Faculty Bibliography

The approach to monitoring anticoagulation in adult patients receiving heparin on extracorporeal membrane oxygenation (ECMO) support is controversial. The objective of this study was to compare the correlation between anti-Xa and aPTT with heparin dose and to describe their association with clinical events in adult ECMO patients. We conducted a retrospective single-center study of 34 adult ECMO patients whose heparin was monitored by anti-Xa or aPTT. The heparin dose-to-assay correlation coefficient was 0.106 for aPTT and 0.414 for anti-Xa (p < 0.001). Major thrombotic and hemorrhagic events occurred in 14.7% and 26.5% of patients, respectively. The median anti-Xa in patients who experienced a major thrombotic event was 0.09 (0.06-0.25) IU/mL compared with 0.36 (0.26-0.44) IU/mL in patients who did not (p = 0.031), whereas the median aPTT did not differ between these groups. The maximum aPTT in patients who experienced a major bleed was 96.9 (76.0-200) seconds compared with 63.5 (44.4-98.6) seconds in patients who did not (p = 0.049), whereas the maximum anti-Xa did not differ between these groups. Monitoring both anti-Xa and aPTT may be warranted to safely provide understanding of pure heparin activity as well as underlying bleeding diatheses in adult ECMO patients.

Objective: Hermansky-Pudlak syndrome (HPS) is a genetic disorder characterized by bleeding diathesis and pulmonary fbrosis (PF). While lung transplantation for PF in HPS has been described, patients are carefully selected and history of severe bleeding is often considered a contraindication. We present a bilateral orthotopic lung transplantation (BOLT) in a patient with HPS, delta-platelet storage pool disorder (DSPD), and history of excessive bleeding.
Method(s): A 48-year-old Puerto Rican woman with oxygen-dependent PF and severe pulmonary hypertension (pHTN) secondary to HPS was evaluated for BOLT. She was denied by all other institutions due to perceived excessive bleeding risk, manifested as chronic bruising and history of heavy menses. She previously received blood transfusions following lung biopsy and during dilation and curettage. Platelet function studies demonstrated absence of dense granules consistent with DSPD. Hematology recommended a protocol including pre-incision platelet and DDAVP administration, repletion of clotting factors while weaning cardiopulmonary bypass (CPB), and adjunct factor VII for diffuse coagulopathy. BOLT was performed 3 days after listing. CPB was utilized due to pHTN and bleeding risk. Factor VII was transfused intraoperatively, and no postoperative bleeding occurred. Pharmacologic deep vein thrombosis prophylaxis was held.
Result(s): The patient was discharged on postoperative day 6. Pulmonary function tests showed forced vital capacity (FVC) 2.5 L, forced expiratory volume in 1 second (FEV1) 2 L, and FEV1/FVC 0.8, and the patient remains well 6 months post-transplantation.
Conclusion(s): Lung transplantation remains the only viable option for HPS patients with P F. While increased bleeding may be encountered, a multidisciplinary protocoled approach can mitigate the bleeding risk. History of excessive bleeding should not be an independent contraindication for lung transplantation in HPS

Objective: Cardiac angiosarcomas often present as multicentric right atrial masses that sometimes manifest as atrial rupture. We present a modifed Cabrol patch repair in a patient with right atrial rupture on imaging who was diagnosed intraoperatively with permeating angiosarcoma.
Method(s): A previously healthy 60-year-old man presented with dyspnea and was found to have subsegmental pulmonary emboli and a pericardial effusion with negative cytology. Three months later, his symptoms recurred and cardiac magnetic resonance imaging demonstrated right atrial destruction and thrombus compressing the right ventricle. Given the lack of diagnosis and potential progression to tamponade, he was taken to the operating room for right atrial repair. Before opening the pericardium, femoral cardiopulmonary bypass was initiated. The right atrium, atrioventricular groove, and anterior right ventricular wall were occupied by bleeding, friable tissue (Figure CC-1a). Frozen section revealed a spindle-cell neoplasm. Given the impossibility of performing an oncologic resection, the right atrium was contained with a modifed Cabrol patch, mimicking the function previously provided by the pericardium. Additional patches covered the surface of the actively bleeding tumor (Figure CC-1b).
Result(s): The patient recovered well and was discharged home 1 week later. Final pathology diagnosed angiosarcoma. He is 7 months postdischarge and completed 14 rounds of paclitaxel-based chemotherapy with moderate radiological improvement.
Conclusion(s): As oncologic resection was impossible, a modifed Cabrol patch repair to mimic the function previously provided by pericardium and to control tumor-associated bleeding was the best decision. While this patient may not have received hemodynamic beneft, we provided a defnitive diagnosis allowing for targeted chemotherapy treatment

