Pneumothorax in acute respiratory distress syndrome on extracorporeal membrane oxygenation support.

INTRODUCTION: Pneumothorax is associated with poor prognosis in patients with acute respiratory distress syndrome (ARDS). We sought to examine the outcomes of patients who are supported on veno-venous extracorporeal membrane oxygenation (VV ECMO) and develop a pneumothorax. METHODS: We retrospectively reviewed all adult VV ECMO patients supported for ARDS between 8/2014-7/2020 at our institution, excluding patients with recent lung resection and trauma. Clinical outcomes were compared between patients with a pneumothorax to those without a pneumothorax. RESULTS: Two hundred eighty patients with ARDS on VV ECMO were analyzed. Of those, 213 did not have a pneumothorax and 67 did. Patients with a pneumothorax had a longer duration of ECMO support (30 days [16-55] versus 12 [7-22], p < 0.001) and hospital length of stay (51 days [27-93] versus 29 [18-49], p < 0.001), and lower survival-to-discharge (58.2% versus 77.5%, p = 0.002) compared to patients without a pneumothorax. Controlling for age, BMI, sex, RESP score and pre-ECMO ventilator days, the odds ratio of survival-to-discharge was 0.41 (95% CI 0.22-0.78) in patients with a pneumothorax compared to those without. There was a lower incidence of significant bleeding when chest tubes were placed by proceduralist services (2.4% versus 16.2%, p = 0.03). Removal of the chest tube prior to ECMO decannulation compared to removal after decannulation was associated with need for replacement (14.3% versus 0%, p = 0.01). CONCLUSION: Patients who develop a pneumothorax and are supported with VV ECMO for ARDS have longer duration on ECMO and decreased survival. Further studies are needed to assess risk factors for development of pneumothorax in this patient population.

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.

Body mass index does not impact survival in COVID-19 patients requiring veno-venous extracorporeal membrane oxygenation.

INTRODUCTION: With the increased demand for veno-venous extracorporeal membrane oxygenation (VV ECMO) during the COVID-19 pandemic, guidelines for patient candidacy have often limited this modality for patients with a body mass index (BMI) less than 40 kg/m2. We hypothesize that COVID-19 VV ECMO patients with at least class III obesity (BMI ≥ 40) have decreased in-hospital mortality when compared to non-COVID-19 and non-class III obese COVID-19 VV ECMO populations. METHODS: This is a single-center retrospective study of COVID-19 VV ECMO patients from January 1, 2014, to November 30, 2021. Our institution used BMI ≥ 40 as part of a multi-disciplinary VV ECMO candidate screening process in COVID-19 patients. BMI criteria were not considered for exclusion criteria in non-COVID-19 patients. Univariate and multivariable analyses were performed to assess in-hospital mortality differences. RESULTS: A total of 380 patients were included in our analysis: The COVID-19 group had a lower survival rate that was not statistically significant (65.7% vs.74.9%, p = .07). The median BMI between BMI ≥ 40 COVID-19 and non-COVID-19 patients was not different (44.5 vs 45.5, p = .2). There was no difference in survival between the groups (73.3% vs. 78.5%, p = .58), nor was there a difference in survival between the COVID-19 BMI ≥ 40 and BMI < 40 patients (73.3, 62.7, p= .29). Multivariable logistic regression with the outcome of in-hospital mortality was performed and BMI was not found to be significant (OR 0.99, 95% CI 0.89, 1.01; p = .92). CONCLUSION: BMI ≥ 40 was not an independent risk factor for decreased in-hospital survival in this cohort of VV ECMO patients at a high-volume center. BMI should not be the sole factor when deciding VV ECMO candidacy in patients with COVID-19.

Decreased PRESET-Score corresponds with improved survival in COVID-19 veno-venous extracorporeal membrane oxygenation.

