracheostomy in coronavirus disease 2019 patients requiring mechanical ventilation and the risk for healthcare providers. DESIGN: Prospective cohort study; patients were enrolled between March 11, and April 29, 2020. The date of final follow-up was July 30, 2020. We used a propensity score matching approach to compare outcomes. Study outcomes were formulated before data collection and analysis. SETTING: Critical care units at two large metropolitan hospitals in New York City. PATIENTS: Five-hundred forty-one patients with confirmed severe coronavirus disease 2019 respiratory failure requiring mechanical ventilation. INTERVENTIONS: Bedside percutaneous dilational tracheostomy with modified visualization and ventilation. MEASUREMENTS AND MAIN RESULTS: Required time for discontinuation off mechanical ventilation, total length of hospitalization, and overall patient survival. Of the 541 patients, 394 patients were eligible for a tracheostomy. One-hundred sixteen were early percutaneous dilational tracheostomies with median time of 9 days after initiation of mechanical ventilation (interquartile range, 7-12 d), whereas 89 were late percutaneous dilational tracheostomies with a median time of 19 days after initiation of mechanical ventilation (interquartile range, 16-24 d). Compared with patients with no tracheostomy, patients with an early percutaneous dilational tracheostomy had a higher probability of discontinuation from mechanical ventilation (absolute difference, 30%; p < 0.001; hazard ratio for successful discontinuation, 2.8; 95% CI, 1.34-5.84; p = 0.006) and a lower mortality (absolute difference, 34%, p < 0.001; hazard ratio for death, 0.11; 95% CI, 0.06-0.22; p < 0.001). Compared with patients with late percutaneous dilational tracheostomy, patients with early percutaneous dilational tracheostomy had higher discontinuation rates from mechanical ventilation (absolute difference 7%; p < 0.35; hazard ratio for successful discontinuation, 1.53; 95% CI, 1.01-2.3; p = 0.04) and had a shorter median duration of mechanical ventilation in survivors (absolute difference, -15 d; p < 0.001). None of the healthcare providers who performed all the percutaneous dilational tracheostomies procedures had clinical symptoms or any positive laboratory test for severe acute respiratory syndrome coronavirus 2 infection. CONCLUSIONS: In coronavirus disease 2019 patients on mechanical ventilation, an early modified percutaneous dilational tracheostomy was safe for patients and healthcare providers and associated with improved clinical outcomes.

Neurological complications during veno-venous extracorporeal membrane oxygenation: Does the configuration matter? A retrospective analysis of the ELSO database.

BACKGROUND: Single- (SL) and double-lumen (DL) catheters are used in clinical practice for veno-venous extracorporeal membrane oxygenation (V-V ECMO) therapy. However, information is lacking regarding the effects of the cannulation on neurological complications. METHODS: A retrospective observational study based on data from the Extracorporeal Life Support Organization (ELSO) registry. All adult patients included in the ELSO registry from 2011 to 2018 submitted to a single run of V-V ECMO were analyzed. Propensity score (PS) inverse probability of treatment weighting estimation for multiple treatments was used. The average treatment effect (ATE) was chosen as the causal effect estimate of outcome. The aim of the study was to evaluate differences in the occurrence and the type of neurological complications in adult patients undergoing V-V ECMO when treated with SL or DL cannulas. RESULTS: From a population of 6834 patients, the weighted propensity score matching included 6245 patients (i.e., 91% of the total cohort; 4175 with SL and 20,270 with DL cannulation). The proportion of patients with at least one neurological complication was similar in the SL (306, 7.2%) and DL (189, 7.7%; odds ratio 1.10 [95% confidence intervals 0.91-1.32]; p = 0.33). After weighted propensity score, the ATE for the occurrence of least one neurological complication was 0.005 (95% CI - 0.009 to 0.018; p = 0.50). Also, the occurrence of specific neurological complications, including intracerebral hemorrhage, acute ischemic stroke, seizures or brain death, was similar between groups. Overall mortality was similar between patients with neurological complications in the two groups. CONCLUSIONS: In this large registry, the occurrence of neurological complications was not related to the type of cannulation in patients undergoing V-V ECMO.

Clinical Outcomes of Pregnant and Postpartum Extracorporeal Membrane Oxygenation Patients.

