RESUMO
BACKGROUND: Extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (BTT) has expanded considerably, though evidence-based selection criteria and long-term outcome data are lacking. The purpose of this study was to evaluate whether risk factors often used to exclude patients from ECMO BTT-specifically older age and not yet being listed for transplant-are validated by long-term outcomes. METHODS: To ensure minimum 5-year follow-up, a retrospective cohort study was performed of adult patients actively listed for lung transplantation at a high-volume center and bridged on ECMO between January 2012 and December 2017. Data was collected through January 1, 2023. RESULTS: Among 50 patients bridged on ECMO, 25 survived to transplant. Median age at listing was 58 (interquartile range [IQR], 42-65) in the transplanted group and 65 (IQR, 56.5-69) in the deceased group (P = 0.051). One-year, 3-year, and 5-year survival were 88% (22/25), 60% (15/25), and 44% (11/25), respectively, with eight patients still living at the time of review. Median time spent at home during the year post-transplant was 340 days (IQR, 314-355). Older age at listing was a negative predictor of survival on ECMO to transplant (odds ratio 0.92 [95% confidence interval, 0.86-0.99], P = 0.01). Thirteen patients were placed on ECMO prior to being listed and three were listed the same day as ECMO cannulation, with 10/16 transplanted. No significant difference in post-transplant survival was found between patients placed on ECMO prior to listing (n = 10) and those already listed (n = 15) (P = 0.93, log-rank). Serial post-transplant spirometry up to 5 years and surveillance transbronchial biopsy demonstrated good allograft function and low rates of cellular rejection. CONCLUSIONS: In one of the oldest cohorts of ECMO BTT patients described, favorable survival outcomes and allograft function were observed up to 5 years irrespective of whether patients were previously listed or bridged to decision. Despite inherent limitations to this retrospective, single-center study, the data presented support the feasibility of ECMO BTT in older and not previously listed advanced lung disease patients.
Assuntos
Oxigenação por Membrana Extracorpórea , Transplante de Pulmão , Humanos , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/tendências , Oxigenação por Membrana Extracorpórea/mortalidade , Transplante de Pulmão/tendências , Transplante de Pulmão/mortalidade , Masculino , Pessoa de Meia-Idade , Feminino , Estudos Retrospectivos , Adulto , Idoso , Resultado do Tratamento , Estudos de Coortes , Fatores de Tempo , Seguimentos , Fatores Etários , Fatores de Risco , Listas de Espera/mortalidade , Taxa de Sobrevida/tendênciasRESUMO
Extracorporeal cardiopulmonary resuscitation (ECPR) is an advanced technique using extracorporeal membrane oxygenation (ECMO) to support patients with refractory cardiac arrest. Age significantly influences ECPR outcomes, with younger patients generally experiencing better survival and neurological outcomes due to many aspects. This review explores the impact of age on ECPR effectiveness, emphasizing the need to consider age alongside other clinical factors in patient selection. Survival rates differ notably between in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA), highlighting the importance of rapid intervention. The potential of artificial intelligence to develop predictive models for ECPR outcomes is discussed, aiming to improve decision-making. Ethical considerations around age-based treatment decisions are also addressed. This review advocates for a balanced approach to ECPR, integrating clinical and ethical perspectives to optimize patient outcomes across all age groups.
Assuntos
Oxigenação por Membrana Extracorpórea , Humanos , Fatores Etários , Oxigenação por Membrana Extracorpórea/mortalidade , Reanimação Cardiopulmonar/métodos , Parada Cardíaca Extra-Hospitalar/mortalidade , Parada Cardíaca Extra-Hospitalar/terapia , Parada Cardíaca/mortalidade , Parada Cardíaca/terapiaRESUMO
OBJECTIVES: Our goal was to determine the predictive role of the combined assessment of the vasoactive-inotropic score (VIS) and lactate levels for the prognosis of patients with postcardiotomy cardiogenic shock (PCS) requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO). METHODS: The data of adult patients with PCS requiring VA-ECMO between January 2015 and December 2018 at a tertiary hospital were analysed retrospectively. The incidence of in-hospital mortality and other clinical outcomes was analysed. The associations of the VIS and the lactate concentration and in-hospital mortality were assessed using logistic regression analysis. RESULTS: A total of 222 patients were included and divided into 4 groups according to the cut-off points of the VIS (24.3) and the lactate level (6.85 mmol/L). The in-hospital mortality rates were 37.7%, 50.7%, 54.8% and 76.5% for the 4 groups (P < 0.001), and the rates of successful weaning off VA-ECMO were 73.9%, 69%, 61.3% and 39.2%, respectively (P = 0.001). Groups 1 and 2 exhibited significant differences compared to group 4 in both in-hospital mortality and weaning rates (P < 0.05). There was a statistically significant difference in the incidence of multiple organ dysfunction between group 1 and group 4 (P < 0.05). Groups 1, 2 and 3 demonstrated significantly improved cumulative 30-day survival compared with group 4 (log-rank test, P < 0.05). Logistic regression analysis revealed that age, a VIS > 24.3 and lactate levels > 6.85 mmol/L were independently predictive of in-hospital mortality. CONCLUSIONS: Among patients with PCS requiring VA-ECMO, the initiation before reaching a VIS > 24.3 and lactate levels > 6.85 mmol/L was associated with improved in-hospital and 30-day outcomes, suggesting that the combined assessment of the VIS and lactate levels may be instructive for determining the initiation of VA-ECMO.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Oxigenação por Membrana Extracorpórea , Mortalidade Hospitalar , Ácido Láctico , Choque Cardiogênico , Humanos , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Masculino , Estudos Retrospectivos , Pessoa de Meia-Idade , Choque Cardiogênico/mortalidade , Choque Cardiogênico/sangue , Choque Cardiogênico/terapia , Ácido Láctico/sangue , Idoso , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Prognóstico , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/sangue , Biomarcadores/sangueRESUMO