Intro: The optimal strategy for weaning of respiratory support during lung recovery of patients requiring VV ECMO for acute respiratory failure is unknown. We hypothesized that earlier liberation from the ventilator in these patients may correlate with improved outcomes.
Method(s): We retrospectively reviewed all VV ECMO patients at our center from November 2015 to May 2019. Patients who were on VV ECMO as bridge to transplant or for isolated intraoperative indications were excluded. The final study population included 18 patients; 6 were liberated from mechanical ventilation prior to ECMO decannulation and 12 were decannulated from ECMO, but remained mechanically ventilated. Demographics and outcomes were compared between the two groups.
Result(s): Patients liberated from the ventilator prior to ECMO were treated for asthma, pneumonia and vasculitis (33% each) versus predominantly pneumonia (58%), had a lower rate of pre-existing lung disease (17% vs 33%), and lower APACHE II scores (median of 21 vs 24). These patients had longer duration of ECMO (220 vs 205 hours), less ventilator days (5 vs 20.5 days), higher average Richmond Agitation Scores (-1 vs -3), fewer days until they were able to get out of bed (4.5 vs 15 days), shorter ICU stays (16 vs 29 days), and were more likely to survive to hospital discharge (100% vs 67%).
Conclusion(s): Early ventilator liberation of patients on VV ECMO was associated with improved outcomes. Our study is limited by small sample size, retrospective design, and potential for confounding due to baseline differences between groups

Introduction: Our institution's Adult ECMO Program started in 2015 and continues to see exponential growth with an average of 89% annual increase in volume. When demand for ECMO exceeds available resources, the multiple teams, resources and processes involved in the care of these patients are challenged to provide excellent outcomes. Our program made specific changes to accommodate increased volume while maintaining quality. Our growth directly impacted staff exposure and expertise, locations of ECMO care, emergent bedside cannulations, and utilization of equipment and supplies.
Result(s): Our team coordinated comprehensive training courses to increase the number of ECMO-credentialed physicians and advanced practice providers. We then focused on improving bedside cannulations. We provided cannulation didactic and simulation training for a cohort of critical care nurses, created a single ECMO Perfusion activation number, and increased available primed circuits. We also rebuilt our cannulation carts, using an exchange process for immediate replenishment of supplies. All carts were streamlined to one lay out and were expanded across the hospital in five different locations. We increased our equipment inventory from 9 to 15 consoles and introduced a more cost-effective ECMO system. Last, we implemented ECMO safety rounds, a biweekly bedside audit of existing safety measures that also allowed for real-time staff education.
Conclusion(s): Our patient outcomes continue to meet the national ELSO benchmarks for survival rates. As our growth continues, all areas require ongoing assessment and evaluation to maintain best practices. With proper planning and resources, quality patient outcomes can be maintained

INTRO: Our Adult ECMO Program cannulates most of our patients in the operating room (OR). However, in the past year, our bedside cannulation volume increased from 13 to 27 across six inpatient units. Because we expect cannulations outside of the OR to increase, the Adult Langone Emergency Response Team (ALERT) nurses were identified as the ideal providers to assist in bedside cannulations.
METHOD(S): Our ECMO Team developed a cannulation program to meet the educational needs of the 20 ALERT nurses. The ECMO Directors and Coordinator held a two hour didactic course, reviewing cannulation procedures, ECMO configurations and nursing roles in a bedside cannulation. We distributed pre & post self-assessments to evaluate the nurses' confidence levels. The ECMO Team then invited ALERT nurses to observe planned cannulations, providing an ideal setting for learning and reflection of the cannulation process. ALERT nurses identified areas for improvement that could aid in emergent initiation of ECMO outside of the OR. The program concluded with a one hour simulation session that provided an opportunity for both teams to clarify expectations of future cannulations.
RESULT(S): Using the Wilcoxon Signed-rank test, we found a statistically significant improvement in pre & post self-assessment scores (p-value <0.001). Direct feedback from ALERT nurses included further clarification for ECMO team activation process, terminology of surgical supplies and additional resources needed to support a bedside cannulation. The program allowed for both teams to strengthen their collaboration that will ultimately result in improved workflow, communication and patient outcomes