BACKGROUND: The use of extracorporeal membrane oxygenation (ECMO) as a rescue therapy for cardiopulmonary failure is expanding in critical care medicine. In this case series, we describe the clinical outcomes of 21 consecutive pregnant or postpartum patients that required venovenous (VV) or venoarterial (VA) ECMO. Our objective was to characterize maternal and fetal survival in peripartum ECMO and better understand ECMO-related complications that occur in this unique patient population. METHODS: Between January 2009 and June 2019, all pregnant and postpartum patients treated with ECMO for respiratory or circulatory failure at a single quaternary referral center were identified. For all patients, indications for ECMO, maternal and neonatal outcomes, details of ECMO support, and anticoagulation and bleeding complications were collected. RESULTS: Twenty-one obstetric patients were treated with ECMO over 10 years. Thirteen patients were treated with VV ECMO and 8 patients were treated with VA ECMO. Six patients were pregnant at the time of cannulation and 3 patients delivered while on ECMO; all 6 maternal and infant dyads survived to hospital discharge. The median gestational age at cannulation was 28 weeks (interquartile range [IQR], 24-31). In the postpartum cohort, ECMO initiation ranged from immediately after delivery up to 46 days postpartum. Fifteen women survived (72%). Major bleeding complications requiring surgical intervention were observed in 7 patients (33.3%). Two patients on VV ECMO required bilateral orthotopic lung transplantation and 1 patient on VA ECMO required orthotopic heart transplantation to wean from ECMO. CONCLUSIONS: Survival for mother and neonate are excellent with peripartum ECMO in a high-volume ECMO center. Neonatal and maternal survival was 100% when ECMO was used in the late second or early third trimester. Based on these results, ECMO remains an important treatment option for peripartum patients with cardiopulmonary failure.

Hemoadsorption for management of patients on veno-venous ECMO support for severe COVID-19 acute respiratory distress syndrome.

BACKGROUND AND AIM: Patients with severe coronavirus disease 2019 (COVID-19) develop a profound cytokine-mediated pro-inflammatory response. This study reports outcomes in 10 patients with COVID-19 supported on veno-venous extracorporeal membrane oxygenation (VV-ECMO) who were selected for the emergency use of a hemoadsorption column integrated in the ECMO circuit. MATERIALS AND METHODS: Pre and posttreatment, clinical data, and inflammatory markers were assessed to determine the safety and feasibility of using this system and to evaluate the clinical effect. RESULTS: During hemoadsorption, median levels of interleukin (IL)-2R, IL-6, and IL-10 decreased by 54%, 86%, and 64%, respectively. Reductions in other markers were observed for lactate dehydrogenase (-49%), ferritin (-46%), d-dimer (-7%), C-reactive protein (-55%), procalcitonin (-76%), and lactate (-44%). Vasoactive-inotrope scores decreased significantly over the treatment interval (-80%). The median hospital length of stay was 53 days (36-85) and at 90-days post cannulation, survival was 90% which was similar to a group of patients without the use of hemoadsorption. CONCLUSIONS: Addition of hemoadsorption to VV-ECMO in patients with severe COVID-19 is feasible and reduces measured cytokine levels. However, in this small series, the precise impact on the overall clinical course and survival benefit still remains unknown.

Perceptions of Training Pathways from Recent Cardiothoracic Surgery Graduates.

BACKGROUND: There are three cardiothoracic surgery (CTS) training pathways-general surgery residency followed by a CTS residency of 2-3 years (traditional), 4 years of general surgery and 3 years of CTS residency (4+3), and an integrated 6-year pathway (I-6). The goal of this study was to survey early career cardiothoracic surgeons regarding their training experiences. METHODS: An email-based survey was sent to cardiothoracic surgeons, who graduated between 2012-2017. Data on training pathway specific variables and overall satisfaction were collected. The primary endpoints were career preparation and satisfaction, scored on a scale from 1-100, 100 being the most positive. RESULTS: Four hundred seventy-seven emails were sent, with a response rate of 95/477 (20%). Seventy-six of the respondents (80%) were male; the mean age was 39. Seventy-seven (81.0%) completed a traditional training pathway, 7 (7.4%) completed a 4+3 pathway, and 11 (11.6%) completed an I-6 pathway. Participants felt prepared for practice with a mean response of 79.8 (range 31-100); mean career satisfaction was 87.6.  When asked which pathway respondents would choose in the current era, 52 (54.7%) would choose a traditional pathway, 17 (17.9%) a 4+3 pathway, and 19 (20.0%) an I-6 program; 7 (7.4%) did not respond. Twenty of 72 (27.8%) traditional pathway trained and 18/18(100%) integrated pathway trained surgeons would choose an integrated pathway. CONCLUSIONS: This is the first survey addressing perceptions of training from early-career cardiothoracic surgeons across all training pathways. Data from this study provides insights to better understand how to improve CTS training for the next generation of surgeons.

