Papers by Maria Elena De Piero
Artificial Organs, Jul 9, 2023
BackgroundHigh‐quality evidence for post‐cardiotomy extracorporeal life support (PC‐ECLS) managem... more BackgroundHigh‐quality evidence for post‐cardiotomy extracorporeal life support (PC‐ECLS) management is lacking. This study investigated real‐world PC‐ECLS clinical practices.MethodsThis cross‐sectional, multi‐institutional, international pilot survey explored center organization, anticoagulation management, left ventricular unloading, distal limb perfusion, PC‐ECLS monitoring, and transfusion practices. Twenty‐nine questions were distributed among 34 hospitals participating in the Post‐cardiotomy Extra‐Corporeal Life Support Study.ResultsOf the 32 centers [16 low‐volume (50%); 16 high‐volume (50%)] that responded, 16 (50%) had dedicated ECLS specialists. Twenty‐six centers (81.3%) reported using additional mechanical circulatory supports. Anticoagulation practices were highly heterogeneous: 24 hospitals (75%) reported using patients bleeding status as a guide, without a specific threshold in 54.2% of cases. Transfusion targets ranged from 7 to 10 g/dL. Most centers used cardiac venting on a case‐by‐case basis (78.1%) and regular distal limb perfusion (84.4%). Nineteen (54.9%) centers reported dedicated monitoring protocols, including daily echocardiography (87.5%), Swan‐Ganz catheterization (40.6%), cerebral near‐infrared spectroscopy (53.1%), and multimodal assessment of limb ischemia. Inspection of the circuit (71.9%), oxygenator pressure drop (68.8%), plasma free hemoglobin (75%), d‐dimer (59.4%), lactate dehydrogenase (56.3%), and fibrinogen (46.9%) are used to diagnose hemolysis and thrombosis.ConclusionsThis study shows remarkable heterogeneity in clinical practices for PC‐ECLS management. More standardized protocols and better implementation of the available evidence are recommended.
Perfusion, May 12, 2023
IntroductionExtraCorporeal Membrane Oxygenation (ECMO) in pediatric patients with COVID-19 has a ... more IntroductionExtraCorporeal Membrane Oxygenation (ECMO) in pediatric patients with COVID-19 has a survival rate similar to adults. Occasionally, patients may need to be cannulated by an ECMO team in a referring hospital and transported to an ECMO center. The ECMO transport of a COVID-19 patient has additional risks than normal pediatric ECMO transport for the possible COVID-19 transmissibility to the ECMO team and the reduction of the ECMO team performance due to the need of wearing full personal protective equipment. Since pediatric data on ECMO transport of COVID-19 patients are lacking, we explored the outcomes of the pediatric COVID-19 ECMO transports collected in the EuroECMO COVID_Neo/Ped Survey.MethodsWe reported five European consecutive ECMO transports of COVID-19 pediatric patients collected in the EuroECMO COVID_Neo/Ped Survey including 52 European neonatal and/or pediatric ECMO centers and endorsed by the EuroELSO from March 2020 till September 2021.ResultsThe ECMO transports were performed for two indications, pediatric ARDS and myocarditis associated to the multisystem inflammatory syndrome related to COVID-19. Cannulation strategies differed among patients according to the age of the patients, transport distance varied between 8 and 390 km with a total transport duration between 5 to 15 h. In all five cases, the ECMO transports were successfully performed without major adverse events. One patient reported a harlequin syndrome and another patient a cannula displacement both without major clinical consequences. Hospital survival was 60% with one patient reporting neurological sequelae. No ECMO team member developed COVID-19 symptoms after the transport.ConclusionFive transports of pediatric patients with COVID-19 supported with ECMO were reported in the EuroECMO COVID_Neo/Ped Survey. All transports were performed by an experienced multidisciplinary ECMO team and were feasible and safe for both the patient and the ECMO team. Further experiences are needed to better characterize these transports and draw insightful conclusions.
