A Case Series of Devastating Intracranial Hemorrhage During Venovenous Extracorporeal Membrane Oxygenation for COVID-19.

OBJECTIVE: Anticoagulation may be a challenge in coronavirus disease 2019 (COVID-19) extracorporeal membrane oxygenation due to endothelial injury and dysregulation of coagulation, which may increase the risk of thrombotic and bleeding complications. This report was created to describe the authors' single institutional experience, with emphasis on the high rate of intracranial hemorrhage for the first 10 patients with COVID-19 placed on venovenous extracorporeal membrane oxygenation (VV ECMO). DESIGN: Case series, retrospective analysis. SETTING: Single institution. PARTICIPANTS: Ten patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patient characteristics, mortality, stroke rate, and length of stay data were collected in all patients. In addition, laboratory values of D-dimer and C-reactive protein and standard measurements of prothrombin and activated partial thromboplastin time were collected on all patients. Ten patients, each confirmed with COVID-19 via reverse transcription-polymerase chain reaction, were supported on VV ECMO for acute respiratory distress syndrome (ARDS) for a mean duration of 9.4 ± 7 days. Four of 10 patients had hemorrhagic strokes, 3 of which resulted in death. At 30 days after initiation of VV ECMO, a total of 7 survivors included 6 patients discharged from the hospital and 1 patient who remained in the intensive care unit. CONCLUSIONS: In this small study of 10 patients, intracranial hemorrhage was a common complication, resulting in a high rate of death. The authors urge caution in the anticoagulation management of VV ECMO for patients with severe ARDS and COVID-19 patients. Close monitoring of all hematologic parameters is recommended during ECMO support while awaiting larger, multicenter studies to examine the best practice.

The Effect of Sedation on Long-Term Psychological Impairment After Extracorporeal Life Support.

OBJECTIVE: This retrospective study aimed to identify the association between long-term psychological impairment and total sedation received during venovenous extracorporeal life support (VV-ECLS) for acute respiratory failure (ARF). DESIGN: This observational retrospective study compared characteristics between patients with and without long-term psychological morbidity at long-term follow-up after VV-ECLS for ARF. SETTING: A single institutional experience in a quaternary referral academic medical center in the United States. PATIENTS: Patients who received VV-ECLS for ARF between January 1, 2015, and April 1, 2017, were identified for selection. Presence of psychiatric morbidity (anxiety and/or depression) was determined with the Hospital Anxiety and Depression Subscale battery at long-term follow-up. INTERVENTIONS: No interventions were made during this retrospective observational study. MEASUREMENTS AND MAIN RESULTS: A total of 42 patients (21 male, 21 female, median age 49 [interquartile range {IQR} 36-57]) completed a telephone interview a median of 14.6 (IQR 7.7-21.1) months after ECLS decannulation. Cohorts were defined as possessing any psychiatric morbidity (anxiety and/or depression) as defined by the Hospital Anxiety and Depression Subscale battery (n = 22 [52%]) versus no psychiatric morbidity (n = 20 [48%]) at long-term follow-up. Patients who had clinically significant psychiatric morbidity received a median of 15.0 (IQR 11.0-17.0) days of continuous intravenous sedation compared with patients who had no psychiatric morbidity, who received a median of 10.0 (IQR 6.5-13.5) days of intravenous sedation; (p = 0.02). CONCLUSIONS: This retrospective analysis identified a significant association between the presence of long-term post-VV-ECLS psychiatric symptoms and the total number of days of intravenous sedation.

Venovenous Extracorporeal Membrane Oxygenation for Patients With Return of Spontaneous Circulation After Cardiac Arrest Owing to Acute Respiratory Distress Syndrome.

OBJECTIVE: The primary objective of this study was to determine the survival to hospital discharge of patients who were treated with venovenous (VV) extracorporeal membrane oxygenation (ECMO) for respiratory failure after cardiac arrest. DESIGN: Retrospective chart review. SETTING: University-affiliated tertiary care hospitals. PARTICIPANTS: The study comprised 21 patients. INTERVENTIONS: Implementation of VV ECMO in patients with return of spontaneous circulation after cardiac arrest owing to respiratory insufficiency. MEASUREMENTS AND MAIN RESULTS: The most common etiology of arrest was pneumonia-associated acute respiratory distress syndrome (8/21 [38%]). Overall, 12/21(57%) patients survived to hospital discharge. Two of 12 (17%) patients required hemodialysis upon discharge. CONCLUSION: VV ECMO may be an appropriate alternative to venoarterial ECMO in select patients with return of spontaneous circulation after cardiac arrest owing to profound respiratory failure.

Acute Respiratory Failure Managed via Inter-Facility Transport for Extracorporeal Life Support: A 3-Year Experience.

OBJECTIVES: The objectives of this study were as follows: (1) to describe a successful design for a mobile lung rescue program, focusing on challenges and resources required to support such a program, and (2) report short-term outcomes for patients placed on venovenous extracorporeal life support (VV-ECLS) by a transferring team before inter-facility transport to a specialized extracorporeal life support (ECLS) center. DESIGN: This retrospective review and analysis used patient chart review to collect outcomes data and resource demand. SETTING: A single institutional experience in an academic center in the United States. PARTICIPANTS: Patient selection targeted the 75 patients who were placed on VV-ECLS for acute respiratory failure at an outside institution by the authors' team before transport from January 1, 2015, through December 31, 2017. INTERVENTIONS: No intervention was made. MEASUREMENTS AND MAIN RESULTS: Average time for dispatch and transfer was 4 hours and 10 minutes for ground and 3 hours and 30 minutes for air transport (p = 0.029). Demand was highest in winter, with 61% (46/75) of patients presenting from November through April, and daytime, with 73% (55/75) occurring from 8 am to 8 pm. Demand increased during the study period, with 21 patients in 2015, 24 in 2016, and 30 in 2017. Mortality was low, with 72% of patients surviving to discharge. CONCLUSIONS: Herein a successful mobile lung rescue program for transfer to a regional ECLS center is described. These findings demonstrate bed availability during high census and presence of a physician for duration of transport. These challenges can be overcome and successful implementation can be made with low mortality, supporting the development of regional ECLS centers.

Aortic Regurgitation in Acute Type-A Aortic Dissection: A Clinical Classification for the Perioperative Echocardiographer in the Era of the Functional Aortic Annulus.

The functional aortic annulus offers a clinical approach for the perioperative echocardiographer to classify the mechanisms of aortic regurgitation in acute type-A dissection. Comprehensive examination of the functional aortic annulus in this setting using transesophageal echocardiography can guide surgical therapy for the aortic root by considering the following important aspects: severity and mechanism of aortic regurgitation, extent of root dissection, and the pattern of coronary artery involvement. The final choice of surgical therapy also should take into account factors, such as patient presentation and surgical experience, to limit mortality and morbidity from this challenging acute aortic syndrome. This review explores these concepts in detail within the framework of the functional aortic annulus, detailed anatomic considerations, and the latest literature.