The unique moral permissibility of uncontrolled lung donation after circulatory death.

Implementing uncontrolled donation after circulatory determination of death (uDCDD) in the United States could markedly improve supply of donor lungs for patients in need of transplants. Evidence from US pilot programs suggests families support uDCDD, but only if they are asked permission for using invasive organ preservation procedures prior to initiation. However, non-invasive strategies that confine oxygenation to lungs may be applicable to the overwhelming majority of potential uDCDD donors that have airway devices in place as part of standard resuscitation. We propose an ethical framework for lung uDCDD by: (a) initiating post mortem preservation without requiring prior permission to protect the opportunity for donation until an authorized party can be found; (b) using non-invasive strategies that confine oxygenation to lungs; and (c) maintaining strict separation between the healthcare team and the organ preservation team. Attempting uDCDD in this way has great potential to obtain more transplantable lungs while respecting donor autonomy and family wishes, securing public support, and enabling authorized persons to affirm or cease preservation decisions without requiring evidence of prior organ donation intent. It ensures prioritization of life-saving, the opportunity to allow willing donors to donate, and respect for bodily integrity while adhering to current ethical norms.

Ethical and logistical concerns for establishing NRP-cDCD heart transplantation in the United States.

Controlled heart donation after circulatory determination of death (cDCD) is well established internationally with good outcomes and could be adopted in the United States to increase heart supply if ethical and logistical challenges are comprehensively addressed. The most effective and resource-efficient method for mitigating warm ischemia after circulatory arrest is normothermic regional perfusion (NRP) in situ. This strategy requires restarting circulation after declaration of death according to circulatory criteria, which appears to challenge the legal circulatory death definition requiring irreversible cessation. Permanent cessation for life-saving efforts must be achieved to assuage this concern and ligating principal vessels maintains no blood flow to the brain, which ensures natural progression to cessation of brain function. This practice-standard in some countries-raises unique concerns about prioritizing life-saving efforts, informed authorization from decision-makers, and the clinician's role in the patient's death. To preserve public trust, medical integrity, and respect for the donor, the donation conversation must not take place until after an un-coerced decision to withdraw life-sustaining treatment made in accordance with the patient's treatment goals. The decision-maker(s) must understand cDCD procedure well enough to provide genuine authorization and the preservation/procurement teams must be kept separate from the clinical care team.

Therapeutic blockade of inflammation in severe COVID-19 infection with intravenous N-acetylcysteine.

Glucose 6-phosphate dehydrogenase (G6PD) deficiency facilitates human coronavirus infection due to glutathione depletion. G6PD deficiency may especially predispose to hemolysis upon coronavirus disease-2019 (COVID-19) infection when employing pro-oxidant therapy. However, glutathione depletion is reversible by N-acetylcysteine (NAC) administration. We describe a severe case of COVID-19 infection in a G6PD-deficient patient treated with hydroxychloroquine who benefited from intravenous (IV) NAC beyond reversal of hemolysis. NAC blocked hemolysis and elevation of liver enzymes, C-reactive protein (CRP), and ferritin and allowed removal from respirator and veno-venous extracorporeal membrane oxygenator and full recovery of the G6PD-deficient patient. NAC was also administered to 9 additional respirator-dependent COVID-19-infected patients without G6PD deficiency. NAC elicited clinical improvement and markedly reduced CRP in all patients and ferritin in 9/10 patients. NAC mechanism of action may involve the blockade of viral infection and the ensuing cytokine storm that warrant follow-up confirmatory studies in the setting of controlled clinical trials.

Management and tolerability of glecaprevir-pibrentasvir pharmacotherapy in hepatitis C viremic heart and lung transplant recipients.

