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Extracorporeal Membrane Oxygenation (ECMO): Current Progress and Clinical Challenges
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Extracorporeal Membrane Oxygenation (ECMO): Current Progress and Clinical Challenges

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Pulmonology".

Deadline for manuscript submissions: closed (25 May 2023) | Viewed by 16598

Special Issue Editors

Dr. Rüdger Kopp

E-Mail Website
Guest Editor
Department of Intensive Care Medicine, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
Interests: intensive care medicine; extracorporeal circulation; acute respiratory distress syndrome; extracorporeal membrane oxygenation; extracorporeal organ support
Prof. Dr. Jutta Arens

E-Mail Website
Guest Editor
Engineering Organ Support Technologies, Department of Biomechanical Engineering, Faculty of Engineering Technology, University of Twente, Enschede, The Netherlands
Interests: organ support technologies; extracorporeal circulation; standardized in vitro test methods

Special Issue Information

Dear Colleagues,

Extracorporeal membrane oxygenation (ECMO) is an established rescue therapy for the most severe cases of hypoxemic acute respiratory distress syndrome with an increasing number of applications, but its further development and additional applications are still challenging.

Although technical evolution in the last 50 years has simplified ECMO and has allowed for the identification of new indications, in particular, the role of “artificial lungs” as chronic support remains unsolved. During the ongoing COVID-19 pandemic, ECMO is an important component of differentiated intensive care medicine, but varying high mortality rates have demonstrated the challenge of managing ECMO due to risks and probabilities for the patient.

In this Special Issue, new technical concepts and their transfer to clinical applications and strategies will be investigated, and as actual clinical data and further challenges will be presented.

In the context of extracorporeal membrane oxygenation, the topics span from acute organ support to transplants and chronic support and from isolated lung failure to combined heart–lung support and extracorporeal cardiopulmonary resuscitation. We are looking forward receiving your manuscripts on these topics.

Dr. Rüdger Kopp
Prof. Dr. Jutta Arens
Guest Editors

Manuscript Submission Information

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Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • ECMO
  • ECLS
  • ECLA
  • ARDS
  • lung transplant
  • eCPR
  • cardiogenic shock
  • pulmonary embolism
  • COPD
  • artificial lung
  • oxygenator
  • cannula
  • blood pump

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Published Papers (7 papers)

