The use of extracorporeal life support (ECLS) as part of cardio-circulatory support has increased rapidly in recent years. Severe hyperlactatemia is not uncommon in this group of patients. Lactate peak concentrations and lactate clearance have already been identified as independent marker for mortality in critical ill patients without mechanical device support. The aim of this study was to determine a supposed correlation between the variables lactate peak concentration and clearance in the blood and mortality in the ECLS context. Therefore, a total of 51 cardiac surgery ICU patients with ECLS therapy were included in this retrospective, clinical observational study (survivors n = 23; non-survivors n = 28). Lactate measurement was performed before, during and after ECLS therapy. Further, common ICU scores (SAPSII, SOFA, TISS28), the rates of transfusion and the different vasopressor therapies will be compared. Significant elevated peak lactate levels and poor lactate clearance were associated with higher mortality during ECLS therapy (p < 0.001). Deceased patients had higher SAPSII scores (p < 0.001), received more transfusions (p < 0.001) and presented with higher rates of epinephrine (p < 0.001). In conclusion, hyperlactatemia during ECLS therapy is a time sensitive emergency. Lactate cannot be cleared in all patients. Reversible causes should be explored and treated. In cases where the cause is irreversible, the prognosis of elevated lactate concentrations and reduced clearance is very poor.

/pdf/elevated-lactate-levels-and-impaired-lactate-clearance-2zlybrei.pdf

Elevated lactate levels and impaired lactate clearance during extracorporeal life support (ECLS) are associated with poor outcome in cardiac surgery patients

/pdf/pressure-gradient-means-flow-1zbian2j.pdf

Pressure gradient means flow

New strategy for distal limb perfusion in venous-arterial extracorporeal membrane oxygenation treatment: application of continuous renal replacement therapy tubing

OBJECTIVES
To synthesize quantitative research findings on the prevalence and risk factors for in-hospital mortality of patients on veno-arterial extracorporeal membrane oxygenation (VA-ECMO).


METHODS
A comprehensive search was conducted for the period from May 2008 to December 2023 by searching the five electronic databases of PubMed, CINAHL, Web of Science, EMBASE, and Cochrane library. The quality of included studies was assessed using the Newcastle-Ottawa scale. The meta-analysis estimated the pooled odds ratio or standard mean difference and 95% confidence intervals.


RESULTS
A total of twenty-five studies with 10,409 patients were included in the analysis. The overall in-hospital mortality of patients on VA-ECMO was 56.7 %. In the subgroup analysis, in-hospital mortality of VA-ECMO for cardiogenic shock and cardiac arrest was 49.2 % and 75.2 %, respectively. The number of significant factors associated with an increased risk of in-hospital mortality in the pre-ECMO period (age, body weight, creatinine, chronic kidney disease, pH, and lactic acid) was greater than that in the intra- and post-ECMO periods. Renal replacement, bleeding, and lower limb ischemia were the most significant risk factors for in-hospital mortality in patients receiving VA-ECMO.


CONCLUSION
Early detection of the identified risk factors can contribute to reducing in-hospital mortality in patients on VA-ECMO. Intensive care unit nurses should provide timely and appropriate care before, during, and after VA-ECMO.


IMPLICATIONS FOR CLINICAL PRACTICE
Intensive care unit nurses should be knowledgeable about factors associated with the in-hospital mortality of patients on VA-ECMO to improve outcomes. The present findings may contribute to developing guidelines for reducing in-hospital mortality among patients considering ECMO.

Prevalence and risk factors for in-hospital mortality of adult patients on veno-arterial extracorporeal membrane oxygenation for cardiogenic shock and cardiac arrest: A systematic review and meta-analysis

The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock is rising. Acute limb ischaemia remains one of the main complications after ECMO initiation. We analysed 104 patients from our databank from January 2015 to December 2021 who were supported with mobile ECMO therapy. We aimed to identify the impact of acute limb ischaemia on short-term outcomes in patients placed on ECMO in our institution. The main indication for ECMO therapy was left ventricular (LV) failure with cardiogenic shock (57.7%). Diameters of arterial cannulas (p = 0.365) showed no significant differences between both groups. Furthermore, concomitant intra-aortic balloon pump (IABP, p = 0.589) and Impella (p = 0.385) implantation did not differ significantly between both groups. Distal leg perfusion was established in approximately 70% of patients in two groups with no statistically significant difference (p = 0.960). Acute limb ischaemia occurred in 18.3% of cases (n = 19). In-hospital mortality was not significantly different (p = 0.799) in both groups. However, the bleeding rate was significantly higher (p = 0.005) in the limb ischaemia group compared to the no-limb ischaemia group. Therefore, early diagnosis and prevention of acute limb ischaemia might decrease haemorrhage complications in patients during ECMO therapy.

