Impact of extracorporeal membrane oxygenation-related complications on in-hospital mortality.

INTRODUCTION: Although extracorporeal membrane oxygenation (ECMO) is a well-established treatment for supporting severe cardiopulmonary failure, the morbidity and mortality of patients requiring ECMO support remain high. Evaluating and correcting potential risk factors associated with any ECMO-related complications may improve care and decrease mortality. This study aimed to assess the predictors of ECMO-related vascular and cerebrovascular complications among adult patients and to test the hypothesis that ECMO-related complications are associated with higher in-hospital mortality rates. METHODS: This single-center, retrospective study included 856 ECMO runs administered via cannulation of the femoral vessels of 769 patients: venoarterial (VA) ECMO (n = 709, 82.8%) and venovenous (VV) ECMO (n = 147, 17.2%). The study outcomes included the occurrence of ECMO-related vascular and cerebrovascular complications and in-hospital death. The association of ECMO-related complications with the risk of in-hospital death was analyzed. RESULTS: The incidences of ECMO-related vascular and cerebrovascular complications were 20.2% and 13.6%, respectively. The overall in-hospital mortality rate was 48.7%: 52.8% among VA ECMO runs and 29.3% among VV ECMO runs. Multivariable analysis indicated that age (P < 0.01), cardiopulmonary cerebral resuscitation (P < 0.01), continuous renal replacement therapy (P < 0.01), and initial platelet count [<50×103/µL (P = 0.02) and 50-100(×103)/µL (P < 0.01)] were associated with an increased risk of in-hospital death. ECMO-related vascular and cerebrovascular complications were not independently associated with higher in-hospital mortality rates for VA or VV ECMO runs. CONCLUSION: ECMO-related vascular and cerebrovascular complications were not associated with an increased risk of in-hospital death among adult patients.

Mechanical versus Bioprosthetic Aortic Valve Replacement in Patients Aged 50 to 70 Years.

Background: This study compared the outcomes of surgical aortic valve replacement (AVR) in patients aged 50 to 70 years based on the type of prosthetic valve used. Methods: We compared patients who underwent mechanical AVR to those who underwent bioprosthetic AVR at our institution between January 2000 and March 2019. Competing risk analysis and the inverse probability of treatment weighting (IPTW) method based on propensity score were employed for comparisons. Results: A total of 1,580 patients (984 patients with mechanical AVR; 596 patients with bioprosthetic AVR) were enrolled. There was no significant difference in early mortality between the mechanical AVR and bioprosthetic AVR groups (0.9% vs. 1.7%, p=0.177). After IPTW adjustment, the risk of all-cause mortality was significantly higher in the bioprosthetic AVR group than in the mechanical AVR group (hazard ratio [HR], 1.39; 95% confidence interval [CI], 1.07-1.80; p=0.014). Competing risk analysis revealed lower risks of stroke (sub-distributional hazard ratio [sHR], 0.44; 95% CI, 0.28-0.67; p<0.001) and anticoagulation- related bleeding (sHR, 0.35; 95% CI, 0.23-0.53; p<0.001) in the bioprosthetic AVR group. Conversely, the risk of aortic valve (AV) reintervention was higher in the bioprosthetic AVR group (sHR, 6.14; 95% CI, 3.17-11.93; p<0.001). Conclusion: Among patients aged 50 to 70 years who underwent surgical AVR, those receiving mechanical valves showed better survival than those with bioprosthetic valves. The mechanical AVR group exhibited a higher risk of stroke and anticoagulation-related bleeding, while the bioprosthetic AVR group showed a higher risk of AV reintervention.

The "Weekend Effect" in Extracorporeal Cardiopulmonary Resuscitation.

