Same but Different-ECMO in COVID-19 and ARDS of Other Etiologies. Comparison of Survival Outcomes and Management in Different ARDS Groups.

Background: COVID-19 has led to increased numbers of patients in need of venovenous extracorporeal membrane oxygenation (ECMO) support, but knowledge on management in comparison to acute respiratory distress syndrome (ARDS) of other etiologies is still lacking. We analyzed venovenous ECMO management and survival outcomes in patients with COVID-19 in comparison to influenza ARDS and pulmonary ARDS of other origin. Results: Retrospective analysis of prospective venovenous ECMO registry-based data collection was performed. One hundred consecutive venovenous ECMO patients with severe ARDS were included (41 COVID-19, 24 influenza A, 35 ARDS of other etiologies). Patients with COVID-19 had higher BMI (body mass index), lower SOFA (Sequential Organ Failure Assessment) and APACHE II (Acute Physiology and Chronic Health Evaluation II) scores, lower C-reactive protein and procalcitonin levels and less vasoactive support at ECMO initiation. Significantly more patients were mechanically ventilated for more than 7 days prior to ECMO initiation in the COVID-19 group, however they were ventilated with lower tidal volumes and more often received additional rescue therapies prior to and on ECMO. COVID-19 patients had significantly more barotrauma and thrombotic events on ECMO. There were no differences in weaning of ECMO, however duration of ECMO runs and ICU length of stay was significantly longer in the COVID-19 group. The leading cause of death in the COVID-19 group was irreversible respiratory failure, while uncontrolled sepsis and multiorgan failure were leading causes in the other 2 groups. All patients who survived ICU treatment were discharged out of hospital, and there were no differences in survival among groups at 180 days. Conclusions: Survival outcomes of venovenous ECMO patients do not differ between COVID-19 and ARDS of other pulmonary etiologies. ARDS guidelines were in greater proportion adhered to in COVID-19 patients, with, however, longer time to ECMO initiation. COVID-19 ARDS seems specific as a more single-organ disease with longer ECMO duration and irreversible respiratory failure as a main cause of ICU mortality.

High fidelity ECMO simulation: a reality check with reality-use of simulation in ECMO teaching program.

Simulation based learning is becoming a crucial part in ECMO education. Simulation can provide a safe but also very realistic learning experience depending on simulation fidelity. In our institution we developed a simulation based ECMO training program that incorporates low- and high-fidelity simulation. Aim of this study was to evaluate effectiveness of low- and high-fidelity simulation teaching strategies in ECMO novices. We conducted four consecutive ECMO training courses that included fifty-one ECMO novices. We describe ECMO training execution and evaluate training effectiveness and perception by structured pre- and post-training questionnaires analysis. Results of our study show extremely high satisfaction rate with simulation training (4.9 ± 0.3, Lickert 5 point scale). High-fidelity simulation was perceived as very realistic and as such represents an important tool in learning immersion and experience. However, participants reported significant decline from their expectations with regard to structured approach to troubleshooting (4.7 ± 0.5 vs 4.3 ± 0.7, p = 0.02) and efficiency improvement (4.7 ± 0.5 vs 4.3 ± 0.6, p = 0.002) after high-fidelity simulation. There was also a significant decline from their expectation on self-confidence improvement (4.7 ± 0.5 vs 4.2 ± 0.7, p = 0.001). Our results therefore show, that complex high-fidelity simulation should probably be used with caution in novice participants, not to discourage them from further learning.

Cardiac Arrest and Inverted Takotsubo Cardiomyopathy Following Intramyometrial Vasopressin Injection During Myomectomy.

Vasopressin is involved in cardiovascular homeostasis that can influence coronary perfusion. It is commonly used as a local vasoconstricting agent during gynaecological procedures. We present a case of cardiac arrest and inverse Takotsubo features following intramyometrial vasopressin administration during myomectomy. The patient was successfully resuscitated and recovered completely. Cardiac presentation was compatible with inverse Takotsubo cardiomyopathy that could have been triggered by high-dose vasopressin-induced coronary vasoconstriction. The patient's cardiac function resolved with no long-term sequelae. Takotsubo cardiomyopathy usually results from an excessive catecholaminergic surge. High-dose vasopressin-induced coronary vasospasm could have been the mechanism underlying the clinical presentation in our patient. LEARNING POINTS: Local vasopressin administration during gynaecological procedures can result in rare but severe cardiovascular compromise.Takotsubo cardiomyopathy can result from multiple rare causes.High-dose vasopressin may cause Takotsubo cardiomyopathy features via coronary vasoconstriction.

Emergency percutaneous implantation of veno-arterial extracorporeal membrane oxygenation in the catheterisation laboratory.

AIMS: Our aim was to describe our protocol for emergency percutaneous implantation of femoral veno-arterial extracorporeal membrane oxygenation (VA ECMO) in the catheterisation laboratory and to compare its effectiveness and safety with implantation in the intensive care unit and the operating room. METHODS AND RESULTS: Our retrospective observational study enrolled 56 consecutive patients undergoing VA ECMO implantation in the catheterisation laboratory (n=23), the intensive care unit (n=8) and the operating room (n=25). Among patients undergoing catheterisation laboratory implantation, 11 patients had profound cardiogenic shock but preserved arterial pulsations, and 12 patients had refractory cardiac arrest undergoing automated mechanical chest compression. Using our fluoroscopy-guided protocol, arterial and venous cannulas were successfully implanted and the desired ECMO flow obtained in each patient. There was no vessel perforation/dissection. Moderate/severe GUSTO or BARC 3 and 5 bleeding occurred in 13%. Ipsilateral limb ischaemia occurred in one of eight patients (13%) with upfront perfusion sheath implantation, and in two of three patients (75%) in whom this strategy was not used (p=0.15). There was no infection at the site of cannula implantation. Complications related to implantation in the catheterisation laboratory were comparable to surgical implantation in the operating room and percutaneous implantation in the intensive care unit using ultrasound guidance. CONCLUSIONS: Fluoroscopy-guided emergency implantation of femoral VA ECMO by an interventional cardiologist in the catheterisation laboratory is effective and safe for both patients in cardiogenic shock and those in refractory cardiac arrest.