The left ventricular outflow tract (LVOT) velocity time integral (VTI) is an easily measured echocardiographic stroke volume index analog. Low values predict adverse outcomes in left ventricular failure. We postulate the left ventricular VTI may be a signal of right ventricular dysfunction in acute pulmonary embolism, and therefore a predictor of poor outcomes. We retrospectively reviewed echocardiograms on all Pulmonary Embolism Response Team activations at our institution at the time of pulmonary embolism diagnosis. Low LVOT VTI was defined as ⩽ 15 cm. We examined two composite outcomes: (1) in-hospital death or cardiac arrest; and (2) shock or need for primary reperfusion therapies. Sixty-one of 188 patients (32%) had a LVOT VTI of ⩽ 15 cm. Low VTI was associated with in-hospital death or cardiac arrest (odds ratio (OR) 6, 95% CI 2, 17.9; p = 0.0014) and shock or need for reperfusion (OR 23.3, 95% CI 6.6, 82.1; p < 0.0001). In a multivariable model, LVOT VTI ⩽ 15 remained significant for death or cardiac arrest (OR 3.48, 95% CI 1.02, 11.9; p = 0.047) and for shock or need for reperfusion (OR 8.12, 95% CI 1.62, 40.66; p = 0.011). Among intermediate-high-risk patients, low VTI was the only variable associated with the composite outcome of death, cardiac arrest, shock, or need for reperfusion (OR 14, 95% CI 1.7, 118.4; p = 0.015). LVOT VTI is associated with adverse short-term outcomes in acute pulmonary embolism. The VTI may help risk stratify patients with intermediate-high-risk pulmonary embolism.

OBJECTIVES/OBJECTIVE:Patients with low left ventricular ejection fraction (LVEF) undergoing high-risk coronary artery bypass grafting (CABG) are at increased risk for postcardiotomy cardiogenic shock. This report describes planned concomitant microaxial temporary mechanical support (MA-TMS) device placement as a viable bridge-to-recovery strategy for high-risk patients receiving surgical revascularization. METHODS:A retrospective review was performed for all patients from October 2017 to May 2019 with low LVEF (<30%), New York Heart Association Class III or IV symptoms, and myocardial viability who underwent CABG with prophylactic MA-TMS support at a single institution (n = 13). RESULTS:Mean patient age was 64.8 years, and 12 patients (92%) were male. Eight patients (62%) presented with acute coronary syndrome. Mean predicted risk of mortality was 4.6%, ranging from 0.6% to 15.6%. An average of 3.4 grafts were performed per patient. Greater than 60% of patients were extubated within 48 hours and out-of-bed within 72 hours, and the average duration of MA-TMS was 5.7 days. Mean postoperative length of stay was 16.7 days. There were no postoperative myocardial infarctions or deaths. CONCLUSIONS:Prophylactic MA-TMS may allow safe and effective surgical revascularization for patients with severe left ventricular dysfunction who may otherwise be offered a durable ventricular assist device.

Background:There is a paucity of data evaluating optimal dosing strategies of commonly utilized opioids and sedatives for patients on extracorporeal membrane oxygenation (ECMO) support where pharmacokinetic and pharmacodynamic variables of these administered agents are altered. Objective: To assess the daily dosing requirement of sedatives and analgesics for patients on venovenous (VV) and venoarterial (VA) ECMO after the initial ECMO cannulation period. Methods: We performed a retrospective, observational study of adult patients receiving sedation and analgesia while receiving ECMO support for at least 24 hours. Patients cannulated at an outside hospital more than 24 hours before transfer, those with a history of intravenous drug use or acute alcohol withdrawal, or those who died within 48 hours of ECMO initiation were excluded. Results: We evaluated 26 patients on ECMO, including 13 on VV and 13 on VA ECMO. The median dose of fentanyl was 140 µg/h, with the VV group requiring a higher dose compared with the VA group (167 vs 106 µg/h, P < 0.001). The median doses of dexmedetomidine and propofol were 0.7 µg/kg/h and 26 µg/kg/min, respectively, with no significant differences between groups (P = 0.38 and P = 0.24, respectively). The median daily doses of fentanyl, dexmedetomidine, and propofol did not significantly increase throughout the time on ECMO support. Conclusions and Relevance: We found that the overall opioid daily dosing requirements were lower than previously reported in the literature. Additionally, light sedation strategies with a target RASS of -1 to 0 are feasible in this patient population.