New-Onset Atrial Arrhythmias Are Independently Associated With In-Hospital Mortality in Veno-Venous Extracorporeal Membrane Oxygenation.

To explore if atrial arrhythmias are associated with in-hospital mortality in veno-venous extracorporeal membrane oxygenation (VV-ECMO) patients. Retrospective observational cohort study. Quaternary care academic medical center. Patients with respiratory failure requiring VV-ECMO for >24 hours between January 1, 2016, and January 1, 2019. None, observational study. Two hundred nineteen VV-ECMO patients were included. Patients were stratified by absence or presence of clinically significant atrial arrhythmias during the VV-ECMO run. Atrial arrhythmias were defined as either atrial fibrillation or atrial flutter that occurred during VV-ECMO and required pharmacologic or electrical intervention. The primary outcome was in-hospital mortality. Secondary outcomes included a composite of thrombotic events, which included ischemic stroke and on-pump arterial thrombosis. Other objectives of this analysis included characterization of atrial arrhythmia incidence, risk factors, and management. A total of 67 patients (30.5%) experienced new-onset atrial arrhythmias post-ECMO cannulation. Age, male sex, and norepinephrine use were independently associated with atrial arrhythmia development. In-hospital mortality was significantly higher in the atrial arrhythmia group (38.8% v 19.1%; p = 0.003). In the multivariate logistic regression analysis, atrial arrhythmias during VV-ECMO were independently associated with increased odds of in-hospital mortality (odds ratio, 2.21; 95% confidence interval, 1.08-4.55; p = 0.03), after controlling for Respiratory Extracorporeal Membrane Oxygenation Survival Prediction score, acute renal failure, total norepinephrine dose, and total cannulation time. New-onset atrial arrhythmias are a frequent complication during VV-ECMO and are independently associated with excessive in-hospital mortality. Thus, their presence may serve as an important prognostic tool in this patient population.

Li C ，Pajoumand M ，Lambert K ，Najia L ，Bathula AL ，Mazzeffi MA ，Galvagno SM ，Tabatabai A ，Grazioli A ，Dahi S ，Hochberg ES ，Plazak ME ... -  《-》

Precannulation International Normalized Ratio is Independently Associated With Mortality in Veno-Arterial Extracorporeal Membrane Oxygenation.

To explore whether precannulation international normalized ratio (INR) is associated with in-hospital mortality in venoarterial extracorporeal membrane oxygenation (VA-ECMO) patients. A retrospective, observational cohort study. A quaternary care academic medical center. Patients with cardiogenic shock on VA-ECMO for >24 hours. None, observational study. A total of 188 patients who were on VA-ECMO were included over three years. Patients were stratified into three groups based on their pre-ECMO INR: INR <1.5, INR 1.5 to 1.8, and INR >1.8. For all patients, demographics, comorbidities, and ECMO details were recorded. The study's primary outcome was in-hospital mortality and secondary outcomes included major bleeding, minor bleeding, allogeneic transfusion, ischemic stroke, intracranial hemorrhage, acute renal failure, acute liver failure, gastrointestinal bleeding, intensive care unit and hospital lengths of stay. A multivariate logistic regression was used to determine whether precannulation INR was associated independently with in-hospital mortality. In-hospital mortality differed significantly by INR group (51.6% INR >1.8 v 42.3% INR 1.5-1.8 v 24.3% INR <1.5; p = 0.004). In a multivariate logistic regression model, precannulation INR >1.8 was associated independently with an increased odds of mortality (odds ratio, 2.48; 95% confidence interval, 1.05-6.04) after controlling for sex, Survival after VA- ECMO score, and ECMO indication. An INR within 1.5 to 1.8 did not confer an increased mortality risk. An INR >1.8 before VA-ECMO cannulation is associated independently with in-hospital mortality. Precannulation INR should be considered by clinicians so that ECMO resources can be better allocated and risks of organ failure and intracranial hemorrhage can be better understood.

Plazak ME ，Grazioli A ，Powell EK ，Menne AR ，Bathula AL ，Madathil RJ ，Krause EM ，Deatrick KB ，Mazzeffi MA ... -  《-》

An External Validation of Scoring Systems in Mortality Prediction in Veno-Venous Extracorporeal Membrane Oxygenation.