OBJECTIVES: The prognosis-predicting factors for non-surgical patients receiving continuous renal replacement therapy (CRRT) and extracorporeal membrane oxygenation (ECMO) remains limited. In this study, we aim to analyze prognosis-predicting factors in the non-surgical patients receiving these two therapies. METHODS: We retrospectively analyzed data from non-surgical patients with ECMO treatment from December 2013 until April 2023. Hospital mortality was primary endpoint of this study. The area under the curve and receiver operating characteristic curves were used to assess the sensitivity and specificity of mortality. The independent risk factors were identified by multivariate logistic regression. The prediction model was a nomogram, and decision curve analysis and the calibration plot were used to assess it. Using restricted cubic spline curves and Spearman correlation, the correlation analysis was performed. RESULTS: The model that incorporated CRRT duration and age surpassed the two variables alone in predicting hospital mortality in non-surgical patients with ECMO therapy (AUC value = 0.868, 95% CI = 0.779-0.956). Older age, CRRT implantation, and duration were independent risk factors for hospital mortality (all p < 0.05). The nomogram predicting outcomes model containing on CRRT implantation and duration was developed, and the consistency between the predicted probability and observed probability and clinical utility of the models were good. CRRT duration was negatively associated with hemoglobin concentration and positively associated with urea nitrogen and serum creatinine levels. CONCLUSION: Hospital mortality in non-surgical ECMO patients was found to be independently associated with older age, longer CRRT duration, and CRRT implantation.
Assuntos
Terapia de Substituição Renal Contínua , Oxigenação por Membrana Extracorpórea , Mortalidade Hospitalar , Nomogramas , Curva ROC , Humanos , Estudos Retrospectivos , Masculino , Feminino , Oxigenação por Membrana Extracorpórea/mortalidade , Pessoa de Meia-Idade , Fatores de Risco , Adulto , Idoso , Prognóstico , Injúria Renal Aguda/terapia , Injúria Renal Aguda/mortalidade , Modelos Logísticos , Fatores EtáriosRESUMO
INTRODUCTION: The optimal modality for renal replacement therapy (RRT) in patients venoarterial extracorporeal membrane oxygenation (VA-ECMO) remains unclear. This study aimed to compare outcomes between continuous renal replacement therapy (CRRT) and peritoneal dialysis (PD) in VA-ECMO patients. METHODS: This single-center retrospective study included VA-ECMO patients who developed AKI and subsequently required CRRT or PD. Data on patient demographics, comorbidities, clinical characteristics, RRT modality, and outcomes were collected. The primary outcome was in-hospital mortality, with secondary outcomes including length of stays, RRT durations, and complications associated with RRT. RESULTS: A total of 43 patients were included (72.1% male, mean age 58.2 ± 15.7 years). Of these, 21 received CRRT and 22 received PD during ECMO therapy. In-hospital mortality rates did not significantly differ between CRRT and PD groups (80.9% vs 90.9%, p = 0.35). However, PD was associated with a higher incidence of catheter-related complications, including malposition (31.8% vs 4.7%, p = 0.046), infection (22.7% vs 4.7%, p = 0.19), and bleeding (18.2% vs 9.5%, p = 0.66), respectively. CONCLUSION: Among patients receiving VA-ECMO-supported RRT, our study revealed comparable in-hospital mortality rates between CRRT and PD, although PD was associated with a higher incidence of catheter-related complications.
Assuntos
Injúria Renal Aguda , Terapia de Substituição Renal Contínua , Oxigenação por Membrana Extracorpórea , Mortalidade Hospitalar , Diálise Peritoneal , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/mortalidade , Oxigenação por Membrana Extracorpórea/métodos , Estudos Retrospectivos , Diálise Peritoneal/métodos , Injúria Renal Aguda/terapia , Injúria Renal Aguda/mortalidade , Idoso , Tempo de Internação , Resultado do Tratamento , AdultoRESUMO
PURPOSE: Pulmonary thromboendarterectomy (PTE) is the treatment for patients with chronic thromboembolic disease. In the immediate postoperative period, some patients may still experience life-threatening complications such as reperfusion lung injury, airway bleeding, and persistent pulmonary hypertension with consequent right ventricular dysfunction. These issues may require support with extracorporeal membrane oxygenation (ECMO) as a bridge to recovery or lung transplantation. This study aims to analyze our series of PTEs that require ECMO. METHODS: A descriptive and retrospective analysis of all PTE performed at the Favaloro Foundation University Hospital was conducted between March 2013 and December 2023. RESULTS: A total of 42 patients underwent PTE with a median age of 47 years (interquartile range: 26-76). The incidence of patients with ECMO was 26.6%, of which 53.6% were veno-venous (VV) ECMO. Preoperatively, a low cardiac index (CI), high right and left filling pressures, and high total pulmonary vascular resistances (PVRs) were associated with ECMO with a statistically significant relationship. The hospital mortality was 11.9%, and the mortality in the ECMO group was 45.5%, with a statistically significant relationship. Veno-arterial ECMO has a worse prognosis than VV ECMO. CONCLUSIONS: Preoperatively, a low CI, high right and left filling pressures, and high total PVRs were associated with ECMO after PTE.
