Unilateral antegrade cerebral perfusion using axillary venoarterial extracorporeal membrane oxygenation during central decannulation.
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ABSTRACT:
SUBMITTER: Ohira S
PROVIDER: S-EPMC8307018 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:ObjectivesTo evaluate the clinical outcomes and perioperative complications associated with complete percutaneous decannulation of femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO) with the MANTA closure device.MethodsThis is a retrospective analysis of a single surgeon consecutive series of 14 patients at a single center who underwent decannulation from VA-ECMO, 10 of whom underwent a percutaneous method of femoral cannula removal.ResultsAfter a mean duration of VA-ECMO support of 7.4 ± 3.8 days, all 10 patients, with arterial cannulas ranging in size from 17 to 21 Fr, underwent percutaneous decannulation with the MANTA closure device, with immediate hemostasis. One patient had acute lower limb ischemia that was recognized intraoperatively and successfully treated with suction embolectomy. Two patients had a pseudoaneurysm at the distal perfusion catheter site recognized on perioperative imaging studies, one resolving with observation and the other necessitating thrombin injection. One patient had a hematoma that resolved with observation.ConclusionsPercutaneous decannulation from VA-ECMO using the MANTA large-bore vascular closure device is feasible and results in immediate hemostasis with excellent angiographic results.
| S-EPMC8300481 | biostudies-literature
Project description:Cardiogenic shock and cardiac arrest contribute pre-dominantly to mortality in acute cardiovascular care. Here, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has emerged as an established therapeutic option for patients suffering from these life-threatening entities. VA-ECMO provides temporary circulatory support until causative treatments are effective and enables recovery or serves as a bridging strategy to surgical ventricular assist devices, heart transplantation or decision-making. However, in-hospital mortality rate in this treatment population is still around 60%. In the recently published ARREST trial, VA-ECMO treatment lowered mortality rate in patients with ongoing cardiac arrest due to therapy refractory ventricular fibrillation compared to standard advanced cardiac life support in selected patients. Whether VA-ECMO can reduce mortality compared to standard of care in cardiogenic shock has to be evaluated in the ongoing prospective randomized studies EURO-SHOCK (NCT03813134) and ECLS-SHOCK (NCT03637205). As an innate drawback of VA-ECMO treatment, the retrograde aortic flow could lead to an elevation of left ventricular (LV) afterload, increase in LV filling pressure, mitral regurgitation, and elevated left atrial pressure. This may compromise myocardial function and recovery, pulmonary hemodynamics-possibly with concomitant pulmonary congestion and even lung failure-and contribute to poor outcomes in a relevant proportion of treated patients. To overcome these detrimental effects, a multitude of venting strategies are currently engaged for both preventive and emergent unloading. This review aims to provide a comprehensive and structured synopsis of existing venting modalities and their specific hemodynamic characteristics. We discuss in detail the available data on outcome categories and complication rates related to the respective venting option.
| S-EPMC10050067 | biostudies-literature
Project description: Not available
| S-EPMC6006205 | biostudies-literature
Project description:ObjectivesWith development of antegrade cerebral perfusion, the necessity of deep hypothermic circulatory arrest (CA) in aortic arch surgery has been called into question. To minimize the adverse effects of hypothermia, surgeons now perform these procedures closer to normothermia. This study examined postoperative outcomes of hemiarch replacement patients using unilateral selective antegrade cerebral perfusion and mild hypothermic CA.MethodsSingle-centre retrospective review of 66 patients undergoing hemiarch replacement with mild hypothermic CA (32°C) and unilateral selective antegrade cerebral perfusion between 2011 and 2018. Antegrade cerebral perfusion was delivered using right axillary artery cannulation. Postoperative data included death, neurological dysfunction, acute kidney injury and renal failure requiring new dialysis. Additional intraoperative metabolic data and blood transfusions were obtained.ResultsEighty-six percent of patients underwent elective surgery. Mean age was 67 ± 3 years. Lowest mean core body temperature was 32 ± 2°C. Average CA was 17 ± 5 min. No intraoperative or 30-day mortality occurred. Survival was 97% at 1 year, 91% at 3 years and 88% at 5 years. Permanent and temporary neurological dysfunction occurred in 1 (2%) and 2 (3%) patients, respectively. Only 3 (5%) patients suffered postoperative stage 3 acute kidney injury requiring new dialysis. Intraoperative transfusions occurred in 44% of patients and no major metabolic derangements were observed.ConclusionsIn patients undergoing hemiarch surgery, mild hypothermia (32°C) with unilateral selective antegrade cerebral perfusion via right axillary cannulation is associated with low mortality and morbidity, offering adequate neurological and renal protection. These findings require validation in larger, prospective clinical trials.