Veno-venous extracorporeal membrane oxygenation (VV ECMO) offers the last resort in the treatment of acute respiratory distress syndrome (ARDS). Various scoring systems have been established, yet external validation of these scoring systems in the Asian population remains scarce. We aim to identify factors associated with hospital mortality and to validate various scoring systems in the prediction of hospital mortality. A retrospective analysis of adults admitted to Pamela Youde Nethersole Eastern Hospital intensive care unit who received VV ECMO from January 1, 2010 to June 30, 2019 was performed. Demographics, ventilation strategies, rescue therapies, and clinical outcomes were compared. The primary outcome was hospital mortality and secondary outcomes were intensive care unit (ICU) mortality, ICU, and hospital length of stay. There were 122 VV ECMO performed for ARDS, of which 78 survived and 44 died. VV ECMO performed for viral pneumonitis was significantly associated with better survival (55.1% vs. 25%, p = 0.001) compared with other causes. As for prediction scores, the PREdiction of Survival on ECMO Therapy-Score had the highest area under receiver operator curve of 0.733 (95% confidence interval [CI]: 0.643-0.823), whereas that of PRedicting dEath for SEvere ARDS on VV ECMO score was 0.662 (95% CI: 0.561-0.764), Respiratory Extracorporeal Membrane Oxygenation Survival Prediction score was 0.657 (95% CI: 0.553-0.761), Sequential Organ Failure Assessment score was 0.652 (95% CI: 0.547-0.757), and VV ECMO mortality score was 0.637 (95% CI: 0.532-0.742). In our cohort, VV ECMO performed for viral pneumonitis was associated with a higher hospital survival. Prediction scores are helpful in our population and provide a useful reference to hospital mortality.

Man MY ，Shum HP ，Lam SM ，Yu JSY ，King BHS ，Yan WW ... -  《-》

Bleeding and thrombotic events in adults supported with venovenous extracorporeal membrane oxygenation: an ELSO registry analysis.

This study aimed at analyzing the prevalence, mortality association, and risk factors for bleeding and thrombosis events (BTEs) among adults supported with venovenous extracorporeal membrane oxygenation (VV-ECMO). We queried the Extracorporeal Life Support Organization registry for adults supported with VV-ECMO from 2010 to 2017. Multivariable logistic regression modeling was used to assess the association between BTEs and in-hospital mortality and the predictors of BTEs. Among 7579 VV-ECMO patients meeting criteria, 40.2% experienced ≥ 1 BTE. Thrombotic events comprised 54.9% of all BTEs and were predominantly ECMO circuit thrombosis. BTE rates decreased significantly over the study period (p < 0.001). The inpatient mortality rate was 34.9%. Bleeding events (1.69 [1.49-1.93]) were more strongly associated with in-hospital mortality than thrombotic events (1.23 [1.08-1.41]) p < 0.01 for both. The BTEs most strongly associated with mortality were ischemic stroke (4.50 [2.55-7.97]) and medical bleeding, including intracranial (5.71 [4.02-8.09]), pulmonary (2.02 [1.54-2.67]), and gastrointestinal (1.54 [1.2-1.98]) hemorrhage, all p < 0.01. Risk factors for bleeding included acute kidney injury and pre-ECMO vasopressor support and for thrombosis were higher weight, multisite cannulation, pre-ECMO arrest, and higher PaCO2 at ECMO initiation. Longer time on ECMO, younger age, higher pH, and earlier year of support were associated with bleeding and thrombosis. Although decreasing over time, BTEs remain common during VV-ECMO and have a strong, cumulative association with in-hospital mortality. Thrombotic events are more frequent, but bleeding carries a higher risk of inpatient mortality. Differential risk factors for bleeding and thrombotic complications exist, raising the possibility of a tailored approach to VV-ECMO management.

Nunez JI ，Gosling AF ，O'Gara B ，Kennedy KF ，Rycus P ，Abrams D ，Brodie D ，Shaefi S ，Garan AR ，Grandin EW ... -  《-》

Cannula-Associated Deep Vein Thrombosis After Venovenous Extracorporeal Membrane Oxygenation in Patients with and Without Systemic Anticoagulation.

Gu Y ，Bjelic M ，Panda K ，Usman AA ，Magnuson R ，Gosev I ... -  《-》