We conducted a retrospective review of thoracic transplant recipients (22 heart and 16 lung transplant recipients) prospectively enrolled in a single-center observational study of HCV NAT+ organ transplantation in HCV NAT- recipients. All recipients were treated with 8 weeks of glecaprevir-pibrentasvir (GP) for HCV viremia in addition to standard triple immunosuppression post-transplant. Thoracic transplant recipients of HCV NAT- organs were used as a control (24 heart and 22 lung transplant recipients). Our primary outcome was to assess the effect of GP on tacrolimus dose requirements. Secondary objectives included assessing drug interactions with common post-transplant medications, adverse effects, and the need to hold or discontinue GP therapy. The median tacrolimus concentration-to-dose ratio (CDR) in the cohort was 184 (99-260) during GP therapy and 154 (78-304) over the first month after GP (P = .79). Trends in median tacrolimus CDR were similar on a per-week basis and per-patient basis. In three instances, concomitant posaconazole and GP led to hyperbilirubinemia and interruption of posaconazole. GP therapy was held in one heart transplant recipient and discontinued in another due to unresolving hyperbilirubinemia. Utilization of GP to treat HCV viremia post-thoracic transplant is feasible and safe, but requires modifications to post-transplant pharmacotherapy and careful monitoring for adverse effects.

Outcomes of the Treatment with Glecaprevir/Pibrentasvir following heart transplantation utilizing hepatitis C viremic donors.

BACKGROUND: The use of direct-acting antivirals (DAA) has expanded transplantation from hepatitis C viremic donors (HCV-VIR). Our team has conducted an open-label, prospective trial to assess outcomes transplanting HCV viremic hearts. Glecaprevir/pibrentasvir (GLE/PIB) was our sole DAA. METHODS: Serial quantitative hepatitis C virus (HCV) RNA PCR was obtained to assess HCV viral titers. Between January 2018 and June 2019, a total of 50 recipients were transplanted. Of these, 22/50 (44%) were from HCV-VIR, the remaining 28 from non-viremic (HCV NON-VIR) donors. An 8-week course of GLE/PIB was initiated at 1 week post-transplant. RESULTS: There was no difference in demographic or clinical parameters between groups. All 22 recipients of HCV-VIR transplants became viremic. GLE/PIB was effective in decreasing viremia to undetectable levels by 6 weeks post-transplant in all patients. The median time to first undetectable HCV quantitative PCR was (4.3 weeks, IQR: 4-5.7 weeks). All patients demonstrated sustained undetectable viral load through 1-year follow-up. There was no difference in survival at one year between HCV NON-VIR 28/28: (100%) vs HCV-VIR 21/22 (95%) recipients. CONCLUSIONS: Our center reports excellent outcomes in transplanting utilizing hearts from HCV-VIR donors. No effect on survival or co-morbidity was found. An 8-week GLE/PIB course was safe and effective when initiated approximately 1 week post-transplant.

Strategic application of modular risk components to safely increase lung transplantation volume.

OBJECTIVES: Considerable growth of individual lung transplant programs remains challenging. We hypothesized that the systematic implementation of modular risk components to a lung transplantation program would allow for expeditious growth without increasing mortality. METHODS: All consecutive patients placed on the lung transplantation waitlist were reviewed. Patients were stratified by an 18-month period surrounding the systematic implementation of the modular risk components Era 1 (1/2014-6/2015) and Era 2 (7/2015-12/2016). Modular risk components were separately evaluated for donors, recipients, and perioperative features. RESULTS: One hundred and thirty-two waitlist patients (Era 1: 48 and Era 2: 84) and 100 transplants (Era 1: 32 and Era 2: 68) were identified. There was a trend toward decreased waitlist mortality (P = .07). In Era 2, the use of ex vivo lung perfusion (P = .05) and donor-recipient over-sizing (P = .005) significantly increased. Moreover, transplantation with a lung allocation score greater than 70 (P = .05), extracorporeal support (P = .06), and desensitization (P = .008) were more common. Transplant rate significantly improved from Era 1 to Era 2 (325 vs 535 transplants per 100 patient years, P = .02). While primary graft dysfunction (PGD) grade 3 at 72 hours (P = .05) was significantly higher in Era 2, 1-year freedom from rejection was similar (86% vs 90%, P = .69) and survival (81% vs 95%, P = .02) was significantly greater in Era 2. CONCLUSIONS: The systematic implementation of a modular risk components to a lung transplantation program can result in a significant increase in center volume. However, measures to mitigate an expected increase in the incidence of PGD must be undertaken to maintain excellent short and midterm outcomes.

Comparison of device-specific adverse event profiles between Impella platforms.