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Research

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11 pages, 1678 KiB  
Article
Use of Recombinant Activated Factor VII in Bleeding Lung Transplant Patients Undergoing Perioperative ECMO Therapy
by Daniel Laxar, Eva Schaden, Marion Wiegele, Konrad Hötzenecker, Stefan Schwarz and Johannes Gratz
J. Clin. Med. 2023, 12(8), 3020; https://doi.org/10.3390/jcm12083020 - 21 Apr 2023
Cited by 1 | Viewed by 1474
Abstract
Background: Hemostasis in critically ill patients represents a fragile balance between hypocoagulation and hypercoagulation, and is influenced by various factors. Perioperative use of extracorporeal membrane oxygenation (ECMO)—increasingly used in lung transplantation—further destabilizes this balance, not least due to systemic anticoagulation. In the case [...] Read more.
Background: Hemostasis in critically ill patients represents a fragile balance between hypocoagulation and hypercoagulation, and is influenced by various factors. Perioperative use of extracorporeal membrane oxygenation (ECMO)—increasingly used in lung transplantation—further destabilizes this balance, not least due to systemic anticoagulation. In the case of massive hemorrhage, guidelines recommend considering recombinant activated Factor VII (rFVIIa) as an ultima ratio treatment only after several preconditions of hemostasis have been established. These conditions are calcium levels ≥ 0.9 mmol/L, fibrinogen levels ≥ 1.5 g/L, hematocrit ≥ 24%, platelet count ≥ 50 G/L, core body temperature ≥ 35 °C, and pH ≥ 7.2. Objectives: This is the first study to examine the effect of rFVIIa on bleeding lung transplant patients undergoing ECMO therapy. The fulfillment of guideline-recommended preconditions prior to the administration of rFVIIa and its efficacy alongside the incidence of thromboembolic events were investigated. Methods: In a high-volume lung transplant center, all lung transplant recipients receiving rFVIIa during ECMO therapy between 2013 and 2020 were screened for the effect of rFVIIa on hemorrhage, fulfillment of recommended preconditions, and incidence of thromboembolic events. Results and Discussion: Of the 17 patients who received 50 doses of rFVIIa, bleeding ceased in four patients without surgical intervention. Only 14% of rFVIIa administrations resulted in hemorrhage control, whereas 71% of patients required revision surgery for bleeding control. Overall, 84% of all recommended preconditions were fulfilled; however, fulfillment was not associated with rFVIIa efficacy. The incidence of thromboembolic events within five days of rFVIIa administration was comparable to cohorts not receiving rFVIIa. Full article
(This article belongs to the Special Issue Extracorporeal Membrane Oxygenation (ECMO): Current Progress and Clinical Challenges)
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11 pages, 1484 KiB  
Article
Therapy and Outcome of Prolonged Veno-Venous ECMO Therapy of Critically Ill ARDS Patients
by Armin N. Flinspach, Florian J. Raimann, Frederike Bauer, Kai Zacharowski, Angelo Ippolito and Hendrik Booke
J. Clin. Med. 2023, 12(7), 2499; https://doi.org/10.3390/jcm12072499 - 25 Mar 2023
Cited by 3 | Viewed by 1895
Abstract
Veno-venous Extracorporeal Membrane Oxygenation (VV-ECMO) therapy has become increasingly used and established in many hospitals as a routine treatment. With ECMO-therapy being a resource-demanding procedure, it is of interest whether a more prolonged VV-ECMO treatment would hold sufficient therapeutic success. Our retrospective study [...] Read more.
Veno-venous Extracorporeal Membrane Oxygenation (VV-ECMO) therapy has become increasingly used and established in many hospitals as a routine treatment. With ECMO-therapy being a resource-demanding procedure, it is of interest whether a more prolonged VV-ECMO treatment would hold sufficient therapeutic success. Our retrospective study included all VV-ECMO runs from 1 January 2020 to 31 June 2022. We divided all runs into four groups (<14 days, 14–27, 28–49, 50+) of different durations and looked for differences overall in hospital survival. Additionally, corresponding treatments and therapeutic modalities, as well as laboratory results, were analyzed. We included 117 patients. Of those, 97 (82.9%) received a VV-ECMO treatment longer than two weeks. We did not find a significant association between ECMO duration (p = 0.15) and increased mortality though a significant correlation between the patients’ age and their probability of survival (p = 0.02). Notably, we found significantly lower interleukin-6 levels with an increase in therapy duration (p < 0.01). Our findings show no association between the duration of ECMO therapy and mortality. Thus, the treatment duration alone may not be used for making assumptions about the prospect of survival. However, attention is also increasingly focused on long-term outcomes, such as post-intensive care syndrome with severe impairments. Full article
(This article belongs to the Special Issue Extracorporeal Membrane Oxygenation (ECMO): Current Progress and Clinical Challenges)
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10 pages, 3307 KiB  
Article
Bronchoscopic Endobronchial Valve Therapy for Persistent Air Leaks in COVID-19 Patients Requiring Veno-Venous Extracorporeal Membrane Oxygenation
by Barbara Ficial, Stephen Whebell, Daniel Taylor, Rita Fernández-Garda, Lawrence Okiror and Christopher I. S. Meadows
J. Clin. Med. 2023, 12(4), 1348; https://doi.org/10.3390/jcm12041348 - 8 Feb 2023
Cited by 2 | Viewed by 1906
Abstract
COVID-19 acute respiratory distress syndrome (ARDS) can be associated with extensive lung damage, pneumothorax, pneumomediastinum and, in severe cases, persistent air leaks (PALs) via bronchopleural fistulae (BPF). PALs can impede weaning from invasive ventilation or extracorporeal membrane oxygenation (ECMO). We present a series [...] Read more.
COVID-19 acute respiratory distress syndrome (ARDS) can be associated with extensive lung damage, pneumothorax, pneumomediastinum and, in severe cases, persistent air leaks (PALs) via bronchopleural fistulae (BPF). PALs can impede weaning from invasive ventilation or extracorporeal membrane oxygenation (ECMO). We present a series of patients requiring veno-venous ECMO for COVID-19 ARDS who underwent endobronchial valve (EBV) management of PAL. This is a single-centre retrospective observational study. Data were collated from electronic health records. Patients treated with EBV met the following criteria: ECMO for COVID-19 ARDS; the presence of BPF causing PAL; air leak refractory to conventional management preventing ECMO and ventilator weaning. Between March 2020 and March 2022, 10 out of 152 patients requiring ECMO for COVID-19 developed refractory PALs, which were successfully treated with bronchoscopic EBV placement. The mean age was 38.3 years, 60% were male, and half had no prior co-morbidities. The average duration of air leaks prior to EBV deployment was 18 days. EBV placement resulted in the immediate cessation of air leaks in all patients with no peri-procedural complications. Weaning of ECMO, successful ventilator recruitment and removal of pleural drains were subsequently possible. A total of 80% of patients survived to hospital discharge and follow-up. Two patients died from multi-organ failure unrelated to EBV use. This case series presents the feasibility of EBV placement in severe parenchymal lung disease with PAL in patients requiring ECMO for COVID-19 ARDS and its potential to expedite weaning from both ECMO and mechanical ventilation, recovery from respiratory failure and ICU/hospital discharge. Full article
