Hybrid extracorporeal membrane oxygenation

Brasseur, Alexandre; Scolletta, Sabino; Lorusso, Roberto; Taccone, Fabio Silvio

doi:10.21037/jtd.2018.03.84

Cited by 74 publications

(72 citation statements)

References 47 publications

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“…Thus, with this transpulmonary passage, poor coronary perfusion may be prevented. 1,27,29,30 Due to the arterial flow separation, it may be assumed that the mixing of returned oxygenated blood with the venous blood may cause no hyperoxygenation or formation of reactive oxygen species: only a fraction of the entire CO is returned into the venous system and mixes with Watershed phenomena during extracorporeal life support an equal or higher fraction of venous blood, resulting in near-normal oxygen saturation.…”

Section: Discussionmentioning

confidence: 99%

“…The mixing of oxygenated blood derived from the extracorporeal system with the venous blood allows an elevated pre‐pulmonary oxygen content, a transpulmonary passage, and the ejection of this oxygenated blood into the coronary system. Thus, with this transpulmonary passage, poor coronary perfusion may be prevented 1,27,29,30 . Due to the arterial flow separation, it may be assumed that the mixing of returned oxygenated blood with the venous blood may cause no hyperoxygenation or formation of reactive oxygen species: only a fraction of the entire CO is returned into the venous system and mixes with an equal or higher fraction of venous blood, resulting in near‐normal oxygen saturation.…”

Section: Discussionmentioning

confidence: 99%

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Watershed phenomena during extracorporeal life support and their clinical impact: a systematic in vitro investigation

et al. 2020

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Aims Extracorporeal life support (ECLS) during acute cardiac failure restores haemodynamic stability and provides life-saving cardiopulmonary support. Unfortunately, all common cannulation strategies and remaining pulmonary blood flow increase left-ventricular afterload and may favour pulmonary congestion. The resulting disturbed pulmonary gas exchange and a residual left-ventricular action can contribute to an inhomogeneous distribution of oxygenated blood into end organs. These complex flow interactions between native and artificial circulation cannot be investigated at the bedside: only an in vitro simulation can reveal the underlying activities. Using an in vitro mock circulation loop, we systematically investigated the impact of heart failure, extracorporeal support, and cannulation routes on the formation of flow phenomena and flow distribution in the arterial tree. Methods and results The mock circulation loop consisted of two flexible life-sized vascular models (aorta and vena cava) driven by two paracorporeal assist devices, resistance elements, and compliance reservoirs to mimic the circulatory system. Several large-bore antegrade and retrograde access ports allowed connection to an ECLS system for extracorporeal support. With four degrees of extracorporeal support-that for cardiac failure, early recovery, late recovery, and weaning-we investigated aortic blood flow velocity, blood flow, and mixing zones using colour-coded Doppler ultrasound in the aorta and its corresponding branches. Full retrograde extracorporeal support (3-4 L/min) perfused major portions of the aorta but did not reach the supra-aortic branches and ascending aorta, resulting in an area in the thoracic aorta demonstrating nearly stagnant blood flow velocities during cardiogenic shock and early recovery (0 ± 4 cm/s; À10 ± 15 cm/s, respectively) confined by two watersheds at the aortic isthmus and renal artery origin. Even increased ECLS flow was unable to shift the watershed towards the aortic arch. Antegrade support resulted in homogeneous flow distribution during all stages of cardiac failure but created a markedly negative flow vector in the ascending aorta during cardiogenic shock and early recovery with increased afterload. Conclusions Our systematic fluid-mechanical analysis confirms the clinical assumption that despite restoring haemodynamic stability, extracorporeal support generates an inhomogeneous distribution of oxygenated blood with an inadequate supply to end organs and increased left-ventricular afterload with absent ventricular unloading. End-organ supply may be monitored by near-infrared spectroscopy, but an obviously non-controllable watershed emphasizes the need for additional measures: pre-pulmonary oxygenation with a veno-arterial-venous ECLS configuration can allow a transpulmonary passage of oxygenated blood, providing improved end-organ supply.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Watershed phenomena during extracorporeal life support and their clinical impact: a systematic in vitro investigation

et al. 2020

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“…The Impella is an axial flow percutaneous ventricular assist device positioned across the aortic valve that propels blood antegrade into the aorta to directly offload the LV throughout the cardiac cycle 28‐30 . In contrast, IABP counterpulsation unloads the LV indirectly through decreasing afterload during systole to promote LV ejection 18,31,32 . However, in the setting of ECMO support, and particularly peripheral cannulation with retrograde perfusion of the aorta, the mechanism by which an IABP may achieve LV unloading is unclear.…”

