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Objectives: Data about COVID-19 patients treated with veno-arterial-ECMO (VA-ECMO) is limited. Reported survival rates range from 27.9% to 77.8%, depending on VA-ECMO indication. A subgroup of patients suffers from circulatory failure due to a COVID-19 associated hyperinflammatory state (CovHI). In these patients, differentiation between inflammation and sepsis is difficult but important. In this retrospective case series, differential diagnoses of COVID-19 associated refractory circulatory failure and survival rates in different indications for VA-ECMO are investigated. Method(s): Retrospective analysis of 28 consecutive COVID-19 patients requiring VA-ECMO at the University Hospital Regensburg between March 2020 and May 2022. Specific treatment for COVID-19 was in accordance with respective guidelines. Mycotic infections were either invasive or met current definitions of COVID19-associated-pulmonary aspergillosis. Result(s): At VA-ECMO initiation, median age was 57.3 years (IQR: 51.4 - 61.8), SOFA score 16 (IQR: 13 - 17) and norepinephrine dosing 0.53mug/kg/min (IQR: 0.32 - 0.78). Virus-variants were: 61% wild-type, 14% Alpha, 18% Delta and 7% Omicron. Survival to hospital discharge was 39%. 17 patients were primarily supported with VA-ECMO only (survival 42%), 3 patients were switched from VV to VA-ECMO (survival 0%), and 8 patients were converted from VA to VAV or VV-ECMO (survival 50%). Indications for VA-ECMO support were pulmonary embolism (PE) (n=5, survival 80%), right heart failure due to secondary pulmonary hypertension (n=5, survival 20%), cardiac arrest (n=4, survival 25%), acute left heart failure (ALHF) (n=11, survival 36%) and refractory vasoplegia (n=3, survival 0%). Inflammatory markers at VA-ECMO initiation were higher in patients with ALHF or vasoplegia;in these patients a higher rate of invasive fungal infections (10/14, 71% vs. 4/14, 29%;p=0.023) compared to the other patients was found. Conclusion(s): Survival on VA-ECMO in COVID-19 depends on VA-ECMO indication, which should be considered in further studies and clinical decisions making. Circulatory failure due to vasoplegia should be considered very carefully as indication for VA-ECMO. A high rate of mycotic infections mandates an intense microbiological workup of these patients and must be considered as an important differential diagnosis to CovHI.
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Objectives: Cases of fulminant myocarditis after mRNA COVID-19 vaccination have been reported. The most severe may need venoarterial extracorporeal membrane oxygenation (V-A ECMO) support. Here we report two cases successfully rescued with V-A ECMO. Method(s): We included all the cases supported with V-A ECMO for refractory cardiogenic shock due to myocarditis secondary to a mRNA SARS-COV2 vaccine in the high-volume adult ECMO Program in Vall Hebron University Hospital since January 2020. Result(s): We identified two cases (table). One of them was admitted for out-of-hospital cardiac arrest. In both, a peripheral V-A ECMO was implanted in the cath lab. An intra-aortic balloon pump was needed in one case for left ventricle unloading. Support could be successfully withdrawn in a mean of five days. No major bleeding or thrombosis complications occurred. Definite microscopic diagnosis could be reached in one case (Image, 3). Treatment was the same, using 1000mg of methylprednisolone/day for 3 days. A cardiac magnetic resonance 10 days after admission showed a significant improvement in systolic function and diffuse oedema and subepicardial contrast intake in different segments (Image, 1-2). Both patients were discharged fully recovered. Conclusion(s): V-A ECMO should be established in cases of COVID-19 vaccine-associated myocarditis with refractory cardiogenic shock during the acute phase. (Table Presented).
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Objectives: Unfractionated heparin (UFH) remains the anticoagulation of choice at most centres for patients receiving extracorporeal membrane oxygenation (ECMO). One disadvantage of UFH relies on its individual dosing requirement to achieve target values. In this context heparin resistance has been described, defined as doses exceeding 35,000 IU UFH/d. However, the incidence of heparin resistance and its association with thromboembolic complications despite anticoagulation within target ranges remains unknown. Method(s): This retrospective study included adults receiving venovenous (VV) and venoarterial (VA) ECMO, or extracorporeal CO2-removal (ECCO2R) between 2010 and May 2022. The primary outcome was the incidence of heparin resistance (>35,000 IU of UFH/d). Secondary outcomes were heparin failure (thromboembolic complications despite anticoagulation within target ranges) and survival. A multivariable poisson regression model was fitted to analyse the effect of heparin resistance, COVID-19 and ECMO type on the incidence rate of thromboembolic events. Result(s): Of 197 included patients, 33 (16.8%) had heparin resistance. Patients with COVID-19 (n=51) had a higher rate of heparin resistance compared to nonCOVID-19 patients (37% vs. 9.6%, P<0.001). Thromboembolic complications occurred at a rate of 5.89/100 ECMO days. There was a significant effect of COVID-19 (incidence rate ratio (IRR) 2.12, 95% confidence interval (CI) 1.4 to 3.3, P<0.001) and ECMO type (VA ECMO: IRR 2.35;95% CI 1.43 to 3.87, P<0.001;ECCO2R: IRR 2.63, 95% CI 1.37 to 4.9, P=0.003;reference VV ECMO) on incidence rate of thromboembolic events, but not of heparin resistance (IRR 1.11, 95% CI 0.7 to 1.76, P=0.7). ECMO duration was longer (25d (IQR 11-33) vs. 8d (IQR 4-18), P<0.001) in patients with heparin resistance, but hospital survival did not differ (23 (70%) vs. 91 (57%), P=0.2). Conclusion(s): The study revealed a high incidence of heparin failure in ECMO patients, especially in those with COVID-19. Heparin resistance had no effect on the incidence rate of thromboembolic events, whereas our data suggest an increased risk in patients with COVID19, VA ECMO and ECCO2R.
