Cardiogenic shock (CS) describes a physiological state of end-organ hypoperfusion characterized by reduced cardiac output in the presence of adequate intravascular volume. Mortality still remains exceptionally high. Veno-arterial extracorporeal membrane oxygenation (VA ECMO) has become the preferred device for short-term hemodynamic support in patients with CS. ECMO provides the highest cardiac output, complete cardiopulmonary support. In addition, the device has portable characteristics, more familiar to medical personnel. VA ECMO provides cardiopulmonary support for patients in profound CS as a bridge to myocardial recovery. This review provides an overview of VA ECMO in salvage of CS, emphasizing the indications, management and further direction.
Abstract： Objective To summarize the clinical experiences of performing extracorporeal membrane oxygenation (ECMO) on patients with heart and respiratory failure, and compare the clinical outcomes of Medtronic system and Quadrox PLS system. Methods We retrospectively analyzed the clinical data of 121 heart and respiratory failure patients who underwent ECMO treatment in Fu Wai Hospital from December 2004 to December 2009. Based on the different systems used, 121 patients were divided into two groups. In group M, there were 65 patients including 41 males and 24 females, with an age of 26.6±25.9 years; and they accepted Medtronic ECMO system treatment. In group Q, there were 56 patients including 39 males and 17 females, with an age of 32.4±23.9 years and they underwent Quadrox PLS ECMO system treatment. The evaluation of the clinical outcomes of these two different systems was based on the comparison of transmembrane pressure drop (TMPD), anticoagulation, hemolysis, plasma leakage, organ function, complication and hospital mortality between the two groups. Results Compared with group M, ECMO with Quadrox PLS system was associated with lower TMPD (at the beginning of ECMO: 15.0±6.0 mm Hg vs.28.0±5.0 mm Hg, P=0.000; 24 hours later: 16.0±5.0 mm Hg vs. 30.0±7.0 mm Hg, P=0.000) and less thrombus formation(7.1% vs.23.1%, P=0.037), less plasma leakage (0.0% vs. 50.8%, P=0.000), less hemolysis (14.3% vs. 29.2%, P=0.047). There were no significant differences between the two groups in support duration, complication rate, and hospital mortality(Pgt;0.05). Conclusion Both devices have similar effects for safe clinical application, but Quadrox PLS ECMO system has a relatively high biocompatibility with lower TMPD, less plasma leakage, and thrombus formation.
Objective To summarize the clinical experiences of venoarterial extracorporeal membrane oxygenation (ECMO) which provides temporary cardiopulmonary assist for critical patients, and preliminary analysis of the cause of failure. Methods From February 2005 to October 2008, 58 adult patients (male 42, female 16) undergoing cardiogenic shock required temporary ECMO support. Age was 44.8±17.6 years, and support duration of ECMO was 131.9±104.7 hours. There were 24 patients (41.4%) with coronary heart disease, 11 patients (19.0%) with cardiomyopathy, 10 patients (17.2%) with cardiac valve disease,and 9 patients (15.5%) with congenital heart disease. Results 22 patients died in hospital. 11 patients (50%) died of multisystem organ failure, 5 patients (22.7%) died of refractory heart failure despite the ECMO support. Another patients died of bleeding and severe pulmonary hypertension etc. The percentage for patients need cardiac resuscitation before ECMO support and patients with acute renal failure treated by continuous renal replacement therapy (CRRT) under ECMO support were obviously higher in dead patients than those in survivor patients (45.5% vs.19.4%, 40.9% vs. 5.6%; P=0.043，0.001). All of the discharged patients were reassessed, mean followup time were 15.6 months. Three patients died of refractory heart failure， 1 patient died of neurologic complications. The other 32 survivors were in good condition with cardiac symptom of New York Heart Association class Ⅰ or Ⅱ. Conclusion ECMO offers effective cardiopulmonary support in adults. Early intervention and control of complications could improve our results with increasing experience. Combining using CRRT during the ECMO support is associated with significantly higher mortality rate. Suffered cardiac arrest prior to ECMO also influences the survival.