Extracorporeal life support: first year of experience implementing the technique in Slovenia.

Extracorporeal life support (ELS) is emerging as a standard treatment option for acute respiratory and/or cardiac failure. In this article we describe our first year of experience with ELS activity in adult medical patients in our center. Veno-venous extracorporeal membrane oxygenation (VV ECMO) support was applied in cases of severe acute respiratory distress syndrome (ARDS) not responsive to conventional treatments. The use of veno-arterial (VA) ECMO support was reserved for cases of cardiac shock refractory to standard treatment and cardiac arrests not responding to conventional resuscitation. A total of 19 patients were treated with ELS during the first year of activity. Eight of these received VV ECMO for ARDS of various etiologies, with a survival rate of 63%. Eleven patients received VA ECMO support due to cardiac failure (2 post-resuscitation). Survival in this group was 45%. We report our results, including complications and organizational issues that we encountered, and describe protocol improvements developed over the short period of time since ELS treatment has been implemented in our center.

Atorvastatin therapy may reduce the incidence of sudden cardiac death in patients with advanced chronic heart failure.

BACKGROUND: In retrospective studies, statin therapy has been related to decreased incidence of sudden cardiac death (SCD) in heart failure. We sought to prospectively investigate a relation between atorvastatin therapy and SCD in patients with advanced chronic heart failure. METHODS AND RESULTS: We enrolled 110 patients with heart failure with a left ventricular ejection fraction less than 30% and cholesterol level greater than 150 mg/dL. Fifty-five patients were randomized to atorvastatin (10 mg/day) (statin group); the remaining 55 patients received no statins (controls). Patients were followed for 1 year. At baseline, the two groups did not differ in age, sex, left ventricular ejection fraction, cholesterol, B-type natriuretic peptide, heart rate variability, or QT variability. During follow-up, 29 patients died (26%) and 2 patients (2%) underwent heart transplantation. Of the 29 deaths, 13 were attributed to pump failure, 15 were attributed to SCD, and 1 was attributed to noncardiac causes. All-cause mortality was lower in the statin group (9/55, 16%) than in controls (20/55, 36%) (P = .017). The same was true of the SCD rate (3/55 [5%] vs. 12/55 [22%], P = .012), but not of the pump failure (5/55 [9%] vs. 8/55 [15%], P = .38). SCD-free survival was 2.3-times higher in the statin group than in controls (P = .01). CONCLUSIONS: Atorvastatin therapy seems to be associated with decreased incidence of SCD in patients with advanced chronic heart failure. Larger studies are ongoing to confirm this hypothesis.

Atorvastatin therapy increases heart rate variability, decreases QT variability, and shortens QTc interval duration in patients with advanced chronic heart failure.

BACKGROUND: Although statins decrease the incidence of ventricular arrhythmias in patients with atherosclerotic heart disease, their potential antiarrhythmic effects in heart failure remain undefined. METHODS AND RESULTS: Of 80 heart failure patients enrolled, 40 were randomized to receive atorvastatin (statin group); the remaining 40 served as controls. At baseline and after 3 months, we measured heart rate variability (HRV), QT variability (QTV), and QTc interval using interactive high-resolution electrocardiogram analysis. The 2 groups did not differ in baseline HRV standard deviation of normal-to-normal intervals (SDNN) (RR): 24.6 +/- 2.8 ms in statin group versus 24.8 +/- 3.1 ms in controls, P = .72; square root of the mean of squared differences between successive intervals (rMSSD) (RR): 21.2 +/- 2.7 ms versus 21.7 +/- 2.9 ms, P = .43), QTV SDNN (QT): 6.4 +/- 1.5 ms versus 6.4+/-1.7, P = .96; rMSSD QT): 9.0 +/- 2.4 ms versus 8.7 +/- 2.9 ms, P = .65, and QTc interval 450 +/- 30 ms versus 446 +/- 27 ms, P = .59. At 3 months, the statin group displayed higher HRV SDNN RR): 27.2 +/- 4.9 ms versus 24.4 +/- 2.8 ms in controls, P = .003; rMSSD RR: 24.7 +/- 4.2 ms versus 21.3 +/- 5.6 ms, P = .004, lower QTV SDNN (QT): 5.1 +/- 1.9 ms versus 6.5 +/- 2.1, P = .004; rMSSD (QT): 6.6 +/- 2.8 ms versus 8.8 +/- 3.1 ms, P = .002, and shorter QTc interval 437 +/- 29 ms versus 450 +/- 25 ms, P = .03 than the control group. CONCLUSIONS: Atorvastatin increases HRV, decreases QTV, and shortens QTc interval, and may thereby reduce the risk of arrhythmias in patients with advanced heart failure.