INTRODUCTION: The PREdiction of Survival on ECMO Therapy Score (PRESET-Score) predicts mortality while on veno-venous extracorporeal membrane oxygenation (VV ECMO) for acute respiratory distress syndrome. The aim of our study was to assess the association between PRESET-Score and survival in a large COVID-19 VV ECMO cohort. METHODS: This was a single-center retrospective study of COVID-19 VV ECMO patients from 15 March 2020, to 30 November 2021. Univariable and Multivariable analyses were performed to assess patient survival and score differences. RESULTS: A total of 105 patients were included in our analysis with a mean PRESET-Score of 6.74. Overall survival was 65.71%. The mean PRESET-Score was significantly lower in the survivor group (6.03 vs 8.11, p < 0.001). Patients with a PRESET-Score less than or equal to six had improved survival compared to those with a PRESET-Score greater than or equal to 8 (97.7% vs. 32.5%, p < 0.001). In a multivariable logistic regression, a lower PRESET-Score was also predictive of survival (OR 2.84, 95% CI 1.75, 4.63, p < 0.001). CONCLUSION: We demonstrate that lower PRESET scores are associated with improved survival. The utilization of this validated, quantifiable, and objective scoring system to help identify COVID-19 patients with the greatest potential to benefit from VV-ECMO appears feasible. The incorporation of the PRESET-Score into institutional ECMO candidacy guidelines can help insure and improve access of this limited healthcare resource to all critically ill patients.

Comparative efficacy and mechanism of action of cardiac progenitor cells after cardiac injury.

Successful cell therapy requires cells to resist the hostile ischemic myocardium, be retained to continue secreting cardioprotective growth factors/exosomes, and resist immunological host responses. Clinically relevant stem/progenitor cells in a rodent model of acute myocardial infarction (MI) demonstrated that neonatal cardiac mesenchymal stromal cells (nMSCs) provide the most robust cardiac functional recovery. Transplanted nMSCs significantly increased the number of tissue reparative macrophages and regulatory T-cells and decreased monocyte-derived inflammatory macrophages and neutrophils in the host myocardium. mRNA microarray and single-cell analyses combined with targeted depletion studies established CD47 in nMSCs as a key molecule responsible for cell retention in the myocardium through an antiphagocytic mechanism regulated by miR34a-5p. Gain and loss-of-function studies demonstrated that miR34a-5p also regulated the production of exosomes and cardioprotective paracrine factors in the nMSC secretome. In conclusion, miR34a-5p and CD47 play an important role in determining the composition of nMSCs' secretome and immune evasion, respectively.

A Comparison of Anticoagulation Strategies in Veno-venous Extracorporeal Membrane Oxygenation.

Bleeding remains a major source of morbidity associated with veno-venous extracorporeal membrane oxygenation (VV-ECMO). Moreover, there remains significant controversy, and a paucity of data regarding the ideal anticoagulation strategy for VV-ECMO patients. All patients undergoing isolated, peripheral VV-ECMO between January 2009 and December 2014 at our institution were retrospectively reviewed. Patients (n = 123) were stratified into one of three sequential eras of anticoagulation strategies: activated clotting time (ACT: 160-180 seconds, n = 53), high-partial thromboplastin time (H-PTT: 60-80 seconds, n = 25), and low-PTT (L-PTT: 45-55 seconds, n = 25) with high-flow (>4 L/min). Pre-ECMO APACHE II scores, SOFA scores, and Murray scores were not significantly different between the groups. Patients in the L-PTT group required less red blood cell units on ECMO than the ACT or H-PTT group (2.1 vs. 1.3 vs. 0.9; p < 0.001) and patients in the H-PTT and L-PTT group required less fresh frozen plasma than the ACT group (0.33 vs. 0 vs. 0; p = 0.006). Overall, major bleeding events were significantly lower in the L-PTT group than in the ACT and H-PTT groups. There was no difference in thrombotic events. In this single-institution experience, a L-PTT, high-flow strategy on VV-ECMO was associated with fewer bleeding and no difference in thrombotic events than an ACT or H-PTT strategy.

Inferior Vena Cava Filter Placement Through a Venovenous Extracorporeal Membrane Oxygenation Circuit.