Objective To summarize and further investigate the initial experience of organ procurement process for organ donation after cardiac death （DCD）. Methods The clinical data，the selected standard，and the organ procurement process of 28 cases of DCD from July 2009 to January 2012 in the liver transplantation center of Guangzhou General Hospital were reviewed and analyzed. Results Twenty-eight cases of DCD all had donated organs successfully. Among these cases，there were 3 cases （10.7%） of the Maastricht Ⅲ， and one case （3.6%） of the Maastricht Ⅳ，and 24 cases （85.7%） of the organ donation after brain death plus cardiac death （DBCD）．Three cases of the Maastricht Ⅲ were practiced the organ procurement process of DCD．One case of the Maastricht Ⅳ was practiced the organ procurement process of DBCD without the extracorporeal membrane oxygenation （ECMO）．Twenty-four cases of DBCD were practiced the organ procurement process of DBCD with the ECMO．The donator warm ischemic time was zero min in DBCD，18 min in Maastricht Ⅳ，and mean 25 min （22-28 min） in MaastrichtⅢ．All the donated organs included 28 livers，40 kidneys，and 2 hearts．And all these organs had been practiced the liver transplantation，the kidney transplantation，and the heart transplantation. Conclusions The organ procurement process for organ DCD includes the DCD process and the DBCD process in China，and the later includes the organ procurement process with the ECMO and without the ECMO．The ECMO could well control the warm ischemia for protecting the donors just without ethics dispute. So，the using of the ECMO for the organ DCD of citizen in China has a very important contribution．
ObjectiveTo explore the clinical value of fibrinogen-albumin-ratio (FAR) in adult extracorporeal membrane oxygenation (ECMO) hemorrhage. MethodsThe clinical data of adult patients receiving ECMO in the West China Hospital from 2018 to 2020 were analyzed retrospectively. Patients were divided into a bleeding group and a non-bleeding group based on whether they experienced bleeding after ECMO. Logistic regression analysis was used to study the relationship between FAR and bleeding, as well as risk factors for death. Receiver operating characteristic (ROC) curve and area under the curve (AUC) were used to analyze the predictive ability of FAR. According to the optimal cut-off value of FAR for predicting hemorrhage, patients were divided into a high-risk group and a low-risk group, and the occurrence of bleeding was compared between the two groups. ResultsA total of 125 patients were enrolled in this study, including 85 males and 40 females, aged 46.00 (31.50, 55.50) years. Among them, 58 patients received veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and 67 patients received veno-venous extracorporeal membrane oxygenation (VV-ECMO). There were 49 patients having bleeding, and the lactate level was higher (P=0.026), the platelet count before ECMO initiation and 24 h after ECMO initiation was lower (P=0.031, 0.020), the fibrinogen level 24 h after ECMO initiation was lower (P=0.049), and the proportion of myocarditis patients was higher (P=0.017) in the bleeding group than those of the non-bleeding group. In the subgroup analysis of ECMO mode, the higher D-Dimer, lactate level and lower FAR before and 24 h after ECMO initiation were associated with bleeding in the VA-ECMO group (P=0.017, 0.011, 0.033, 0.005). The 24 h FAR was independently correlated with bleeding (P=0.048), and AUC was 0.714. The cut-off value was 55.73. According to this optimal cut-off value, 25 patients were divided into the high-risk group (≤55.73) and 33 into the low-risk group (>55.73). There was a higher incidence of bleeding in the high-risk group compared to the low-risk group (unadjusted P=0.002; P=0.013 for multivariable adjustment). In the VV-ECMO group, the relationship between FAR and bleeding events was not significant (P>0.05). ConclusionLow 24 h FAR is an independent risk factor for bleeding in VA-ECMO patients, and the diagnostic cut-off value is 55.73.
Extracorporeal membrane oxygenation (ECMO), as an extracorporeal life support technology, can provide respiratory support and hemodynamic support according to different modes. The significant advantages of ECMO in the treatment of acute respiratory distress syndrome and the development of its oxygenator, pump, and heparin-coated circuits have promoted its application and exploration in thoracic surgery. ECMO can be used during the perioperative period of lung transplantation and can be applied for patients who cannot maintain one-lung ventilation, or have a high risk of anesthesia, or undergo complex thoracic surgery involving trachea, carina, mediastinum and esophagus. This article will review the application and progress of ECMO in general thoracic surgery.
