Fulminant myocarditis induced by SARS-CoV-2 infection without severe lung involvement: insights into COVID-19 pathogenesis.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection often leads to pulmonary complications. Cardiovascular sequelae, including myocarditis and heart failure, have also been reported. Here, the study presents two fulminant myocarditis cases infected by SARS-CoV-2 exhibiting remarkable elevation of cardiac biomarkers without significant pulmonary injury, as determined by imaging examinations. Immunohistochemical staining reveals viral antigen within cardiomyocytes, indicating that SARS-CoV-2 could directly infect myocardium. The full viral genomes from respiratory, anal, and myocardial specimens are obtained via next-generation sequencing. Phylogenetic analyses of the whole genome and spike gene indicate that viruses in the myocardium/pericardial effusion and anal swabs are closely related and cluster together yet diverge from those in the respiratory samples. In addition, unique mutations are found in the anal/myocardial strains compared to the respiratory strains, suggesting tissue-specific virus mutation and adaptation. These findings indicate genetically distinct SARS-CoV-2 variants have infiltrated and disseminated within myocardial tissues, independent of pulmonary injury, and point to different infection routes between the myocardium and respiratory tract, with myocardial infections potentially arising from intestinal infection. These findings highlight the potential for systemic SARS-CoV-2 infection and the importance of a thorough multi-organ assessment in patients for a comprehensive understanding of the pathogenesis of COVID-19.

The effects of tranexamic acid in patients treated with extracorporeal membrane oxygenation after cardiac surgery.

BACKGROUND: The lysine analog tranexamic acid (TXA) is used as a blood protective drug in cardiac surgery, but efficacy and safety outcomes in patients treated with extracorporeal membrane oxygenation (ECMO) after surgery remain poorly understood. METHODS: From January 1, 2017 to December 31, 2022, we retrospectively analyzed patients assisted by ECMO after cardiac surgery and divided them into TXA and control groups depending on whether TXA was used or not. The primary study outcome was red blood cell (RBC) transfusion during ECMO. RESULTS: In total, 321 patients treated with ECMO after cardiac surgery were assessed; 185 patients were eligible for inclusion into to the TXA-intervention group and 136 into to the control group. RBC transfusion during ECMO was 8.0 IU (4.0 IU-14.0 IU) in the TXA group versus 10.0 IU (6.0 IU-16.0 IU) in the control group (p = .034). Median total chest drainage volume after surgery was 1460.0 mL (650.0-2910.0 mL) and 1680.0 mL (900.0-3340.0 mL) in TXA and control groups, respectively (p = .021). Postoperative serum D-dimer levels were significantly lower in the TXA group when compared with the control group; 1.125 µg/mL (0.515-2.176 µg/mL) versus 3.000 µg/mL (1.269-5.862 µg/mL), p < .001. Serious adverse events, including vascular occlusive events, did not differ meaningfully between groups. CONCLUSIONS: In patients treated with ECMO after cardiac surgery, TXA infusion modestly but significantly reduced RBC transfusions and chest tube output when compared with the control group.

Impact of renal complications on outcome in adult patients with acute fulminant myocarditis receiving venoarterial extracorporeal membrane oxygenation: an analysis of nationwide CSECLS database in China.

BACKGROUND: Limited data are available on renal complications in patients with acute fulminant myocarditis (AFM) receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) support in China. To evaluate the impact of renal complications on outcomes in adult patients with AFM supported with VA-ECMO. METHODS: Data were extracted from Chinese Society of ExtraCorporeal Life Support (CSECLS) Registry database. Adult patients who were diagnosed with AFM receiving VA-ECMO support in the database were included. The primary outcome was 30-day mortality in patients with AFM supported with VA-ECMO. Logistic regression model was used to examine the impact of renal complications on 30-day mortality by adjusting confounders. RESULTS: A total of 202 patients were included. The median age was 38 years (IQR 29-48) and males (n = 103) represented 51.0% of the total accounted patients. The median ECMO duration was 142.9 h (IQR 112.1-188.8 h). 178 (88.1%) patients weaned from ECMO and 156 (71.9%) patients survived. 94(46.5%) patients developed renal complications while on ECMO course. Patients with renal complications had higher 30-day mortality (40.7% (37 of 94) vs 8.3% (9 of 108), P < 0.001) compared with those without. The development of renal complications was related to a 3.12-fold increase risk of 30-day mortality (adjusted OR 3.120, 95%CI 1.002-6.577, P = 0.049). Increasing age (adjusted OR1.025, 95% CI 1.008-1.298, P = 0.040) and higher SOFA score (adjusted OR 1.162, 95%CI 1.012-1.334, P = 0.034) were independent risk factors of renal complications. CONCLUSIONS: Our findings demonstrated that patients with AFM receiving VA-ECMO at high risk of developing renal complications. Advancing age and higher SOFA score was associated with increased risk of developing renal complications. The onset of renal complications was significantly associated with 30-day mortality.

