PMID- 29073930 OWN - NLM STAT- MEDLINE DCOM- 20180928 LR - 20181113 IS - 1466-609X (Electronic) IS - 1364-8535 (Print) IS - 1364-8535 (Linking) VI - 21 IP - 1 DP - 2017 Oct 26 TI - Functional evaluation of sublingual microcirculation indicates successful weaning from VA-ECMO in cardiogenic shock. PG - 265 LID - 10.1186/s13054-017-1855-2 [doi] LID - 265 AB - BACKGROUND: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly adopted for the treatment of cardiogenic shock (CS). However, a marker of successful weaning remains largely unknown. Our hypothesis was that successful weaning is associated with sustained microcirculatory function during ECMO flow reduction. Therefore, we sought to test the usefulness of microcirculatory imaging in the same sublingual spot, using incident dark field (IDF) imaging in assessing successful weaning from VA-ECMO and compare IDF imaging with echocardiographic parameters. METHODS: Weaning was performed by decreasing the VA-ECMO flow to 50% (F(50)) from the baseline. The endpoint of the study was successful VA-ECMO explantation within 48 hours after weaning. The response of sublingual microcirculation to a weaning attempt (WA) was evaluated. Microcirculation was measured in one sublingual area (single spot (ss)) using CytoCam IDF imaging during WA. Total vessel density (TVDss) and perfused vessel density (PVDss) of the sublingual area were evaluated before and during 50% flow reduction (TVDss(F50), PVDss(F50)) after a WA and compared to conventional echocardiographic parameters as indicators of the success or failure of the WA. RESULTS: Patients (n = 13) aged 49 +/- 18 years, who received VA-ECMO for the treatment of refractory CS due to pulmonary embolism (n = 5), post cardiotomy (n = 3), acute coronary syndrome (n = 2), myocarditis (n = 2) and drug intoxication (n = 1), were included. TVDss(F50) (21.9 vs 12.9 mm/mm(2), p = 0.001), PVDss(F50) (19.7 vs 12.4 mm/mm(2), p = 0.01) and aortic velocity-time integral (VTI) at 50% flow reduction (VTI(F50)) were higher in patients successfully weaned vs not successfully weaned. The area under the curve (AUC) was 0.99 vs 0.93 vs 0.85 for TVDss(F50) (small vessels) >12.2 mm/mm(2), left ventricular ejection fraction (LVEF) >15% and aortic VTI >11 cm. Likewise, the AUC was 0.91 vs 0.93 vs 0.85 for the PVDss(F50) (all vessels) >14.8 mm/mm(2), LVEF >15% and aortic VTI >11 cm. CONCLUSION: This study identified sublingual microcirculation as a novel potential marker for identifying successful weaning from VA-ECMO. Sustained values of TVDss(F50) and PVDss(F50) were found to be specific and sensitive indicators of successful weaning from VA-ECMO as compared to echocardiographic parameters. FAU - Akin, Sakir AU - Akin S AUID- ORCID: 0000-0003-0700-1930 AD - Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. s.akin@erasmusmc.nl. AD - Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. s.akin@erasmusmc.nl. FAU - Dos Reis Miranda, Dinis AU - Dos Reis Miranda D AD - Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. FAU - Caliskan, Kadir AU - Caliskan K AD - Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. FAU - Soliman, Osama I AU - Soliman OI AD - Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. FAU - Guven, Goksel AU - Guven G AD - Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. AD - Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. FAU - Struijs, Ard AU - Struijs A AD - Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. FAU - van Thiel, Robert J AU - van Thiel RJ AD - Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. FAU - Jewbali, Lucia S AU - Jewbali LS AD - Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. AD - Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. FAU - Lima, Alexandre AU - Lima A AD - Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. FAU - Gommers, Diederik AU - Gommers D AD - Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. FAU - Zijlstra, Felix AU - Zijlstra F AD - Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. FAU - Ince, Can AU - Ince C AD - Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. LA - eng PT - Journal Article PT - Observational Study DEP - 20171026 PL - England TA - Crit Care JT - Critical care (London, England) JID - 9801902 SB - IM MH - Adult MH - Aged MH - Aged, 80 and over MH - Extracorporeal Membrane Oxygenation/methods/*standards MH - Female MH - Humans MH - Male MH - Microcirculation/*physiology MH - Middle Aged MH - Mouth Floor/*blood supply/physiopathology MH - *Prognosis MH - Prospective Studies MH - Shock, Cardiogenic/classification MH - Ventilator Weaning/methods/*standards PMC - PMC5658964 OTO - NOTNLM OT - Cardiac recovery OT - Cardiogenic shock OT - CytoCam OT - Incident dark field imaging OT - Microcirculation OT - Sublingual OT - VA-ECMO OT - Weaning COIS- ETHICS APPROVAL AND CONSENT TO PARTICIPATE: The protocol was approved by the Medical Ethical Committee of Erasmus Medical Center of Rotterdam, the Netherlands (NL45915.078.13). CONSENT FOR PUBLICATION: Written informed consent was obtained from either patients or patient representatives. COMPETING INTERESTS: Dr. Ince has developed SDF imaging and is listed as inventor on related patents commercialized by Micro Vision Medical (MVM) under a license from the Academic Medical Center (AMC). He has been a consultant for MVM in the past but has not been involved with this company for more than 5 years now and does not hold shares. Braedius Medical, a company owned by a relative of Dr. Ince, has developed and designed a handheld microscope called CytoCam-IDF imaging. Dr. Ince has no financial relationship of any sort with Braedius Medical, i.e., has never owned shares or received consultancy or speaker fees from Braedius Medical. Dr. Reis Miranda received speaking fees from NovaLung. All other authors state that they have no conflict of interest. PUBLISHER'S NOTE: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. EDAT- 2017/10/28 06:00 MHDA- 2018/10/03 06:00 PMCR- 2017/10/26 CRDT- 2017/10/28 06:00 PHST- 2017/06/03 00:00 [received] PHST- 2017/10/05 00:00 [accepted] PHST- 2017/10/28 06:00 [entrez] PHST- 2017/10/28 06:00 [pubmed] PHST- 2018/10/03 06:00 [medline] PHST- 2017/10/26 00:00 [pmc-release] AID - 10.1186/s13054-017-1855-2 [pii] AID - 1855 [pii] AID - 10.1186/s13054-017-1855-2 [doi] PST - epublish SO - Crit Care. 2017 Oct 26;21(1):265. doi: 10.1186/s13054-017-1855-2.