We present a technique for performing endovascular procedures by obtaining vascular access directly through a venovenous extracorporeal membrane oxygenation (VV ECMO) circuit. This technique is demonstrated in a lung transplant recipient, supported on VV ECMO, whose course was complicated by an extensive right femoral vein and inferior vena cava deep venous thrombosis. The patient was successfully managed by the placement of an inferior vena cava filter using the VV ECMO circuit as a point of access to the circulatory system before cessation of VV ECMO support and decannulation.

A Minimally Invasive Approach to Left Ventricular Assist Device Insertion Facilitates Subsequent Explant.

A minimally invasive approach to left ventricular assist device (LVAD) insertion may benefit patients at the time of implant, but whether the approach to LVAD insertion influences the outcome of subsequent cardiovascular reoperations is unknown. Here we present the case of a 50-year-old male who underwent LVAD insertion through a minimally invasive approach and subsequently had left ventricular recovery. LVAD explant was performed without the use of any blood products or inotropic support. This case demonstrates that a minimally invasive approach to LVAD insertion may also facilitate subsequent device explant.

Exosomes isolated from human cardiosphere-derived cells attenuate pressure overload-induced right ventricular dysfunction.

OBJECTIVES: Cardiosphere-derived cell (CDC) transplantation has been shown to attenuate right ventricular (RV) dysfunction in patients with hypoplastic left heart syndrome. However, live cell transplantation requires complex handling protocols that may limit its use. Exosomes are protein and nucleic acid-containing nanovesicles secreted by many cell types, including stem cells, which have been shown to exert a cardioprotective effect comparable with whole cells following myocardial injury. We therefore sought to evaluate 3 human CDC-derived exosome preparations in a juvenile porcine model of acute pressure-induced RV dysfunction. METHODS: Twenty immunocompetent juvenile Yorkshire pigs (7-10 kg) underwent pulmonary arterial banding followed by intramyocardial test agent administration: control (n = 6), XO-1 (n = 4), XO-2 (n = 5), and XO-3 (n = 5). Animals were monitored for 28 days postoperatively with periodic phlebotomy and echocardiography, followed by extensive postmortem gross and histopathologic analysis. RESULTS: All animals survived the banding operation. One died suddenly on postoperative day 1; another was excluded due to nonstandard response to banding. Of the remaining animals, there were no clinical concerns. RV fractional area change was improved in the XO-1 and XO-2 groups relative to controls at postoperative day 28. On histologic analysis, exosome-treated groups exhibited decreased cardiomyocyte hypertrophy with respect to controls. CONCLUSIONS: Human CDC-derived exosome administration was associated with significant preservation of RV systolic function in the setting of acute pressure overload. Such acellular preparations may prove superior to whole cells and may represent a novel therapeutic approach to clinical myocardial injury.

Early airway dehiscence: Risk factors and outcomes with the rising incidence of extracorporeal membrane oxygenation as a bridge to lung transplantation.

BACKGROUND: Anastomotic complications occur in 7% to 18% of lung transplant recipients, among which airway dehiscence (AD) is particularly catastrophic. Using multi-institutional registry data, this study compared preoperative recipient/donor risk factors and outcomes in patients with and without AD and analyzed the effect of extracorporeal membrane oxygenation (ECMO) on the incidence of AD. METHODS: Data on adult lung transplants from 2007 to 2017 were provided by the Scientific Registry of Transplant Recipients. Patients receiving isolated lobar transplantation and patients with unknown AD status were excluded. Multivariable logistic regression identified independent risk factors for AD. Kaplan-Meier curves and log-rank tests describe mortality and graft survival. RESULTS: Of 18 122 lung transplants, 275 (1.5%) experienced AD. While the incidence of ECMO steadily increased from 0.7% to 5.9% over the study period, the incidence of AD remained relatively constant. Multivariable analysis revealed recipient male gender and prolonged ( > 48 hours) posttransplant mechanical ventilation as independent predictive factors for AD, while advanced donor age and single left lung transplant were protective factors. Recipient chronic steroid use, recipient diabetes, donor diabetes, and donor smoking history were not predictive of AD. Mortality and graft failure were significantly worse in the AD group. CONCLUSIONS: Despite increased ECMO utilization, the incidence of AD has remained stable. Multiple independent risk factors for AD were identified and poor postoperative outcomes confirmed. However, many known impediments to wound healing such as recipient chronic steroid use, recipient and donor diabetes, and donor smoking were not identified as risk factors for AD, reinforcing the critical role of technical performance.