Assuntos
Endarterectomia , Oxigenação por Membrana Extracorpórea , Mortalidade Hospitalar , Embolia Pulmonar , Humanos , Oxigenação por Membrana Extracorpórea/mortalidade , Oxigenação por Membrana Extracorpórea/efeitos adversos , Pessoa de Meia-Idade , Endarterectomia/efeitos adversos , Endarterectomia/mortalidade , Masculino , Estudos Retrospectivos , Feminino , Resultado do Tratamento , Adulto , Idoso , Embolia Pulmonar/mortalidade , Embolia Pulmonar/cirurgia , Embolia Pulmonar/fisiopatologia , Fatores de Tempo , Fatores de Risco , Artéria Pulmonar/fisiopatologia , Artéria Pulmonar/cirurgia , Hipertensão Pulmonar/mortalidade , Hipertensão Pulmonar/fisiopatologia , Hipertensão Pulmonar/cirurgiaRESUMO
OBJECTIVE: Patients on extracorporeal membrane oxygenation (ECMO) are often complex and have a high mortality rate. Currently, risk assessment and treatment decisions for patients receiving ECMO are controversial. Therefore, we sought to identify risk factors for mortality in patients receiving ECMO and provide a reference for patient management. METHODS: We retrospectively analyzed the clinical data of 199 patients who received ECMO support from December 2013 to April 2023. Univariate and multivariable logistic regression analyses were used to identify risk factors. The cutoff value was determined by receiver operating characteristic (ROC) curve analysis. RESULTS: A total of 199 patients were selected for this study, and the mortality rate was 76.38%. More than half of the patients underwent surgery during hospitalization. Multivariable logistic regression analysis revealed that continuous renal replacement therapy (CRRT) implantation (OR = 2.994; 95% CI, 1.405-6.167; p = 0.004) and age (OR = 1.021; 95% CI, 1.002-1.040; p = 0.032) were the independent risk factors for mortality. In the ROC curve analysis, age had the best predictive effect (AUC 0.646, 95% CI 0.559-0.732, p = 0.003) for death when the cutoff value was 48.5 years. Furthermore, in patients receiving combined CRRT and ECMO, lack of congenital heart disease and previous surgical history were the independent risk factors for mortality. CONCLUSIONS: CRRT implantation and age were independent risk factors for patients with ECMO implantation in a predominantly surgical cohort. In patients receiving a combination of CRRT and ECMO, lack of congenital heart disease and previous surgical history were independent risk factors for mortality.
Assuntos
Oxigenação por Membrana Extracorpórea , Curva ROC , Humanos , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Masculino , Estudos Retrospectivos , Pessoa de Meia-Idade , Fatores de Risco , Adulto , Modelos Logísticos , Terapia de Substituição Renal Contínua , Medição de Risco , Fatores Etários , Idoso , Mortalidade HospitalarRESUMO
BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has gained traction as a bridge to heart transplantation (HT) but remains associated with increased waitlist mortality. This study explores whether this risk is modified by underlying heart failure (HF) etiology. METHODS: Using the Organ Procurement and Transplantation Network registry, we conducted a retrospective review of first-time adult HT candidates from 2018 through 2022. Patients were categorized as "ECMO", if ECMO was utilized during the waitlisting period, or "No ECMO" otherwise. Patients were then stratified according to the following HF etiology: ischemic cardiomyopathy (CMP), dilated nonischemic CMP, restrictive CMP, hypertrophic CMP, and congenital heart disease (CHD). After baseline comparisons, waitlist mortality was characterized for ECMO and HF etiology using the Fine-Gray regression. RESULTS: A total of 16 143 patients were identified of whom 7.0% (n = 1063) were bridged with ECMO. Compared to No ECMO patients, ECMO patients had shorter waitlist durations (46.3 vs. 185.0 days, p < 0.01) and were more likely to undergo transplantation (75.3% vs. 70.3%, p < 0.01). Outcomes analysis revealed that ECMO was associated with increased mortality risk (subdistribution hazard ratio [SHR]: 3.42, p < 0.01), a risk that persisted in all subgroups and was notably high in CHD (SHR: 4.83, p < 0.01) and hypertrophic CMP (SHR: 9.78, p < 0.01). HF etiology comparison within ECMO patients revealed increased mortality risk with CHD (SHR: 3.22, p < 0.01). Within No ECMO patients, hypertrophic CMP patients had lower mortality risk (SHR: 0.64, p = 0.03). CONCLUSIONS: The increased waitlist mortality risk with ECMO persisted after stratification by HF etiology. These findings can help decision-making surrounding candidacy for cannulation and prognostic evaluation.