BACKGROUND: The Impella (Abiomed) ventricular support system is a family of temporary mechanical circulatory support (MCS) devices used to treat patients with cardiogenic shock, acute cardiogenic decompensation, and for high-risk percutaneous or surgical revascularization. These devices include the percutaneously implanted 2.5/cardiac power (CP) and the surgically implanted 5.0/left direct (LD). Despite the beneficial effects and increased usage of these devices, data to assess adverse outcomes and guide clinician decision-making between the Impella CP and 5.0/LD are limited. METHODS: This is a retrospective analysis of 91 consecutive patients who required at least 24 h of Impella support, from January 1, 2015 to December 31, 2019. Groups were stratified based on either initial Impella CP or 5.0/LD placement. Clinical outcomes and in-hospital complications were compared. RESULTS: Impella CP was implanted in 66 patients (mean age: 61 ± 15 years, male 71.2%) and Impella 5.0/LD was implanted in 25 patients (mean age: 62 ± 9 years, male 84.0%). There was greater stability of device position (p = .033), less incidence of hemolysis (p < .001), and less frequent need for additional MCS (p = .001) in patients implanted with the Impella 5.0/LD compared with Impella CP in this study cohort. Patients with Impella 5.0/LD were more likely to survive from Impella and survive to discharge. CONCLUSIONS: This study suggests that for patients who require temporary MCS for more than 24 h, the Impella 5.0/LD may have a more favorable device-specific adverse profile compared with the Impella CP.

Implantation of Left Ventricular Assist Device After Descending Aortic Stent Graft for Mural Thrombus.

In patients with intraluminal thrombus, commonly applied temporary circulatory support modalities are contraindicated secondary to concern regarding distal or proximal (specifically veno-arterial extracorporeal membrane oxygenation) embolization of the thrombus. Therefore, in patients with cardiogenic shock and synchronous intraluminal descending aortic thrombus, support options are quite limited. We report a case of a 66-year-old man in cardiogenic shock, due to an ischemic cardiomyopathy, who also had intramural thrombus with an intraluminal component in the descending thoracic aorta. An endovascular stent graft was inserted inside the aorta over the location of the mural thrombus. This allowed for the placement of an intra-aortic balloon pump (IABP) for pre-operative optimization. After 3 days, a left ventricular assist device (LVAD) was implanted via left anterolateral thoracotomy with hemi-sternotomy, and the IABP was removed. Post-operatively, he had a relatively uncomplicated course without signs of embolic phenomena and ultimately was discharged home. Surveillance computed tomography imaging at 6 months showed no endovascular leak or migration of the stent. This case demonstrates the feasibility of aortic stent graft placement to allow safe insertion of an IABP in the setting of aortic mural thrombus.  Furthermore, it demonstrates the safety and feasibility of LVAD implantation after recent aortic stent graft placement.

Methylprednisolone may be associated with improved lung compliance in acute respiratory distress syndrome patients on veno-venous extracorporeal membrane oxygenation.

INTRODUCTION: Methylprednisolone has been used for acute respiratory distress syndrome with variable results. Veno-venous extracorporeal membrane oxygenation use in acute respiratory distress syndrome has increased. Occasionally, both are used. We hypothesized that methylprednisolone could improve lung compliance and ease weaning from extracorporeal membrane oxygenation in acute respiratory distress syndrome patients. METHODS: We retrospectively reviewed all patients in our veno-venous extracorporeal membrane oxygenation unit treated with methylprednisolone over a 20 month period. Methylprednisolone was initiated for inability to wean off veno-venous extracorporeal membrane oxygenation. Dynamic compliance (Cdyn) was calculated at cannulation, methylprednisolone initiation, and decannulation. Demographics, extracorporeal membrane oxygenation-specific data, and ventilator data were collected. Wilcoxon rank-sum test was used to test for differences in dynamic compliance. RESULTS: A total of 12 veno-venous extracorporeal membrane oxygenation patients received methylprednisolone. Mean age was 50 (±15) years. Seven had influenza. Methylprednisolone was started on median Day 16 (interquartile range: 11-22) of veno-venous extracorporeal membrane oxygenation. In total, 10 patients had veno-venous extracorporeal membrane oxygenation decannulation on median Day 12 (7-22) after methylprednisolone initiation. Two patients died before decannulation. The 10 decannulated patients had initial median dynamic compliance (mL × cm H2O-1) of 12 (7-23), then 16 (10-24) at methylprednisolone initiation, and then 44 (34-60) at decannulation. Dynamic compliance was higher at decannulation than methylprednisolone initiation (p = 0.002), and unchanged from cannulation to methylprednisolone initiation for all patients (p = 0.97). A total of 10 patients had significant infections. None had significant gastrointestinal bleed or wound healing issues. CONCLUSION: Methylprednisolone may be associated with improved compliance in acute respiratory distress syndrome allowing for decannulation from veno-venous extracorporeal membrane oxygenation. High rates of infection are associated with methylprednisolone use in veno-venous extracorporeal membrane oxygenation. Further studies are required to identify appropriate patient selection for methylprednisolone use in patients on veno-venous extracorporeal membrane oxygenation.