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Objectives: To evaluate the outcomes and risk factors associated with mortality of patients cannulated on ECMO in the context of covid infection during the pandemics in a newly implemented ECMO center Methods: This was a unicentric observational retrospective study performed at Real Hospital Portugues, in Recife, state of Pernambuco, Brazil. All consecutive patients with laboratory confirmed SARS-CoV-2 infection cannulated for VV-ECMO or VA-ECMO for severe ARDS from march 2020 to december 2021 were included retrospectively. Patients recieving ECMO for isolated refratory cardiogenic shock were excluded. Descriptive statistics and association tests were used to analyze characteristics, management and patient outcomes during that period. Result(s): In our cohort of 47 ECMO for covid associated ARDS (CARDS), 39 patients (83%) were admitted by our emergency department. 8 patients (17%) had been transferred from other hospitals as soons as they had been cannulated. 32 patients (68%) were male, median age was 50 years (18-69). Mean body mass index was 31 (21,4-46,3). 37 patients (78%) had at least 1 comorbidity. Major bleeding occurred in 34 (72%) patients. Venous thromboembolism and hemolysis ocurred in 19 (40%) and 13 (23%) patients, respectively. When we compared treatments before ECMO initiation (imunoglobulin, tocilizuman, nitric oxide, neuromuscular blockade and proning), proning was associated with better survival (RR 0,67 IC 0,46-0,97 p 0,029). The mean duration in mechanical ventilation until ECMO cannulation was 9,69 days and mean time in ECMO was 23 days. The 90- day mortality was approximately 72%. Conclusion(s): The only variable associated with a better chance of survival was proning before ECMO. Our mortality (72%) is higher than reported from a recent meta-analysis of 1986 ECMO patients implanted during the first pandemic year(37,1%). However it is similar to a German populational registry of covid patients receiving VV-ECMO (73%). Althought it;s impossible to make causal inferences with such a design and sample sizes, we believe that describing the experience of smaller and newly implemented ECMO centers serves as motivation to improve quality and also to plan for future episodes of pressure on health system.
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Background: Only recently studies have been able to demonstrate the safety and efficacy of purification therapies in inflammatory diseases. Here we present the management of a young (21y) male patient in severe cardiogenic shock due to COVID-19 perymyocarditis admitted to the ICU at Bolzano Central Hospital. November 30th 2020 the patient developed high fever (>40 C) and diarrhea. After unsuccessfully being treated orally with a macrolide he was admitted to a peripheral hospital the 4th of December. The day after he deteriorated, required transfer to the ICU, endotracheal intubation and pharmacological cardiovascular support (Norepinephrine, Levosimendan). Antimicrobial treatment was started with piperacillin/tazobactam, linezolid and metronidazole. Despite multiple radiological and microbiological diagnostic attempts the origin of this severe septic shock remained unclear. December 6th the patient was transferred to Bolzano Central Hospital for VA-ECMO evaluation. Method(s): The transesophageal echocardiography revealed 15-20% of EF, lactate (5,2 mmol/l), cardiac enzymes (TropT 1400 mcg/l) and inflammatory parameters (PCT 35 ng/ml, IL-6 685 pg/ml) were elevated. We performed cardiac monitoring via Swan-Ganz catheter. The cardiac index was 1,6 l/min/m2. The peak dosage for Norepinephrine reached 7,5mg/h (1,47 mcg/kg/min). At Bolzano ICU we facilitate the pharmacological therapy with milrinone, vasopressin and low dose epinephrine. Furthermore, we impost continuous hemodiafiltration with CytoSorb filter. Result(s): Only hours after the start of filtration therapy the patient improved and we were able to gradually reduce catecholamine therapy, lactate values decreased. A VA-ECMO implantation was no more necessary. December 10th, we saw a stable patient without ventilatory or cardiovascular support, at echocardiography we revealed a normal EF. Conclusion(s): Clinically we saw a young patient in severe septic/cardiogenic shock due to perimyocarditis. Yet diagnostic attempts (CT-scan, multiple blood/urinary/liquor cultures) remained negative. Despite multiple negative PCR tests for SARS-CoV2 infection we performed specific immunoglobulin analysis and received a positive result for IgM. We therefore conclude on a COVID-19 associated perymyocarditis. Furthermore, this case illustrates the potential benefit of cytokine filtration and elimination in COVID-19 patients with altered IL6 levels.
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Objectives: To present a series of immunosuppressed patients (oncohematological disease, congenital immunosuppression, hematopoietic stem cell (HSCT), and solid organ transplant) assisted on ECMO. Method(s): Descriptive, retrospective study (2011-2020) of a cohort of 9 immunosuppressed patients, supported on ECMO. Medical records were reviewed and demographic, clinical, and analytical variables were collected. Result(s): In our series of 9 patients, 5 were male, the median age was 8 years [RIC 3-11 years]. Considering the underlying disease, 6 were oncologic, 1 liver transplant and 2 with congenital immunodeficiency after HSCT. 4 were under active chemotherapy (median 6 days after the last cycle [RIC 5-188]). 6 were admitted due to acute respiratory failure, 3 due to hemodynamic instability (3/9), (one septic shock). The median PEEP was 12 [RIC 9-15] and FiO2 100% (81-100%). 78% (6) required vasoactive drugs (median inotropic score 35 [RIC 0-75]. 40%. 5 had severe neutropenia and/or plateletopenia in the 24 hours prior to ECMO, and alterations in acid-base balance (median pH 7. 1 [RIC 6.9-7.15]. 5 were on multiorgan failure. TPrimary ECMO transport was performed in 4 patients (44%). Cannulation was peripheral in 80% (57% cervical, 43% femoral) and central in 20%;70% VA-ECMO. Median time of assistance was 15 days [RIC 3.5-31.5] in cardiac ECMO (4), and 29 days [RIC 13.5-42] and in pulmonary ECMO (n=5). The median total time of admission was 45 days [RIC 27-59]. 9 had an infection, 2 COVID after HSCT, and 8 bleeding complications, but only one required surgical revision. Renal replacement therapy was used in 5 (median 9 days [RIC 5-34.5]). Other therapies used were polymyxin hemadsorption(2), intratracheal surfactant(2), plasma exchange(1), infusion of mesenchymal cells(1) and specific memory T lymphocytes(2). 4 patients died, 5 survived decannulation, 2 died later, with an overall survival rate to hospital discharge of 33% (3/9). Conclusion(s): Despite having a worse prognosis, ECMO can increase survival in immunosuppressed patients, in situations that are challenging and require a multidisciplinary approach.