Background: The phenomenon known as the "weekend effect" impacts various medical disciplines. We compared outcomes between regular hours and off hours to investigate the presence of the weekend effect in extracorporeal cardiopulmonary resuscitation (ECPR). Methods: Between January 2018 and December 2020, 159 patients at our center were treated with veno-arterial extracorporeal membrane oxygenation (ECMO) for cardiac arrest. We assessed the time required for ECMO preparation, the rate of successful weaning, and the rate of in-hospital mortality. These factors were compared among regular hours ("daytime": weekdays from 7:00 AM-7:00 PM), off hours on weekdays ("nighttime": weekdays from 7:00 PM-7:00 AM), and off hours on weekends and holidays ("weekend": Fridays at 7:00 PM to Mondays at 7:00 AM). Results: The time from the recognition of cardiac arrest to the arrival of the ECMO team was shortest for the daytime group and longest for those treated over the weekend (daytime, 10.0 minutes; nighttime, 12.5 minutes; weekend, 15.0 minutes; p=0.064). The time from the ECMO team's arrival to ECMO initiation was shortest for the daytime and longest for the nighttime group (daytime, 13.0 minutes; nighttime, 18.5 minutes; weekend, 14.0 minutes; p=0.028). No significant difference was observed in the rate of successful ECMO weaning (daytime, 48.3%; nighttime, 39.5%; weekend, 36.1%; p=0.375). Conclusion: In situations involving CPR, the time to arrival of the ECMO team was longer during off hours. Furthermore, ECMO insertion required more time at night than during the other periods. These findings warrant specific training in decision-making and emergent ECMO insertion.

Clinical implications of pleural effusion following left ventricular assist device implantation.

BACKGROUND: Studies on the association between pleural effusion (PE) and left ventricular assist devices (LVADs) are limited. This study aimed to examine the characteristics and the clinical impact of PE following LVAD implantation. METHODS: This study is a prospective analysis of patients who underwent LVAD implantation from June 2015 to December 2022. We investigated the prognostic impact of therapeutic drainage (TD) on clinical outcomes. We also compared the characteristics and clinical outcomes between early and late PE and examined the factors related to the development of late PE. RESULTS: A total of 71 patients was analyzed. The TD group (n=45) had a longer ward stay (days; median [interquartile range]: 31.0 [23.0-46.0] vs. 21.0 [16.0-34.0], P=0.006) and total hospital stay (47.0 [36.0-82.0] vs. 31.0 [22.0-48.0], P=0.002) compared to the no TD group (n=26). Early PE was mostly exudate, left-sided, and neutrophil-dominant even though predominance of lymphocytes was the most common finding in late PE. Patients with late PE had a higher rate of reintubation within 14 days (31.8% vs. 4.1%, P=0.004) and longer hospital stays than those without late PE (67.0 [43.0-104.0] vs. 36.0 [28.0-48.0], P<0.001). Subgroup analysis indicated that female sex, low body mass index, cardiac resynchronization therapy, and hypoalbuminemia were associated with late PE. CONCLUSIONS: Compared to patients not undergoing TD, those undergoing TD had a longer hospital stay but not a higher 90-day mortality. Patients with late PE had poor clinical outcomes. Therefore, the correction of risk factors, like hypoalbuminemia, may be required.

Early left atrial venting versus conventional treatment for left ventricular decompression during venoarterial extracorporeal membrane oxygenation support: The EVOLVE-ECMO randomized clinical trial.

AIMS: Few studies have reported data on the optimal timing of left ventricular (LV) unloading during venoarterial extracorporeal membrane oxygenation (VA-ECMO) for cardiac arrest or shock. This study evaluated the feasibility of an early LV unloading strategy compared with a conventional strategy in VA-ECMO. METHODS AND RESULTS: Between December 2018 and August 2022, 60 patients at two institutions were randomized in a 1:1 ratio to receive early (n = 30) or conventional (n = 30) LV unloading strategies. The early LV unloading strategy was defined as LV unloading performed at the time of VA-ECMO insertion. LV unloading was performed using a percutaneous transseptal left atrial cannulation via the femoral vein incorporated into the ECMO venous circuit. The early and conventional LV unloading groups included 29 (96.7%) and 23 (76.7%) patients, respectively (median time from VA-ECMO insertion to LV unloading: 48.4 h, interquartile range 47.8-96.5 h). The groups showed no significant differences in the rate of VA-ECMO weaning as the primary endpoint (70.0% vs. 76.7%; relative risk 0.91; 95% confidence interval 0.67-1.24; p = 0.386) and survival to discharge (53.3% vs. 50.0%, p = 0.796). However, the pulmonary congestion score index at 48 h after LV unloading was significantly improved only in the early LV unloading group (2.0 ± 0.7 vs. 1.7 ± 0.6 at baseline vs. at 48 h; p = 0.008). CONCLUSIONS: Compared with the conventional approach, early LV unloading did not improve the VA-ECMO weaning rate, despite the rapid improvement in pulmonary congestion. Therefore, the results of this study do not support the application of this strategy after VA-ECMO insertion.

