Bridging the gap: safety and outcomes of intensivist-led ECMO retrievals.

Purpose: Most extracorporeal membrane oxygenation (ECMO) cannulations are performed by cardiothoracic surgeons (CTS). Due to an increase in utilization of ECMO and limited availability of CTS, there is a mismatch between ECMO demand and CTS accessibility for remote cannulations. We report our intensivist-led program's experience in remote ECMO cannulations, retrievals, complications, and outcomes. Materials and methods: A prospective, single-center, observational study was performed on patients that required ECMO cannulation at the referring facilities and were transported to our institution between program initiation, on October 1, 2014 to September 30, 2022. Results were presented as mean ± SD, median (min - max) or number (%). Results: Since program commencement, 305 patients were accepted for ECMO retrieval. Three hundred and three patients were placed on ECMO at the 47 referring hospitals among 5 states. In our study, 185 (61%) patients required veno-arterial ECMO and 115 (38%) were placed on veno-venous ECMO. Three patients (1%) were cannulated for veno-arteriovenous ECMO. Twenty patients were cannulated under cardio-pulmonary resuscitation. Most of the patients were transported by ambulance (79%), 14% by helicopter, and 7% by airplane. Six out of the 303 patients did not leave the referring facility. All patients that left the referring hospitals arrived safely to our institution. No major complications occurred in route. Conclusion: Our study's findings indicate that non-CTS physicians can successfully cannulate and retrieve patients with a low complication profile.

Oncostatin M for characterizing the inflammatory burden and outcome of V-V ECMO in ARDS patients.

BACKGROUND: Assessing the outcome of Veno-Venous Extracorporeal Membrane Oxygenation (V-V ECMO) support remains challenging as plasma lactate (pLA), the widely used tool for this purpose, has been shown unreliable. We hypothesized that plasma oncostatin M (pOSM), a sensitive marker of leukocyte activation in infection and inflammation, could address this deficiency. METHODS: Plasma OSM levels were measured by ELISA in 30 Acute Respiratory Distress Syndrome (ARDS) patients, prior to cannulation (baseline) and decannulation. RESULTS: Based on the absolute pOSM levels at presentation, patients were separated into two groups, A and B. Patients in group A had low pOSM levels (Mean ± SD; Median, 1.1 ± 3.8; 0 pg/mL), whereas group B had high pOSM levels (1548 ± 1999; 767 pg/mL) [t-test: p < 0.01]. The percentage of pOSM levels at decannulation relative to baseline OSM levels was significantly higher in those who died (116.8 ± 68.0; 85.3%) than those who survived (47.6 ± 25.5; 48.9%) [t-test: p = 0.02; Mann-Whitney U Test: p = 0.01]. Conversely, no significant difference was observed in the percentage of pLA levels between those who died (142.9 ± 179.9; 89.8%) and those who survived (79.3 ± 34.3; 81.8%) [t-test: p = 0.31; Mann-Whitney U Test: p = 0.63]. CONCLUSION: These early findings suggested critical value of absolute and relative pOSM to characterize the inflammatory burden of ARDS patients and the outcome of their V-V ECMO support.

Extracorporeal life support in pregnant and postpartum women with COVID-19-related acute respiratory distress syndrome.

OBJECTIVE: Extracorporeal membrane oxygenation (ECMO) is an intervention used for patients with acute respiratory distress syndrome (ARDS) from COVID-19 who have failed conventional ventilatory strategies. Very few studies have given insight into the outcomes of pregnant and postpartum patients requiring ECMO support. METHODS: Single center, retrospective, observational study of female pregnant and postpartum patients suffering COVID-19 ARDS and requiring ECMO. RESULTS: Eight SARS-CoV-2 positive patients were identified. The average age was 31 ± 4 years, with Body Mass Indices (BMI) and SOFA scores ranging between 32-49 and 8-11, respectively. Two patients were pregnant at the time of ECMO initiation, two were peripartum, and four were postpartum. Five patients (63%) had bleeding, and one patient had a hysterectomy. Seven patients (88%) were supported by V-V ECMO and one with V-A ECMO. Patients had between one and three circuit exchanges due to oxygenator failure or clots in the circuit. All patients were in ICU between 7 and 74 days, with hospital length of stay between 8 and 81 days. All patients were weaned off ECMO and were successfully discharged from the hospital. All newborns were born via cesarean section, and all survived to discharge. CONCLUSION: Our study shows a 100% neonatal and maternal survival rate demonstrating that ECMO in this patient population is safe. These patients should be transferred to experienced high-volume ECMO centers with the ability to perform emergent cesarean sections. ECMO should be considered a life-saving therapy for pregnant women with severe COVID-19 with an overall excellent maternal and neonatal survival rate.

