Search Results (141)

Background: Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is increasingly used to support patients with refractory cardiogenic shock or cardiac arrest. While femoral artery cannulation remains the most common arterial access, axillary artery cannulation has emerged as a valuable alternative in selected cases. Objective: This narrative review aims to synthesize current evidence and expert opinion on axillary artery cannulation in V-A ECMO, focusing on its technical feasibility, physiologic implications, and clinical outcomes. Methods: A comprehensive literature search was performed in PubMed and Scopus using relevant keywords related to ECMO, axillary artery, cannulation techniques, and outcomes. Emphasis was placed on prospective and retrospective clinical studies, expert consensus statements, and technical reports published over the past two decades. Results: Axillary cannulation provides antegrade aortic flow, potentially reducing the risk of differential hypoxia and improving upper body perfusion. However, the technique presents unique technical challenges and may carry risks such as hyperperfusion syndrome or arterial complications. Emerging data suggest favorable outcomes in selected patient populations when performed in experienced centers. Conclusions: Axillary cannulation represents a promising arterial access route in V-A ECMO, particularly in cases with contraindications to femoral cannulation or when upper-body perfusion is a concern. Further prospective studies are needed to better define patient selection criteria and long-term outcomes. Full article

Objectives: This study aimed to evaluate the impact of cannulation site preference—femoral versus axillary—on postoperative complications and in-hospital mortality in patients undergoing peripheral venoarterial extracorporeal membrane oxygenation (VA ECMO) due to cardiogenic shock. Methods: In this single-center, retrospective study, 85 patients who received peripheral VA ECMO support between January 2013 and July 2023 were analyzed. Patients were divided into two groups based on arterial cannulation site: femoral cannulation (FC, n = 47) and axillary cannulation (AC, n = 38). Preoperative, intraoperative, and postoperative variables were compared. Cannulation-related complications were categorized as vascular, neurological, or pulmonary. The primary endpoints were postoperative complications and in-hospital mortality. Results: There were no statistically significant differences between the FC and AC groups in terms of demographics, comorbidities, surgical procedures, or ECMO weaning times. Rates of vascular, neurological, and pulmonary complications were similar between groups. Mortality and postoperative dialysis rates did not differ significantly. The low rate of ischemic complications in the FC group may be explained by the use of distal perfusion catheters, which are considered the standard approach to prevent leg ischemia. Both cannulation techniques demonstrated comparable safety and efficacy profiles. Conclusions: Both femoral and axillary cannulation sites can be safely used for peripheral VA ECMO when selected based on individual patient conditions and institutional experience. Cannulation strategy should be tailored according to the urgency of the clinical situation, anatomical feasibility, and anticipated duration of support. Further prospective, randomized studies are required to establish the optimal cannulation approach. Full article

Background and Clinical Significance: Fulminant pulmonary embolism (PE) leading to an out-of-hospital cardiac arrest (OHCA) is associated with a high mortality rate and cardiopulmonary resuscitation (CPR) frequently failing to achieve return of spontaneous circulation (ROSC). Extracorporeal CPR (eCPR) has emerged as a potential life-saving intervention. Case Presentation: A 66-year-old woman suffered an OHCA due to massive PE, presenting with pulseless electrical activity (PEA). After 90 min of pre- and in-hospital CPR without sustained ROSC, venoarterial extracorporeal membrane oxygenation (va-ECMO) was initiated as eCPR upon arrival at the hospital. Even after implantation of the va-ECMO, there was initially a pronounced acidosis (pH 6.9) with a high elevated lactate level (>30 mmol/L); these factors, together with the prolonged low-flow period, indicated a poor prognosis. Further diagnostic tests revealed intracranial hemorrhage (subdural hematoma), and systemic lysis was not possible. With persistent right heart failure, surgical thrombectomy was performed during hospitalization. Intensive multidisciplinary management finally led to successful therapy and weaning from mechanical ventilation, as well as to complete neurological recovery (CPC-Score 1-2). Conclusions: This case illustrates that eCPR can facilitate survival with good favorable neurological outcomes despite initially poor prognostic predictors. It underscores the importance of refining patient selection criteria and optimizing management strategies for eCPR in refractory cardiac arrest secondary to PE. Full article