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Introduction: TBX1 haploinsufficiency is an inborn error of immunity with the phenotype of DiGeorge Syndrome. DiGeorge Syndrome has variable immunodeficiency associated with grade of thymic hypoplasia ranging from mild with no infections to severe requiring thymus implant. Enterovirus is an example of an opportunistic infection that can be fatal in these patients. Case Presentation: A 1 year old girl with TBX1 haploinsufficiency complicated by Tetralogy of Fallot, pulmonary atresia, high arched palate, and vesicovaginal fistula presented for elective cardiac repair surgery from another country due to failure to thrive and cyanosis. She had no prior infectious history but was on sulfamethoxazole-trimethoprim for prophylaxis. She was asymptomatic with a negative COVID test but no other infectious studies performed. Immediately postoperatively, she was febrile and nasal respiratory viral panel was positive for rhinovirus/enterovirus with increased procalcitonin and leukocytosis with left shift. She decompensated with multi-organ failure and cardiac arrest on postoperative day two. She was cannulated to veno-arterial extracorporeal membrane oxygenation (ECMO). Pre-operatively, she had a normal absolute lymphocyte count. No thymus tissue was observed in surgery. She had profound CD3 lymphopenia to 130 cells/cmm when critically ill. Enteroviral meningitis was suspected as no infectious, cardiac, or other pathology could be identified causing decompensation. Enteroviral serum polymerase chain reaction (PCR) test was negative while lumbar puncture deferred due to clinical status. She was treated with immunoglobulin. Offlabel investigational drug pocapavir was considered but deferred to patient's irreversible neurological status. The patient was disconnected from ECMO and expired. Discussion(s): Though we cannot confirm that this patient had enteroviral meningitis, invasive enteroviral infections are associated with elevated transaminases, coagulopathy, and seizures all present in our patient. There has also been reported negative serum enteroviral PCR but positive CSF enteroviral PCR in an immunodeficient patient. Additionally, this case highlights the importance of immunologic evaluation in patients with DiGeorge Syndrome and questions if asymptomatic viral screening for viruses like enterovirus should be considered pre-operatively in patients with inborn errors of immunity. This case highlights potential treatment options for invasive enteroviral infections in patients with inborn errors of immunity: high dose immunoglobulin, fluoxetine, and pocapavir.Copyright © 2023 Elsevier Inc.
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Introduction: Children requiring venoarterial (VA) extracorporeal membrane oxygenation for long durations may have increased risk of complications compared to venovenous (VV) ECMO. The purpose of this study was to evaluate the feasibility and safety of conversion from VA to VV ECMO. Method(s): This is a retrospective review of all children requiring VA ECMO who underwent conversion to VV ECMO at a single institution, from 2015- 2022. Indications for and methods of conversion were examined as well as adverse events including re-operation, ischemic complications, renal failure, and mortality. Descriptive statistics were calculated. Result(s): Of 422 pediatric patients on initial VA ECMO, only three children (0.7%) underwent conversion from VA to VV support, ages 10-19: for hypoxic respiratory failure due to COVID19, for cardiac dysfunction following orthotopic heart transplant, and for sepsis with associated left ventricular dysfunction. The indications for conversion were bleeding from cannulation site (n=2, 66%) and an anticipated prolonged ECMO run (n=1, 33%). For all three patients, the method of conversion was cutdown with femoral arterial repair followed by placement of additional jugular venous cannulas (n=2, 66%) or insertion of a singular jugular bicaval venous cannula with removal of the femoral cannulas (n=1, 33%). The median time on VA ECMO prior to conversion was 8 days (range 4-54 days). All 3 patients were managed with renal replacement therapy with 1 patient (33%) progressing to long term dialysis. There were no significant ischemic limb complications although one (33%) patient developed a femoral artery pseudoaneurysm that required re-operation. Two of the three patients (66%) were able to be decannulated at a median of 23.5 days (range 8-39 days) following conversion to VV ECMO and survived to discharge. The other patient was unable to be decannulated after successful conversion and care was withdrawn. Conclusion(s): Based on this small pilot study, conversion to VV ECMO from initial femoral VA ECMO cannulation is safe and feasible. Indications for conversion include coagulopathy and need for extended ECMO run after recovery of cardiac function.