Assuntos
Oxigenação por Membrana Extracorpórea , Insuficiência Cardíaca , Transplante de Coração , Listas de Espera , Humanos , Oxigenação por Membrana Extracorpórea/mortalidade , Transplante de Coração/mortalidade , Masculino , Listas de Espera/mortalidade , Feminino , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/terapia , Insuficiência Cardíaca/cirurgia , Estudos Retrospectivos , Pessoa de Meia-Idade , Prognóstico , Seguimentos , Taxa de Sobrevida , Fatores de Risco , Sistema de Registros , Adulto , Obtenção de Tecidos e ÓrgãosRESUMO
BACKGROUND: Perioperative heparin-free anticoagulation extracorporeal membrane oxygenation (ECMO) for lung transplantation is rarely reported. OBJECTIVE: To evaluate the impact of a heparin-free strategy on bleeding and thrombotic events, blood transfusion, and coagulation function during the early perioperative period and on prognosis, and to observe its effect on different ECMO types. DESIGN: A retrospective cohort study. METHODS: Data were collected from 324 lung transplantation patients undergoing early perioperative heparin-free ECMO between August 2017 and July 2022. Clinical data including perioperative bleeding and thrombotic events, blood product transfusion, coagulation indicators and 1-year survival were analysed. RESULTS: Patients were divided in venovenous (VV; n = 251), venoarterial (VA; n = 40) and venovenous-arterial (VV-A; n = 33) groups. The VV group had the lowest intraoperative bleeding and thoracic drainage within 24 h postoperatively. Vein thrombosis occurred in 30.2% of patients within 10 days postoperatively or 1 week after ECMO withdrawal, and no significant difference was found among the three groups. Double lung transplantation, increased intraoperative bleeding, and increased postoperative drainage were associated with vein thrombosis. Except for acute myocardial infarction in one patient, no other serious thrombotic events occurred. The VV-ECMO group had the lowest demand for blood transfusion. The highest prothrombin time and the lowest fibrinogen levels were observed in the VA group during ECMO run, while the highest platelet counts were found in the VV group. Both intraoperative bleeding and thoracic drainage within 24 h postoperatively were independent predictors for 1-year survival, and no thrombosis-related deaths occurred. CONCLUSION: Short-term heparin-free anticoagulation, particularly VV-ECMO, did not result in serious thrombotic events or thrombosis-related deaths, indicating that it is a safe and feasible strategy for perioperative ECMO in lung transplantation.
Assuntos
Anticoagulantes , Coagulação Sanguínea , Oxigenação por Membrana Extracorpórea , Transplante de Pulmão , Trombose , Humanos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/mortalidade , Estudos Retrospectivos , Transplante de Pulmão/efeitos adversos , Transplante de Pulmão/mortalidade , Feminino , Masculino , Pessoa de Meia-Idade , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Adulto , Trombose/prevenção & controle , Trombose/etiologia , Fatores de Tempo , Coagulação Sanguínea/efeitos dos fármacos , Resultado do Tratamento , Fatores de Risco , Transfusão de Sangue , Heparina/administração & dosagem , Heparina/efeitos adversos , Hemorragia Pós-Operatória/prevenção & controle , Hemorragia Pós-Operatória/etiologia , Hemorragia Pós-Operatória/mortalidade , Perda Sanguínea Cirúrgica/prevenção & controleRESUMO
BACKGROUND: Cardiopulmonary resuscitation (CPR) is the cornerstone intervention for cardiac arrest, with extracorporeal CPR (ECPR) demonstrating enhanced survival and neurologic outcomes in in-hospital cardiac arrest. This study explores the time interval between CPR initiation and the onset of extracorporeal membrane oxygenation (ECMO) in ECPR recipients, investigating its impact on survival outcomes. METHODS: This retrospective analysis included 1950 adults who received CPR at a single medical center between March 2019 and April 2023. Data from 198 adult patients who had ECMO inserted during CPR were analyzed. The interval from CPR initiation to ECMO initiation was quantified and categorized as ≤20, 20-40, and >40 min. Cox regression analysis assessed associations between CPR-to-ECMO time and short- and long-term mortalities. RESULTS: Among the 198 patients who underwent ECPR, 116 (58.6%) experienced 30-day mortality. Initiation of ECMO within 20 min occurred in 46 (23.2%), whereas 74 (37.4%) had ECMO initiated after 40 min. Cox regression revealed a significant association between time from CPR to ECMO initiation and 30-day mortality (adjusted hazard ratio [HR]: 2.20 in >40 min, HR: 2.63 in 20-40 min, p = 0.006) and 6-month mortality (HR: 1.81, in >40 min, HR: 1.99 in 20-40 min, p = 0.021). CONCLUSIONS: This study revealed that, in ECPR recipients, a shorter duration between CPR initiation and ECMO flow commencement is associated with improved short- and long-term patient prognoses. These findings emphasize the critical role of timely ECMO application in optimizing outcomes for patients undergoing ECPR.