Outcomes of COVID-19 in heart failure, LVAD, and heart transplant patients in an advanced heart failure practice.

Background: Patients with heart failure face increased morbidity and mortality when infected with COVID-19. The objective of this study was to evaluate the outcomes of patients with Heart Failure (HF), Left Ventricular Assist Devices (LVADs), or Heart Transplants (HTx) diagnosed with COVID-19 within an advanced HF practice. Methods: Out of 2635 patients followed, 96 patients were diagnosed with COVID-19 between March 2020 and January 2021. Median hospital length of stay (LOS), requirement for mechanical ventilation (MV), and mortality rate were evaluated. Results: The distribution of COVID-19 among the 96 patients was: HF = 43 (45 %), LVAD = 16 (17 %) and HTx = 37 (38 %). Among 43 HF patients, 5 (12 %) died, 18 (42 %) required hospitalization with an LOS of 7 days, 5 (12 %) required ICU and 4 (9 %) required MV. Of the 16 LVAD patients, 2 (13 %) died, 8 (50 %) required hospitalization with an LOS of 11 days, 3 (19 %) required ICU and 3 (19 %) required MV. Among 37 HTx patients, 7 (19 %) died, 23 (62 %) required hospitalization with an LOS of 9 days, 6 (16 %) required ICU and 6 (16 %) required MV. Conclusion: This report is among the first to describe the impact of COVID-19 on a diverse advanced HF practice. It highlights the risks associated with COVID-19 faced by the HF, LVAD and HTx patients. A 90-day mortality rate of 19 % with HTx patients acquiring COVID-19 is ominous as is a mortality rate of 12 % each for HF and LVAD patients. This clinical impact should serve as a reminder of unique challenges with these populations.

The ProtekDuo for percutaneous V-P and V-VP ECMO in patients with COVID-19 ARDS.

OBJECTIVE: The ProtekDuo with oxygenator mimics veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) in veno-pulmonary (V-P) configuration. We have recently developed a new configuration by utilizing a 25 Fr multistage femoral venous drainage cannula and by returning oxygenated blood through both lumina of the double lumen ProtekDuo cannula (V-VP configuration), thereby creating partial right ventricular bypass and oxygenated blood flow of up to seven LPM. We investigated our experience with V-P and V-VP ECMO in patients suffering from COVID-19 acute respiratory distress syndrome (ARDS). METHODS: Single center, retrospective observational study. RESULTS: Of nine patients, one was initiated on V-A, two on V-P, and six on V-V ECMO. All patients were reconfigured to V-P and five patients in addition had V-VP ECMO configuration. All patients had at least one and up to three circuit exchanges. Patients were on ECMO support between 20 and 122 (55 ± 29) days, were in ICU between 46 and 161 (78 ± 40) days with a total hospital length of stay between 35 and 171 (82 ± 42) days. Six of nine (67%) patients could successfully be weaned off ECMO, survived, and were discharged. CONCLUSION: The ProtekDuo cannula in V-P configuration provides ECMO blood flow while reducing RV flow, wall-stress and dilatation, as well as oxygen consumption. The V-VP configuration is useful to provide high blood flows of up to seven LPM of oxygenated blood, and partial RV support without over-circulating the pulmonary vascular bed. Our results show that V-P and V-VP ECMO configurations are feasible, have good outcome and are without complications.

Oncostatin M: a Potential Biomarker to Predict Infection in Patients with Left Ventricular Assist Devices.

Infection is a serious adverse event limiting left ventricular assist device (LVAD) therapy in advanced heart failure patients, but a reliable means to identify patients at increased risk of infection is still lacking. We hypothesized that preoperative elevated levels of plasma Oncostatin M (OSM), a cytokine marker of leukocyte activation and inflammation, would be predictive of subsequent infection. We measured plasma OSM in 41 LVAD patients one day before LVAD implantation and postoperatively over two months. Preoperative plasma OSM levels were normal in 27 patients (group A, 4.9 ± 3.2 pg/ml) but elevated in 14 patients (group B, 1649.0 ± 458.9 pg/ml) ( p = 0.003). Early postoperative levels rose in both groups and declined rapidly in group A, with group B declining slowly over two months. Significantly more infections developed in group B than group A patients over two months postimplantation ( p = 0.004). No other routine clinical assessment or laboratory testing afforded this differentiation. These findings suggest that preoperative plasma OSM levels may assist in identifying patients at increased risk of infections after LVAD implantation.