Comparison of Veno-arterial Extracorporeal Membrane Oxygenation Configurations for Patients Listed for Heart Transplantation.

BACKGROUND AND OBJECTIVES: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as a bridge to eventual heart transplantation (HT) is increasingly used worldwide. However, the effect of different VA-ECMO types on HT outcomes remains unclear. METHODS: This was a retrospective observational study of 111 patients receiving VA-ECMO and awaiting HT. We assessed 3 ECMO configuration groups: peripheral (n=76), central (n=12), and peripheral to central ECMO conversion (n=23). Cox proportional hazards regression and landmark analysis were conducted to analyze the effect of the ECMO configuration on HT and in-hospital mortality rates. We also evaluated adverse events during ECMO support. RESULTS: HT was performed in the peripheral (n=48, 63.2%), central (n=10, 83.3%), and conversion (n=11, 47.8%) ECMO groups (p=0.133) with a median interval of 10.5, 16, and 30 days, respectively (p<0.001). The cumulative incidence of HT was significantly lower in the conversion group (hazard ratio, 0.292, 95% confidence interval, 0.145-0.586, p=0.001). However, there was no difference in in-hospital mortality (log-rank p=0.433). In the landmark analysis, in-hospital mortality did not differ significantly among the 3 groups. Although we did note a trend toward lower HT in the conversion group, the difference was not statistically significant. Surgical site bleeding occurred mainly in the central, while limb ischemia occurred mainly in the peripheral groups. CONCLUSIONS: We suggest that if patients are being stably supported with their initial ECMO configuration, whether it is central or peripheral, it should be maintained, and ECMO conversion should only be cautiously performed when necessary.

Prognosis of Venoarterial Extracorporeal Membrane Oxygenation in Mixed, Cardiogenic and Septic Shock.

Mixed cardiogenic-septic shock (MS), defined as the combination of cardiogenic (CS) and septic (SS) shock, is often encountered in cardiac intensive care units. Herein, the authors compared the impact of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in MS, CS, and SS. Of 1,023 patients who received VA-ECMO from January 2012 to February 2020 at a single center, 211 with pulmonary embolism, hypovolemic shock, aortic dissection, and unknown causes of shock were excluded. The remaining 812 patients were grouped based on the cause of shock at VA-ECMO application: i) MS (n = 246, 30.3%), ii) CS (n = 466, 57.4%), iii) SS (n = 100, 12.3%). The MS group was younger and had lower left ventricular ejection fraction than the CS or SS group did. The 30 day and 1 year mortalities were the highest in SS (30 day mortality: 50.4% vs. 43.3% vs. 69.0%, p < 0.001 for MS versus CS versus SS, respectively; 1 year mortality: 67.5% vs. 53.2% vs. 81.0%, p < 0.001 for MS versus CS versus SS, respectively). Posthoc analysis showed that the 30 day mortality of MS was not different from CS, while the 1 year mortality of MS was worse than CS but better than SS. Venoarterial extracorporeal membrane oxygenation application for MS may help improve survival and should therefore be considered if indicated.

Role of extracorporeal membrane oxygenation as a salvage therapy for liver transplantation recipients in a high-volume transplant center.

Extracorporeal membrane oxygenation (ECMO) has been used sporadically in adult orthotopic liver transplantation (OLT) recipients for the treatment of acute cardiopulmonary failure. This retrospective study aimed to identify OLT patients who would benefit from ECMO support. We reviewed 109 OLT patients who received ECMO support for more than 24 h from January 2007 to December 2020. Among the enrolled patients, 15 (13.8%) experienced 18 ECMO-related complications and 12 (11.0%) experienced ECMO reapplication after weaning during the same hospitalization period. The successful weaning rates were 50.98% in patients who received ECMO support during the peritransplantation period (0-30 days from transplantation) and 51.72% in patients who received ECMO support in the post-OLT period (more than 30 days after OLT); 24 (47.1%) and 23 (39.7%) patients survived until hospital discharge, respectively. The 109 enrolled OLT recipients who received ECMO support during the perioperative period had a 1-year survival rate of 42.6%. Multivariate analyses identified the following as significant and independent risk factors for in-hospital mortality: ECMO treatment prior to 2011 ( p = 0.04), septic shock as the indication for ECMO treatment ( p = 0.001), and a total bilirubin level of ≥5.0 mg/dl ( p = 0.02). The outcomes of adult OLT recipients with ECMO treatment were acceptable in terms of weaning success and survival until hospital discharge. This study confirmed that ECMO treatment for OLT recipients with septic shock and elevated bilirubin levels might be associated with a higher in-hospital mortality and demonstrated the importance of a multidisciplinary ECMO team approach.