The low hemoglobin levels were associated with mortality in post-cardiotomy patients undergoing venoarterial extracorporeal membrane oxygenation.

BACKGROUND: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is used as a rescue strategy for patients with refractory post-cardiotomy cardiogenic shock (PCS). These patients often have varying degrees of reduced hemoglobin levels, and there are few detailed investigations about the impact of hemoglobin level on their mortality. The objective of this study was to evaluate whether hemoglobin levels at day 1 from VA-ECMO initiation were associated with in-hospital mortality. METHODS: We performed a retrospective analysis of adult VA-ECMO patients over approximately a 2-year period. We divided patients into survival and death groups based on their clinical outcomes and compared the differences in parameters between the two groups. Multivariate logistic regression analyses were performed to estimate whether hemoglobin level was related to the mortality. RESULTS: One hundred and sixteen patients were included in final analysis. There were 52 patients in the survival group and 64 in the death group. The patients were younger in the survival group than the death group (58 vs 63, p = .023). The median (IQR) hemoglobin level at day 1 was 80 (73-89) × g/L, and the median (IQR) RelΔ hemoglobin was 41% (32-48%). Survival patients had a higher hemoglobin level at day 1 and a lower RelΔ hemoglobin than the death patients (91 vs 76 g/L, p < .001; 35% vs 45%, p < .001). The multivariable logistic regression analyses showed that the low hemoglobin levels at day 1 were independently associated with in-hospital mortality (OR 0.808; 95% CI, 0.747-0.874; p < .001). The AUROC for hemoglobin level was 0.89 (95% CI, 0.83-0.95) which was better than that of RelΔ hemoglobin (0.77, 95% CI, 0.68-0.86). CONCLUSIONS: In patients receiving VA-ECMO for PCS, the low hemoglobin levels at day 1 were independently associated with in-hospital mortality.

Sepsis induces non-classic innate immune memory in granulocytes.

Secondary infection in patients with sepsis triggers a new wave of inflammatory response, which aggravates organ injury and increases mortality. Trained immunity boosts a potent and nonspecific response to the secondary challenge and has been considered beneficial for the host. Here, using a murine model of polymicrobial infection, we find that the primary infection reprograms granulocytes to boost enhanced inflammatory responses to the secondary infection, including the excessive production of inflammatory cytokines, respiratory burst, and augmented phagocytosis capacity. However, these reprogramed granulocytes exhibit "non-classic" characteristics of innate immune memory. Two mechanisms are independently involved in the innate immune memory of granulocytes: a metabolic shift in favor of glycolysis and fatty acid synthesis and chromatin remodeling leading to the transcriptional inactivity of genes encoding inhibitors of TLR4-initiated signaling pathways. Counteracting the deleterious effects of stressed granulocytes on anti-infection immunity might provide a strategy to fight secondary infections during sepsis.

Impact of Nosocomial Infection on in-Hospital Mortality Rate in Adult Patients Under Venoarterial Extracorporeal Membrane Oxygenation After Cardiac Surgery.

Objective: There was no consensus on the impact of nosocomial infection on In-hospital mortality rate in patients receiving ECMO. This study aimed to investigate the impact of nosocomial infection (NI) on In-hospital mortality rate in adult patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) after cardiac surgery. Materials and Methods: This retrospective study included 503 adult patients who underwent VA-ECMO after cardiac surgery. The impact of time-dependent NIs on In-hospital mortality rate within 28 days of ECMO initiation was investigated using a Cox regression model. The cumulative incidence function for death was compared between patients with NIs and those without NIs using a competing risk model. Results: Within 28 days after ECMO initiation, 206 (41.0%) patients developed NIs, and 220 (43.7%) patients died. The prevalence rates of NIs were 27.8% and 20.3% during and after ECMO therapy, respectively. The incidence rates of NIs during and after ECMO therapy were 49‰ and 25‰, respectively. Time-dependent NI was an independent risk factor for predicting death (hazard ratio = 1.05, 95% confidence interval = 1.00-1.11). The cumulative incidence of death in patients with NI was significantly higher than that in patients without NI at each time point within 28 days of ECMO initiation. (Z = 5.816, P = 0.0159). Conclusion: NI was a common complication in adult patients who received VA-ECMO after cardiac surgery, and time-dependent NI was an independent risk factor for predicting mortality in these patients. Using a competing risk model, we confirmed that NIs increased the risk of In-hospital mortality rate in these patients.