Assuntos
Reanimação Cardiopulmonar , Oxigenação por Membrana Extracorpórea , Parada Cardíaca , Humanos , Oxigenação por Membrana Extracorpórea/mortalidade , Oxigenação por Membrana Extracorpórea/métodos , Reanimação Cardiopulmonar/métodos , Masculino , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Prognóstico , Parada Cardíaca/terapia , Parada Cardíaca/mortalidade , Idoso , Tempo para o Tratamento , Fatores de Tempo , AdultoRESUMO
BACKGROUND: Systemic hemodynamics and specific ventilator settings have been shown to predict survival during venoarterial extracorporeal membrane oxygenation (ECMO). How the right heart (the right ventricle and pulmonary artery) affect survival during venoarterial ECMO is unknown. We aimed to identify the relationship between right heart function with mortality and the duration of ECMO support. METHODS: Cardiac ECMO runs in adults from the Extracorporeal Life Support Organization Registry between 2010 and 2022 were queried. Right heart function was quantified via pulmonary artery pulse pressure (PAPP) for pre-ECMO and on-ECMO periods. A multivariable model was adjusted for modified Society for Cardiovascular Angiography and Interventions stage, age, sex, and concurrent clinical data (ie, pulmonary vasodilators and systemic pulse pressure). The primary outcome was in-hospital mortality. RESULTS: A total of 4442 ECMO runs met inclusion criteria and had documentation of hemodynamic and illness severity variables. The mortality rate was 55%; nonsurvivors were more likely to be older, have a worse Society for Cardiovascular Angiography and Interventions stage, and have longer pre-ECMO endotracheal intubation times (P<0.05 for all) than survivors. Increasing PAPP from pre-ECMO to on-ECMO time (ΔPAPP) was associated with reduced mortality per 2 mmâ Hg increase (odds ratio, 0.98 [95% CI, 0.97-0.99]; P=0.002). Higher on-ECMO PAPP was associated with mortality reduction across quartiles with the greatest reduction in the third PAPP quartile (odds ratio, 0.75 [95% CI, 0.63-0.90]; P=0.002) and longer time on ECMO per 10 mmâ Hg (beta, 15 [95% CI, 7.7-21]; P<0.001). CONCLUSIONS: Early on-ECMO right heart function and interval improvement from pre-ECMO values were associated with mortality reduction during cardiac ECMO. Incorporation of right heart metrics into risk prediction models should be considered.
Assuntos
Pressão Sanguínea , Oxigenação por Membrana Extracorpórea , Ventrículos do Coração , Artéria Pulmonar , Artéria Pulmonar/fisiopatologia , Oxigenação por Membrana Extracorpórea/mortalidade , Hemodinâmica , Humanos , Masculino , Feminino , Adolescente , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Ventrículos do Coração/fisiopatologiaRESUMO
BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has been presented as a potential therapeutic option for patients with cardiogenic shock complicating myocardial infarction (CS-MI). We aimed to investigate the efficacy and safety of ECMO in CS-MI. METHODS: A systematic review and meta-analysis synthesizing evidence from randomized controlled trials obtained from PubMed, Embase, Cochrane, Scopus, and Web of Science until September 2023. We used the random-effects model to report dichotomous outcomes using risk ratio and continuous outcomes using mean difference with a 95% confidence interval. Finally, we implemented a trial sequential analysis to evaluate the reliability of our results. RESULTS: We included four trials with 611 patients. No significant difference was observed between ECMO and standard care groups in 30-day mortality with pooled RR of 0.96 (95% CI: 0.81-1.13, p = 0.60), acute kidney injury (RR: 0.65, 95% CI: 0.41-1.03, p = 0.07), stroke (RR: 1.16, 95% CI: 0.38-3.57, p = 0.80), sepsis (RR: 1.06, 95% CI: 0.77-1.47, p = 0.71), pneumonia (RR: 0.99, 95% CI: 0.58-1.68, p = 0.96), and 30-day reinfarction (RR: 0.95, 95% CI: 0.25-3.60, p = 0.94). However, the ECMO group had higher bleeding events (RR: 2.07, 95% CI: 1.44-2.97, p < 0.0001). CONCLUSION: ECMO did not improve clinical outcomes compared to the standard of care in patients with CS-MI but increased the bleeding risk.
Assuntos
Oxigenação por Membrana Extracorpórea , Infarto do Miocárdio , Ensaios Clínicos Controlados Aleatórios como Assunto , Choque Cardiogênico , Humanos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/mortalidade , Choque Cardiogênico/terapia , Choque Cardiogênico/mortalidade , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/etiologia , Choque Cardiogênico/fisiopatologia , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/terapia , Infarto do Miocárdio/diagnóstico , Resultado do Tratamento , Fatores de Risco , Masculino , Feminino , Pessoa de Meia-Idade , Medição de Risco , Idoso , Fatores de TempoRESUMO
OBJECTIVES: We investigated donors with brain death on extracorporeal membrane oxygenation support, a clinically challenging situation due to hemodynamic instability frequently encountered in these donors, which may threaten organ function. MATERIALS AND METHODS: We described our experience with 15 utilized brain death donors on extracorporeal membrane oxygenation support, consecutively admit-ted in our intensive care unit (which is a referral center for extracorporeal membrane oxygenation) from 2018 to 2023. We investigated whether utilization rate for brain death donors on extracor-poreal membrane oxygenation was affected by the introduction of a monitoring hemodynamic schedule during the 6-hour observation period. RESULTS: The utilization rate was 78% in period 1 and 88% in period 2. No statistically significant differences were observed for age, sex, and the incidence of cardiovascular risk factors between period 1 and period 2. The cause of death was postanoxic encephalopathy in all but 1 donor, who was on venovenous extracorporeal membrane oxygenation for refractory respiratory failure and developed cerebral hemorrhage. Number of organs per donor was 2 in all the population with no significant differences between period 1 and period 2. In the overall population, 15 livers were transplanted, 11 kidneys, 1 heart, and 1 pancreas. In our population, left ventricular ejection fraction severe dysfunction was observed in all donors except in the donor on venovenous extracorporeal membrane oxygenation; the organ from this donor was deemed unsuitable for transplant. No significant differences were observed in hemodynamic data between the 2 subgroups. All donors were on 2 vasoactive drugs (norepinephrine and vasopressin) to maintain adequate perfusion (mean arterial pressure >60 mm Hg). Three donors were oligoanuric (due to postarrest acute renal failure). CONCLUISONS: In our series of 15 consecutive brain death donors on extracorporeal membrane oxygenation, a strict monitoring regimen during the 6-hour obser-vation period was associated with a higher utilization rate.