The feasibility of extracorporeal cardiopulmonary resuscitation for patients with active cancer who undergo in-hospital cardiac arrest.

Indications of extracorporeal cardiopulmonary resuscitation (ECPR) are still debatable, particularly in patients with cancer. Prediction of the prognosis of in-hospital cardiac arrest (IHCA) in patients with cancer receiving ECPR is important given the increasing prevalence and survival rate of cancer. We compared the neurologic outcomes and survival rates of IHCA patients with and without cancer receiving ECPR. Data from the extracorporeal membrane oxygenation registry between 2015 and 2019 were used in a retrospective manner. The primary outcome was 6-month good neurologic outcome, defined as a Cerebral performance category score of 1 or 2. The secondary outcomes were 1- and 3-month good neurologic outcome, and 6-month survival. Among 247 IHCA patients with ECPR, 43 had active cancer. The 6-month good neurologic outcome rate was 27.9% and 32.4% in patients with and without active cancer, respectively (P > 0.05). Good neurologic outcomes at 1-month (30.2% vs. 20.6%) and 3-month (30.2% vs. 28.4%), and the survival rate at 6-month (39.5% vs. 36.5%) were not significantly different (all P > 0.05) Active cancer was not associated with 6-month good neurologic outcome by logistic regression analyses. Therefore, patients with IHCA should not be excluded from ECPR solely for the presence of cancer itself.

Right Ventricular Assist Device With Extracorporeal Membrane Oxygenation for Bridging Right Ventricular Heart Failure to Lung Transplantation: A Single-Center Case Series and Literature Review.

OBJECTIVE: Right ventricular heart failure (RVHF) is a critical complication in patients with respiratory failure, particularly among those who transitioned to lung transplantation using venovenous (VV) extracorporeal membrane oxygenation (ECMO). In these patients, both cardiac and respiratory functions are supported using venoarterial or venoarterial-venous ECMO. However, these modalities increase the risk of device-related complications, such as thromboembolism, bleeding, and limb ischemia, and they may disturb early rehabilitation. Due to these limitations, a right ventricular assist device with an oxygenator (Oxy-RVAD) using ECMO may be considered for patients with RVHF with VV ECMO. DESIGN: A retrospective case series and literature review. SETTING: A single tertiary care university hospital. PARTICIPANTS: The study comprised lung transplantation candidates on ECMO bridging who developed right-sided heart failure. INTERVENTIONS: An RVAD with ECMO. MEASUREMENTS AND MAIN RESULTS: Of eight patients who underwent the study protocol, seven were bridged successfully to lung transplantation (BTT), and all patients with BTT were discharged, with a 30-day survival rate of 100% (7/7 patients). The 180-day survival rate was 85% (6/7 patients). CONCLUSIONS: The study suggested that Oxy-RVAD using ECMO may be a viable option for bridging patients with RVHF to lung transplantation. TRIAL REGISTRATION: Retrospectively registered.

Vasoactive-Inotropic Score as a Determinant of Timely Initiation of Venoarterial Extracorporeal Membrane Oxygenation in Patients With Cardiogenic Shock.