Soluble ST2 predicts continuous renal replacement therapy in patients receiving venoarterial extracorporeal membrane oxygenation.

OBJECTIVE: This study aimed to evaluate the relationship between plasma soluble ST2 (sST2) levels 24 h after extracorporeal membrane oxygenation (ECMO) initiation and continuous renal replacement therapy (CRRT) in patients receiving venoarterial ECMO (V-A ECMO) support. METHODS AND RESULTS: Data of patients who received ECMO support for postcardiotomy cardiogenic shock between January 2017 and July 2019 were retrospectively collected from Beijing Anzhen Hospital, Capital Medical University. Ultimately, 116 patients were included in the present study for analysis. The concentration of sST2 was determined by enzyme-linked immunosorbent assay (ELISA). The log10 sST2 levels were higher in patients undergoing CRRT than those who did not (6.06 vs. 6.22, p = 0.019). Patients undergoing CRRT had a lower survival rate than those who did not (32.8% vs. 67.3%, p < 0.001). In the univariate logistic regression analysis, sST2, HCO3-, lactate, and creatinine levels 24 h after ECMO initiation were related to CRRT (p < 0.05). In the multivariate logistic regression analysis, HCO3- and sST2 were identified as independent risk factors for CRRT use in patients undergoing ECMO (p < 0.05). The area under receiver operator characteristic curve (AUC) for sST2 and HCO3- together was 0.72 (95% confidence interval (CI), 0.79-0.91), which was better than those of sST2 or HCO3- alone (0.63 vs. 0.67). CONCLUSIONS: sST2 and HCO3-levels at 24 h after ECMO initiation were associated with CRRT and could predict CRRT use in postcardiotomy cardiogenic shock patients undergoing ECMO.

Clinical outcome and risk factors for acute fulminant myocarditis supported by venoarterial extracorporeal membrane oxygenation: An analysis of nationwide CSECLS database in China.

BACKGROUND: To assess the outcomes and risk factors for adult patients with acute fulminant myocarditis (AFM) supported with venoarterial extracorporeal membrane oxygenation (VA ECMO) in China mainland. METHODS: Data were extracted from Chinese Society of ExtraCorporeal Life Support (CSECLS) Registry database. Data from adult patients who were diagnosed with AFM and needed VA ECMO in the database were retrospectively analyzed. The primary outcome was 90-day mortality after ECMO initiation in patients with AFM supported with VA ECMO. Cox proportional hazard regression model was used to examine the risk factors associated with 90-day mortality. RESULTS: Among 221 patients enrolled and followed up to 90 days, 186 (84.2%) patients weaned from ECMO and 159 (71.9%) patients survived and discharged home. The median age was 38 years (IQR 29-49) and males (n = 115) represented 52.0% of the total accounted patients. The median ECMO duration was 134 h (IQR 96-177 h). The main adverse event during ECMO course was bleeding (16.3%), followed by infection (15.4%). In the multivariate Cox model analysis, cardiac arrest prior to ECMO initiation (adjusted HR 2.529; 95%CI: 1.341-4.767, p = 0.004), lower pH value (adjusted HR 0.016; 95%CI: 0.010-0.059, p < 0.001) and higher lactate concentration at 24 h after ECMO initiation (adjusted HR 1.146; 95%CI: 1.075-1.221, p < 0.001) were associated with 90-day mortality. CONCLUSIONS: 71.9% patients with AFM (clinical diagnosed) supported with VA ECMO survived. Cardiac arrest prior to ECMO, lower pH and higher lactate concentration at 24 h after ECMO initiation were correlated with 90-day mortality of AFM patients supported with VA ECMO.

A nomogram to predict nosocomial infection in patients on venoarterial extracorporeal membrane oxygenation after cardiac surgery.

