Position Paper on Global Extracorporeal Membrane Oxygenation Education and Educational Agenda for the Future: A Statement From the Extracorporeal Life Support Organization ECMOed Taskforce.

Objectives: The purpose of this position paper is two-fold: first, to describe the state of extracorporeal membrane oxygenation education worldwide, noting current limitations and challenges; and second, to put forth an educational agenda regarding opportunities for an international collaborative approach toward standardization.

Design: Relevant medical literature was reviewed through literature search, and materials from national organizations were accessed through the Internet. Taskforce members generated a consensus statement using an iterative consensus process through teleconferences and electronic communication.

The Starling Relationship and Veno-Arterial ECMO: Ventricular Distension Explained.

The use of veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) to support patients with acute heart failure has been associated with ventricular distension and pulmonary edema, the mechanism of which is not fully understood. This study examined the impact of VA ECMO on left ventricular (LV) Starling curves to elaborate a framework for anticipating and treating LV distension. A previously developed and validated model of the cardiovascular system was used to generate pressure-volume (PV) loops and Starling curves while holding mean arterial pressure (mABP) constant at a range of values either by adjusting systemic resistance or by adding VA ECMO support.

Extracorporeal Membrane Oxygenation for End-Stage Interstitial Lung Disease With Secondary Pulmonary Hypertension at Rest and Exercise: Insights From Simulation Modeling.

Interstitial lung disease (ILD) represents a collection of lung disorders with a lethal trajectory with few therapeutic options with the exception of lung transplantation. Various extracorporeal membrane oxygenation (ECMO) configurations have been used for bridge to transplant (BTT), yet no optimal configuration has been clearly demonstrated. Using a cardiopulmonary simulation, we assessed different ECMO configurations for patients with end-stage ILD to assess the physiologic deficits and help guide the development of new long-term pulmonary support devices.

Physiologic determinants of mitral inflow pattern using a computer simulation: insights into Doppler echocardiography in diverse phenotypes.

Background: Although echo Doppler recordings of mitral inflow patterns are often employed clinically to identify "diastolic dysfunction," abnormal flow profiles may be seen in a diverse set of disorders in which the specific physiologic determinants are not well defined.

Methods: We used a validated cardiovascular simulation model to assess the effects of four hemodynamic parameters on Doppler measures of LV filling: (1) total blood volume, (2) diastolic stiffness (LV Beta), (3) systemic vascular resistance (SVR), and (4) pulmonary vascular resistance (PVR). In each simulation, we calculated instantaneous flow through the mitral valve as a function of time.

Severe pulmonary hypertension due to chronic echinococcal pulmonary emboli treated with targeted pulmonary vascular therapy and hepatic resection.

Hydatid disease (human echinococcosis) is a zoonotic infection caused by larval forms (metacestodes) of the genus Echinococcus. Although pulmonary hypertension (PH) due to hydatid disease has been described, it is quite rare. We report a patient with chronic echinococcal embolic PH in whom treatment with novel PH therapies permitted successful resection of the hepatic cyst with a good outcome.

A computational method of prediction of the end-diastolic pressure-volume relationship by single beat.

The end-diastolic pressure-volume relation (EDPVR) is an important descriptor of passive cardiac pump properties. However, clinical utility has been limited by the need for measurement of pressures and volumes over relatively large ranges. In this protocol, we describe an algorithm to estimate the entire EDPVR in humans from a single measured pressure-volume (P-V) point.

Single-beat estimation of end-diastolic pressure-volume relationship: a novel method with potential for noninvasive application.

Whereas end-systolic and end-diastolic pressure-volume relations (ESPVR, EDPVR) characterize left ventricular (LV) pump properties, clinical utility of these relations has been hampered by the need for invasive measurements over a range of pressure and volumes. We propose a single-beat approach to estimate the whole EDPVR from one measured volume-pressure (Vm and Pm) point. Ex vivo EDPVRs were measured from 80 human hearts of different etiologies (normal, congestive heart failure, left ventricular assist device support).

Mechanical unloading during left ventricular assist device support increases left ventricular collagen cross-linking and myocardial stiffness.

Background: Left ventricular assist devices (LVADs) induce reverse remodeling of the failing heart except for the extracellular matrix, which exhibits additional pathophysiological changes, although their mechanisms and functional consequences are unknown.

Methods And Results: Hearts were obtained at transplant from patients with idiopathic dilated cardiomyopathy (DCM) not requiring LVAD support (n=30), patients requiring LVAD support (n=16; LVAD duration, 145+/-33 days), and 5 nonfailing hearts. Left (LV) and right ventricular (RV) ex vivo pressure-volume relationships were measured, and chamber and myocardial stiffness constants were determined.

Mechanisms of heart failure with well preserved ejection fraction in dogs following limited coronary microembolization.

Objective: It has been suggested that in some settings, heart failure (HF) may occur with normal ejection fraction (EF) as a consequence of undetected systolic dysfunction. However, others have argued that this can only occur in the presence of diastolic dysfunction. We therefore sought to determine the contribution of diastolic dysfunction in an animal model of HF with normal EF.

Transesophageal echocardiography guided placement of a coronary sinus pacing lead.

Cardiac resynchronization therapy for the treatment of medically refractory heart failure requires coronary sinus lead placement for left ventricular pacing. Coronary sinus lead placement is technically difficult with success rates reported between 53% to 98% and implantation times ranging from 90 minutes to 5 hours. We report the use of intraoperative transesophageal echocardiography to guide coronary sinus lead placement when conventional fluoroscopy failed.

Cardiac contractility modulation by electric currents applied during the refractory period.

Inotropic effects of electric currents applied during the refractory period have been reported in cardiac muscle in vitro using voltage-clamp techniques. We investigated how electric currents modulate cardiac contractility in normal canine hearts in vivo. Six dogs were instrumented to measure regional segment length, ventricular volume (sonomicrometry), and ventricular pressure.