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Intro: Multisystem Inflammatory Syndrome in Children (MIS-C) is a post-infectious inflammatory response after exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which can cause acute cardiac dysfunction requiring mechanical circulatory support (MCS). MCS utilization for MIS-C is complicated by a propensity for thrombosis, which threatens circuit integrity. This study describes a cohort of MIS-C patients requiring MCS, their outcomes, and the anticoagulation strategies utilized. Method(s): A retrospective case series of patients diagnosed with MIS-C needing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) at Children's Healthcare of Atlanta from March 1, 2020 to June 30, 2022. VA-ECMO variables, laboratory data, complications, and outcomes were collected. Result(s): Seven patients (all male) with severe MIS-C required VA-ECMO for acute cardiac dysfunction. Median age was 13 years (range 4-15 years). Median ICU stay was 13 days (range 6-17 days) with a median ECMO duration of 7 days (IQR 3-8 days) and median mechanical ventilation duration of 8 days (IQR 5-11 days). All seven patients survived to hospital discharge with good neurologic outcomes. Median time to qualitatively normal ventricular function by echocardiogram was 9.5 days (IQR 3-21 days). Heparin was initially used in 6 patients, bivalrudin initially used in 1 patient, and 1 patient converted from heparin to bivalirudin for refractory systemic thrombosis. Median heparin dose was 206u/kg/d (IQR 192-276u/kg/d) with median anti-Xa levels of 0.75 (IQR 0.1-1.1) and median daily PTT 102 seconds (IQR 83-107 seconds). Median daily PTT of patients receiving bivalirudin was 86 seconds (80-93 seconds). Median R-values by thromboelastography were 38 seconds (IQR 25-55 seconds). Two patients required catheter directed thrombolysis with tissue plasminogen activator (t-PA) for refractory intracardiac thrombi, both were initially started on heparin. Significant cannula thrombosis occurred in 2 patients, 1 initially started on heparin and 1 initially on bivalrudin. Bleeding resulting in compartment syndrome occurred in one patient on heparin requiring fasciotomy of the upper extremities, this patient was not receiving t-PA. Conclusion(s): Anticoagulation management for MIS-C patients requiring ECMO is fraught with challenges. A successful management strategy may necessitate higher heparin assay levels, the use of direct thrombin inhibitors for refractory thrombosis, and the deployment of catheter directed thrombolysis. In this case series, CDT was safely and successfully used in two patients. Further studies are required to understand the optimal anticoagulation strategy for these patients to minimize complications.
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Case Presentation: A 10 year old male with prior COVID-19 exposure presented with 7 days of fever, rash, cough, vomiting, and hypotension. Laboratory evaluation was notable for SARS-CoV2 antibodies, elevated cardiac enzymes, BNP, and inflammatory markers. Initial echocardiogram showed normal cardiac function and a small LAD coronary aneurysm. He was diagnosed with Multisystemic Inflammatory Syndrome in Children (MIS-C) and given methylprednisolone and IVIG. Within 24 hours, he developed severe LV dysfunction and progressive cardiorespiratory failure requiring VA-ECMO cannulation and anticoagulation with bivalirudin. Cardiac biopsy demonstrated lymphocytic infiltration consistent with myocarditis. On VA-ECMO, he had transient periods of complete AV block. With immunomodulator treatment (anakinra, infliximab) and 5 days of plasmapheresis, inflammatory symptoms and cardiac function improved. He weaned off ECMO, and anticoagulation was transitioned to enoxaparin. He had left sided weakness 5 days later, and brain MRI revealed an MCA infarct. Ten days later, he had focal right sided weakness and repeat MRI showed multiple hemorrhagic cortical lesions, thought to be thromboembolic with hemorrhagic conversion secondary to an exaggerated inflammatory response to an MSSA bacteremia in the setting of MIS-C. Enoxaparin was discontinued. After continued recovery and a slow anakinra and steroid wean, he has normal coronary arteries, cardiac function, and baseline ECG but requires ongoing neurorehabilitation. Discussion(s): COVID-19 infection in children is often mild, but MIS-C is an evolving entity that can present with a wide range of features and severity. This case highlights two concepts. While first degree AV block is often reported in MIS-C, there is potential for progression to advanced AV block. Close telemetry monitoring is critical, especially if there is evidence of myocarditis. MIS-C shares features with Kawasaki disease, with a notable difference being a higher likelihood of shock and cardiac dysfunction in MIS-C. In MIS-C patients with cardiovascular collapse requiring ECMO, there is a risk for stroke. There should be a low threshold for neuroimaging and multidisciplinary effort to guide anticoagulation in these complex cases.
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Background: Eosinophilic myocarditis is a rare inflammatory cardiomyopathy with a poor prognosis. SARS-CoV-2 (COVID-19) illness has been associated with myocarditis, particularly of lymphocytic etiology. Although there have been cases of eosinophilic myocarditis associated with COVID-19 vaccination, there have been few reported cases secondary to COVID-19 illness, with the majority being diagnosed via post-mortem autopsy. Case: A 44-year-old woman with no significant medical history other than recent COVID-19 illness 6 weeks prior presented with progressive dyspnea. Patient developed acute dyspnea and diffuse pruritic rash after taking hydroxyzine. Labs were significant for mild eosinophilia. Echocardiography showed biventricular systolic dysfunction with left ventricular ejection fraction of 40%, and a moderate pericardial effusion that was drained percutaneously. She underwent left heart and right heart catheterization showing elevated biventricular filling pressures, Fick cardiac index of 1.6 L/min/m2, and no coronary disease. She was started on intravenous diuretics and transferred to our facility for further management. Her course was complicated by cardiogenic shock requiring intra-aortic balloon pump (IABP) support. Mixed venous saturations continued to decline and the patient was placed on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. The patient underwent endomyocardial biopsy (EMB) showing marked interstitial infiltration of eosinophils and macrophages with myocyte injury (see image). She was intubated with mechanical ventilation as well due to worsening pulmonary edema and hypoxemia. She was started on intravenous steroids with improvement of hemodynamics and myocardial function and eventually VA- ECMO was decannulated to low-dose inotropic support which in turn was ultimately weaned after 3 days of mechanical support. Conclusion(s): Eosinophilic myocarditis is a rare and under-recognized sequela of acute COVID-19 infection associated with high mortality rates. It requires prompt diagnosis and aggressive supportive care, including temporary mechanical circulatory support. There are few literature-reported cases of COVID-19 myocarditis requiring use of both IABP and VA-ECMO, none of which were used in biopsy-proven eosinophilic myocarditis, with most of these cases resulting in either fatal or unreported outcomes. Most cases of covid myocarditis required IV glucocorticoids therapy in conjunction with IVIG or interferon therapy. Here, we present a rare case of cardiogenic shock secondary to biopsy-proven eosinophilic myocarditis associated with recent COVID-19 illness with a survival outcome after temporary use of IABP and VA-ECMO support, as well as aggressive immunosuppressive therapy.Copyright © 2022