INTRODUCTION: After cardiac surgery, patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) have a higher risk of nosocomial infection in the intensive care unit (ICU). We aimed to establish an intuitive nomogram to predict the probability of nosocomial infection in patients on VA-ECMO after cardiac surgery. METHODS: We included patients on VA-ECMO after cardiac surgery between January 2011 and December 2020 at a single center. We developed a nomogram based on independent predictors identified using univariate and multivariate logistic regression analyses. We selected the optimal model and assessed its performance through internal validation and decision-curve analyses. RESULTS: Overall, 503 patients were included; 363 and 140 patients were randomly divided into development and validation sets, respectively. Independent predictors derived from the development set to predict nosocomial infection included older age, white blood cell (WBC) count abnormality, ECMO environment in the ICU, and mechanical ventilation (MV) duration, which were entered into the model to create the nomogram. The model showed good discrimination, with areas under the curve (95% confidence interval) of 0.743 (0.692-0.794) in the development set and 0.732 (0.643-0.820) in the validation set. The optimal cutoff probability of the model was 0.457 in the development set (sensitivity, 0.683; specificity, 0.719). The model showed qualified calibration in both the development and validation sets (Hosmer-Lemeshow test, p > .05). The threshold probabilities ranged from 0.20 to 0.70. CONCLUSIONS: For adult patients receiving VA-ECMO treatment after cardiac surgery, a nomogram-monitoring tool could be used in clinical practice to identify patients with high-risk nosocomial infections and provide an early warning.

Intra-aortic balloon pump impacts the regional haemodynamics of patients with cardiogenic shock treated with femoro-femoral veno-arterial extracorporeal membrane oxygenation.

AIMS: To investigate the impact of intra-aortic balloon pump (IABP) on the regional haemodynamics of patients with severe cardiogenic shock undergoing femoro-femoral veno-arterial extracorporeal membrane oxygenation (VA-ECMO). METHODS AND RESULTS: From July 2017 to April 2018, a total of 39 adult patients with cardiogenic shock receiving both IABP and ECMO for circulatory support were enrolled consecutively in a university-affiliated cardiac surgery intensive care unit. The blood flow rates (BFRs) of the bilateral femoral artery (IABP side: iFA, ECMO side: eFA) and carotid artery (left: LCA, right: RCA) and the velocity time integral (VTI) of aortic root were assessed by ultrasonography and compared when IABP was on and off. Seventeen of 39 (43.6%) patients survived to discharge, and 29 (74.4%) survived on ECMO. A total of 172 pairs of data (IABP on and off) were collected in this study, measured on the median of 2.0 (1.0, 4.5) days after patients received VA-ECMO. The BFR on both sides of FA (iFA: 176.4 ± 104.5 vs. 152.2 ± 139.8 mL/min, P < 0.01; eFA: 299.3 ± 279.9 vs. 242.4 ± 258.8 mL/min, P < 0.01) and the aortic VTI (10.1 ± 4.4 vs. 8.5 ± 4.4 cm, P < 0.01) decreased significantly when turning the IABP off, while the BFR on both sides of CA remained unchanged (LCA: 555.7 ± 326.9 vs. 578.6 ± 328.0 mL/min, P = 0.27; RCA: 550.0 ± 331.1 vs. 533.0 ± 303.5 mL/min, P = 0.30). The LCA BFR dramatically increased after turning the IABP off (296.8 ± 129.7 vs. 401.4 ± 278.1 mL/min, P = 0.02) in patients with cardiac stunning (defined as pulse pressure ≤ 5 mmHg). However, there was no significant difference in LCA BFR between IABP-On and IABD-Off (359.6 ± 105.4 mL/min vs. 389.6 ± 139.3 mL/min, P = 0.31) in patients with cardiac stunning receiving a higher ECMO blood flow (> 3.5 L/min). CONCLUSIONS: Concomitant IABP used in patients undergoing femoro-femoral VA-ECMO was associated with increased aortic VTI and BFR in bilateral FA. The change in CA BFR depended on cardiac function. A decreased LCA BFR was observed in patients with cardiac stunning when IABP was turned on, which might be compensated by a higher ECMO blood flow. Further study is needed to confirm the relationship between BFR and extremities and neurological complications.

Risk factors and outcomes for patients with bleeding complications receiving extracorporeal membrane oxygenation: An analysis of the Chinese Extracorporeal Life Support Registry.