Circulating exosomes derived from transplanted progenitor cells aid the functional recovery of ischemic myocardium.

The stem cell field is hindered by its inability to noninvasively monitor transplanted cells within the target organ in a repeatable, time-sensitive, and condition-specific manner. We hypothesized that quantifying and characterizing transplanted cell-derived exosomes in the recipient plasma would enable reliable, noninvasive surveillance of the conditional activity of the transplanted cells. To test this hypothesis, we used a human-into-rat xenogeneic myocardial infarction model comparing two well-studied progenitor cell types: cardiosphere-derived cells (CDCs) and c-kit+ cardiac progenitor cells (CPCs), both derived from the right atrial appendage of adults undergoing cardiopulmonary bypass. CPCs outperformed the CDCs in cell-based and in vivo regenerative assays. To noninvasively monitor the activity of transplanted CDCs or CPCs in vivo, we purified progenitor cell-specific exosomes from recipient total plasma exosomes. Seven days after transplantation, the concentration of plasma CPC-specific exosomes increased about twofold compared to CDC-specific exosomes. Computational pathway analysis failed to link CPC or CDC cellular messenger RNA (mRNA) with observed myocardial recovery, although recovery was linked to the microRNA (miRNA) cargo of CPC exosomes purified from recipient plasma. We further identified mechanistic pathways governing specific outcomes related to myocardial recovery associated with transplanted CPCs. Collectively, these findings demonstrate the potential of circulating progenitor cell-specific exosomes as a liquid biopsy that provides a noninvasive window into the conditional state of the transplanted cells. These data implicate the surveillance potential of cell-specific exosomes for allogeneic cell therapies.

A novel adaptor system enables endovascular access through extracorporeal life support circuits.

OBJECTIVE: Extracorporeal life support has traditionally been used as a supportive platform for patients with cardiopulmonary failure. Many of these patients require endovascular access for the performance of diagnostic or therapeutic procedures, and obtaining vascular access in these patients can be problematic. We sought to develop a novel system that allows the extracorporeal life support circuit to serve as an access point to the cardiovascular system. METHODS: By using computer-aided design, modeling, and 3-dimensional printing, a novel adaptor that can be easily inserted and removed from an extracorporeal life support circuit was developed. A mock loop was used to measure flow and pressure at various pump speeds with insertion of guidewires and catheters through the adaptor. The ability of the system to enable performance of endovascular procedures in vivo was then tested in a porcine extracorporeal life support model. RESULTS: By using a small arterial cannula (15F) at 3500 RPM and 3.2 LPM, 15% and 24% decrements in circuit flow were observed when a 0.035" guidewire and 5F angiography catheter, respectively, were passed through the adaptor (P < .001). However, when using a larger arterial cannula (23F) at 3500 RPM and 4.7 LPM, only 3% and 5% decrements in flow were observed (P < .001), respectively, with intermediate changes when using 17F to 21F cannulas. In vivo testing confirmed that this system enables the performance of a variety of endovascular procedures, including left ventriculography, aortic root and coronary angiography, and descending aortography. CONCLUSIONS: This novel system successfully enables endovascular access through an extracorporeal life support circuit. This technology may transform extracorporeal life support from a purely supportive strategy to a platform for endovascular intervention.

The Incidence and Outcomes of Surgical Pulmonary Embolectomy in North America.

