ASAIO journal : a peer-reviewed journal of the American Society for Artificial Internal Organs
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Review Historical Article
The evolution of extracorporeal life support as a bridge to lung transplantation.
The use of extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation was reported for the first time more than three decades ago; nevertheless, its use in lung transplantation was largely abandoned because of poor patient survival and frequent complications. The outcomes of patients bridged to lung transplantation using ECMO have substantially improved in the last 5 years. Recent advances in extracorporeal life support technology now allow patients with end-stage lung disease to be successfully supported for prolonged periods of time, preventing the use of mechanical ventilation and facilitating physical rehabilitation and ambulation while the patients awaits lung transplantation. This review briefly describes the evolution of ECMO use in lung transplantation and summarizes the available technology and current approaches to provide ECMO support.
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Axial flow left ventricular assist device (LVAD) implantation is an effective therapy for patients with advanced heart failure. As the preoperative hepatic and renal function play a critical role in determining adverse events after LVAD implantation, we analyzed the predictive role of the model for end-stage liver disease (MELD) score in determining in-hospital mortality after surgery. One hundred twenty-six patients underwent implant of an LVAD at our institution. ⋯ The MELD score was not predictive of inhospital mortality in these patients (p = 0.97). The MELD score is predictive of early mortality in patients undergoing LVAD implantation as their first cardiac surgery. Use of this score to select patients for LVAD implantation may be appropriate.
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Ventricular assist device (VAD) thrombosis is a devastating, potentially fatal complication suffered by patients requiring mechanical circulatory support. We present a patient with thrombosis of a HeartMate II VAD with concurrent hemolysis and increased carbon monoxide formation. Using a specialized thrombelastographic assay, we detected marked plasmatic hypercoagulability mediated in part by the formation of carboxyhemefibrinogen.
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Allogeneic transfusion, or transfusion of blood banked blood has been associated with a litany of complications for the recipient. These complications plus associated cost has led to the development of a concept called "patient blood management," which recognizes that allogeneic transfusion may be necessary; however, all effort should be expended at minimizing its need. ⋯ This process can take place in the intraoperative or postoperative period. This article describes the technology, how it works, and how to maximize the utility of the system.
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The best method of monitoring anticoagulation during extracorporeal membrane oxygenation (ECMO) is unknown. We conducted a prospective observational study in a tertiary pediatric intensive care unit. Antifactor Xa, antithrombin (AT), and factor VIII activity (FVIII) were measured in blood samples collected at 6, 12, and every 24 hours, respectively, of ECMO. ⋯ This study emphasizes the age differences as well as the variability over days of coagulation monitoring assays during ECMO. ACT is poorly correlated with antifactor Xa and AT modifies the relationship between ACT and the heparin dose, indicating that results should be interpreted with caution when managing anticoagulation on ECMO. Additional studies are warranted to determine optimal ECMO anticoagulation monitoring.