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Background: The role of genetic conditions in the development of cardiomyopathy is well established;however, recognition and referral for genetic testing remains underutilized. Systematic review of complex cases can increase general awareness in this area of practice. Here we describe the case of a patient with resolved severe stress induced cardiomyopathy (SIC), who was ultimately found to have heterozygous transthyretin-mediated amyloidosis (TTRA). Case: A 27-year-old man (family history positive for a brother status post heart transplant) presented with ataxia and cough due to legionella pneumonia. TTE showed left ventricular (LV) diastolic diameter of 6.2cm, LV ejection fraction 20-25%. He suffered rapid decompensation with mixed cardiogenic/septic shock requiring peripheral VA ECMO and Impella-CP placement. Course notable for brief cardiac arrest on hospital day (HD) 2, incidental diagnosis of COVID 19 on HD 14, conversion to VV ECMO on HD 15, and ECMO decannulation on HD 23. Repeat TTE prior to discharge showed normalization of biventricular function. Discussion(s): Despite resolution of refractory shock and normalization of biventricular function prior to discharge, the TTE finding of mild LV dilation and strong family history prompted outpatient pursuit of genetic testing which revealed a heterozygous TTRA mutation (val142ile). Work-up to assess cardiac involvement included: a 99m-technetium pyrophosphate scintigraphy found to be indeterminate, an aborted endomyocardial biopsy due to inability to smoothly advance a bioptome (presumably related to ECMO cannulation), and a cardiac MRI (pending at the time of this submission). If a cardiac phenotype is discovered, the patient will be started on targeted treatment of cardiac amyloid. Screening of first-degree family members has been initiated. Conclusion(s): Given the current state of under-diagnosis of genetic cardiomyopathies and its association with significant morbidity and mortality, it is prudent to consider genetic testing in young patients based on clinical history. Examples of clinical scenarios to prompt further testing include: anatomical findings (i.e. cardiac chamber enlargement, left ventricular hypertrophy), family history of cardiomyopathy, or clinical markers suggestive of alternative diagnoses (i.e. neuropathy, renal insufficiency, mediastinal lymphadenopathy). This thoughtful and algorithmic use of genetic testing may help improve long-term patient outcomes given improvements in both detection, family screening, and treatment for disease-specific cardiomyopathies.Copyright © 2022
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Background The prevalence of anxiety and depression has increased following the COVID pandemic. Young women are disproportionally at risk of suicidal behaviors. Ingestion of Taxus baccata (English Yew) may lead to cardiotoxicity and death. Intoxication is known to be resistant to standard treatments with no effective antidotes. Case A 20-year-old female with a history of major depressive disorder presented to our emergency department unresponsive in pulseless ventricular tachycardia (VT) (figure 1A). She underwent CPR and achieved ROSC, however, was persistently hypotensive despite multiple pressors and was subsequently placed on VA ECMO. Review of a home journal revealed a plan to ingest 50 grams of Yew with suicidal intent. Decision-making Taxoids have been reported to have similar properties to digoxin and therefore digoxin-specific FAB antibodies were administered. She was also started on amiodarone and lidocaine for management of VT. After 3 hours she converted into sinus rhythm and had no further episodes of VT. Her clinical course was complicated by severe LV dysfunction and dilation while on VA-ECMO necessitating placement of an LV impella. By day three, all mechanical support was weaned off and she had normalization of her EF. Patient was discharged to an inpatient psychiatry facility on day 7 of hospitalization. Conclusion Ingestion of English Yew with suicidal intent is rare but may cause cardiogenic shock and VT requiring aggressive hemodynamic support until the toxin is metabolized. [Formula presented]Copyright © 2023 American College of Cardiology Foundation
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Background: Little is known on the impact of COVID-19-associated intensive care medical therapy including extracorporeal life support/membrane oxygenation (ECMO) on the long-term well-being of survivors. The aim of this study is to comprehensively characterize recovery six months after ECMO treatment for COVID-19-associated pulmonary failure. Method(s): All patients requiring veno-venous or veno-arterial ECMO for COVID-19-associated respiratory and/or circulatory failure between April 2020 and September 2021 were included in this retrospective analysis. Parameters included age, gender, time of ECMO treatment, and survival at hospital discharge and 6 months post-ECMO initiation. Comprehensive follow-up covering cardiopulmonary, neurocognitive, psychological, and functional status, as well as the health-related quality of life was assessed in discharged survivors. Result(s): Sixty patients (median age: 60.5 [51.0-65.0] years, range: 20-72 years, 23.3% female) were treated with venovenous or veno-arterial ECMO for severe COVID-19-related pulmonary failure with or without associated circulatory failure. 41.7% (n = 25) were successfully weaned off ECMO after 24.0 (17.5-32.5, range: 10-65) days, and 40.0% (n = 24) survived to hospital discharge. At 6 months post ECMO initiation, 20 patients were alive (33.3% of all patients, 83.3% survival conditioned on survival to discharge). Of these, 19 underwent comprehensive follow-up after 6.0 (5.0-9.0) months (133 months of cumulative follow-up time). 57.9% showed no relevant or only mild deficits, while 26.3% showed moderate, and 15.8% severe deficits. Cardiopulmonary status (mMRC level: 2.0 [1.0-2.0], 84.2% <= 2, NYHA level 2.0 [2.0-3.0], no patient in need of home oxygen) and level of independence (73.7% with no or mild disability and independent in daily life) were satisfactory. The rate of cognitive impairments was substantial (52.6%). In 21.1%, minimal or slight depression was observed, in 26.3% moderate depression, and 15.8% showed signs of post-traumatic stress disorder. Altogether, marked impacts on social and work life were observed. Conclusion(s): ECMO can serve as a salvage therapy for patients with severest COVID-19-related pulmonary failure, but the total burden of deficits six months after ECMO initiation is substantial with effects on social life and work status. The focus of our efforts thus needs to shift from solely acute survival to meaningful long-term recovery.