BACKGROUND: There has been renewed interest in surgical pulmonary embolectomy (SPE) for the treatment of pulmonary embolism, but the real-world incidence and outcomes of SPE have yet to be well described using a large, granular data set. We examined the modern experience with SPE in North America as reported to the Society of Thoracic Surgery Adult Cardiac Surgery Database (STS ACSD). METHODS: The STS ACSD was queried for all isolated SPE for the treatment of acute pulmonary embolism (2011 to 2015). Groups were stratified based on presentation: no cardiogenic shock (NCS), cardiogenic shock without arrest (CS), and cardiogenic shock with cardiac arrest (CS/CA). Preoperative characteristics, intraoperative variables, postoperative in-hospital complications, and operative mortality were compared. Multivariable logistic regression was performed to identify risk factors for in-hospital mortality. RESULTS: Of the 1,144 centers reporting during the study period, only 310 performed at least 1 SPE (overall mean, 0.42 ± 1.03 cases • year-1 • center-1). A total of 1,075 eligible SPE were identified (NCS = 719, CS = 203, CS/CA = 153). Median age was 57 years (interquartile range, 45 to 67), 54% were male, and preoperative thrombolysis was used in 8%. Overall, operative mortality was 16%, but increased with presenting acuity (NCS = 8%, CS = 23%, CS/CA = 44%, p < 0.001). Independent predictors of operative mortality included age, obesity, cardiogenic shock, preoperative arrest, chronic lung disease, unresponsive neurologic state, and prolonged cardiopulmonary bypass time. CONCLUSIONS: SPE is uncommonly performed in North America, and, in selected patients, it may be associated with favorable outcomes. Nevertheless, significant mortality exists, and attention to patient presentation and other risk factors may help distinguish patients appropriate for SPE.

Stem Cell Therapy for Hypoplastic Left Heart Syndrome: Mechanism, Clinical Application, and Future Directions.

Hypoplastic left heart syndrome is a type of congenital heart disease characterized by underdevelopment of the left ventricle, outflow tract, and aorta. The condition is fatal if aggressive palliative operations are not undertaken, but even after the complete 3-staged surgical palliation, there is significant morbidity because of progressive and ultimately intractable right ventricular failure. For this reason, there is interest in developing novel therapies for the management of right ventricular dysfunction in patients with hypoplastic left heart syndrome. Stem cell therapy may represent one such innovative approach. The field has identified numerous stem cell populations from different tissues (cardiac or bone marrow or umbilical cord blood), different age groups (adult versus neonate-derived), and different donors (autologous versus allogeneic), with preclinical and clinical experience demonstrating the potential utility of each cell type. Preclinical trials in small and large animal models have elucidated several mechanisms by which stem cells affect the injured myocardium. Our current understanding of stem cell activity is undergoing a shift from a paradigm based on cellular engraftment and differentiation to one recognizing a primarily paracrine effect. Recent studies have comprehensively evaluated the individual components of the stem cells' secretomes, shedding new light on the intracellular and extracellular pathways at the center of their therapeutic effects. This research has laid the groundwork for clinical application, and there are now several trials of stem cell therapies in pediatric populations that will provide important insights into the value of this therapeutic strategy in the management of hypoplastic left heart syndrome and other forms of congenital heart disease. This article reviews the many stem cell types applied to congenital heart disease, their preclinical investigation and the mechanisms by which they might affect right ventricular dysfunction in patients with hypoplastic left heart syndrome, and finally, the completed and ongoing clinical trials of stem cell therapy in patients with congenital heart disease.

Regenerative medicine therapy for single ventricle congenital heart disease.