BACKGROUND: The predictive role of the vasoactive-inotropic score (VIS) for clinical outcomes after venoarterial extracorporeal membrane oxygenation (VA-ECMO) in patients with cardiogenic shock is not well known. This study investigated the predictive value of VIS on in-hospital outcomes and the determination of optimal timing for the initiation of VA-ECMO.Methods and Results:Overall, 160 patients with cardiogenic shock requiring VA-ECMO who were treated between December 2012 and August 2018 were analyzed. The in-hospital outcomes according to VIS were compared. Pre-ECMO VIS had an area under the receiver-operating characteristic curve (AUC) of 0.60 (P=0.03) for the prediction of in-hospital death. When the patients were divided into the high (≥32) and low (<32) VIS groups, the high VIS group had a higher rate of in-hospital death (P=0.002) and a lower rate of ECMO weaning (P=0.004). The difference in in-hospital death according to VIS was significant only in patients with a cardiogenic shock of non-ischemic etiology (P=0.01). Extracorporeal cardiopulmonary resuscitation (hazard ratio [HR], 1.99), age (HR, 1.02), pre-ECMO lactate (HR, 1.06), and VIS ≥32 (HR, 2.46) were independently predictive of in-hospital death. CONCLUSIONS: Among patients with cardiogenic shock requiring VA-ECMO, the initiation of VA-ECMO before reaching high VIS (≥32) showed better in-hospital outcomes, suggesting that VIS may be a potential marker for determining the initiation of hemodynamic support with VA-ECMO.

Experience of International Air Transportation and Subsequent Lung Transplant in a Patient with COVID-19-associated Acute Respiratory Distress Syndrome: a Case Report.

We report an inspiring case of a 55-year-old Korean female diagnosed with coronavirus disease 2019 (COVID-19)-associated acute respiratory distress syndrome (ARDS) in Mexico. The patient was assessed for lung transplant as a salvage therapy for treatment-refractory ARDS following no signs of clinical improvement for > 7 weeks, despite best treatment. The patient was transported from Mexico to Korea by air ambulance under venovenous extracorporeal membrane oxygenation (ECMO) support. She was successfully bridged to lung transplant on day 88, 49 days after the initiation of ECMO support. ECMO was successfully weaned at the end of operation, and no bleeding or primary graft dysfunction was observed within the first 72 hours. The patient was liberated from mechanical ventilation on postoperative day 9 and transferred to the general ward 5 days later. Despite the high doses of immunosuppressants, there was no evidence of viral reactivation after transplant. At 3 months post-transplantation, she was discharged to home without complication. Our experience suggests that successful lung transplant for COVID-19-associated ARDS is feasible even in a patient with prolonged pre-transplant ECMO support. Lung transplant may be considered a salvage therapy for COVID-19-associated ARDS that does not respond to conventional treatments.

Extracorporeal Membrane Oxygenation for Coronavirus Disease 2019: Expert Recommendations from The Korean Society for Thoracic and Cardiovascular Surgery.

Since the first reported case of coronavirus disease 2019 (COVID-19) in December 2019, the numbers of confirmed cases and deaths have continued to increase exponentially despite multi-factorial efforts. Although various attempts have been made to improve the level of evidence for extracorporeal membrane oxygenation (ECMO) treatment over the past 10 years, most experts still hesitate to take an active position on whether to apply ECMO in COVID-19 patients. Several ECMO management guidelines have been published recently, but they reflect some important differences from the Korean medical system and aspects of real-world medical practice in Korea. We aimed to find evidence on the efficacy of ECMO for COVID-19 patients by reviewing the published literature and to propose expert recommendations by analyzing the Korean COVID-19 ECMO registry data.

Outcomes of left ventricular unloading with a transseptal cannula during extracorporeal membrane oxygenation in adults.

We evaluated the benefit of left ventricular (LV) unloading using a percutaneous transseptal left atrial (LA) drain catheter via femoral vein incorporated into the ECMO venous circuit. This single-center retrospective observational study analyzed clinical outcomes of the LA venting group (N = 62) who underwent percutaneous transseptal LA drain placement comparing with the conventionally treated control group (N = 62) with an arterial pulse pressure below 10 mm Hg for at least 24 hours from December 2012 to August 2018. The ECMO weaning rate (61.3% vs. 38.7%, P = .012) and cardiac transplantation rate (29.0% vs. 11.3%, P = .014) were higher in the LA venting group than in the control group. Inhospital mortality was not significantly different (56.5% vs. 69.4%, P = .191). Pulmonary congestion mostly improved after LA decompression (61.3%, P = .003). A serum lactate level at 24 hours after LA venting of more than 2.2 mmol/L was associated with poor outcomes. LA venting via transseptal cannula reduced pulmonary venous congestion and achieved higher rates of successful ECMO weaning and cardiac transplantation. Placement of a transseptal venous drain cannula should be considered in patients with uncontrolled pulmonary edema secondary to severe LV loading undergoing VA-ECMO.