The Lancet Respiratory Medicine, May 1, 2023
Oxford University Press eBooks, Mar 1, 2022
Right ventricular failure after cardiac surgery is a complex disease that may impair the outcome ... more Right ventricular failure after cardiac surgery is a complex disease that may impair the outcome after valve repair/replacement, bypass surgery, as well as left ventricular assist device implantations and heart transplant. This condition is associated with higher mortality and prolonged in-hospital stay as well as failure of the primary graft in case of cardiac transplant or of the implanted durable left ventricular assist device. Despite maximal medical management, severe right ventricular failure may at times be unresponsive to optimal pharmacological treatment and therefore could require the use of mechanical circulatory support. Several strategies have been described to assist the right ventricle in the postcardiotomy setting. New percutaneous devices, specifically designed for the right support, have been introduced into clinical practice. The minimally invasive approach by facilitated implantation and decreased incidence of complications during the mechanical cardiocirculatory support may offer improved results and ultimate outcome.
Trends in Anaesthesia and Critical Care, Dec 1, 2018
Artificial Organs, May 1, 2022
ObjectiveMyocardial damage occurs in up to 25% of coronavirus disease 2019 (COVID‐19) cases. Whil... more ObjectiveMyocardial damage occurs in up to 25% of coronavirus disease 2019 (COVID‐19) cases. While veno‐venous extracorporeal life support (V‐V ECLS) is used as respiratory support, mechanical circulatory support (MCS) may be required for severe cardiac dysfunction. This systematic review summarizes the available literature regarding MCS use rates, disease drivers for MCS initiation, and MCS outcomes in COVID‐19 patients.MethodsPubMed/EMBASE were searched until October 14, 2021. Articles including adults receiving ECLS for COVID‐19 were included. The primary outcome was the rate of MCS use. Secondary outcomes included mortality at follow‐up, ECLS conversion rate, intubation‐to‐cannulation time, time on ECLS, cardiac diseases, use of inotropes, and vasopressors.ResultsTwenty‐eight observational studies (comprising both ECLS‐only populations and ECLS patients as part of larger populations) included 4218 COVID‐19 patients (females: 28.8%; median age: 54.3 years, 95%CI: 50.7–57.8) of whom 2774 (65.8%) required ECLS with the majority (92.7%) on V‐V ECLS, 4.7% on veno‐arterial ECLS and/or Impella, and 2.6% on other ECLS. Acute heart failure, cardiogenic shock, and cardiac arrest were reported in 7.8%, 9.7%, and 6.6% of patients, respectively. Vasopressors were used in 37.2%. Overall, 3.1% of patients required an ECLS change from V‐V ECLS to MCS for heart failure, myocarditis, or myocardial infarction. The median ECLS duration was 15.9 days (95%CI: 13.9–16.3), with an overall survival of 54.6% and 28.1% in V‐V ECLS and MCS patients. One study reported 61.1% survival with oxy‐right ventricular assist device.ConclusionMCS use for cardiocirculatory compromise has been reported in 7.3% of COVID‐19 patients requiring ECLS, which is a lower percentage compared to the incidence of any severe cardiocirculatory complication. Based on the poor survival rates, further investigations are warranted to establish the most appropriated indications and timing for MCS in COVID‐19.
The Annals of Thoracic Surgery
Artificial Organs
BackgroundHigh‐quality evidence for post‐cardiotomy extracorporeal life support (PC‐ECLS) managem... more BackgroundHigh‐quality evidence for post‐cardiotomy extracorporeal life support (PC‐ECLS) management is lacking. This study investigated real‐world PC‐ECLS clinical practices.MethodsThis cross‐sectional, multi‐institutional, international pilot survey explored center organization, anticoagulation management, left ventricular unloading, distal limb perfusion, PC‐ECLS monitoring, and transfusion practices. Twenty‐nine questions were distributed among 34 hospitals participating in the Post‐cardiotomy Extra‐Corporeal Life Support Study.ResultsOf the 32 centers [16 low‐volume (50%); 16 high‐volume (50%)] that responded, 16 (50%) had dedicated ECLS specialists. Twenty‐six centers (81.3%) reported using additional mechanical circulatory supports. Anticoagulation practices were highly heterogeneous: 24 hospitals (75%) reported using patients bleeding status as a guide, without a specific threshold in 54.2% of cases. Transfusion targets ranged from 7 to 10 g/dL. Most centers used cardiac ven...
