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      Venovenous Extracorporeal Life Support in Single-Ventricle Patients with Acute Respiratory Distress Syndrome

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          Abstract

          There is new and growing experience with venovenous extracorporeal life support (VV ECLS) for neonatal and pediatric patients with single-ventricle physiology and acute respiratory distress syndrome (ARDS). Outcomes in this population have been defined but could be improved; survival rates in single-ventricle patients on VV ECLS for respiratory failure are slightly higher than those in single-ventricle patients on venoarterial ECLS for cardiac failure (48 vs. 32–43%), but are lower than in patients with biventricular anatomy (58–74%). To that end, special consideration is necessary for patients with single-ventricle physiology who require VV ECLS for ARDS. Specifically, ARDS disrupts the balance between pulmonary and systemic blood flow through dynamic alterations in cardiopulmonary mechanics. This complexity impacts how to run the VV ECLS circuit and the transition back to conventional support. Furthermore, these patients have a complicated coagulation profile. Both venous and arterial thrombi carry marked risk in single-ventricle patients due to the vulnerability of the pulmonary, coronary, and cerebral circulations. Finally, single-ventricle palliation requires the preservation of low resistance across the pulmonary circulation, unobstructed venous return, and optimal cardiac performance including valve function. As such, the proper timing as well as the particular conduct of ECLS might differ between this population and patients without single-ventricle physiology. The goal of this review is to summarize the current state of knowledge of VV ECLS in the single-ventricle population in the context of these special considerations.

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          Most cited references54

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          Prolonged extracorporeal oxygenation for acute post-traumatic respiratory failure (shock-lung syndrome). Use of the Bramson membrane lung.

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            Extracorporeal membrane oxygenation in severe acute respiratory failure. A randomized prospective study.

            Nine medical centers collaborated in a prospective randomized study to evaluate prolonged extracorporeal membrane oxygenation (ECMO) as a therapy for severe acute respiratory failure (ARF). Ninety adult patients were selected by common criteria of arterial hypoxemia and treated with either conventional mechanical ventilation (48 patients) or mechanical ventilation supplemented with partial venoarterial bypass (42 patients). Four patients in each group survived. The majority of patients suffered acute bacterial or viral pneumonia (57%). All nine patients with pulmonary embolism and six patients with posttraumatic acute respiratory failure died. The majority of patients died of progressive reduction of transpulmonary gas exchange and decreased compliance due to diffuse pulmonary inflammation, necrosis, and fibrosis. We conclude that ECMO can support respiratory gas exchange but did not increase the probability of long-term survival in patients with severe ARF.
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              Pulmonary hypertension in severe acute respiratory failure.

              We repeatedly assessed pulmonary and systemic hemodynamics in 30 patients undergoing therapy for severe acute respiratory failure of diverse causes. Pulmonary-artery hypertension and elevated pulmonar vascular resistance were observed in all patients after correction of systemic hypoxemia. Increasing pulmonary blood flow by isoproterenol infusion or decreasing pulmonary blood flow by partial bypass of the right side of the heart minimally altered pulmonary-artery pressure. Although neither elevated pulmonary vascular resistance nor low cardiac index reliably predicted death, survivors had preogressive decreases of pulmonary vascular resistance with time, whereas nonsurvivors tended to maintain or increase pulmonary vascular resistance. Right ventricular stroke-work index was markedly elevated in all patients. The work load imposed upon the right ventricle by elevation of pulmonary vascular resistance may be a factor limiting survival in severe acute respiratory failure.
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                Author and article information

                Contributors
                Journal
                Front Pediatr
                Front Pediatr
                Front. Pediatr.
                Frontiers in Pediatrics
                Frontiers Media S.A.
                2296-2360
                28 June 2016
                2016
                : 4
                : 66
                Affiliations
                [1] 1Department of Pediatrics, University of California San Francisco , San Francisco, CA, USA
                [2] 2Cardiovascular Research Institute, University of California San Francisco , San Francisco, CA, USA
                Author notes

                Edited by: Antonio Francesco Corno, Glenfield Hospital, UK

                Reviewed by: Yasuhiro Fujii, Okayama University Hospital, Japan; Madhusudan Ganigara, Mount Sinai Medical Centre, USA

                *Correspondence: Peter Oishi, peter.oishi@ 123456ucsf.edu

                Specialty section: This article was submitted to Pediatric Cardiology, a section of the journal Frontiers in Pediatrics

                Article
                10.3389/fped.2016.00066
                4923132
                27446889
                060680f5-a0a0-4ec6-8de4-b4a747eca698
                Copyright © 2016 Nair and Oishi.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                History
                : 30 April 2016
                : 01 June 2016
                Page count
                Figures: 0, Tables: 2, Equations: 0, References: 60, Pages: 9, Words: 7186
                Funding
                Funded by: Research Training in Pediatric Critical Care
                Categories
                Pediatrics
                Review

                venovenous extracorporeal life support,extracorporeal membrane oxygenation,single ventricle,congenital heart disease,acute respiratory distress syndrome,cannulation,thrombosis,anticoagulation

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