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Background Indications and practice of extracorporeal membrane oxygenation (ECMO) use in pregnant patients are known;however, there is minimal evidence outside of meta-analysis and case series that comprehensively documents the outcomes. This study systematically evaluates the outcomes of ECMO utilization for peripartum patients in the setting of respiratory and/or cardiovascular failure. Methods All peripartum patients from 2018 to 2021 from a single center were screened to see if ECMO was initiated in the setting of cardiac, pulmonary, or combined failure. 15 patients met inclusion criteria of requiring ECMO while pregnant or up until 6 weeks postpartum. The patient demographics;operative details;ECMO registry data;critical care characteristics;adverse events per the codes for extracorporeal life support complications;and adverse outcome for maternal, fetus, and neonates were all collected. Results The cohort studied had a mean age of 30.3 years old, was racially diverse, and had few preexisting medical conditions before pregnancy. ECMO was indicated in 10/15 patients due to COVID-19 and 4/15 patients due to cardiac disease. ECMO was intended to be a bridge to recovery for 14/15 patients of which 11/14 patients recovered to discharge. The temporary ventricular decompression therapies used in VA ECMO patients were limited to the Protek Duo Right Ventricular Assist Device and TandemHeart device. No patients required transplantation or a durable mechanical device. Notable complications: 1 intrauterine fetal demise from placental malperfusion before ECMO was started;4 maternal deaths, of which 3 were related to ECMO;4 cardiac arrest events;1 limb ischemia event after ECMO cannulation;4 cannulation site hematomas;0 cannulation site hemorrhage;1 cardiac arrhythmia event;2 patients comprised all the intracranial hemorrhage events;and 2 patients comprised all the Gastrointestinal hemorrhage events. Conclusion To our knowledge;this is the first comprehensive documentation of adverse events in peripartum patients describing maternal, fetal, neonatal, and ECMO related outcomes. This data provides a standard format to evaluate risks of ECMO use in peripartum patients.Copyright © 2023 American College of Cardiology Foundation
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Case Report: Purpose: Milrinone is an inodilator that is used in the treatment of cardiogenic dysfunction and shock. It causes increased cardiac output by stimulating myocardial contractility, enhancing cardiac relaxation, and reducing afterload via phosphodiesterase III inhibition, preventing cyclic adenosine monophosphate (cAMP) degradation. Increased cAMP concentrations are known to inhibit platelet aggregation. Veno-arterial-extracorporeal membrane oxygenation (VA-ECMO) is an extracorporeal treatment option for inotrope-refractory cardiogenic shock and is often used in conjunction with inodilators. Often, patients supported on ECMO require systemic anticoagulation to prevent clotting complications. Therefore, thromboelastography (TEG) with platelet mapping is used to help gauge a patient's clotting status and gives clinicians information about the degree of platelet inhibition present. We present the case of two patients, both supported on VA-ECMO, who developed platelet inhibition with clinically significant bleeding while on milrinone, requiring the cessation of the milrinone infusion. Cases: First, we present an adult female in her fourth decade of life who required VA-ECMO for Covid-19 ARDS and cardiogenic shock. TEG platelet mapping was obtained for clinically significant bleeding from her trachea and gastrointestinal tract. Ten days after starting milrinone, adenosine-5'-diphosphate (ADP) inhibition was elevated at 67.4% and arachidonic acid (AA) inhibition normal at 1.8%. Twenty days after starting milrinone, ADP inhibition was 93.3% and AA inhibition was 76.4%. Milrinone discontinued and repeat TEG platelet mapping (10 days after discontinuation) showed ADP inhibition of 76.8% and AA inhibition of 0%. Her lowest ADP inhibition was 41.9%, approximately 1 month after milrinone discontinuation. Milrinone again attempted and ADP inhibition was 87.9% and AA inhibition 89.2% within 24 hours of initiation. No data available for platelet inhibition prior to starting milrinone. Next, we present a 9 year old female with acute myeloid leukemia who required VA-ECMO for septic shock. Initial TEG platelet mapping, obtained 2 days after milrinone initiation, showed ADP inhibition of 43.6% and AA inhibition of 98.7%. Two days after discontinuation of milrinone, her ADP inhibition was 19.6% but AA inhibition remained elevated at 91.9%. However, after 4 days off milrinone, her ADP inhibition was normal at 15.5% and AA inhibition mildly elevated at 33.6%. No data available for platelet inhibition prior to starting milrinone. Conclusion(s): Milrinone is a known platelet inhibitor due to increased intracellular cAMP concentrations. For patients on ECMO and milrinone, care should be given to the degree of platelet inhibition and potential risk of clinically significant bleeding. Further studies are needed to further investigate the correlation between milrinone, platelet inhibition, and clinically significant bleeding in ECMO patients. Copyright © 2023 Southern Society for Clinical Investigation.