| S-EPMC8691572 | biostudies-literature
Project description:Venoarterial extracorporeal membrane oxygenation (vaECMO) is a well-established treatment option for severe cardiogenic shock of various etiologies. Although trials have explored weaning strategies, a brief and conclusive overview is lacking. We present the different aspects of weaning and provide an evidence- and experienced-based guide for clinicians managing patients under vaECMO in the preweaning, weaning, and postweaning phases.
| S-EPMC7190048 | biostudies-literature
Project description:Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a mechanical system that provides rapid and short-term support for patients with cardiac failure. In many patients, pulmonary function is also impaired, resulting in poorly-oxygenated cardiac outflow competing against well-oxygenated VA-ECMO outflow, a condition known as North-South syndrome. North-South syndrome is a primary concern because of its potential to cause cerebral hypoxia, which has a critical influence on neurological complications often seen in this patient population. In order to reduce ischemic neurological complications, it is important to understand how clinical decisions regarding VA-ECMO parameters influence blood oxygenation. Here, we studied the impacts of flow rate and cannulation site on oxygenation using a one-dimensional (1D) model to simulate blood flow. Our model was initially tested by comparing blood flow results to those observed from experimental work in VA-ECMO patients. The 1D model was combined with a two-phase flow model to simulate oxygenation. Additionally, the influence of various other clinician-tunable parameters on oxygenation in the common carotid arteries (CCAs) were tested, including, blood viscosity, cannula position within the insertion artery, heart rate, and systemic vascular resistance (SVR), as well as geometrical changes such as arterial radius and length. Our results indicated that blood oxygenation to the brain strongly depended on the cannula insertion site and the VA-ECMO flow rate with a weaker but potentially significant dependence on arterial radius. During femoral cannulation, VA-ECMO flow rates greater than ~4.9L/min were needed to perfuse the CCAs. However, axillary and central cannulation began to perfuse the CCAs at significantly lower flow (~1L/min). These results may help explain the incidence of cerebral hypoxia in this patient population and the common need to change cannulation strategies during treatment to address this clinical problem. While this work describes patient-averaged results, determining these relationships between VA-ECMO parameters and cerebral hypoxia is an important step towards future work to develop patient-specific models that clinicians can use to improve outcomes.
| S-EPMC7707150 | biostudies-literature
Project description:ObjectiveTo compare the short- and long-term outcomes of unilateral and bilateral antegrade cerebral perfusion (uni-ACP and bi-ACP) in acute type A aortic dissection (ATAAD) repair.MethodsFrom 2001 to 2017, 307 patients underwent surgical repair of an ATAAD using uni-ACP (n = 140) and bi-ACP (n = 167). Data were collected through the Department of Cardiac Surgery Data Warehouse, medical record review, and the National Death Index database.ResultsThe demographics and preoperative comorbidities were similar between the uni-ACP and bi-ACP groups. Both groups had similar rates of procedures for aortic valve/root, ascending aorta, frozen elephant trunk, and other concomitant procedures. Perioperative outcomes were not significantly different between the 2 groups (30-day mortality: uni-ACP 3.4% vs bi-ACP 7.8%, P = .12) except reoperation for bleeding was significantly lower in uni-ACP (5% vs 12%, P = .03). Between the uni-ACP and bi-ACP groups, overall postoperative stroke rate (6% vs 9%, P = .4) and left brain stroke rate (0.7% vs 3.0%, P = .23) were not significantly different. The odds ratio of uni-ACP versus bi-ACP was 0.87 (P = .80) for postoperative stroke and 0.86 (P = .81) for operative mortality. The mid-term survival was better in the uni-ACP group, P = .027 (5-year: 84% vs 76%). The hazard ratio of all-time mortality for uni-ACP versus bi-ACP was 0.74 (95% confidence interval, 0.33-1.65), P = .46.ConclusionsIn ATAAD, both uni-ACP and bi-ACP are equally effective to protect the brain with low postoperative stroke rates and mortality in hemiarch to zone 3 arch replacement. Uni-ACP is recommended for its simplicity and less manipulation of arch branch vessels.