Assuntos
Morte Encefálica , Seleção do Doador , Oxigenação por Membrana Extracorpórea , Doadores de Tecidos , Humanos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/mortalidade , Masculino , Feminino , Adulto , Doadores de Tecidos/provisão & distribuição , Pessoa de Meia-Idade , Fatores de Risco , Estudos Retrospectivos , Hemodinâmica , Fatores de Tempo , Resultado do Tratamento , Transplante de Órgãos/efeitos adversos , Causas de Morte , Adulto JovemRESUMO
PURPOSE: Severe acute respiratory distress syndrome (ARDS) with PaO2/FiO2 < 80 mmHg is a life-threatening condition. The optimal management strategy is unclear. The aim of this meta-analysis was to compare the effects of low tidal volumes (Vt), moderate Vt, prone ventilation, and venovenous extracorporeal membrane oxygenation (VV-ECMO) on mortality in severe ARDS. METHODS: We performed a frequentist network meta-analysis of randomised controlled trials (RCTs) with participants who had severe ARDS and met eligibility criteria for VV-ECMO or had PaO2/FiO2 < 80 mmHg. We applied the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to discern the relative effect of interventions on mortality and the certainty of the evidence. RESULTS: Ten RCTs including 812 participants with severe ARDS were eligible. VV-ECMO reduces mortality compared to low Vt (risk ratio [RR] 0.77, 95% confidence interval [CI] 0.59-0.99, moderate certainty) and compared to moderate Vt (RR 0.75, 95% CI 0.57-0.98, low certainty). Prone ventilation reduces mortality compared to moderate Vt (RR 0.78, 95% CI 0.66-0.93, high certainty) and compared to low Vt (RR 0.81, 95% CI 0.63-1.02, moderate certainty). We found no difference in the network comparison of VV-ECMO compared to prone ventilation (RR 0.95, 95% CI 0.72-1.26), but inferences were based solely on indirect comparisons with very low certainty due to very wide confidence intervals. CONCLUSIONS: In adults with ARDS and severe hypoxia, both VV-ECMO (low to moderate certainty evidence) and prone ventilation (moderate to high certainty evidence) improve mortality relative to low and moderate Vt strategies. The impact of VV-ECMO versus prone ventilation remains uncertain.
Assuntos
Oxigenação por Membrana Extracorpórea , Metanálise em Rede , Respiração Artificial , Síndrome do Desconforto Respiratório , Humanos , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/mortalidade , Síndrome do Desconforto Respiratório/terapia , Síndrome do Desconforto Respiratório/mortalidade , Síndrome do Desconforto Respiratório/fisiopatologia , Decúbito Ventral/fisiologia , Respiração Artificial/métodos , Respiração Artificial/estatística & dados numéricos , Decúbito Dorsal , Volume de Ventilação Pulmonar/fisiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Hipóxia/terapia , Hipóxia/mortalidadeRESUMO
INTRODUCTION: A feared complication of an acute myocardial infarction (AMI) is cardiac arrest (CA). Even if return of spontaneous circulation is achieved, cardiogenic shock (CS) is common. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) supports patients with CS and is often used in conjunction with an Impella device (2.5 and CP) to off-load the left ventricle, although limited evidence supports this approach. METHODS: The goal of this study was to determine whether a mortality difference was observed in VA-ECMO alone versus VA-ECMO with Impella (ECPELLA) in patients with CS from AMI and CA. A retrospective chart review of 50 patients with AMI-CS and CA and were supported with VA-ECMO (n = 34) or ECPELLA (n = 16) was performed. The primary outcome was all-cause mortality at 6-months from VA-ECMO or Impella implantation. Secondary outcomes included in-hospital mortality and complication rates between both cohorts and intensive care unit data. RESULTS: Baseline characteristics were similar, except patients with ST-elevation myocardial infarction were more likely to be in the VA-ECMO group (p = 0.044). The ECPELLA cohort had significantly worse survival after VA-ECMO (SAVE) score (p = 0.032). Six-month all-cause mortality was not significantly different between the cohorts, even when adjusting for SAVE score. Secondary outcomes were notable for an increased rate of minor complications without an increased rate of major complications in the ECPELLA group. CONCLUSIONS: Randomized trials are needed to determine if a mortality difference exists between VA-ECMO and ECPELLA platforms in patients with AMI complicated by CA and CS.