Extracorporeal membrane oxygenation (ECMO) is a crucial life support therapy for patients with severe cardiac and respiratory failure. However, the complications associated with venoarterial ECMO (VA-ECMO), including thrombus formation, bleeding, and hemolysis, remain significant challenges that impact patient outcomes and healthcare costs. These complications primarily arise from blood–material interactions within the ECMO circuit, necessitating the development of biocompatible materials to optimize hemocompatibility. This review provides an updated overview of the latest advancements in VA-ECMO materials, focusing on cannula, oxygenators, and centrifugal pumps. Various surface modifications, such as heparin coatings, nitric oxide-releasing polymers, phosphorylcholine (PC)-based coatings, and emerging omniphobic surfaces, have been explored to mitigate thrombosis and bleeding risks. Additionally, novel oxygenator membrane technologies, including zwitterionic polymers and endothelial-mimicking coatings, offer promising strategies to enhance biocompatibility and reduce inflammatory responses. In centrifugal pumps, magnetic levitation systems and hybrid polymer-composite impellers have been introduced to minimize shear stress and thrombogenicity. Despite these advancements, no single material has fully addressed all complications, and further research is needed to refine surface engineering strategies. This review highlights the current progress in ECMO biomaterials and discusses future directions in developing more effective and durable solutions to improve patient safety and clinical outcomes. Full article

Background: Severe poisoning can lead to catastrophic cardiovascular collapse, often progressing to multiorgan failure and death. While intensive supportive care and pharmacological intervention remain the cornerstone of management, cases of refractory cardiogenic shock, particularly those caused by membrane stabilizing agents and calcium channel blockers, pose a significant therapeutic challenge. Extracorporeal membrane oxygenation (ECMO) has emerged as a potential life-saving intervention in critically ill patients. This review examines the feasibility, clinical outcomes, and optimal indications for ECMO in the management of drug-induced cardiogenic shock. Methods: A systematic narrative review was conducted to evaluate the current evidence of ECMO use in poisoning-related cardiovascular failure, with a particular focus on patient selection criteria and the prognostic determinants of therapeutic resistance. Results: Extracorporeal membrane oxygenation may serve as a crucial hemodynamic support strategy in drug-induced circulatory collapse. Most reported cases involve peripheral ECMO, demonstrating variable but promising survival outcomes. Conclusions: Despite its potential to rescue patients from otherwise fatal toxic cardiomyopathy, the role of ECMO remains incompletely defined. Further prospective studies are essential to refine patient selection criteria and identify the toxicant-specific predictors of therapeutic failure. A deeper understanding of these factors may enhance clinical decision making and improve survival rates in severe poisoning cases. Full article

Background: Cardiogenic shock is a life-threatening condition characterized by the failure of the heart to maintain adequate circulation, leading to multi-organ dysfunction. While it is most commonly associated with acute myocardial infarction or cardiomyopathies, cardiogenic shock can also arise in unusual settings, such as severe malnutrition in patients with anorexia nervosa, a psychiatric disorder characterized by extreme restriction of food intake. Methods: Here, we describe the management of three patients with anorexia nervosa and severe cardiogenic shock, who were treated in our cardiological intensive care unit between December 2022 and January 2025. Two patients were successfully resuscitated after experiencing cardiac arrest, and two required mechanical circulatory support, including Venoarterial Extracorporeal Membrane Oxygenation and microaxial flow pump. The patients presented with a range of complications including multi-organ failure and respiratory distress. Due to the fragile balance between intensive cardiac and nutritional management, as well as the comorbidity of chronic malnutrition, therapeutic decisions were made carefully, including cautious electrolyte management, targeted nutritional therapy, and the use of advanced circulatory support. Conclusions: The treatment approach and beneficious outcomes underline the necessity of a multidisciplinary strategy in managing these critically ill patients with complex, interwoven pathologies. Our experience suggests that early recognition of cardiogenic shock and timely intervention with mechanical circulatory support may significantly improve patient survival in this high-risk cohort. Careful management of nutritional therapy and supplementation of trace elements and vitamins is crucial. Full article

We investigated echocardiographic and hemodynamic effects of intraaortic balloon pump (IABP) in 26 patients with cardiogenic shock on veno-arterial membrane oxygenation (VA ECMO). Our study demonstrated an 8.1% increase in left ventricular velocity time integral (p = 0.023) without reduction in left ventricular diameters and 4.7% decrease in right ventricular end diastolic base diameter (p = 0.05) when using IABP 1:1 mode compared to no augmentation. This was associated with a 3.2% decrease in heart rate (p < 0.001) and a 3.0% increase in mixed venous oxygen saturation (p = 0.057). Since the magnitude of the documented favorable changes is rather small, the clinical relevance of concomitant IABP in patients with cardiogenic shock on VA ECMO remains questionable. Full article