OBJECTIVE: Bleeding is a severe complication of patients supported with extracorporeal membrane oxygenation (ECMO). This study aimed to analyze the occurrence, risk factors, and clinical outcomes of patients on ECMO with bleeding complications. METHODS: ECMO cases reported to the multicenter ECMO registry database of the Chinese Society of Extracorporeal Life Support (CSECLS) from January 2017 to December 2020 were enrolled. General information, ECMO indications, application, complications, and patient outcomes were collected and analyzed. RESULTS: A total of 6541 ECMO patients from 112 centers were enrolled. Overall, 1185 patients (18.1%) presented with one of the following bleeding complications, including 82 cases (1.3%) with severe bleeding during ECMO catheterization, 462 cases (7.1%) with bleeding at the ECMO cannulation site, 200 cases (3.5%) with bleeding at the surgical site, 180 cases (2.8%) with cerebral hemorrhage, 99 cases (1.5%) with pulmonary hemorrhage, 200 cases (3.5%) with gastrointestinal hemorrhage, 82 cases (1.3%) with ECMO withdrawal, and 118 (1.8%) deaths due to severe bleeding. Extracorporeal cardiopulmonary resuscitation (ECPR) patients had the highest incidence of bleeding complications (22.4%), followed by those on circulatory support (18.7%) and respiratory support (15.4%) (p < 0.001). Multivariate analysis showed that pediatric patients (odds ratio [OR] 1.509, p < 0.001), patients receiving renal replacement therapy (OR 1.932, p < 0.001), and patients receiving central ECMO cannulation (OR 3.023, p < 0.001) were independent risk factors for all bleeding complications, while peripheral cannulation (OR 0.712, p < 0.001) was an independent protective factor. Patients with any bleeding complication had significantly higher in-hospital mortality than patients without (61.9% vs. 46.3%, p < 0.001). CONCLUSION: Up to 18.1% of ECMO patients in the CSECLS registry experienced bleeding complications, which was associated with higher in-hospital mortality, especially in patients who received ECPR, patients on circulatory support, and pediatric patients, which should arouse the attention of clinicians.

Percutaneous versus surgical cannulation for femoro-femoral VA-ECMO in patients with cardiogenic shock: Results from the Extracorporeal Life Support Organization Registry.

PURPOSE: Percutaneous cannulation is increasingly used for veno-arterial extracorporeal membrane oxygenation (VA-ECMO). However, there is limited evidence about the benefit of this approach compared with conventional surgical cannulation. By using a large international database, this study was designed to compare in-hospital outcomes in cardiac shock patients who received femoro-femoral VA-ECMO with percutaneous versus surgical cannulation. METHODS: Adults with refractory cardiogenic shock treated with percutaneous (percutaneous group) or surgical (surgical group) femoro-femoral VA-ECMO between January 2008 and December 2019 were extracted from the international Extracorporeal Life Support Organization registry. The primary outcome was in-hospital mortality. Multivariable logistic regression analyses were performed to assess the association between percutaneous cannulation and in-hospital outcomes. RESULTS: Among 12,592 patients meeting study inclusion, 9,249 (73%) underwent percutaneous cannulation. The proportion of patients undergoing percutaneous cannulation increased from 32% to 84% over the study period (p < 0.01 for trend). In-hospital mortality (53% vs 58%; p < 0.01), cannulation site bleeding (19% vs 22%; p < 0.01), and systemic infection (8% vs 15%; p < 0.01) occurred less frequently in the percutaneous group compared to the surgical group. In adjusted analyses, percutaneous cannulation was independently associated with lower rates of in-hospital mortality (odds ratio [OR] 0.76; 95% CI 0.70-0.84; p < 0.01), cannulation site bleeding (OR 0.70; 95% CI 0.60-0.80; p < 0.01) and systemic infection (OR, 0.63; 95% CI 0.54-0.74; p < 0.01). Severe limb ischemia was more frequently observed in the percutaneous group (5% vs 3%; p < 0.01). However, this association was not significant in adjusted analysis (OR 1.28; 95% CI 0.93-1.62; p = 0.15). CONCLUSIONS: Compared with surgical cannulation, percutaneous cannulation was independently associated with lower in-hospital mortality and fewer complications.