Epidemiology and Clinical Characteristics of Bloodstream Infection in Patients Under Extracorporeal Membranous Oxygenation.

BACKGROUND: Bloodstream infection (BSI) is an important complication of extracorporeal membranous oxygenation (ECMO) and a major cause of mortality. This study evaluated the epidemiological and clinical characteristics of BSI that occur during ECMO application according to microbial etiology. METHODS: Adult patients who underwent ECMO from January 2009 to December 2016 were retrospectively analyzed for BSI episodes at a 2,700-bed, tertiary center. Epidemiological and clinical characteristics and outcomes of BSI were evaluated and were compared for etiologic groups (gram-positive cocci, gram-negative rods, and fungi groups). Risk factors for 14-day mortality were analyzed. RESULTS: A total of 1,100 patients underwent ECMO during the study period, and 65 BSI episodes occurred in 61 patients. The BSI incidence was 8.3 episodes/1,000 ECMO days, which significantly decreased over time (P = 0.03), primarily in gram-positive cocci BSI. Gram-positive cocci, gram-negative rods, and fungi accounted for 38%, 40%, and 22% of the 73 blood isolates, respectively. Baseline characteristics were comparable between groups. Catheter-related infection (CRI) and pneumonia were the most common sources of BSI; 52% of gram-positive cocci BSIs and 79% of fungi BSIs were caused by CRI, and 75% of gram-negative BSIs by pneumonia. Patients with gram-negative rods BSI died more frequently and earlier than those with other BSIs. Independent risk factors for 14-day mortality were older age and gram-negative rods BSI. CONCLUSIONS: The decreased BSI incidence during ECMO was mainly because of the decrease of gram-positive cocci BSI. The high early mortality of gram-negative rods BSI makes prevention and adequate treatment necessary.

Eighteen Years of Follow-up after Resection of a Giant Coronary Artery Aneurysm and Reconstruction with a Vein Graft

Giant coronary artery aneurysms are rare and challenging to treat because of variation in the presenting symptoms and the lack of established management guidelines. We report the case of a patient with a 6-cm-wide giant coronary artery aneurysm that was resected, followed by reconstruction using a saphenous vein graft and 18 years of follow-up.

Transit Time Flowmetry and Vein Size Are Predictive of Arteriovenous Fistula Maturation.

BACKGROUND: This study aimed to assess the effect of vessel size and flow characteristics on the maturation of autogenous radiocephalic arteriovenous fistulae (RCAVFs). METHODS: We retrospectively reviewed records of patients undergoing RCAVF creation at a single medical center from January 2013 to December 2019. Operative variables were compared between patients whose fistulae matured and those whose fistulae failed to mature. RESULTS: Overall, 152 patients (33 of whom were women) with a mean age of 62.6±13.6 years underwent RCAVF creation; functional maturation was achieved in 123. No statistically significant differences were observed between patients in whom maturation was or was not achieved in terms of the following variables: female sex (20.3% vs. 25.0%), radial artery size (2.5 vs. 2.4 mm), and pulsatility index (0.69 vs. 0.62). Low intraoperative transit time flowmetry (TTF; 150.4 vs. 98.1 mL/min) and small vein size (2.4 vs. 2.0 mm) were associated with failure of maturation. The best cutoff diameter for RCAVF TTF and cephalic vein size were 105 mL/min and 2.45 mm, respectively. CONCLUSION: In patients who undergo RCAVF creation, vein diameter on preoperative ultrasonography and intraoperative TTF are predictors of functional maturation. We identified an intraoperative TTF cutoff value that can be used for intraoperative decision-making.

Influence of a high-intensity staffing model in a cardiac surgery intensive care unit on postoperative clinical outcomes.