One of the most complex forms of congenital heart disease (CHD) involving single ventricle physiology is hypoplastic left heart syndrome (HLHS), characterized by underdevelopment of the left ventricle (LV), mitral and aortic valves, and narrowing of the ascending aorta. The underdeveloped LV is incapable of providing long-term systemic flow, and if left untreated, the condition is fatal. Current treatment for this condition consists of three consecutive staged palliative operations: the first is conducted within the first few weeks of birth, the second between 4 to 6 months, and the third and final surgery within the first 4 years. At the conclusion of the third surgery, systemic perfusion is provided by the right ventricle (RV), and deoxygenated blood flows passively to the pulmonary vasculature. Despite these palliative interventions, the RV, which is ill suited to provide long-term systemic perfusion, is prone to eventual failure. In the absence of satisfying curative treatments, stem cell therapy may represent one innovative approach to the management of RV dysfunction in HLHS patients. Several stem cell populations from different tissues (cardiac and non-cardiac), different age groups (adult- vs. neonate-derived), and different donors (autologous vs. allogeneic), are under active investigation. Preclinical trials in small and large animal models have elucidated several mechanisms by which these stem cells affect the injured myocardium, and are driving the shift from a paradigm based upon cellular engraftment and differentiation to one based primarily on paracrine effects. Recent studies have comprehensively evaluated the individual components of the stem cells' secretomes, shedding new light on the intracellular and extracellular pathways at the center of their therapeutic effects. This research has laid the groundwork for clinical application, and there are now several trials of stem cell therapies in pediatric populations that will provide important insights into the value of this therapeutic strategy in the management of HLHS and other forms of CHD. This article reviews the many stem cell types applied to CHD, their preclinical investigation and the mechanisms by which they might affect RV dysfunction in HLHS patients, and finally, the completed and ongoing clinical trials of stem cell therapy in patients with CHD.

Triage and optimization: A new paradigm in the treatment of massive pulmonary embolism.

BACKGROUND: Massive pulmonary embolism (PE) remains a highly fatal condition. Although venoarterial extracorporeal membrane oxygenation (VA-ECMO) and surgical pulmonary embolectomy in the management of massive PE have been reported previously, the outcomes remain less than ideal. We hypothesized that the institution of a protocolized approach of triage and optimization using VA-ECMO would result in improved outcomes compared with historical surgical management. METHODS: All patients with a massive PE referred to the cardiac surgery service between 2010 and 2017 were retrospectively reviewed. Patients were stratified by treatment strategy: historical control versus the protocolized approach. In the historical control group, the primary intervention was surgical pulmonary embolectomy. In the protocol approach group, patients were treated based on an algorithmic approach using VA-ECMO. The primary outcome was 1-year survival. RESULTS: A total of 56 patients (control, n = 27; protocol, n = 29) were identified. All 27 patients in the historical control group underwent surgical pulmonary embolectomy, whereas 2 of 29 patients in the protocol approach group were deemed appropriate for direct surgical pulmonary embolectomy. The remaining 27 patients were placed on VA-ECMO. In the protocol approach group, 15 of 29 patients were treated with anticoagulation alone and 14 patients ultimately required surgical pulmonary embolectomy. One-year survival was significantly lower in the historical control group compared with the protocol approach group (73% vs 96%; P = .02), with no deaths occurring after surgical pulmonary embolectomy in the protocol approach group. CONCLUSIONS: A protocolized strategy involving the aggressive institution of VA-ECMO appears to be an effective method to triage and optimize patients with massive PE to recovery or intervention. Implementation of this strategy rather than an aggressive surgical approach may reduce the mortality associated with massive PE.

Outcomes after surgical pulmonary embolectomy for acute submassive and massive pulmonary embolism: A single-center experience.

OBJECTIVES: Ideal treatment strategies for submassive and massive pulmonary embolism remain unclear. Recent reports of surgical pulmonary embolectomy have demonstrated improved outcomes, but surgical technique and postoperative outcomes continue to be refined. The aim of this study is to describe in-hospital survival and right ventricular function after surgical pulmonary embolectomy for submassive and massive pulmonary embolism with excessive predicted mortality (≥5%). METHODS: All patients undergoing surgical pulmonary embolectomy (2011-2015) were retrospectively reviewed. Patients with pulmonary embolism were stratified as submassive, massive without arrest, and massive with arrest. Submassive was defined as normotensive with right ventricular dysfunction. Massive was defined as prolonged hypotension due to the pulmonary embolism. Preoperative demographics, intraoperative variables, and postoperative outcomes were compared. RESULTS: A total of 55 patients were identified: 28 as submassive, 18 as massive without arrest, and 9 as massive with arrest. All patients had a right ventricle/left ventricle ratio greater than 1.0. Right ventricular dysfunction decreased from moderate preoperatively to none before discharge (P < .001). In-hospital and 1-year survival were 93% and 91%, respectively, with 100% survival in the submassive group. No patients developed renal failure requiring hemodialysis at discharge or had a postoperative stroke. CONCLUSIONS: In this single institution experience, surgical pulmonary embolectomy is a safe and effective therapy to treat patients with a submassive or massive pulmonary embolism. Although survival in this study is higher than previously reported for patients treated with medical therapy alone, a prospective trial comparing surgical therapy with medical therapy is necessary to further elucidate the role of surgical pulmonary embolectomy in the treatment of pulmonary embolism.

