Hemolysis and Nonhemorrhagic Stroke During Venoarterial Extracorporeal Membrane Oxygenation

Omar Saeed, William A. Jakobleff, Stephen J. Forest, Thiru Chinnadurai, Nicolas Mellas, Sabarivinoth Rangasamy, Yu Xia, Shivank Madan, Prakash Acharya, Mohammad Algodi, Snehal R. Patel, Julia Shin, Sasa Vukelic, Daniel B. Sims, Morayma Reyes Gil, Henny H. Billett, Jorge Kizer, Daniel J. Goldstein, Ulrich P. Jorde

Research output: Contribution to journalArticle

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Abstract

Background: Hemolysis, even at low levels, activates platelets to create a prothrombotic state and is common during mechanical circulatory support. We examined the association of low-level hemolysis (LLH) and nonhemorrhagic stroke during venoarterial extracorporeal membrane oxygenation (VA ECMO) support. Methods: A single-center retrospective review of all adult patients placed on VA ECMO from January 2012 to September 2017 was conducted. To determine the association between LLH and nonhemorrhagic stroke, patients were categorized as those with and without LLH. LLH was defined by 48-hour plasma free hemoglobin (PFHb) of 11 to 50 mg/dL after VA ECMO implantation. Results: Of 201 patients who underwent VA ECMO placement, 150 (75%) met inclusion criteria and comprised the study population. They were 55 ± 14 years of age and 50 (33%) were women. Sixty-two (41%) patients had LLH. Patients with LLH had a higher likelihood of incident nonhemorrhagic stroke during VA ECMO support (20 [32%] versus 4 [5%]; adjusted hazard ratio [HR], 7.6; 95% confidence interval [CI], 2.2 to 25.9; p = 0.001). The severity of LLH was associated with an incrementally higher likelihood of a nonhemorrhagic stroke (PFHb 26 to 50 mg/dL: HR, 11.3; 95% CI, 3.6 to 35.1; p = 0.001; PFHb 11 to 25 mg/dL: HR, 4.4; 95% CI, 1.36 to 14.85; p = 0.014) in comparison with no LLH. Those with LLH had a 2-fold greater increase in mean platelet volume after VA ECMO placement (0.98 ± 1.1 fL versus 0.49 ± 0.96 fL; p = 0.03). Patients with a nonhemorrhagic stroke had a higher operative mortality (20 [83%] versus 57 [45%]; adjusted HR, 3.1; 95% CI, 1.8 to 5.3; p < 0.001). Conclusions: Hemolysis at low levels during VA ECMO support is associated with subsequent nonhemorrhagic stroke.

Original languageEnglish (US)
JournalAnnals of Thoracic Surgery
DOIs
StatePublished - Jan 1 2019

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Extracorporeal Membrane Oxygenation
Hemolysis
Stroke
Confidence Intervals
Hemoglobins
Mean Platelet Volume
Blood Platelets

ASJC Scopus subject areas

  • Surgery
  • Pulmonary and Respiratory Medicine
  • Cardiology and Cardiovascular Medicine

Cite this

Hemolysis and Nonhemorrhagic Stroke During Venoarterial Extracorporeal Membrane Oxygenation. / Saeed, Omar; Jakobleff, William A.; Forest, Stephen J.; Chinnadurai, Thiru; Mellas, Nicolas; Rangasamy, Sabarivinoth; Xia, Yu; Madan, Shivank; Acharya, Prakash; Algodi, Mohammad; Patel, Snehal R.; Shin, Julia; Vukelic, Sasa; Sims, Daniel B.; Reyes Gil, Morayma; Billett, Henny H.; Kizer, Jorge; Goldstein, Daniel J.; Jorde, Ulrich P.

In: Annals of Thoracic Surgery, 01.01.2019.

Research output: Contribution to journalArticle

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title = "Hemolysis and Nonhemorrhagic Stroke During Venoarterial Extracorporeal Membrane Oxygenation",
abstract = "Background: Hemolysis, even at low levels, activates platelets to create a prothrombotic state and is common during mechanical circulatory support. We examined the association of low-level hemolysis (LLH) and nonhemorrhagic stroke during venoarterial extracorporeal membrane oxygenation (VA ECMO) support. Methods: A single-center retrospective review of all adult patients placed on VA ECMO from January 2012 to September 2017 was conducted. To determine the association between LLH and nonhemorrhagic stroke, patients were categorized as those with and without LLH. LLH was defined by 48-hour plasma free hemoglobin (PFHb) of 11 to 50 mg/dL after VA ECMO implantation. Results: Of 201 patients who underwent VA ECMO placement, 150 (75{\%}) met inclusion criteria and comprised the study population. They were 55 ± 14 years of age and 50 (33{\%}) were women. Sixty-two (41{\%}) patients had LLH. Patients with LLH had a higher likelihood of incident nonhemorrhagic stroke during VA ECMO support (20 [32{\%}] versus 4 [5{\%}]; adjusted hazard ratio [HR], 7.6; 95{\%} confidence interval [CI], 2.2 to 25.9; p = 0.001). The severity of LLH was associated with an incrementally higher likelihood of a nonhemorrhagic stroke (PFHb 26 to 50 mg/dL: HR, 11.3; 95{\%} CI, 3.6 to 35.1; p = 0.001; PFHb 11 to 25 mg/dL: HR, 4.4; 95{\%} CI, 1.36 to 14.85; p = 0.014) in comparison with no LLH. Those with LLH had a 2-fold greater increase in mean platelet volume after VA ECMO placement (0.98 ± 1.1 fL versus 0.49 ± 0.96 fL; p = 0.03). Patients with a nonhemorrhagic stroke had a higher operative mortality (20 [83{\%}] versus 57 [45{\%}]; adjusted HR, 3.1; 95{\%} CI, 1.8 to 5.3; p < 0.001). Conclusions: Hemolysis at low levels during VA ECMO support is associated with subsequent nonhemorrhagic stroke.",
author = "Omar Saeed and Jakobleff, {William A.} and Forest, {Stephen J.} and Thiru Chinnadurai and Nicolas Mellas and Sabarivinoth Rangasamy and Yu Xia and Shivank Madan and Prakash Acharya and Mohammad Algodi and Patel, {Snehal R.} and Julia Shin and Sasa Vukelic and Sims, {Daniel B.} and {Reyes Gil}, Morayma and Billett, {Henny H.} and Jorge Kizer and Goldstein, {Daniel J.} and Jorde, {Ulrich P.}",
year = "2019",
month = "1",
day = "1",
doi = "10.1016/j.athoracsur.2019.03.030",
language = "English (US)",
journal = "Annals of Thoracic Surgery",
issn = "0003-4975",
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TY - JOUR

