Oxygen debt repayment in the early phase of veno-arterial extracorporeal membrane oxygenation: a cluster analysis.

INTRODUCTION: Early oxygen debt repayment is predictive of successful weaning from veno-arterial extracorporeal membrane oxygenation (V-A ECMO). However, studies are limited by the patient cohort's heterogeneity. This study aimed to understand the early state of oxygen debt repayment and its association with end-organ failure and 30-day survival using cluster analysis. METHODS: A retrospective, single-center study was conducted on 153V-A ECMO patients. Patients were clustered using a two-step cluster analysis based on oxygen debt and its repayment during the first 24 h of ECMO. Primary outcomes were end-organ failure and 30-day survival. RESULTS: The overall mortality was 69.3%. For cluster analysis, 137 patients were included, due to an incomplete data set. The mortality rate in this subset was 67.9%. Three clusters were generated, representing increasing levels of total oxygen debt from cluster 1 to cluster 3. Thirty-day survival between clusters was significantly different (cluster 1: 46.9%, cluster 2: 23.4%, and cluster 3: 4.8%, p = 0.001). Patients in cluster 3 showed less decrement in liver enzymes, creatinine, and urea blood levels. There were significant differences in the baseline oxygen debt and the need for continuous veno-venous hemofiltration (CVVH) between survivors and non-survivors (p < 0.05). Forty-seven patients (34.3%) migrated between clusters within the first 24 h of support. Among these patients, 43.4% required CVVH. Notably, patients requiring CVVH and who migrated to a cluster with a higher oxygen debt repayment showed better survival rates compared to those who migrated to a cluster with a lower oxygen debt repayment. CONCLUSIONS: Oxygen debt repayment during the first 24 h of V-A ECMO shows to correspond with survival, where the baseline oxygen debt value and the necessity for continuous kidney replacement therapy appear to be influential.

Importance of confirming the underlying diagnosis in patients with myocardial infarction and non-obstructive coronary arteries (MINOCA): a single-centre retrospective cohort study.

BACKGROUND: Many patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) are discharged without a known aetiology for their clinical presentation. This study sought to assess the effect of this 'indeterminate MINOCA' diagnosis on the prevalence of recurrent cardiovascular events and presentations to the Cardiac Emergency Department (CED). METHODS: We retrospectively analysed all patients meeting the diagnostic MINOCA criteria presenting at a large secondary hospital between January 2017 and April 2019. PARTICIPANTS: Patients were divided into the (1) 'indeterminate MINOCA', or (2) 'MINOCA with diagnosis' group. The primary outcome was the occurrence of major adverse cardiac events (MACE) defined as the composite of all-cause mortality, non-fatal myocardial infarction, stroke and any revascularisation procedure. Secondary outcomes were all recurrent visits at the CED, and MACE including unplanned cardiac hospitalisation. RESULTS: In 62/198 (31.3%) MINOCA patients, a conclusive diagnosis was found (myocardial infarction, (peri)myocarditis, cardiomyopathy, or miscellaneous). MINOCA patients with a confirmed diagnosis were younger compared to those with an indeterminate diagnosis (56.7 vs. 62.3 years, p = 0.007), had higher maximum troponin-T [238 ng/L vs. 69 ng/L, p < 0.001] and creatine kinase (CK) levels [212U/L vs. 152U/L, p = 0.007], and presented more frequently with electrocardiographic signs of ischaemia (71.0% vs. 47.1%, p = 0.002). Indeterminate MINOCA patients more often showed recurrent CED presentations (36.8% vs. 22.6%, p = 0.048), however the occurrence of cardiovascular events was equal (8.8 vs. 8.1%, p = 0.86). Multivariable analysis showed that elevated levels of troponin-T and CK, ST-segment deviation on electrocardiography, reduced left ventricular ejection fraction, regional wall motion abnormalities, and performance of additional examination methods were independent predictors for finding the underlying MINOCA cause. CONCLUSIONS: Only in one-third of MINOCA patients a conclusive diagnosis for the acute presentation was identified. Recurrent CED visits were more often observed in the indeterminate MINOCA group, while the occurrence of cardiovascular events was similar across groups. TRIAL REGISTRATION: Retrospectively registered.

Quality of life following adult veno-venous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review.

BACKGROUND: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) has been used successfully for the past decade in adult patients with acute respiratory distress syndrome (ARDS) refractory to conventional ventilatory support. However, knowledge of the health-related quality of life (HRQoL) in VV-ECMO patients is still limited. Thus, this study aimed to provide a comprehensive overview of the HRQoL following VV-ECMO support in ARDS patients. METHODS: A systematic search was performed on PubMed and Web of Science databases from January 1st, 2009 to October 19th, 2020. Studies reporting on HRQoL following VV-ECMO for ARDS in adults were included. Two authors independently selected studies, extracted data, and assessed methodological quality. RESULTS: Eight studies were eligible for inclusion, consisting of seven observational studies and one randomized controlled trial (total N = 441). All eight studies had a quantitative design and reported 265 VV-ECMO survivors to have a reduced HRQoL compared to a generally healthy population. Follow-up time varied between six months to three years. Additionally, only four studies (total N = 335) compared the HRQoL of VV-ECMO (N = 159) to conventionally treated survivors (N = 176), with one study showing a significantly better HRQoL in VV-ECMO survivors, while three studies were stating comparable HRQoL across groups. Notably, most survivors in these studies appeared to experience varying degrees of anxiety, depression, and post-traumatic stress disorder (PTSD). CONCLUSIONS: ARDS survivors supported by VV-ECMO have a decline in HRQoL and suffered from physical and psychological impairments. This HRQoL reduction is comparable or even better to the HRQoL in conventionally treated ARDS survivors.