OBJECTIVE: Various staffing models have been applied in intensive care units (ICUs) to improve outcomes. However, there is a lack of evidence regarding the effect of staffing models in cardiac surgery ICUs. Thus, we aimed to evaluate the efficacy of high-intensity staffing in cardiac surgery ICUs. METHODS: From January 2013 to December 2016, 4676 adult patients were admitted to our cardiac surgery ICU after surgery. Excluding patients undergoing minor surgery or noncardiac-related surgery, 4038 patients were analyzed. Beginning in January 2015, patients were divided into low-intensity group (n = 1784) and high-intensity group (n = 2254) according to the study period. Primary outcomes were ICU and hospital length of stay, rates of transfusion and infection, and readmission to the ICU. Secondary outcomes were 30-day and ICU mortality. To reduce potential confounders, propensity score-matched analysis was performed. RESULTS: In the high-intensity group, ICU and hospital length of stay were significantly shorter (P < .001). Incidence of readmission was lower in the high-intensity group (3.1% vs 12.5%; P < .05). Infection rate in respiratory tract and bloodstream was lower in the high-intensity group (3.1% vs 5.0%; P < .05). Transfusion rate and amount were also significantly lower in the high-intensity group (P < .05). However, 30-day (1.9% vs 2.1%; P = .71) and ICU mortality (2.1% vs 2.7%; P = .31) were comparable between the groups. CONCLUSIONS: High-intensity staffing model during daytime hours by cardiac surgery intensivists significantly improved ICU-related outcomes. However, high-intensity staffing did not affect early mortality after cardiac surgery.

Right ventricular assist device with an oxygenator using extracorporeal membrane oxygenation as a bridge to lung transplantation in a patient with severe respiratory failure and right heart decompensation.

Right heart decompensation is a fatal complication in patients with respiratory failure, particularly in those transitioned to lung transplantation using veno-venous extracorporeal membrane oxygenation (V-V ECMO). In these patients, veno-arterial (V-A ECMO) or veno-arterialvenous extracorporeal membrane oxygenation (V-AV ECMO) is used to support both cardiac and respiratory function. However, these processes may increase the risk of device-related complications such as bleeding, thromboembolism, and limb ischemia. In the present case, a 64-year-old male patient with idiopathic pulmonary fibrosis developed respiratory failure and commenced treatment with V-V ECMO as a bridge to lung transplantation. Unfortunately, the patient developed right heart decompensation and required both cardiac and respiratory support during treatment with V-V ECMO. Instead of adding arterial cannulation, he was switched to a novel configuration, a right ventricular assist device with an oxygenator (Oxy- RVAD) using ECMO, with drainage cannulation from the femoral vein and return cannulation to the main pulmonary artery. The patient was successfully bridged to lung transplantation without serious complications after 10 days of Oxy-RVAD support. To the best of our knowledge, this is an extreme rare and challenging case of Oxy-RVAD using ECMO in a patient successfully bridged to lung transplantation.

Use of extracorporeal membrane oxygenation in patients with acute high-risk pulmonary embolism: a case series with literature review.

BACKGROUND: Although extracorporeal membrane oxygenation (ECMO) has been used for the treatment of acute high-risk pulmonary embolism (PE), there are limited reports which focus on this approach. Herein, we described our experience with ECMO in patients with acute high-risk PE. METHODS: We retrospectively reviewed medical records of patients diagnosed with acute high-risk PE and treated with ECMO between January 2014 and December 2018. RESULTS: Among 16 patients included, median age was 51 years (interquartile range [IQR], 38 to 71 years) and six (37.5%) were male. Cardiac arrest was occurred in 12 (75.0%) including two cases of out-of-hospital arrest. All patients underwent veno-arterial ECMO and median ECMO duration was 1.5 days (IQR, 0.0 to 4.5 days). Systemic thrombolysis and surgical embolectomy were performed in seven (43.8%) and nine (56.3%) patients, respectively including three patients (18.8%) received both treatments. Overall 30-day mortality rate was 43.8% (95% confidence interval, 23.1% to 66.8%) and 30-day mortality rates according to the treatment groups were ECMO alone (33.3%, n=3), ECMO with thrombolysis (50.0%, n=4) and ECMO with embolectomy (44.4%, n=9). CONCLUSIONS: Despite the vigorous treatment efforts, patients with acute high-risk PE were related to substantial morbidity and mortality. We report our experience of ECMO as rescue therapy for refractory shock or cardiac arrest in patients with PE.