(This article belongs to the Special Issue Extracorporeal Membrane Oxygenation (ECMO): Current Progress and Clinical Challenges)
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6 pages, 1167 KiB  
Article
Prophylactic Awake Peripheral V-A ECMO during TAVR
by Timur Lesbekov, Abdurashid Mussayev, Serik Alimbayev, Rymbay Kaliyev, Aidyn Kuanyshbek, Linar Faizov, Zhuldyz Nurmykhametova, Aigerim Kunakbayeva and Aigerim Sadykova
J. Clin. Med. 2023, 12(3), 859; https://doi.org/10.3390/jcm12030859 - 20 Jan 2023
Cited by 3 | Viewed by 1826
Abstract
Introduction: TAVR remains a complex procedure that may result in serious intraprocedural complications. In many of these circumstances, venoarterial extracorporeal membrane oxygenation (V-A ECMO) helps to manage complications, provides a hemodynamic back-up, and bridges to an emergency open heart surgery. The clinical outcomes [...] Read more.
Introduction: TAVR remains a complex procedure that may result in serious intraprocedural complications. In many of these circumstances, venoarterial extracorporeal membrane oxygenation (V-A ECMO) helps to manage complications, provides a hemodynamic back-up, and bridges to an emergency open heart surgery. The clinical outcomes of 27 patients who underwent prophylactic implantation of peripheral V-A ECMO (pV-A ECMO) during high-risk transcatheter aortic valve replacement (TAVR) cases are described. Methods: From June 2012 to October 2022, 590 consecutive patients underwent TAVR at our center. Of these, 27 patients (4.5%) underwent TAVR with pV-AECMO because they were deemed very high risk for periprocedural complications and formed the study population. Results: There were no pV-A ECMO, hemodynamic or TAVR implantation complications. Decannulation of the ECMO system was performed in 92.6% of cases at the end of the procedure in the hybrid-operating theatre. The mean duration of pV-A ECMO for procedure support was 51.4 ± 10.3 min. There were no ECMO-related vascular or bleeding complications. Conclusion: This study shows that the prophylactic placement of awake peripheral V-A ECMO provides excellent temporary cardio-circulatory and pulmonary support during very high-risk TAVR procedures. Full article
(This article belongs to the Special Issue Extracorporeal Membrane Oxygenation (ECMO): Current Progress and Clinical Challenges)
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8 pages, 228 KiB  
Article
Extracorporeal Life Support for Cardiogenic Shock in Octogenarians: Single Center Experience
by Nadezda Scupakova, Karolis Urbonas, Agne Jankuviene, Lina Puodziukaite, Povilas Andrijauskas, Vilius Janusauskas, Aleksejus Zorinas, Kestutis Laurusonis, Pranas Serpytis and Robertas Samalavicius
J. Clin. Med. 2023, 12(2), 585; https://doi.org/10.3390/jcm12020585 - 11 Jan 2023
Cited by 1 | Viewed by 1418
Abstract
Background: The age limit for the use of extracorporeal membrane oxygenation (ECMO) support for post-cardiotomy cardiac failure is not defined. The aim of the study was to evaluate the outcomes of octogenarians supported with ECMO due to cardiogenic shock. Methods: A retrospective review [...] Read more.
Background: The age limit for the use of extracorporeal membrane oxygenation (ECMO) support for post-cardiotomy cardiac failure is not defined. The aim of the study was to evaluate the outcomes of octogenarians supported with ECMO due to cardiogenic shock. Methods: A retrospective review of consecutive elderly patients supported with ECMO during a 13-year period in a tertiary care center. Patient’s demographic variables, comorbidities, perioperative data and outcomes were collected from patient medical records. Data of octogenarian patients were compared with the septuagenarian group. The main outcomes of the study was in hospital mortality, 6-month survival and 1-year survival after hospital discharge and discharge options. Multivariate logistic regression analysis was performed to identify the factors associated with hospital survival. Results: Eleven patients (18.3%) in the elderly group were octogenarians (aged 80 years or above), and forty-nine (81.7%) were septuagenarians (aged 70–79 years). There were no differences except age in demographic and preoperative variables between groups. Pre ECMO SAVE, SOFA, SAPS—II and inotropic scores were significantly higher in septuagenarians than octogenarians. There was no statistically significant difference in hospital mortality, 6-month survival, 1 year survival or discharge options between groups. Conclusions: ECMO could be successfully used in selected octogenarian patients undergoing cardiac surgery to support a failing heart. An early decision to initiate ECMO therapy in elderly post-cardiotomy shock patients is associated with favorable outcomes. Full article
(This article belongs to the Special Issue Extracorporeal Membrane Oxygenation (ECMO): Current Progress and Clinical Challenges)
11 pages, 1643 KiB  
Article
The Impact of Recirculation on Extracorporeal Gas Exchange and Patient Oxygenation during Veno-Venous Extracorporeal Membrane Oxygenation—Results of an Observational Clinical Trial
by Johannes Gehron, Dirk Bandorski, Konstantin Mayer and Andreas Böning
J. Clin. Med. 2023, 12(2), 416; https://doi.org/10.3390/jcm12020416 - 4 Jan 2023
Cited by 5 | Viewed by 1619
Abstract
Background: Recirculation during veno-venous extracorporeal membrane oxygenation reduces extracorporeal oxygen exchange and patient oxygenation. To minimize recirculation and maximize oxygen delivery (DO2) the interaction of cannulation, ECMO flow and cardiac output requires careful consideration. We investigated this interaction in an observational [...] Read more.
Background: Recirculation during veno-venous extracorporeal membrane oxygenation reduces extracorporeal oxygen exchange and patient oxygenation. To minimize recirculation and maximize oxygen delivery (DO2) the interaction of cannulation, ECMO flow and cardiac output requires careful consideration. We investigated this interaction in an observational trial. Methods: In 19 patients with acute respiratory distress syndrome and ECMO, we measured recirculation with the ultrasound dilution technique and calculated extracorporeal oxygen transfer (VO2), extracorporeal oxygen delivery (DO2) and patient oxygenation. To assess the impact of cardiac output (CO), we included CO measurement through pulse contour analysis. Results: In all patients, there was a median recirculation rate of approximately 14–16%, with a maximum rate of 58%. Recirculation rates >35% occurred in 13–14% of all cases. In contrast to decreasing extracorporeal gas exchange with increasing ECMO flow and recirculation, patient oxygenation increased with greater ECMO flows. High CO diminished recirculation by between 5–20%. Conclusions: Extracorporeal gas exchange masks the importance of DO2 and its effects on patients. We assume that increasing DO2 is more important than reduced VO2. A negative correlation of recirculation to CO adds to the complexity of this phenomenon. Patient oxygenation may be optimized with the direct measurement of recirculation. Full article
(This article belongs to the Special Issue Extracorporeal Membrane Oxygenation (ECMO): Current Progress and Clinical Challenges)
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Review