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) for the management of refractory cardiogenic shock (CS) has been widely used in recent years. Increased left ventricular (LV) afterload induced by retrograde flow remains a limiting factor, which is particularly evident during peripheral VA ECMO support. The concomitant use of the intra-aortic balloon pump (IABP) is an established strategy to achieve LV unloading during VA ECMO support. Nevertheless, there remains controversy about the combined use of IABP during central or peripheral VA ECMO in terms of beneficial effects and outcome. We developed a simulation setting to study left ventricular unloading with IABP during peripheral and central VA ECMO using CARDIOSIM©, an established software simulator of the cardiovascular system. The aim was to quantitatively evaluate potential differences between the two VA ECMO configurations and ascertain the true beneficial effects compared to VA ECMO alone. The combined use of central VA ECMO and IABP decreased left ventricular end systolic volume and left ventricular end diastolic volume by 5–10%; right ventricular end systolic volume and right ventricular end diastolic volume by 10–20%; left atrial end systolic volume and left atrial end diastolic volume by 5–10%. Up to 25% reduction in mean left atrial pressure, up to 15% reduction in pulmonary capillary wedge pressure and up to 25% reduction in mean pulmonary arterial pressure was observed. From an energetic point of view, left ventricular external work decreased by 10–15% whilst up to 40%vreduction in right ventricular external work was observed. The findings make central VA ECMO plus IABP the most appropriate combination for left and right ventricle unloading. Full article

Background: Veno-venous extracorporeal membrane oxygenation (V-V ECMO) represents a progressively adopted life-sustaining intervention worldwide, particularly in the management of acute respiratory distress syndrome. Nevertheless, data concerning the prognostic significance of fungal isolation in this setting remain unclear. This study aims (i) to assess the incidence of fungal infection and colonization in a homogeneous cohort of V-V ECMO patients, and (ii) to evaluate the association between fungal infection or colonization and 1-year mortality, with a focus on the impact of specific fungal species. Methods: All consecutive adults admitted to the Intensive Care Units of five Italian university-affiliated hospitals and requiring V-V ECMO were screened. Exclusion criteria were age < 18 years, pregnancy, veno-arterial or mixed ECMO-configuration, incomplete records and survival < 24 h after V-V ECMO placement. A standard protocol of microbiological surveillance was applied and the distinction between different fungal species were made through in vivo and vitro tests. Cox-proportional hazards models, Kaplan–Meier curves and linear logistic regressions were applied for investigating mortality. Results: Two-hundred and seventy-nine V-V ECMO patients (72% male) were enrolled. The overall fungal isolation was 41% (n. 114): 23% infections and 18% colonizations. The overall 1-year mortality, among fungal isolations, was 40%, with no different risk in case of fungal infection (26 out of 63, 41%) (aHR 0.85, 95% CI [0.53–1.37], p-value 0.505) and colonization (20 out of 51, 39%) (aHR 0.86, 95%CI [0.51–1.43], p-value 0.556), as compared to patients never detecting fungi (68 out of 165, 41%, reference). According to the isolated mycotic species, as compared to Candida sp. group (reference), the risk of death was greater when different fungal species (e.g., Aspergillus sp. and Candida sp.) were concomitantly isolated in the same patient (OR 1.17, 95%CI [1.12–11.07], p-value 0.031. Conclusions: In the overall population, 23% V-V ECMO patients recorded ‘late’ fungal infections and 18% fungal colonizations, with a similar risk of death as compared to patients never experiencing fungi during the V-V ECMO course. The detection of concomitant different fungal species was an independent risk factor for 1-year mortality. Full article

Background: Lymphomas account for approximately 10% of cancers diagnosed during pregnancy, with Hodgkin’s lymphoma being the most common. However, non-Hodgkin lymphomas, including primary mediastinal large B-cell lymphoma (PMBCL), also represent a significant proportion. Both mediastinal lymphomas and pregnancy develop a hypercoagulable state, increasing the risk of venous thromboembolism and massive pulmonary embolism (PE), requiring extracorporeal membrane oxygenation (ECMO). Methods: Clinical data, blood test and imagings have been collected by the medical records of the patient. Results: We present a 25-year-old woman, at 32 weeks of gestation, who presented to the emergency department with progressive dyspnea and asthenia. Echocardiography revealed a hemodynamically significant pericardial effusion and severe right ventricular dysfunction. Given the severity of her condition, she underwent an emergency caesarean section and subsequently a pericardial drainage. A chest computed tomography scan revealed an incidental mediastinal mass along with a massive PE. Despite pericardial drainage, she remained hemodynamically unstable. Since thrombolysis was contraindicated for the recent cesarean section, venoarterial ECMO was initiated. Systemic anticoagulation was guaranteed by heparin, which shifted to argatroban for heparin resistance. The mediastinal mass was also biopsied, and the diagnosis of PMBCL carried out. Cytoreductive chemotherapy was initiated with the COMP-R regimen (i.e., cyclophosphamide, vincristine, methotrexate, prednisone, and rituximab), and the patient progressively improved up to ICU and hospital discharge. Conclusions: This case highlights the challenges in managing a complicated patient requiring early multidisciplinary intervention, which was crucial for stabilizing the patient and optimizing fetal and maternal prognosis. Full article