Extracorporeal Membrane Oxygenation-Related Nosocomial Infection after Cardiac Surgery in Adult Patients

Abstract Introduction: The evaluation of extracorporeal membrane oxygenation-related nosocomial infection (ECMO-related NI) in a homogeneous cohort remains scarce. This study analyzed ECMO-related NI in adult patients who have undergone cardiac surgery. Methods: From January 2012 to December 2017, 322 adult patients who have received ECMO support after cardiac surgery were divided into the infection group (n=131) and the non-infection group (n=191). ECMO-related NI was evaluated according to demographic data, surgical procedures, and ECMO parameters. Results: The incidence of ECMO-related NI was 85.4 cases per 1000 ECMO days. Acinetobacter baumannii was the most common pathogen causing blood stream infection and respiratory tract infection. Prolonged duration of surgery (P=0.042) and cardiopulmonary bypass assist (P=0.044) increased the risk of ECMO-related NI. Body mass index (odds ratio [OR]: 1.077; 95% confidence interval [CI]: 1.004-1.156; P=0.039) and duration of ECMO support (OR: 1.006; 95% CI: 1.003-1.009; P=0.0001) were the independent risk factors for ECMO-related NI. Duration of ECMO support > 144 hours (OR: 2.460; 95% CI: 1.155-7.238; P<0.0001) and ECMO-related NI (OR: 3.726; 95% CI: 1.274-10.895; P=0.016) increased significantly the risk of in-hospital death. Conclusion: Prolonged duration of ECMO support was an independent risk factor for NI. Surgical correcting latent causes of cardiopulmonary failure and shortening duration of ECMO whenever possible would reduce susceptibility to NI.

Severe Patients With ARDS With COVID-19 Treated With Extracorporeal Membrane Oxygenation in China: A Retrospective Study.

Background: The novel coronavirus disease 2019 (COVID-19) pandemic has become a global health crisis affecting over 200 countries worldwide. Extracorporeal membrane oxygenation (ECMO) has been increasingly used in the management of COVID-19-associated end-stage respiratory failure. However, the exact effect of ECMO in the management of these patients, especially with regards to complications and mortality, is unclear. Methods: This is the largest retrospective study of ECMO treated COVID-19 patients in China. A total of 50 ECMO-treated COVID-19 patients were recruited. We describe the main characteristics, the clinical features, ventilator parameters, ECMO-related variables and management details, and complications and outcomes of COVID-19 patients with severe acute respiratory distress syndrome (ARDS) that required ECMO support. Results: For those patients with ECMO support, 21 patients survived and 29 died (mortality rate: 58.0%). Among those who survived, PaO2 (66.3 mmHg [59.5-74.0 mmHg] and PaO2/FiO2 (68.0 mmHg [61.0-76.0 mmHg]) were higher in the survivors than those of non-survivors (PaO2: 56.8 mmHg (49.0-65.0 mmHg), PaO2/FiO2 (58.2 mmHg (49.0-68.0 mmHg), all P < 0.01) prior to ECMO. Patients who achieved negative fluid balance in the early resuscitation phase (within 3 days) had a higher survival rate than those who did not (P = 0.0003). Conclusions: In this study of 50 cases of ECMO-treated COVID-19 patients, a low PO2/FIO2 ratio before ECMO commencement may indicate a poor prognosis. Negative fluid balance in the early resuscitation phase during ECMO treatment was a predictor of increased survival post-ECMO treatment.

Extracorporeal membrane oxygenation (ECMO) for critically ill patients with coronavirus disease 2019 (COVID-19): A retrospective cohort study.

PURPOSE: The role of extracorporeal membrane oxygenatio (ECMO) for rescue therapy of respiratory failure in critically ill coronavirus disease 2019 (COVID-19) patients remains controversial. We aimed to evaluate the clinical outcomes of ECMO in the treatment of COVID-19 compared with conventional ventilation support. METHODS: In this retrospective cohort study, data were collected on extremely critical patients with COVID-19 from January 2020 to March 2020 in intensive care unit of a hospital in charge by national rescue team in Wuhan, China, the epicenter of pandemic. Patients were classified into the ECMO group and the conventional ventilation non-ECMO group. Clinical characteristics, technical characteristics, laboratory results, mortality, and complications of the two groups were analyzed. RESULTS: 88 patients with extremely critical COVID-19 were screened; 34 received ECMO support and 31 received conventional ventilation support. Both groups had comparable characteristics at baseline in terms of age, gender, and comorbidities. Before ECMO or conventional therapy, patients in the two groups had sever acute respiratory distress syndrome with a mean partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2 /FiO2 ) ratio of 69.6 and 75.4, respectively. At the time of reporting, patients in the ECMO had significantly lower in-hospital mortality compared with the control group (58.8 vs. 93.5%, p = .001). CONCLUSION: ECMO is shown to decrease the mortality of extremely critical ill COVID-19 patients compared with the conventional treatment. Although complications occurred frequently, ECMO could still be a rescue therapy for the treatment of COVID-19 during the pandemic.