Assuntos
Oxigenação por Membrana Extracorpórea , Parada Cardíaca , Coração Auxiliar , Mortalidade Hospitalar , Infarto do Miocárdio , Choque Cardiogênico , Humanos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/mortalidade , Masculino , Pessoa de Meia-Idade , Feminino , Estudos Retrospectivos , Parada Cardíaca/terapia , Parada Cardíaca/mortalidade , Parada Cardíaca/fisiopatologia , Infarto do Miocárdio/complicações , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/fisiopatologia , Infarto do Miocárdio/terapia , Idoso , Choque Cardiogênico/terapia , Choque Cardiogênico/mortalidade , Choque Cardiogênico/fisiopatologia , Resultado do Tratamento , Função Ventricular EsquerdaRESUMO
OBJECTIVE: To investigate the association between driving pressure (ΔP) and 90-day mortality in patients following lung transplantation (LTx) in patients who developed primary graft dysfunction (PGD). METHODS: This prospective, observational study involved consecutive patients who, following LTx, were admitted to our intensive care unit (ICU) from January 2022 to January 2023. Patients were separated into two groups according to ΔP at time of admission (i.e., low, ≤15 cmH2O or high, >15 cmH2O). Postoperative outcomes were compared between groups. RESULTS: In total, 104 patients were involved in the study, and of these, 69 were included in the low ΔP group and 35 in the high ΔP group. Kaplan-Meier analysis of 90-day mortality showed a statistically significant difference between groups with survival better in the low ΔP group compared with the high ΔP group. According to Cox proportional regression model, the variables independently associated with 90-day mortality were ΔP and pneumonia. Significantly more patients in the high ΔP group than the low ΔP group had PGD grade 3 (PGD3), pneumonia, required tracheostomy, and had prolonged postoperative extracorporeal membrane oxygenation (ECMO) time, postoperative ventilator time, and ICU stay. CONCLUSIONS: Driving pressure appears to have the ability to predict PGD3 and 90-day mortality of patients following LTx. Further studies are required to confirm our results.
Assuntos
Transplante de Pulmão , Humanos , Transplante de Pulmão/mortalidade , Transplante de Pulmão/efeitos adversos , Masculino , Feminino , Estudos Prospectivos , Pessoa de Meia-Idade , Adulto , Disfunção Primária do Enxerto/mortalidade , Disfunção Primária do Enxerto/etiologia , Unidades de Terapia Intensiva , Estimativa de Kaplan-Meier , Complicações Pós-Operatórias/mortalidade , Pressão , Oxigenação por Membrana Extracorpórea/mortalidade , Fatores de RiscoRESUMO
OBJECTIVES: To examine trends in utilization and outcomes among patients with the acute respiratory distress syndrome (ARDS) requiring prolonged venovenous extracorporeal membrane oxygenation (VV ECMO) support. DESIGN: Retrospective observational cohort study. SETTING: Adult patients in the Extracorporeal Life Support Organization registry. PATIENTS: Thirteen thousand six hundred eighty-one patients that required ECMO for the support of ARDS between January 2012 and December 2022. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Mortality while supported with VV ECMO and survival to hospital discharge based on ECMO duration were examined utilizing multivariable logistic regression. Among the 13,681 patients supported with VV ECMO, 4,040 (29.5%) were supported for greater than or equal to 21 days and 975 (7.1%) for greater than or equal to 50 days. Patients supported with prolonged VV ECMO were less likely to be discharged alive from the hospital compared with those with short duration of support (46.5% vs. 59.7%; p < 0.001). However, among patients supported with VV ECMO greater than or equal to 21 days, duration of extracorporeal life support was not significantly associated with mortality (odds ratio [OR], 0.99; 95% CI, 0.98-1.01; p = 0.87 and adjusted OR, 0.99; 95% CI, 0.97-1.02; p = 0.48). Even in those supported with VV ECMO for at least 120 days (n = 113), 52 (46.0%) of these patients were ultimately discharged alive from the hospital. CONCLUSIONS: Prolonged VV ECMO support of ARDS has increased and accounts for a substantial portion of cases. Among patients that survive for greater than or equal to 21 days while receiving VV ECMO support, duration is not predictive of survival to hospital discharge and clinical recovery may occur even after very prolonged VV ECMO support.
Assuntos
Oxigenação por Membrana Extracorpórea , Sistema de Registros , Síndrome do Desconforto Respiratório , Humanos , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/mortalidade , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Síndrome do Desconforto Respiratório/terapia , Síndrome do Desconforto Respiratório/mortalidade , Masculino , Estudos Retrospectivos , Feminino , Pessoa de Meia-Idade , Adulto , Fatores de Tempo , Prevalência , IdosoRESUMO
BACKGROUND: This study aimed to investigate the association between the temporal transitions in heart rhythms during cardiopulmonary resuscitation (CPR) and outcomes after out-of-hospital cardiac arrest. METHODS: This was an analysis of the prospectively collected databases in 3 academic hospitals in northern and central Taiwan. Adult patients with out-of-hospital cardiac arrest transported by emergency medical service between 2015 and 2022 were included. Favorable neurological recovery and survival to hospital discharge were the primary and secondary outcomes, respectively. Time-specific heart rhythm shockability was defined as the probability of shockable rhythms at a particular time point during CPR. The temporal changes in the time-specific heart rhythm shockability were calculated by group-based trajectory modeling. Multivariable logistic regression analyses were performed to examine the association between the trajectory group and outcomes. Subgroup analyses examined the effects of extracorporeal CPR in different trajectories. RESULTS: The study comprised 2118 patients. The median patient age was 69.1 years, and 1376 (65.0%) patients were male. Three distinct trajectories were identified: high-shockability (52 patients; 2.5%), intermediate-shockability (262 patients; 12.4%), and low-shockability (1804 patients; 85.2%) trajectories. The median proportion of shockable rhythms over the course of CPR for the 3 trajectories was 81.7% (interquartile range, 73.2%-100.0%), 26.7% (interquartile range, 16.7%-37.5%), and 0% (interquartile range, 0%-0%), respectively. The multivariable analysis indicated both intermediate- and high-shockability trajectories were associated with favorable neurological recovery (intermediate-shockability: adjusted odds ratio [aOR], 4.98 [95% CI, 2.34-10.59]; high-shockability: aOR, 5.40 [95% CI, 2.03-14.32]) and survival (intermediate-shockability: aOR, 2.46 [95% CI, 1.44-4.18]; high-shockability: aOR, 2.76 [95% CI, 1.20-6.38]). The subgroup analysis further indicated extracorporeal CPR was significantly associated with favorable neurological outcomes (aOR, 4.06 [95% CI, 1.11-14.81]) only in the intermediate-shockability trajectory. CONCLUSIONS: Heart rhythm shockability trajectories were associated with out-of-hospital cardiac arrest outcomes, which may be a supplementary factor in guiding the allocation of medical resources, such as extracorporeal CPR.