Background and Objectives: Left ventricle (LV) overloading during veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) is detrimental to myocardial recovery. To determine whether LV unloading using transaortic catheter venting (TACV) is effective, we analyzed the effect of TACV in a human-sized porcine model. Materials and Methods: Hypoxic biventricular dysfunction was induced in 11 pigs using femoro-femoral VA-ECMO and custom-made TACV catheters in the LV through the common carotid artery. Hemodynamic conditions were then simulated. The TACV was either opened or closed under a controlled ECMO flow. Conversely, the ECMO flow was adjusted, varying from 1 L to 4 L, with and without TACV; 2115 observations were collected. Results: In comparing observations without TACV (TACV−) and with TACV (TACV+), the change in left ventricular end-diastolic pressure (LVEDP) after TACV application was −1.2 mmHg (p < 0.001). In the linear regression model, the reduction in LVEDP was maximized when the baseline LVEDP and ECMO flow were higher. When escalating the ECMO flow in the respective settings of TACV− and TACV+, the rise in LVEDP was significantly lower in TACV+. Conclusions: TACV decreased LVEDP; this effect was more prominent when ECMO flow and baseline LVEDP were higher. These findings suggest that TACV might support LV recovery through effective unloading, even when ECMO flow is high. Full article

Background: Pheochromocytoma and paraganglioma are catecholamine-secreting tumors, rarely presenting with pheochromocytoma multisystem crisis (PMC), a life-threatening endocrine emergency. The severity of the condition includes a refractory cardiogenic shock and may therefore require the use of temporary mechanical circulatory support. The aim of this review is to describe the incidence of pheochromocytoma and paraganglioma crises associated with refractory cardiogenic shock, the physiopathological impact of this condition on the myocardial function, the role of temporary mechanical circulatory support (tMCS) in its management, and the outcomes of this specific population. Methods: For the purpose of this narrative review, a literature search of PubMed was conducted as of 16 November 2024. Medical Subject Headings (MeSH) terms used included extracorporeal circulation”, “Impella”, “pheochromocytoma”, “paraganglioma”, and “cardiogenic shock”, combined with Boolean “OR” and “AND”. Data from case series, retrospective studies, and systematic reviews were considered. Seven studies reporting on 45 patients who developed PMC with cardiogenic shock requiring tMCS were included. Patients were young, with a median age of 43 years (range 25–65) at presentation. Most cases presented with severe hemodynamic instability, blood pressure lability, and rapid progression to severe left ventricular dysfunction. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was the most common tMCS used to stabilize patients, initiate specific pheochromocytoma treatments, and, in some cases, provide circulatory support during emergent surgery. The median duration of VA-ECMO support was 4 days (range 1–7) and the reported mean in-hospital survival rate was 93.5%. Following VA-ECMO weaning, survivors showed full recovery of the left ventricular ejection fraction (LVEF). Conclusions: The cardiac dysfunction observed in PMC-associated cardiogenic shock may be severe and life-threatening but appears reversible. tMCS should therefore be considered in eligible cases, as a bridge to recovery, treatment, or surgery. The reported survival rates are impressively high, suggesting possibly a substantial risk of publication bias. Full article

Background/Objectives: Brain ischemia is a frequent complication in patients undergoing veno-arterial extracorporeal membrane oxygenation (va-ECMO) therapy due to hypoperfusion, low oxygenation, and thromboembolism. While concomitant intra-aortic balloon pump (IABP) therapy may improve the perfusion of the supra-aortic branches, it may also favor thromboembolism. This retrospective study aimed to evaluate the effects of combined va-ECMO and IABP therapy on procedural brain infarction compared to va-ECMO therapy alone, with a specific focus on analyzing the types of infarctions. Methods: Cranial computed tomography (CCT) scans of consecutive patients receiving va-ECMO therapy were analyzed retrospectively. Subgroups were formed for patients with combined therapy (ECMO and IABP) and va-ECMO therapy only. The types of infarctions and the potential impacts of va-ECMO vs. combined therapy with IABP on stroke were investigated. Results: Overall, 146 patients (36 female, 110 male, mean age 61 ± 13.3 years) were included, with 69 undergoing combined therapy and 77 patients receiving va-ECMO therapy alone. In total, 14 stroke events occurred in 11 patients in the ECMO-only group and there were 12 events in 12 patients in the ECMO + IABP-group, showing no significant difference (p = 0.61). The majority of infarctions were of thromboembolic (n = 23; 88%) origin, with 14 stroke-events in 12 patients in the ECMO + IABP-group and 9 stroke events in the ECMO-only group. The survival rate within 30 days of treatment was 29% in the ECMO-only group and 32% in the ECMO + IABP group. Conclusions: The results of this retrospective study show that concomitant IABP therapy appears to be neither protective nor more hazardous in relation to ECMO-related stroke. Thus, the indication for additional IABP therapy should be assessed independently from the procedural risk of brain ischemia. Thromboembolic infarctions seem to represent the most common type of infarction in ECMO, especially within the first 48 h of treatment. Full article