Extracorporeal Membrane Oxygenation-Related Nosocomial Infection after Cardiac Surgery in Adult Patients.

INTRODUCTION: The evaluation of extracorporeal membrane oxygenation-related nosocomial infection (ECMO-related NI) in a homogeneous cohort remains scarce. This study analyzed ECMO-related NI in adult patients who have undergone cardiac surgery. METHODS: From January 2012 to December 2017, 322 adult patients who have received ECMO support after cardiac surgery were divided into the infection group (n=131) and the non-infection group (n=191). ECMO-related NI was evaluated according to demographic data, surgical procedures, and ECMO parameters. RESULTS: The incidence of ECMO-related NI was 85.4 cases per 1000 ECMO days. Acinetobacter baumannii was the most common pathogen causing blood stream infection and respiratory tract infection. Prolonged duration of surgery (P=0.042) and cardiopulmonary bypass assist (P=0.044) increased the risk of ECMO-related NI. Body mass index (odds ratio [OR]: 1.077; 95% confidence interval [CI]: 1.004-1.156; P=0.039) and duration of ECMO support (OR: 1.006; 95% CI: 1.003-1.009; P=0.0001) were the independent risk factors for ECMO-related NI. Duration of ECMO support > 144 hours (OR: 2.460; 95% CI: 1.155-7.238; P<0.0001) and ECMO-related NI (OR: 3.726; 95% CI: 1.274-10.895; P=0.016) increased significantly the risk of in-hospital death. CONCLUSION: Prolonged duration of ECMO support was an independent risk factor for NI. Surgical correcting latent causes of cardiopulmonary failure and shortening duration of ECMO whenever possible would reduce susceptibility to NI.

Drainage From Superior Vena Cava Improves Upper Body Oxygenation in Patients on Femoral Veno-Arterial Extracorporeal Membrane Oxygenation.

OBJECTIVE: To investigate the feasibility of drainage from the superior vena cava (SVC) to improve upper body oxygenation in patients with cardiogenic shock undergoing femoral veno-arterial extracorporeal membrane oxygenation (VA ECMO). METHODS: Seventeen adult patients receiving peripheral femoral VA ECMO for circulatory support were enrolled. The femoral drainage cannula was shifted three times (from the inferior vena cava (IVC) level to the SVC level and then the IVC level again), all under ultrasound guidance, at an interval of 15 minutes. The blood gas levels of the right radial artery (RA) and SVC and cerebral oxygen saturation (ScO2) were measured and compared. RESULTS: Fifteen patients (88.2%) were successfully weaned from ECMO, and 12 patients (70.6%) survived to discharge. The oxygen saturation (SO2) and oxygen partial pressure (PO2) of the RA (97.0 ± 3.5% to 98.3 ± 1.5%, P < 0.05, SO2; 127.4 ± 58.2 mmHg to 153.1 ± 67.8 mmHg, P < 0.05, PO2) and SVC (69.5 ± 9.0% to 75.7 ± 8.5%, P < 0.05, SO2; 38.5 ± 5.6 mmHg to 43.6 ± 6.4 mmHg, P < 0.05, PO2) were increased; ScO2 was also increased on both sides (left: 50.6 ± 8.6% to 55.0 ± 9.0%, P < 0.05; right: 48.7 ± 9.2% to 52.3 ± 9.8%, P < 0.05) when the femoral drainage cannula was shifted from the IVC level to the SVC level. When the femoral drainage cannula was shifted from SVC level to the IVC level again, the SO2 and PO2 of RA (98.3 ± 1.5% to 96.9 ± 3.2%, P <0.05, SO2; 153.1 ± 67.8 mmHg to 125.8 ± 63.3 mmHg, P <0.05, PO2) and SVC (75.7 ± 38.5% to 70.4 ± 7.6%, P <0.05, SO2; 43.6 ± 6.4 mmHg to 38.9 ± 4.5 mmHg, P <0.05, PO2) were decreased; ScO2 was also reduced on both sides (left: 55.0 ± 9.0% to 50.7 ± 8.2%, P < 0.05; right: 52.3 ± 9.8% to 48.7 ± 9.3%, P <0.05). CONCLUSION: Drainage from the SVC by shifting the cannula upward could improve upper body oxygenation in patients with cardiogenic shock undergoing femoral VA ECMO. This cannulation strategy provides an alternative solution for differential hypoxia.