Assuntos
Reanimação Cardiopulmonar , Bases de Dados Factuais , Cardioversão Elétrica , Parada Cardíaca Extra-Hospitalar , Recuperação de Função Fisiológica , Humanos , Parada Cardíaca Extra-Hospitalar/terapia , Parada Cardíaca Extra-Hospitalar/mortalidade , Parada Cardíaca Extra-Hospitalar/diagnóstico , Parada Cardíaca Extra-Hospitalar/fisiopatologia , Masculino , Idoso , Feminino , Reanimação Cardiopulmonar/mortalidade , Estudos Retrospectivos , Pessoa de Meia-Idade , Cardioversão Elétrica/instrumentação , Cardioversão Elétrica/mortalidade , Cardioversão Elétrica/efeitos adversos , Resultado do Tratamento , Fatores de Tempo , Taiwan/epidemiologia , Fatores de Risco , Idoso de 80 Anos ou mais , Frequência Cardíaca , Medição de Risco , Oxigenação por Membrana Extracorpórea/mortalidade , Oxigenação por Membrana Extracorpórea/efeitos adversosRESUMO
OBJECTIVE: This study aimed to examine the changes in absolute value and decline rate of early serum cardiac troponin T (cTnT) and N-terminal pro b-type natriuretic peptide (NT-proBNP) in neonates who received veno-arterial (V-A) extracorporeal membrane oxygenation (ECMO) support therapy within the first week of life. METHODS: We retrospectively collected clinical data and laboratory test results of 18 neonates who underwent V-A ECMO support within one week of birth, from July 2021 to June 2023, using the electronic medical record system. These patients were categorized into survival and death groups. Comparative analyses of the absolute values and decline rates of cTnT and NT-proBNP were made between the groups at baseline, and at 24, 48, and 72 h post-ECMO initiation. RESULTS: Out of the 18 neonates, 12 survived (survival rate: 66.7%), while 6 succumbed. The survival group exhibited significantly lower absolute values of cTnT and NT-proBNP than the death group, and their decline rates were significantly higher. Notably, all neonates without an early decline in cTnT and NT-proBNP levels were in the death group. CONCLUSION: The early changes in the absolute value and decline rate of serum cTnT and NT-proBNP in neonates undergoing V-A ECMO may serve as predictors of their prognosis.
Assuntos
Biomarcadores , Oxigenação por Membrana Extracorpórea , Peptídeo Natriurético Encefálico , Fragmentos de Peptídeos , Troponina T , Humanos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/mortalidade , Peptídeo Natriurético Encefálico/sangue , Troponina T/sangue , Recém-Nascido , Fragmentos de Peptídeos/sangue , Estudos Retrospectivos , Masculino , Feminino , Biomarcadores/sangue , Fatores de Tempo , Resultado do Tratamento , Valor Preditivo dos Testes , Fatores de RiscoRESUMO
BACKGROUND: Massive pulmonary embolism (MPE) carries significant 30-day mortality risk, and a change in societal guidelines has promoted the increasing use of extracorporeal membrane oxygenation (ECMO) in the immediate management of MPE-associated cardiovascular shock. This narrative review examines the current status of ECMO in MPE. METHODS: A literature review was performed from 1982 to 2022 searching for the terms "Pulmonary embolism" and "ECMO," and the search was refined by examining those publications that covered MPE. RESULTS: In the patient with MPE, veno-arterial ECMO is now recommended as a bridge to interventional therapy. It can reliably decrease right ventricular overload, improve RV function, and allow hemodynamic stability and restoration of tissue oxygenation. The use of ECMO in MPE has been associated with lower mortality in registry reviews, but there has been no significant difference in outcomes between patients treated with and without ECMO in meta-analyses. Applying ECMO is also associated with substantial multisystem morbidity due to systemic inflammatory response, bleeding with coagulopathy, hemorrhagic stroke, renal dysfunction, and acute limb ischemia, which must be factored into the outcomes. CONCLUSIONS: The application of ECMO in MPE should be combined with an aggressive interventional pulmonary interventional program and should strictly adhere to the current selection criteria.