Critical Care
Following publication of the original article [1], the authors identified that the collaborating ... more Following publication of the original article [1], the authors identified that the collaborating authors part of the collaborating author group CCCC Consortium was missing. The collaborating author group is available and included as Additional file 1 in this article.
The Lancet Respiratory Medicine
Perfusion
Introduction Limb ischemia is a severe complication of peripheral veno-arterial extracorporeal li... more Introduction Limb ischemia is a severe complication of peripheral veno-arterial extracorporeal life support (V-A ECLS). Several techniques have been developed to prevent this, but it remains a major and frequent adverse event (incidence: 10–30%). In 2019, a new cannula with bidirectional flow (retrograde towards the heart and antegrade towards the distal limb) has been introduced. A single-centre experience with this cannula in patients undergoing peripheral V-A ECLS is herewith reported. Methods This prospective observational study included adults (≥18 years) undergoing V-A ECLS from January 2021 to October 2022 with the use of a bidirectional femoral artery cannula. Primary outcome was limb ischemia requiring intervention during cardio-circulatory support. Secondary outcomes were compartment syndrome, limb amputation, cannulation site bleeding, need for other surgical intervention due to cannula related complications, duplex ultrasound parameters from the femoral vessels, and in-h...
Scientific Data
The International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC) COVID-19 da... more The International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC) COVID-19 dataset is one of the largest international databases of prospectively collected clinical data on people hospitalized with COVID-19. This dataset was compiled during the COVID-19 pandemic by a network of hospitals that collect data using the ISARIC-World Health Organization Clinical Characterization Protocol and data tools. The database includes data from more than 705,000 patients, collected in more than 60 countries and 1,500 centres worldwide. Patient data are available from acute hospital admissions with COVID-19 and outpatient follow-ups. The data include signs and symptoms, pre-existing comorbidities, vital signs, chronic and acute treatments, complications, dates of hospitalization and discharge, mortality, viral strains, vaccination status, and other data. Here, we present the dataset characteristics, explain its architecture and how to gain access, and provide tools to facilitate ...
Perfusion
Objective The Awake Extracorporeal Life Support (ECLS) practice combined with physiotherapy is in... more Objective The Awake Extracorporeal Life Support (ECLS) practice combined with physiotherapy is increasing. However, available evidence for this approach is limited, with unclear indications on timing, management, and protocols. This review summarizes available literature regarding Awake ECLS and physiotherapy application rates, practices, and outcomes in adults, providing indications for future investigations. Methods Four databases were screened from inception to February 2021, for studies reporting adult Awake ECLS with/without physiotherapy. Primary outcome was hospital discharge survival, followed by Extracorporeal Membrane Oxygenation (ECMO) duration, extubation, Intensive Care Unit stay. Results Twenty-nine observational studies and one randomized study were selected, including 1,157 patients (males n = 611/691, 88.4%) undergoing Awake ECLS. Support type was reported in 1,089 patients: Veno-Arterial ECMO (V-A = 39.6%), Veno-Venous ECMO (V-V = 56.8%), other ECLS (3.6%). Exclusi...
Extracorporeal Membrane Oxygenation, 2022
Right ventricular failure after cardiac surgery is a complex disease that may impair the outcome ... more Right ventricular failure after cardiac surgery is a complex disease that may impair the outcome after valve repair/replacement, bypass surgery, as well as left ventricular assist device implantations and heart transplant. This condition is associated with higher mortality and prolonged in-hospital stay as well as failure of the primary graft in case of cardiac transplant or of the implanted durable left ventricular assist device. Despite maximal medical management, severe right ventricular failure may at times be unresponsive to optimal pharmacological treatment and therefore could require the use of mechanical circulatory support. Several strategies have been described to assist the right ventricle in the postcardiotomy setting. New percutaneous devices, specifically designed for the right support, have been introduced into clinical practice. The minimally invasive approach by facilitated implantation and decreased incidence of complications during the mechanical cardiocirculatory...