Single-Center Experience With Venovenous ECMO for Influenza-Related ARDS.

OBJECTIVES: This study was designed to determine whether venovenous extracorporeal membrane oxygenation (VV ECMO) reduced mortality in patients with influenza-related acute respiratory distress syndrome (ARDS). DESIGN: A retrospective cohort study was performed. Baseline characteristics of participants were compared and Kaplan-Meier survival analysis was used to compare survival at last medical center follow-up. Cox proportional hazards modeling also was performed to test for univariate associations between salient variables and mortality. SETTING: A single-center ECMO referral university hospital. PARTICIPANTS: All patients admitted with influenza-related ARDS during the 2015 to 2016 influenza season. INTERVENTIONS: Mechanical ventilation alone versus mechanical ventilation and ECMO cannulation. MEASUREMENTS AND MAIN RESULTS: A total of 26 patients with influenza-related ARDS were included in the cohort. Thirteen patients were treated with VV ECMO while 13 were not. Twelve of the ECMO patients and 8 of the non-ECMO patients were transferred from outside hospitals. Patients treated with ECMO were younger and had less hypertension and diabetes mellitus. There was no difference in baseline sequential organ failure assessment score between the 2 groups. In-hospital mortality for ECMO patients was 15.4% versus 46.7% for patients not treated with ECMO. Survival at last medical center follow-up was better in patients treated with ECMO (p = 0.02). Age, highest blood carbon dioxide level, and treatment without ECMO were all associated with increased mortality. CONCLUSIONS: Influenza-related ARDS has a high mortality rate and patients treated only with mechanical ventilation have worse outcome than those managed with VV ECMO. More liberal use of ECMO should be considered in patients with influenza-related ARDS.

Minimally Invasive Surgical Pulmonary Embolectomy: A Potential Alternative to Conventional Sternotomy.

OBJECTIVE: Surgical pulmonary embolectomy has gained increasing popularity over the past decade with multiple series reporting excellent outcomes in the treatment of submassive pulmonary embolism. However, a significant barrier to the broader adoption of surgical pulmonary embolectomy remains the large incision and long recovery after a full sternotomy. We report the safety and efficacy of using a minimally invasive approach to surgical pulmonary embolectomy. METHODS: All consecutive patients undergoing surgical pulmonary embolectomy for a submassive pulmonary embolism (2015-2017) were reviewed. Patients were stratified as conventional or minimally invasive. The minimally invasive approach included a 5- to 7-cm skin incision with upper hemisternotomy to the third intercostal space. The primary outcomes were in-hospital and 90-day survival. RESULTS: Thirty patients (conventional = 20, minimally invasive = 10) were identified. Operative time was similar between the two groups, but cardiopulmonary bypass time was significantly longer in the minimally invasive group (58 vs 94 minutes, P = 0.04). While ventilator time and intensive care unit length of stay were similar between groups, hospital length of stay was 4.5 days shorter in the minimally invasive group, and there was a trend toward less blood product use. In-hospital and 90-day survival was 100%. Within the minimally invasive cohort, median right ventricular dysfunction at discharge was none-mild and no patient experienced postoperative renal failure, deep sternal wound infection, sepsis, or stroke. CONCLUSIONS: Minimally invasive surgical pulmonary embolectomy appears to be a feasible approach in the treatment of patients with a submassive pulmonary embolism. A larger, prospective analysis comparing this modality with conventional surgical pulmonary embolectomy may be warranted.