| S-EPMC7061338 | biostudies-literature
Project description: Not available
| S-EPMC9390622 | biostudies-literature
Project description:BackgroundExtracorporeal membrane oxygenation (ECMO) is an effective therapy for supporting infants with reversible cardiopulmonary failure. Still, survivors are at risk for long-term neurodevelopmental impairments, the cause of which is not fully understood.ObjectiveTo elucidate the effects of ECMO on the newborn brain. We hypothesized that the cerebral metabolic profile of neonates who received ECMO would differ from neonates who did not receive ECMO. To address this, we used magnetic resonance spectroscopy (1H-MRS) to investigate the effects of venoarterial and venovenous ECMO on cerebral metabolism.Methods41 neonates treated with ECMO were contrasted to 38 age-matched neonates.ResultsAll 1H-MRS data were acquired from standardized grey matter and white matter regions of interest using a short-echo (TE = 35 milliseconds), point-resolved spectroscopy sequence (PRESS) and quantitated using LCModel. Metabolite concentrations (mmol/kg) were compared across groups using multivariate analysis of covariance. Elevated creatine (p = 0.002) and choline (p = 0.005) concentrations were observed in the grey matter among neonates treated with ECMO relative to the reference group. Likewise, choline concentrations were elevated in the white matter (p = 0.003) while glutamate was reduced (p = 0.03). Contrasts between ECMO groups revealed lower osmolite concentrations (e.g. myoinositol) among the venovenous ECMO group.ConclusionNeonates who underwent ECMO were found to have an abnormal cerebral metabolic profile, with the pattern of abnormalities suggestive of an underlying inflammatory process. Additionally, neonates who underwent venovenous ECMO had low cerebral osmolite concentrations as seen in vasogenic edema.
| S-EPMC5199081 | biostudies-literature
Project description:Spinal cord infarction (SCI) is a rare disease among central nervous system vascular diseases. Only a little is known about venoarterial extracorporeal membrane oxygenation (VA-ECMO)-related SCI. Retrospective observational study conducted, from 2006 to 2019, in a tertiary referral center on patients who developed VA-ECMO-related neurovascular complications, focusing on SCI. During this period, among the 1893 patients requiring VA-ECMO support, 112 (5.9%) developed an ECMO-related neurovascular injury: 65 (3.4%) ischemic strokes, 40 (2.1%) intracranial bleeding, one cerebral thrombophlebitis (0.05%) and 6 (0.3%) spinal cord infarction. Herein, we report a series of six patients with refractory cardiogenic shock or cardiac arrest receiving circulatory support with VA-ECMO who developed subsequent SCI during ECMO course, confirmed by spine MRI after ECMO withdrawal. All six patients had long-term neurological disabilities. VA-ECMO-related SCI is a rare but catastrophic complication. Its diagnosis is usually delayed due to sedation requirement and/or ICU acquired weakness after sedation withdrawal, leading to difficulties in monitoring their neurological status. Even if no specific treatment exist for SCI, its prompt diagnosis is mandatory, to prevent secondary spine insults of systemic origin. Based on these results, we suggest that daily sedation interruption and neurological exam of the lower limbs should be performed in all VA-ECMO patients. Large registries are mandatory to determine VA-ECMO-related SCI risk factor and potential therapy.
| S-EPMC7260457 | biostudies-literature