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SESSION TITLE: Impact of Health Disparities and Differences SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Vulnerable patients, including minorities and underserved populations whose care relies on public hospitals, have limited access to advanced cardiac or respiratory care in shock centers or extracorporeal membrane oxygenation (ECMO)-capable hospitals, especially when socioeconomic or insurance barriers play a role in patient selection. Our aim is to describe the implementation of an ECMO program for cardiac and respiratory failure during the COVID-19 pandemic in the largest public health system in the country, as a strategy to mitigate healthcare disparities and improve access to care for minorities. METHODS: We collected clinical, demographic and socioeconomic data of all patients undergoing ECMO at Bellevue Hospital Center, the shock and ECMO center for New York City’s Health and Hospitals’ network. This public health system includes 11 Hospitals and provides care to 1 million New Yorkers. The decision to proceed with ECMO took place with a multidisciplinary team discussion, which was also in charge of providing longitudinal care during their hospitalization. RESULTS: A total of 49 patients were included [30 veno-venous (VV) ECMO, 19 venoarterial (VA) ECMO, including 9 extracorporeal cardiopulmonary resuscitation (ECPR)] from April 1st, 2020 to March 30th, 2022. The median age was 42.6 years, 57% were male, 38% were Hispanic, 35% African American, 14% white, 6% Asian and 8.2% had other ethnicities;33% were uninsured, 49% lived below the poverty level reported for New York City and 20% were undocumented. Level of education was 8th grade or less in 2.1%, high school in 24.5%, ≤ 2 years of college in 10.2%, >4 years of college in 12.2% and unknown in 51%. ECMO survival was 56% for VV ECMO, 44% for VA ECMO and 33% for ECPR. Survival to discharge was 56% for VV, 33% for VA and 33% for ECPR. One VV ECMO patient was bridged to lung transplant, there were no patients bridged to LVAD or heart transplant. Bleeding complications occurred in 3 patients (6%) and there were no procedural related complications. CONCLUSIONS: Our multidisciplinary ECMO program demonstrates feasibility to provide care to underserved and vulnerable populations with outcomes comparable to the national average, despite the challenges related to the potential limitations in bridging strategies for such patients. While socioeconomic and insurance status have a key role in bridging options for ECMO, they should not be a major determinant in denying patients advanced cardiopulmonary support if clinically indicated. CLINICAL IMPLICATIONS: Access to advance cardiorespiratory therapies including ECMO for vulnerable populations is a present need and is feasible with a multidisciplinary team DISCLOSURES: Speaker/Speaker's Bureau relationship with Zoll Please note: 3 years Added 04/04/2022 by Carlos Alviar, value=Honoraria No relevant relationships by Fariha Asef No relevant relationships by Sripal Bangalore No relevant relationships by Samuel Bernard No relevant relationships by Lauren Bianco No relevant relationships by Nishay Chitkara No relevant relationships by Jennifer Cruz No relevant relationships by Michael DiVita Research support relationship with Eurofins Viracor Please note: 12/1/2021 ongoing Added 12/23/2021 by Randal Goldberg, value=Grant/Research Support No relevant relationships by Kerry Hena No relevant relationships by William Howe No relevant relationships by Norma Keller no disclosure on file for Ma-Rosario Mertola;no disclosure on file for Thor Milland;No relevant relationships by vikramjit mukherjee No relevant relationships by Kayla Nunemacher No relevant relationships by Mansi Patel No relevant relationships by Radu Postelnicu No relevant relationships by Deepak Pradhan No relevant relationships by Vito Stasolla no disclosure on file for Amit Uppal;No relevant relationships by Susan Vlahakis No relevant relationships by Kah Loon Wan no disclosure on file for Victoria Yunaev;
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SESSION TITLE: Extraordinary Cardiovascular Reports SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: The COVID-19 pandemic has resulted in millions of deaths worldwide. Many cases involved a primary pulmonary process, yet myocarditis associated with COVID-19 has been observed.1 We present a novel case of rapidly progressive fulminant peri-myocarditis with minimal lung involvement in acute COVID-19 infection. CASE PRESENTATION: A 39-year-old female with no medical history presented with chest pain and dyspnea with an acute COVID-19 infection. She had a brief cardiac arrest with rapid ROSC and no intubation. Chest CT angiogram showed essentially normal pulmonary parenchyma and moderate pericardial effusion. EKG showed sinus tachycardia with global ST segment elevation. An echocardiogram showed an ejection fraction (EF) of 25% with a moderate sized pericardial effusion and right ventricle collapse. She was transferred for emergent drainage of the effusion to our institution. Her circulatory shock initially improved following pericardial drainage, yet she declined warranting increasing vasopressor and inotropic support. An emergent echo showed an EF of less than 10% and no re-accumulation of pericardial fluid. It was clear that the patient required mechanical circulatory support (MCS) and was transferred to the catheterization lab. While in the lab, the patient suffered cardiac arrest and an Impella device was placed during prolonged ACLS without achieving ROSC. Venoarterial ECMO cannulation was then performed. She was transferred to a cardiac transplant center where she later developed multi-organ failure leading to death. DISCUSSION: While COVID-19 has been shown to affect multiple organs apart from the lungs, this case was notable due to minimal pulmonary involvement. The patient's manifestation of her infection was almost entirely cardiac in nature. MCS was discussed in the catheterization lab at the time of pericardial drain insertion. The decision was made to not pursue MCS as the patient's shock had improved. Additionally, the patient did not undergo pulmonary arterial catheter (PAC) placement. Prompt placement of a PAC has been associated with early access to MCS and reduced in-hospital mortality.2 Perhaps we would have obtained MCS earlier if PAC data supported this intervention before the patient deteriorated. It will be important to consider primary cardiac manifestations of COVID-19 infection and early consideration of invasive hemodynamic monitoring to identify a need for timely MCS. CONCLUSIONS: We present the first reported case of fulminant peri-myocarditis in the absence of acute hypoxemic respiratory failure or radiographic pulmonary parenchymal lung abnormality. Isolated rapidly progressive cardiogenic shock secondary to COVID-19 associated peri-myocarditis is a phenomenon important for critical care clinicians to be aware of during this pandemic. One should have a low threshold to establish invasive hemodynamic monitoring and consideration for early MCS in these cases. Reference #1: Siripanthong B, Nazarian S, Muser D, et al. Recognizing COVID-19-related myocarditis: The possible pathophysiology and proposed guideline for diagnosis and management. doi:10.1016/j.hrthm.2020.05.001 Reference #2: Osman M, Syed M, Patel B, et al. Invasive Hemodynamic Monitoring in Cardiogenic Shock Is Associated With Lower In-Hospital Mortality. Journal of the American Heart Association J Am Heart Assoc. 2021;10:21808. doi:10.1161/JAHA.121.021808 DISCLOSURES: No relevant relationships by Samuel Bullick No relevant relationships by Jonathan Greenberg No relevant relationships by Scott Slusarenko