/pdf/acute-limb-ischaemia-during-ecmo-support-a-6-year-experience-3birchu8.pdf

Acute Limb Ischaemia during ECMO Support: A 6-Year Experience

Due to its low incidence, isolated cardiac sarcoidosis (ICS) is often missed or misdiagnosed. Herein, we describe a case of ICS in a 52-year-old male patient. Advanced imaging, including cardiac magnetic resonance (CMR) and fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET), could not only screen high-risk patients for establishing diagnosis, but also guide endomyocardial biopsy (EMB) for improving cardiac disease detection rate. This case highlights the importance of multimodal imaging for screening and necessity of EMB for diagnosis.

/pdf/case-report-a-case-of-isolated-cardiac-sarcoidosis-diagnosed-tlh14hr9.pdf

Case report: A case of isolated cardiac sarcoidosis diagnosed by multimodal imaging and endomyocardial biopsy

The cardiac variant of Fabry disease (FD) has high rates of missed diagnosis and misdiagnosis due to the lack of systemic symptoms. Here, we report a case of a 68-year-old female with delayed-onset FD presenting as concentric left ventricular hypertrophy (LVH) with right bundle branch block, atrial fibrillation, and diastolic dysfunction, which was first presented with coronary artery spasm. Early cardiac-specific signs are crucial for diagnosing this disease due to the lack of extracardiac indications and the late onset of symptoms. This case raises a new red flag that patients with unexplained LVH and its atypical electrocardiographic (ECG) manifestations accompanied by diastolic dysfunction should be considered for FD. We also recommend further refinement of examinations associated with Fabry disease, which will contribute to the early diagnosis and treatment of the disease.

Unexplained Left Ventricular Hypertrophy Diagnosed as a Cardiac Variant of Late-Onset Fabry Disease: A Case Report

A rare case report: acute necrotizing encephalopathy and acute fulminant myocarditis

Transcatheter Intervention for Multiple Valve Diseases in a Patient With Cardiogenic Shock.

Background This study aimed to summarize and analyse the risk factors, clinical features, as well as prevention and treatment of limb ischemia complications in patients on veno-arterial extracorporeal membrane oxygenation (V-A ECMO). Methods We retrospectively analyzed 179 adult patients who had undergone V-A ECMO support in the Cardiac Care Unit of the First Hospital of Lanzhou University between March 2019 and December 2021. Patients were divided into the limb ischemia group (LI group) and the non-limb ischemia group (nLI group) according to whether limb ischemia occurred on the ipsilateral side of femoral artery cannulation. In the LI group, patients were salvaged with a distal perfusion cannula (DPC) according to each patient's clinical conditions. The baseline data and ECMO data were compared between the two groups, and risk factors for limb ischemia complications were screened using multiple logistic regression analysis. Results Overall, 19 patients (10.6%) had limb ischemia complications, of which 5 (2.8%) were improved after medication adjustment, 12 (8.4%) were salvaged with a DPC, and 2 had undergone surgical intervention. There were significant differences in terms of Extracorporeal Cardiopulmonary Resuscitation (ECPR), Intra-aortic balloon pump (IABP), peak vasoactive-inotropic score (VIS) within 24 h after ECMO (VIS-max), Left ventricular ejection fraction (LVEF), weaning from ECMO, and discharge rate between the two groups. ECPR, IABP, and VIS-max in the LI group were significantly higher than those in the nLI group, whereas weaning from ECMO, discharge rate, and LVEF were significantly lower in the LI group compared to those in the nLI group. Furthermore, multiple logistic regression analysis revealed that diabetes [odds ratio (OR) = 4.338, 95% confidence interval (CI): 1.193–15.772, P = 0.026], IABP (OR = 1.526, 95% CI: 1.038–22.026, P = 0.049) and VIS-max (OR = 1.054, 95% CI: 1.024–1.085, P < 0.001) were independent risk factors for limb ischemia complications in patients who underwent V-A ECMO. Conclusion Diabetes, prevalence of IABP and VIS-max value in analyzed groups were independent risk factors for predicting limb ischemia complications in patients who underwent V-A ECMO. The cannulation strategy should be optimized during the establishment of V-A ECMO, and limb ischemia should be systematically evaluated after ECMO establishment. A DPC can be used as a salvage intervention for the complications of critical limb ischemia.

Limb Ischemia Complications of Veno-Arterial Extracorporeal Membrane Oxygenation

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Case report: A case of isolated cardiac sarcoidosis diagnosed by multimodal imaging and endomyocardial biopsy

Unexplained Left Ventricular Hypertrophy Diagnosed as a Cardiac Variant of Late-Onset Fabry Disease: A Case Report

A rare case report: acute necrotizing encephalopathy and acute fulminant myocarditis

Transcatheter Intervention for Multiple Valve Diseases in a Patient With Cardiogenic Shock.

Limb Ischemia Complications of Veno-Arterial Extracorporeal Membrane Oxygenation