Meta-Analysis of Peripheral or Central Extracorporeal Membrane Oxygenation in Postcardiotomy and Non-Postcardiotomy Shock.

BACKGROUND: Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) application in postcardiotomy shock (PCS) and non-PCS is increasing. VA-ECMO plays a critical role in the management of these patients, yet may be associated with serious complications. METHODS: A systematic review of all available reports in the literature of patients receiving VA-ECMO, either directly or indirectly, comparing central cannulation (right atrial to ascending aorta) versus peripheral cannulation (femoral vein to femoral artery or axillary artery) were analyzed. The primary endpoint was survival. Cerebrovascular events, limb complications, bleeding requiring reoperation, sepsis, continuous venovenous hemofiltration, and transfusions were also assessed in both groups. RESULTS: Seventeen retrospective case series clearly describing the VA-ECMO access and including 1,691 patients with PCS and non-PCS were found. The peripheral approach was more commonly used (980 patients, 57.9%) than the central one. There was no difference in the analysis between the two techniques regarding all-cause mortality risk ratio (1.00, 95% confidence interval: 0.94 to 1.08, I2 = 0%, p = 0.92). No statistical differences were found between peripheral and central VA-ECMO with regard to cerebrovascular events, limb complications, or sepsis rates. Peripheral cannulation was associated with a significant reduction in the risk of bleeding (p = 0.02), continuous venovenous hemofiltration (p = 0.03), transfusion of red blood cells units (p < 0.00001), fresh frozen plasma units (p = 0.0002), and platelets units (p < 0.00001). CONCLUSIONS: Peripheral and central VA-ECMO configurations showed comparable inhospital survival for PCS and non-PCS. The risk of bleeding, continuous venovenous hemofiltration, and blood product transfusion was significantly lower with the peripheral cannulation strategy.

Modalities and Effects of Left Ventricle Unloading on Extracorporeal Life support: a Review of the Current Literature.

INTRODUCTION/AIM: Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support is increasingly used in refractory cardiogenic shock and cardiac arrest, but is characterized by a rise in afterload of the left ventricle (LV) which may ultimately either further impair or delay cardiac contractility improvement. The aim of this study was to provide a comprehensive overview regarding the different LV venting techniques and results currently available in the literature. METHODS: A systematic literature search was performed in the PubMed database: 207 articles published between 1993 and 2016 were included. Papers dealing with pre-clinical studies, overlapping series, and association with other assist devices were excluded from the review, with 45 published papers finally selected. Heterogeneous indications for LV unloading were reported. The selected literature was divided into subgroups, according to the location or the performed procedure for LV venting. RESULTS: Case reports or case series accounted for 60% of the papers, while retrospective study represented 29% of them. Adult series were present in 67%, paediatric patients in 29%, and a mixed population in 4%. LV unloading was performed percutaneously in 84% of the cases. The most common locations of unloading was the left atrium (31%), followed by indirect unloading (intra-aortic balloon pump) (27%), trans-aortic (27%), LV (11%), and pulmonary artery (4%). Percutaneous trans-septal approach was reported in 22%. Finally, the unloading was conducted surgically in 16%,with open chest surgery in 71%, and minimally invasive surgery in 29% of surgical cases. CONCLUSION: Nowadays, only a few data are available about left heart unloading in V-A ECMO support. Despite the well-known controversy, IABP remains widely used in combination with V-A ECMO. Percutaneous approaches utilizing unloading devices is becoming an increasingly used option. However, further studies are required to establish the optimal LV unloading method.

Severe thrombocytopenia and its clinical impact after implant of the stentless Freedom Solo bioprosthesis.

BACKGROUND: This single-center study analyzed the occurrence of severe thrombocytopenia and its clinical effect after concomitant and isolated aortic valve replacement (AVR) with the stentless Freedom Solo (FS) prosthetic valve (Sorin Group, Saluggia, Italy). METHODS: Between October 2009 and February 2012, 151 consecutive patients underwent AVR with a FS, either isolated (lone-FS group) or concomitant with another procedure (all-FS group). These groups were compared with 152 consecutive patients implanted with a stented Edwards Lifesciences Perimount (EP) bioprosthesis (Edwards Lifesciences, Irvine, CA). Primary end point was the incidence of severe thrombocytopenia (platelet count < 50 × 10(9)/L). Secondary end points were clinical outcomes, administered transfusions (red blood cells, thrombocytes, frozen plasma), and adverse events. Rinsing the FS before implantation with saline solution was also evaluated. RESULTS: Platelet counts were significantly lower in the all-FS and lone-FS groups than in the EP group during the first 5 days (p < 0.001). Average nadir was 102 ± 50 in lone-FS group and 130 ± 35 in lone-EP group (p < 0.001). Independent predictors for severe thrombocytopenia were FS, body surface area, and preoperative platelet count. No significant difference was found in transfusions or adverse events. Intensive care unit stay was slightly increased in the lone-FS group (p = 0.04). Rinsing the FS did not prevent thrombocytopenia. CONCLUSIONS: AVR with FS was associated with severe thrombocytopenia during the first postoperative days. Besides a slightly longer hospitalization in the intensive care unit in the FS group, the clinical outcome did not differ significantly, indicating thrombocytopenia was a transient and self-recovering phenomenon, not affecting clinical outcome. Rinsing the FS did not prevent thrombocytopenia.