ObjectiveTo summarize the experience of applying extracorporeal membrane oxygenation (ECMO) after cardiac surgery in adult patient. MethodsWe retrospectively analyzed the clinical data of 27 patients underwent ECMO from December 2011 to October 2013. There were 15 males and 12 females at the mean age of 51±11 years ranging from 41 to 73 years. Vein-artery perfusion was performed in all 27 patients. ResultsAll 27 patients underwent ECMO. The mean time of using ECMO was 81.2±36.4 hours ranging from 48.0-192.0 hours. The mean time of hospital stay was 307.8±97.0 hours ranging from 168.0-480.0 hours. The rate of weaning from ECMO was 77.8% (21/27). The rate of discharge was 51.9% (14/27). The rate of perioperative mortality was 44.4% (12/27). ConclusionEffective monitoring with other supportive equipments is helpful to promote the result of ECMO.
Although extracorporeal membrane oxygenation (ECMO) has been in existence since the 1970s as a means of supporting respiratory or cardiac function, early application of this technology was plagued by high complication rates. Peripheral veno-arterial extracorporeal membrane oxygenation (V-A ECMO) causes higher left ventricular end-diastolic pressure, pulmonary edema, left ventricular distention, ventricular arrhythmia, low coronary perfusion, myocardial ischemia, substantial thrombus formation within left ventricule cavity and even multiple organ dysfunction. Mechanical left ventricular decompression is required to treat these related complications. In this article, we reviewed the problems associated with left ventricular decompression supported by peripheral V-A ECMO in patients with cardiogenic shock.
Objective To introduce the method and effect of common cardiop ulmonary bypass(CPB) switched to closed extracorporeal circulation by medtronic extracorporeal membrane oxygenation(ECMO) package. Methods From Junuary 2007 to June 2008, common CPB switched to closed extracorporeal circulation by Medtronic ECMO package adding blood reservoir and artery microembolus filtrator was used to 15 patients with grave heart disease to provide CPB support during operation on heart and cardiac function support after operation. The circulation was built through femoral arteryfemoral veinsuperior vena cava intubation or aortaright auricle intubation. There were 10 male and 5 female aged from 6582 years (74.0±9.3 years) and weighed from 6389 kg (69.0±11.4 kg). There were 11 cases with old myocardial infarction, 1 case with acute myocardial infarction, 1 case with old myocardial infarction complicated with mitral stenosis and mitral incompetence, and 2 cases reopened and undergone double valve replacement. Results For all the 15 patients, the closed circulation time was 31112 min（77.3±21.5 min）. The CPB time was 51-84 min（69.7±9.8 min）. The ostoperative mechanical ventilation time was 414 h（8.3±2.9 h）. The 24 hchest drainage was 110-360 ml（227.3±80.4 ml）. All patients were cured and discharged successfully with cardiac function classification in grade ⅠⅡ. Thirteen cases were followed up. The followup time was 412 months. Their cardiac function recovered well and no complication occurred. Conclusion This method could provide effective support for heart and lung before operation，during operation and after operation. This method could save material cost. The heparin paintcoat could reduce inflammatory reaction and it is good for patients’ recovery.
Objective To summarize the clinical manifestations, diagnosis and treatment of severe primary graft dysfunction ( PGD grade 3 ) in early stage after lung transplantation. Methods From September 2002 to December 2010, there were 10 patients with severe PGD ( grade 3) in early stage after lung transplantation ( LTx) in 100 patients with end-stage lung disease underwent LTx in Wuxi People’s Hospital. In which there were 2 cases with chronic obstructive pulmonary disease, 4 with idiopathic pulmonary fibrosis,1 case with lung tuberculosis, 1 case with silicosis, 2 cases with bronchiectasis. There were 7 patients with single LTx [ 3 cases with extracorporeal membrane oxygenation ( ECMO) support] and 3 patients with bilateral LTx ( 1 case with ECMO support) . Results The surgical procedures of these 10 patients were successful, however severe PGD occurred on 1-5 days after operation. 4 cases died of respiratory failure with negative fluid balance and mechanical ventilation support, and 2 cases recovered. 4 cases underwent ECMO support, in which 2 cases successfully weaned from ECMO and discharged from hospital, others died of multiple organ failure.Conclusions Severe PGD is one of the fatal early complication after lung transplantation. Early diagnosis and treatment are very important to improve the perioperative mortality rate.