Preoperative intra-aortic balloon pump inserted in acute myocardial infarction patients without cardiogenic shock undergoing surgical coronary revascularization.

OBJECTIVES: The benefit of preoperative intra-aortic balloon pump implantation in high-risk cardiac surgery patients is still debated. The role of preoperative intra-aortic balloon pump insertion in acute myocardial infarction patients without cardiogenic shock undergoing off-pump coronary artery bypass grafting remains unknown. This study aimed to determine the efficacy and safety of the preoperative intra-aortic balloon pump insertion in those patients undergoing off-pump coronary artery bypass grafting. METHODS: A total of 421 consecutive acute myocardial infarction patients without cardiogenic shock who underwent isolated off-pump coronary artery bypass grafting were enrolled in this retrospective observational propensity score-matched analysis study. Patients who received intra-aortic balloon pump before off-pump coronary artery bypass grafting (the intra-aortic balloon pump group, n = 157) were compared with those who had not (control group, n = 264). The 30-day postoperative survival, postoperative complications, and postoperative hospital length of stay were compared between the two groups. RESULTS: A total of 99 pairs of patients were matched. The preoperative intra-aortic balloon pump did not show a 30-day postoperative survival benefit compared with the control group (hazard ratio, 0.9; 95% confidence interval, 0.2-4.2; p = 0.92). Patients with preoperative intra-aortic balloon pump were more likely to have shorter postoperative lengths of stay (8 (6-11) days vs. 10 (6-15) days, p = 0.02) and decreased total days in the hospital (median days: 18.2 vs. 21.8, p = 0.02) compared to patients without balloon pumps. CONCLUSION: Preoperative intra-aortic balloon pump insertion in acute myocardial infarction patients without cardiogenic shock undergoing off-pump coronary artery bypass grafting improved convalescence as shown by significantly shorter postoperative lengths of hospital stay.

Vascular complications in adult postcardiotomy cardiogenic shock patients receiving venoarterial extracorporeal membrane oxygenation.

BACKGROUND: The rate, prognostic impacts, and predisposing factors of major vascular complications (MVCs) in patients underwent venoarterial extracorporeal membrane oxygenation (VA-ECMO) by surgical cut-down are poorly understood. The purpose of this study was to identify these parameters in adult VA-ECMO patients. METHODS: Adult postcardiotomy cardiogenic shock (PCS) patients receiving VA-ECMO by femoral surgical cut-down cannulation from January 2004 to December 2015 were enrolled in this study. Patients were separated into two groups depending on the presence of MVCs. Multivariate logistic regression was performed to identify factors independently associated with MVCs. RESULTS: Of 432 patients with PCS treated with VA-ECMO, 252 patients (58.3%) were weaned off VA-ECMO and 153 patients (35.4%) survived to discharge. MVCs were seen in 72 patients (16.7%), including bleeding or hematoma in the cannulation site (8.6%), limb ischemia requiring fasciotomy (8.6%), femoral artery embolism (0.7%), and retroperitoneal bleeding (0.7%). The rate of survival to discharge was 16.7 and 39.2% in patients with or without MVCs, respectively (p < 0.001). Obesity, concomitant with intra-aortic balloon pump (IABP), Sequential Organ Failure Assessment (SOFA) score at 24 h post-ECMO, and hemostasis disorder were shown to be associated with MVCs. MVCs were an independent risk factor for in-hospital mortality by multivariate analysis (odds ratio 3.91; 95% confidence interval, 1.67-9.14; p = 0.013). CONCLUSIONS: MVCs are common and associated with higher in-hospital mortality among adult PCS patients receiving peripheral VA-ECMO support. The obesity, concomitant with IABP, SOFA score at 24 h post-ECMO, and hemostasis disorder were independent risk factor of MVCs.