Section: Discussionmentioning

confidence: 99%

Left ventricle unloading strategies in ECMO: A single‐center experience

et al. 2020

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Introduction Extracorporeal membrane oxygenation (ECMO) is a life‐saving technology capable of restoring perfusion but is not without significant complications that limit its realizable therapeutic benefit. ECMO‐induced hemodynamics increase cardiac afterload risking left ventricular distention and impaired cardiac recovery. To mitigate potentially harmful effects, multiple strategies to unload the left ventricle (LV) are used in clinical practice but data supporting the optimal approach is presently lacking. Materials & Methods We reviewed outcomes of our ECMO population from September 2015 through January 2019 to determine if our LV unloading strategies were associated with patient outcomes. We compared reactive (Group 1, n = 30) versus immediate (Group 2, n = 33) LV unloading and then compared patients unloaded with an Impella CP (n = 19) versus an intra‐aortic balloon pump (IABP, n = 16), analyzing survival and ECMO‐related complications. Results Survival was similar between Groups 1 and 2 (33 vs 42%, P = .426) with Group 2 experiencing more clinically‐significant hemorrhage (40 vs. 67%, P = .034). Survival and ECMO‐related complications were similar between patients unloaded with an Impella versus an IABP. However, the Impella group exhibited a higher rate of survival (37%) than predicted by their median SAVE score (18%). Discussion Based on this analysis, reactive unloading appears to be a viable strategy while venting with the Impella CP provides better than anticipated survival. Our findings correlate with recent large cohort studies and motivate further work to design clinical guidelines and future trial design.

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“…Peripheral cannulation may be complicated by a persistent low cardiac output in case of veno-venous cannulation (VV-ECMO) or by differential hypoxia (i.e., lower PaO 2 in the upper than in the lower body) in case of veno-arterial cannulation (VA-ECMO) and severe impairment of pulmonary function associated with cardiac recovery [ 5 ]. The treatment of such complications remains challenging, but the hybrid ECMO modes, using a third or fourth cannula, may provide additional support when traditional VV or VA configurations fail to ensure adequate tissue perfusion and oxygenation [ 6 ]. In this setting, the veno-arteriovenous configuration (V-AV), where the return outflow (return cannula) is divided in two flows, one toward the aorta to provide circulatory support and the second toward the right atrium to provide respiratory support, has been shown to effectively control these complications related to the initial ECMO configuration [ 7 ]; however, no data have been reported on the early effects of V-AV ECMO on patients’ physiology in this setting.…”

Section: Introductionmentioning

confidence: 99%

Early Findings after Implementation of Veno-Arteriovenous ECMO: A Multicenter European Experience

et al. 2021

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Extracorporeal membrane oxygenation (ECMO) is increasingly used to treat cardiopulmonary failure in critically ill patients. Peripheral cannulation may be complicated by a persistent low cardiac output in case of veno-venous cannulation (VV-ECMO) or by differential hypoxia (e.g., lower PaO2 in the upper than in the lower body) in case of veno-arterial cannulation (VA-ECMO) and severe impairment of pulmonary function associated with cardiac recovery. The treatment of such complications remains challenging. We report the early effects of the use of veno-arterial-venous (V-AV) ECMO in this setting. Methods: Retrospective analysis including patients from five different European ECMO centers (January 2013 to December 2016) who required V-AV ECMO. We collected demographic data as well as comorbidities and ECMO characteristics, hemodynamics, and arterial blood gas values before and immediately after (i.e., within 2 h) V-AV implementation. Results: A total of 32 patients (age 53 (interquartiles, IQRs: 31–59) years) were identified: 16 were initially supported with VA-ECMO and 16 with VV-ECMO. The median time to V-AV conversion was 2 (1–5) days. After V-AV implantation, heart rate and norepinephrine dose significantly decreased, while PaO2 and SaO2 significantly increased compared to baseline values. Lactate levels significantly decreased from 3.9 (2.3–7.1) to 2.8 (1.4–4.4) mmol/L (p = 0.048). A significant increase in the overall ECMO blood flow (from 4.5 (3.8–5.0) to 4.9 (4.3–5.9) L/min; p < 0.01) was observed, with 3.0 (2.5–3.2) L/min for the arterial and 2.8 (2.1–3.6) L/min for the venous return flows. Conclusions: In ECMO patients with differential hypoxia or persistently low cardiac output syndrome, V-AV conversion was associated with improvement in some hemodynamic and respiratory parameters. A significant increase in the overall ECMO blood flow was also observed, with similar flow distributed into the arterial and venous return cannulas.

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Hybrid extracorporeal membrane oxygenation

Cited by 74 publications

References 47 publications

Watershed phenomena during extracorporeal life support and their clinical impact: a systematic in vitro investigation

Watershed phenomena during extracorporeal life support and their clinical impact: a systematic in vitro investigation

Left ventricle unloading strategies in ECMO: A single‐center experience

Early Findings after Implementation of Veno-Arteriovenous ECMO: A Multicenter European Experience

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