T1 - Hemolysis and Nonhemorrhagic Stroke During Venoarterial Extracorporeal Membrane Oxygenation

AU - Saeed, Omar

AU - Jakobleff, William A.

AU - Forest, Stephen J.

AU - Chinnadurai, Thiru

AU - Mellas, Nicolas

AU - Rangasamy, Sabarivinoth

AU - Xia, Yu

AU - Madan, Shivank

AU - Acharya, Prakash

AU - Algodi, Mohammad

AU - Patel, Snehal R.

AU - Shin, Julia

AU - Vukelic, Sasa

AU - Sims, Daniel B.

AU - Reyes Gil, Morayma

AU - Billett, Henny H.

AU - Kizer, Jorge

AU - Goldstein, Daniel J.

AU - Jorde, Ulrich P.

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Background: Hemolysis, even at low levels, activates platelets to create a prothrombotic state and is common during mechanical circulatory support. We examined the association of low-level hemolysis (LLH) and nonhemorrhagic stroke during venoarterial extracorporeal membrane oxygenation (VA ECMO) support. Methods: A single-center retrospective review of all adult patients placed on VA ECMO from January 2012 to September 2017 was conducted. To determine the association between LLH and nonhemorrhagic stroke, patients were categorized as those with and without LLH. LLH was defined by 48-hour plasma free hemoglobin (PFHb) of 11 to 50 mg/dL after VA ECMO implantation. Results: Of 201 patients who underwent VA ECMO placement, 150 (75%) met inclusion criteria and comprised the study population. They were 55 ± 14 years of age and 50 (33%) were women. Sixty-two (41%) patients had LLH. Patients with LLH had a higher likelihood of incident nonhemorrhagic stroke during VA ECMO support (20 [32%] versus 4 [5%]; adjusted hazard ratio [HR], 7.6; 95% confidence interval [CI], 2.2 to 25.9; p = 0.001). The severity of LLH was associated with an incrementally higher likelihood of a nonhemorrhagic stroke (PFHb 26 to 50 mg/dL: HR, 11.3; 95% CI, 3.6 to 35.1; p = 0.001; PFHb 11 to 25 mg/dL: HR, 4.4; 95% CI, 1.36 to 14.85; p = 0.014) in comparison with no LLH. Those with LLH had a 2-fold greater increase in mean platelet volume after VA ECMO placement (0.98 ± 1.1 fL versus 0.49 ± 0.96 fL; p = 0.03). Patients with a nonhemorrhagic stroke had a higher operative mortality (20 [83%] versus 57 [45%]; adjusted HR, 3.1; 95% CI, 1.8 to 5.3; p < 0.001). Conclusions: Hemolysis at low levels during VA ECMO support is associated with subsequent nonhemorrhagic stroke.

AB - Background: Hemolysis, even at low levels, activates platelets to create a prothrombotic state and is common during mechanical circulatory support. We examined the association of low-level hemolysis (LLH) and nonhemorrhagic stroke during venoarterial extracorporeal membrane oxygenation (VA ECMO) support. Methods: A single-center retrospective review of all adult patients placed on VA ECMO from January 2012 to September 2017 was conducted. To determine the association between LLH and nonhemorrhagic stroke, patients were categorized as those with and without LLH. LLH was defined by 48-hour plasma free hemoglobin (PFHb) of 11 to 50 mg/dL after VA ECMO implantation. Results: Of 201 patients who underwent VA ECMO placement, 150 (75%) met inclusion criteria and comprised the study population. They were 55 ± 14 years of age and 50 (33%) were women. Sixty-two (41%) patients had LLH. Patients with LLH had a higher likelihood of incident nonhemorrhagic stroke during VA ECMO support (20 [32%] versus 4 [5%]; adjusted hazard ratio [HR], 7.6; 95% confidence interval [CI], 2.2 to 25.9; p = 0.001). The severity of LLH was associated with an incrementally higher likelihood of a nonhemorrhagic stroke (PFHb 26 to 50 mg/dL: HR, 11.3; 95% CI, 3.6 to 35.1; p = 0.001; PFHb 11 to 25 mg/dL: HR, 4.4; 95% CI, 1.36 to 14.85; p = 0.014) in comparison with no LLH. Those with LLH had a 2-fold greater increase in mean platelet volume after VA ECMO placement (0.98 ± 1.1 fL versus 0.49 ± 0.96 fL; p = 0.03). Patients with a nonhemorrhagic stroke had a higher operative mortality (20 [83%] versus 57 [45%]; adjusted HR, 3.1; 95% CI, 1.8 to 5.3; p < 0.001). Conclusions: Hemolysis at low levels during VA ECMO support is associated with subsequent nonhemorrhagic stroke.

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DO - 10.1016/j.athoracsur.2019.03.030

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