Background and Objectives: The coronavirus disease 2019 pandemic presented unprecedented challenges in balancing infection control measures with the timely management of ST-segment elevation myocardial infarction (STEMI), a time-sensitive condition. This study investigates the pandemic’s effects on STEMI management times and outcomes at a high-volume medical center in Taiwan. Materials and Methods: A retrospective analysis of 1309 STEMI patients was conducted at Chang Gung Memorial Hospital between 2017 and 2022. Patients were divided into pre-pandemic and pandemic groups. Measurement outcomes include in-hospital mortality rate, management times (e.g., door-to-balloon time), the rates of intra-aortic balloon pump (IABP) and/or veno-arterial extracorporeal membrane oxygenation (VA-ECMO) usage, mechanical ventilation, inotropic support, and the length of intensive care unit (ICU) and hospital stay. Kaplan–Meier survival analysis and statistical comparisons were performed to assess temporal trends and prognostic outcomes. Results: No significant difference in in-hospital mortality was observed between pre-pandemic (5.85%) and pandemic (7.03%) groups (p = 0.45). The pandemic group experienced longer management times, including door-to-cath arrival (p = 0.0335) and door-to-balloon time (p = 0.014), although all times remained below the 90 min threshold. Quality improvements during the first outbreak allowed the institution to handle higher case volumes during subsequent waves without further delays. Ninety-day survival analysis showed no significant disparity between groups (p = 0.3655). Conclusions: Pandemic-related delays in STEMI management were effectively mitigated through workflow optimization, preventing significant increases in mortality rates. This study highlights the adaptability of healthcare systems in responding to crises while maintaining quality care for time-sensitive emergencies. Future multicenter studies could provide broader insights into global STEMI management strategies under pandemic conditions. Full article

Background and aims: The effect of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) on left atrial pressure (LAP) in the presence of interventricular interaction and the Frank–Starling mechanism is unknown. We developed and validated a mock circulatory loop (MCL) incorporating a novel, 3D-printed biventricular heart model and Frank–Starling algorithm, and used this model to assess the determinants of LAP during VA-ECMO support. Methods: The MCL was designed to allow a separate ventricle or biventricular configuration, with or without an active Frank–Starling mechanism. The biventricular model with Frank–Starling mechanism was validated in terms of (1) the presence and degree of ventricular interactions; (2) its ability to simulate Frank–Starling physiology; and (3) its capacity to simulate normal and pathological cardiac states. In the separate ventricle and biventricular with Frank–Starling models, we assessed the effect on LAP of changes in mean aortic pressure (mAoP), ECMO pump speed, LV contractility and ECMO return flow direction. Results: In the biventricular configuration, clamping RA inflow decreased RAP, with a concurrent decrease in LAP, consistent with direct ventricular interaction. With a programmed Frank–Starling mechanism, decreasing RAP was associated with a significant reduction in both LV outflow and LV end-systolic pressure. In the biventricular model with a Frank–Starling algorithm, the MCL was able to reproduce pre-defined normal and pathological cardiac output, and arterial and ventricular pressures. Increasing aortic pressure caused a linear increase in LAP in the separate ventricle model, which was attenuated in the biventricular model with Frank–Starling mechanism. Increasing ECMO pump speed caused no change in LAP in the separate ventricle model (p = 0.75), but significantly decreased LAP in the biventricular model with Frank–Starling mechanism (p = 0.039), with stabilization of LAP at the highest pump speeds. Changing the direction of VA-ECMO return flow did not affect LAP in either the separate ventricle (p = 0.91) or biventricular model with Frank–Starling mechanism (p = 0.76). Conclusions: Interventricular interactions and the Frank–Starling mechanism can be simulated in a physical, biventricular MCL. In their presence, the effects of VA-ECMO on LAP are mitigated, with LAP reduction and stabilization at maximal VA-ECMO speeds. Full article