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15 pages, 564 KiB  
Review
Simulators and Simulations for Extracorporeal Membrane Oxygenation: An ECMO Scoping Review
by Wytze C. Duinmeijer, Libera Fresiello, Justyna Swol, Pau Torrella, Jordi Riera, Valentina Obreja, Mateusz Puślecki, Marek Dąbrowski, Jutta Arens and Frank R. Halfwerk
J. Clin. Med. 2023, 12(5), 1765; https://doi.org/10.3390/jcm12051765 - 22 Feb 2023
Cited by 5 | Viewed by 4809
Abstract
High-volume extracorporeal membrane oxygenation (ECMO) centers generally have better outcomes than (new) low-volume ECMO centers, most likely achieved by a suitable exposure to ECMO cases. To achieve a higher level of training, simulation-based training (SBT) offers an additional option for education and extended [...] Read more.
High-volume extracorporeal membrane oxygenation (ECMO) centers generally have better outcomes than (new) low-volume ECMO centers, most likely achieved by a suitable exposure to ECMO cases. To achieve a higher level of training, simulation-based training (SBT) offers an additional option for education and extended clinical skills. SBT could also help to improve the interdisciplinary team interactions. However, the level of ECMO simulators and/or simulations (ECMO sims) techniques may vary in purpose. We present a structured and objective classification of ECMO sims based on the broad experience of users and the developer for the available ECMO sims as low-, mid-, or high-fidelity. This classification is based on overall ECMO sim fidelity, established by taking the median of the definition-based fidelity, component fidelity, and customization fidelity as determined by expert opinion. According to this new classification, only low- and mid-fidelity ECMO sims are currently available. This comparison method may be used in the future for the description of new developments in ECMO sims, making it possible for ECMO sim designers, users, and researchers to compare accordingly, and ultimately improve ECMO patient outcomes. Full article
(This article belongs to the Special Issue Extracorporeal Membrane Oxygenation (ECMO): Current Progress and Clinical Challenges)
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