The Lancet Respiratory Medicine
Background Extracorporeal membrane oxygenation (ECMO) has been widely used in patients with COVID... more Background Extracorporeal membrane oxygenation (ECMO) has been widely used in patients with COVID-19, but uncertainty remains about the determinants of in-hospital mortality and data on post-discharge outcomes are scarce. The aims of this study were to investigate the variables associated with in-hospital outcomes in patients who received ECMO during the first wave of COVID-19 and to describe the status of patients 6 months after ECMO initiation. Methods EuroECMO-COVID is a prospective, multicentre, observational study developed by the European Extracorporeal Life Support Organization. This study was based on data from patients aged 16 years or older who received ECMO support for refractory COVID-19 during the first wave of the pandemic-from March 1 to Sept 13, 2020-at 133 centres in 21 countries. In-hospital mortality and mortality 6 months after ECMO initiation were the primary outcomes. Mixed-Cox proportional hazards models were used to investigate associations between patient and management-related variables (eg, patient demographics, comorbidities, pre-ECMO status, and ECMO characteristics and complications) and in-hospital deaths. Survival status at 6 months was established through patient contact or institutional charts review. This study is registered with ClinicalTrials.gov, NCT04366921, and is ongoing. Findings Between March 1 and Sept 13, 2020, 1215 patients (942 [78%] men and 267 [22%] women; median age 53 years [IQR 46-60]) were included in the study. Median ECMO duration was 15 days (IQR 8-27). 602 (50%) of 1215 patients died in hospital, and 852 (74%) patients had at least one complication. Multiorgan failure was the leading cause of death (192 [36%] of 528 patients who died with available data). In mixed-Cox analyses, age of 60 years or older, use of inotropes and vasopressors before ECMO initiation, chronic renal failure, and time from intubation to ECMO initiation of 4 days or more were associated with higher in-hospital mortality. 613 patients did not die in hospital, and 547 (95%) of 577 patients for whom data were available were alive at 6 months. 102 (24%) of 431 patients had returned to full-time work at 6 months, and 57 (13%) of 428 patients had returned to part-time work. At 6 months, respiratory rehabilitation was required in 88 (17%) of 522 patients with available data, and the most common residual symptoms included dyspnoea (185 [35%] of 523 patients) and cardiac (52 [10%] of 514 patients) or neurocognitive (66 [13%] of 512 patients) symptoms. Interpretation Patient's age, timing of cannulation (<4 days vs ≥4 days from intubation), and use of inotropes and vasopressors are essential factors to consider when analysing the outcomes of patients receiving ECMO for COVID-19. Despite post-discharge survival being favourable, persisting long-term symptoms suggest that dedicated post-ECMO follow-up programmes are required. Funding None.
The Journal of Thoracic and Cardiovascular Surgery
Background Optimizing cardiovascular monitoring and support during veno-venous Extracorporeal Mem... more Background Optimizing cardiovascular monitoring and support during veno-venous Extracorporeal Membrane Oxygenation (V-V ECMO) is essential to ensure overall adequacy of end-organ perfusion and proper titration of extracorporeal support. Despite an increasing V-V ECMO use, guidelines on monitoring of cardiovascular function during mechanical support are lacking, with current approaches mostly based on clinicians’ experience rather than evidence-based recommendations. This scoping review focused on basic and more advance methods for hemodynamic monitoring during V-V ECMO in adult patients. Methods Databases (PubMed, EMBASE and Cochrane CENTRAL) and reference lists of relevant articles were searched from inception until November 2021. We included studies of any methodology that addressed the a priori key questions relating to hemodynamic monitoring during respiratory extracorporeal support. Results Overall, 465 articles were screened, and 106 articles were included for detailed analysi...
Current Opinion in Critical Care
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Papers by Maria Elena De Piero