TY - JOUR
T1 - Transcranial Doppler microemboli and acute brain injury in extracorporeal membrane oxygenation
T2 - A prospective observational study
AU - HERALD (Hopkins Exploration, Research, and Advancement in Life support Devices) Investigators
AU - Caturegli, Giorgio
AU - Kapoor, Shrey
AU - Ponomarev, Vladimir
AU - Kim, Bo Soo
AU - Whitman, Glenn J.R.
AU - Ziai, Wendy
AU - Cho, Sung Min
AU - Zhang, Lucy Q.
AU - Mayasi, Yunis
AU - Gusdon, Aaron
AU - Ergin, Bahattin
AU - Keller, Steven
AU - Acton, Matthew
AU - Rando, Hannah
AU - Alejo, Diane
AU - Calligy, Kate
AU - Anderson, Scott
AU - Shou, Benjamin
AU - Mendez-Tellez, Pedro A.
AU - Chang, Henry
AU - Sussman, Marc
AU - Wilcox, Christopher
AU - Brown, Patricia
AU - Peeler, Anna
N1 - Funding Information:
A.G. and S.M.C. are supported by the National Institutes of Health (NIH). W.C.Z. is supported by the NIH and has received consulting fees from C.R. Bard, Inc, outside of the area of work commented on here. All other authors reported no conflicts of interest.
Publisher Copyright:
© 2022 The Author(s)
PY - 2022/10
Y1 - 2022/10
N2 - Objective: Extracorporeal membrane oxygenation (ECMO) carries a high morbidity of acute brain injury (ABI) with resultant mortality increase. Transcranial Doppler (TCD) allows real-time characterization of regional cerebral hemodynamics, but limited data exist on the interpretation of microembolic signals (MES) in ECMO. Methods: This prospective cohort study was conducted at a single tertiary care center, November 2017 through February 2022, and included all adult patients receiving venoarterial (VA) and venovenous (VV) ECMO undergoing TCD examinations, which all included MES monitoring. Results: Of 145 patients on ECMO who underwent at least 1 TCD examination, 100 (68.9%) patients on VA-ECMO received 187 examinations whereas 45 (31.1%) patients on VV-ECMO received 65 examinations (P =. 81). MES were observed in 35 (35.0%) patients on VA-ECMO and 2 (4.7%) patients on VV-ECMO (P < .001), corresponding to 46 (24.6%) and 2 (3.1%) TCD examinations, respectively. MES were present in 29.4% of patients on VA-ECMO without additional cardiac support, compared with 38.1% with intra-aortic balloon pump and 57.1% with left ventricular assist device, but these differences were not statistically significant (P =. 39; P =. 20, respectively). Presence or number of MES was not associated with VA-ECMO cannulation mode (23.4% MES presence in peripheral cannulation vs 25.8% in central cannulation, P =. 80). In both VA- and VV-ECMO, MES presence or number was not associated with presence of clot or fibrin in the ECMO circuit or with any studied hemodynamic, laboratory, or ECMO parameters at the time of TCD. ABI occurred in 38% and 31.1% of patients on VA- and VV-ECMO, respectively. In multivariable logistic regression analyses, neither ABI nor a composite outcome of arterial thromboembolic events was associated with presence or number of MES in VA- ECMO. Conclusions: TCD analysis in a large cohort of patients on ECMO demonstrates a significant number of MES, especially in patients on VA-ECMO with intra-aortic balloon pump, and/or left ventricular assist device. However, clinical associations and significance of TCD MES remain unresolved and warrant further correlation with systematic imaging and long-term neurologic follow-up.
AB - Objective: Extracorporeal membrane oxygenation (ECMO) carries a high morbidity of acute brain injury (ABI) with resultant mortality increase. Transcranial Doppler (TCD) allows real-time characterization of regional cerebral hemodynamics, but limited data exist on the interpretation of microembolic signals (MES) in ECMO. Methods: This prospective cohort study was conducted at a single tertiary care center, November 2017 through February 2022, and included all adult patients receiving venoarterial (VA) and venovenous (VV) ECMO undergoing TCD examinations, which all included MES monitoring. Results: Of 145 patients on ECMO who underwent at least 1 TCD examination, 100 (68.9%) patients on VA-ECMO received 187 examinations whereas 45 (31.1%) patients on VV-ECMO received 65 examinations (P =. 81). MES were observed in 35 (35.0%) patients on VA-ECMO and 2 (4.7%) patients on VV-ECMO (P < .001), corresponding to 46 (24.6%) and 2 (3.1%) TCD examinations, respectively. MES were present in 29.4% of patients on VA-ECMO without additional cardiac support, compared with 38.1% with intra-aortic balloon pump and 57.1% with left ventricular assist device, but these differences were not statistically significant (P =. 39; P =. 20, respectively). Presence or number of MES was not associated with VA-ECMO cannulation mode (23.4% MES presence in peripheral cannulation vs 25.8% in central cannulation, P =. 80). In both VA- and VV-ECMO, MES presence or number was not associated with presence of clot or fibrin in the ECMO circuit or with any studied hemodynamic, laboratory, or ECMO parameters at the time of TCD. ABI occurred in 38% and 31.1% of patients on VA- and VV-ECMO, respectively. In multivariable logistic regression analyses, neither ABI nor a composite outcome of arterial thromboembolic events was associated with presence or number of MES in VA- ECMO. Conclusions: TCD analysis in a large cohort of patients on ECMO demonstrates a significant number of MES, especially in patients on VA-ECMO with intra-aortic balloon pump, and/or left ventricular assist device. However, clinical associations and significance of TCD MES remain unresolved and warrant further correlation with systematic imaging and long-term neurologic follow-up.
KW - ECMO
KW - MES
KW - TCD
KW - brain injury
KW - emboli
KW - extracorporeal membrane oxygenation
KW - stroke
KW - transcranial Doppler
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U2 - 10.1016/j.xjtc.2022.07.026
DO - 10.1016/j.xjtc.2022.07.026
M3 - Article
C2 - 36276670
AN - SCOPUS:85138090304
SN - 2666-2507
VL - 15
SP - 111
EP - 122
JO - JTCVS Techniques
JF - JTCVS Techniques
ER -