Early tracheostomy after initiation of venovenous extracorporeal membrane oxygenation is associated with decreased duration of extracorporeal membrane oxygenation support.

Timing of tracheostomy placement for patients with respiratory failure requiring venovenous extracorporeal membrane oxygenation support is variable and continues to depend on surgeon preference. We retrospectively reviewed all consecutive adult patients supported with peripheral venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome at a single institution with the hypothesis that early tracheostomy (within 7 days of extracorporeal membrane oxygenation initiation) decreases the duration of extracorporeal membrane oxygenation support. The primary endpoint was duration of extracorporeal membrane oxygenation support. Secondary endpoints included mortality, overall and intensive care unit length of stay, duration of mechanical ventilation, and time from extracorporeal membrane oxygenation initiation to liberation from ventilator, intensive care unit discharge, and hospital discharge. Overall and extracorporeal membrane oxygenation-associated hospital costs were compared. A total of 50 patients were identified for inclusion (early n = 21; late n = 29). Baseline characteristics including indices of disease severity were similar between groups. Duration of extracorporeal membrane oxygenation support was significantly shorter in the early tracheostomy group (12 vs. 21 days; p = 0.005). Median extracorporeal membrane oxygenation-related costs were significantly decreased in the early tracheostomy group ($3,624 vs. $5,603, p = 0.03). Early tracheostomy placement is associated with decreased time on extracorporeal membrane oxygenation support and reduced extracorporeal membrane oxygenation-related costs in this cohort. Validation in a prospective cohort or a clinical trial is indicated.

Von Willebrand Factor-GP1bα Interactions in Venoarterial Extracorporeal Membrane Oxygenation Patients.

OBJECTIVE: Evaluate extracorporeal membrane oxygenation (ECMO) patients' platelet adhesion and aggregation under shear stress and determine whether addition of von Willebrand factor (VWF) concentrate improves platelet function. Also, explore whether reduced platelet adhesion and aggregation is associated with clinical bleeding during ECMO. DESIGN: Prospective observational cohort study with translational component. SETTING: Academic medical center. PARTICIPANTS: Consecutive venoarterial (VA) ECMO patients were screened and 20 patients enrolled. INTERVENTIONS: VWF multimers, VWF antigen, ristocetin cofactor activity, and plasma glycocalicin levels were measured and values were compared at study points: ECMO day 1 or 2, day 3, and day 5. Platelet adhesion and aggregation were measured in vitro using the total thrombus analysis system. Platelet function was expressed as area under the flow-pressure curve (AUC). VWF concentrate was added in vitro and the AUC after VWF supplementation (VWF AUC) was compared with baseline AUC. Further, baseline AUCs and VWF AUCs were compared between patients who experienced bleeding during ECMO and those who did not. MEASUREMENTS AND MAIN RESULTS: ECMO patients had high VWF antigen levels, high ristocetin cofactor activity, and large VWF multimer loss. Platelet counts fell over the first 5 days on ECMO, and plasma glycocalicin levels were elevated mildly. ECMO patients had severely low platelet adhesion and aggregation in vitro: median AUC = 5.8 (3.5-9.7) ECMO day 1 or 2, median AUC = 6.3 (5.3-11.1) day 3, and median AUC = 5.5 (4.1-8.1) day 5. There was no significant change in AUC over time (p = 0.47). Addition of VWF concentrate increased the AUC compared to baseline at each point (all p < 0.05), but VWF AUC values remained low. Patients with bleeding during ECMO had a low VWF AUC at all points, whereas those without bleeding had a higher VWF AUC on ECMO day 3. CONCLUSIONS: VA ECMO patients have severely impaired platelet function, which improved but did not normalize with VWF concentrate. The data suggest that GP1bα receptor loss of dysfunction also contributes to impaired platelet adhesion and aggregation during ECMO. Based on these findings, clinical bleeding in ECMO patients is unlikely to be correctable with VWF supplementation alone.