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SESSION TITLE: Not the Normal Host: Infections Still Matter SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: Utilization of ECMO support for refractory cardiogenic, and respiratory failure has increased exponentially over the last 20 years. The advent of miniaturized and portable machines has led to a shift of cannulation strategies in the operating room/cath lab to the bedside. Transitioning to bedside cannulation has been previously reported as safe, with minimal risk for mortality or catheter site infections. However, bedside cannulations in the critically ill crashing patient raises concern for sterility. The aim of this study was to assess the risk of ECMO cannula site infections in bedside vs operating room/catheterization suite. METHODS: It is a retrospective single institution case series review of 52 adult and pediatric patients who were required either Veno-Venous (VV) or Veno-Arterial (VA) ECMO. Data gathering was used to quantify the rate of catheter site infections after initiation of extracorporeal support. Catheter site infections were defined as localized erythema, fluctuance, or purulence from the cannula site within 7 days of of ECMO cannula placement. RESULTS: A total of 42 (81%) pts had bedside cannulation, and the other 10 (19%), were done in IR suite/cath lab. The total number of catheter site infections was 1 (2.4%) in the bedside cannulation group. There were no infections in the non-bedside cannulation groups. 13 (30%) of the bedside cannulations, and 3 (30%) of the non-bedside cannulation group were on antibiotics during or prior to cannula insertion. CONCLUSIONS: Current literature suggests that the prevalence of infections on ECMO is 10-12%,. Traditionally, this has predisposed most cannulations to be performed in the surgical setting rather than at bedside. During the recent COVID pandemic, the frequency of bedside cannulation for ECMO had increased and was not associated with significant morbidity, and mortality. The risk of infection from the catheter site had also been determined to be minimal to none. From the data gathered above, it can be safely assumed that the risk of catheter site infection with bedside cannulation is minimal. However, the major contributing factor to decreased infection risk appears to be meticulous cannula site nursing care. The current ECMO nursing protocol utilized at our hospital required twice daily dressing changes with stringent chlorhexidine cleanses prior to redressing. The only case of catheter site infection we experienced was when this protocol was deviated. CLINICAL IMPLICATIONS: Utilizations of bedside ECMO cannulation techniques carries minimal risk for catheter site infections. It is important to state that nursing driven protocols for cannula site dressing changes, has one of the biggest implications on the risk of catheter site infections. Therefore, with the employment of appropriate nursing protocols, the concern for catheter site infections should not preclude the decision to proceed with bedside cannulation. DISCLOSURES: No relevant relationships by Ajit Alexander No relevant relationships by Melodie Blackmon Scientific Medical Advisor relationship with ALung Technologies, Inc. Please note: $5001 - $20000 by Steven Conrad, value=Consulting fee No relevant relationships by ANIBAL DOMINGUEZ no disclosure on file for Jonathan Eaton;No relevant relationships by Laurie Grier No relevant relationships by Rajkamal Hansra No relevant relationships by Prathik Krishnan No relevant relationships by Nathaniel LSUHSC-Shreveport No relevant relationships by Alex Manuel No relevant relationships by Jonathan Packer No relevant relationships by arunima sharma no disclosure on file for Chris Trosclair;No relevant relationships by Gregory Vo No relevant relationships by Robert Walter
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SESSION TITLE: ECMO and ARDS in COVID-19 Infections SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: The purpose of the study is to determine the incidence of bloodstream infections in COVID19 patients treated with ECMO in relation to steroid days and days of ECMO cannulation. METHODS: Retrospective analysis of data for COVID19 patients treated with ECMO in a tertiary academic medical center from January 2020 until July 2021 was performed. Data including baseline patients’ characteristics, type, and duration of ECMO support, type and days of steroids used, blood culture results, and organism type were collected. An institutional review board (IRB) approval was obtained before data collection. A two-tailed T-test was used to calculate the P-value, P-value of <0.05 was considered significant. RESULTS: A Total of 34 patients were analyzed, 3 of them were on (Veno-Arterial) VA ECMO and 31 on (Veno-Venous) VV ECMO, 32 out of 34 (94%) patients received steroids (Dexamethasone alone 16 patients, Methylprednisolone 1 patient and 15 patients received multiple steroid types). Seventeen patients had positive blood cultures (50%), average steroid days for patients with positive blood cultures was 21.6 days compared to 11.8 days for patients with negative blood cultures (P-Value:0.01), Average ECMO days for patients with positive blood cultures was 40.5 days compared to 18.8 days for patients with negative blood cultures ( P-Value:0.01). Staphylococcus epidermidis was found in 47% of the cultures, Enterococcus Faecalis was found in 24% of cultures while MRSA, MSSA, and Candida Albicans were found in 6% of cultures. CONCLUSIONS: Bloodstream Infections during ECMO cannulation are common and carry significant morbidity and mortality in patients. Longer ECMO days and longer duration of steroid use were found to be associated with higher rates of bloodstream infections in our patient’s sample. This could be related to the instrumentation risk or immunosuppression from steroids or other factors not evaluated in this study. CLINICAL IMPLICATIONS: Bloodstream infections are common in patients treated with ECMO, the risk of infections increases with longer ECMO and steroid days. Knowledge of such risks and trying to minimize them such as cautious use of steroids might help in the prevention of infections. Further studies are needed to better assess this risk. DISCLOSURES: No relevant relationships by Varun Halani No relevant relationships Added 03/21/2022 by Ghassan Kamel, value=Honoraria Removed 03/21/2022 by Ghassan Kamel No relevant relationships Added 03/22/2022 by Ghassan Kamel, value=Honoraria Removed 03/22/2022 by Ghassan Kamel No relevant relationships by Ahmad Sharayah