title: An arterio-venous bridge for gradual weaning from adult veno-arterial extracorporeal life support.
abstract: OBJECTIVE
  Weaning from extracorporeal life support (ELS) is particularly challenging when cardiac recovery is slow, largely incomplete and hard to predict. Therefore, we describe an individualized gradual weaning strategy using an arterio-venous (AV) bridge incorporated into the circuit to facilitate weaning.
  
  
  METHODS
  Thirty adult patients weaned from veno-arterial ELS using an AV bridge were retrospectively analyzed. Serial echocardiography and hemodynamic monitoring were used to assess cardiac recovery and load responsiveness. Upon early signs of myocardial recovery, an AV bridge with an Hoffman clamp was added to the circuit and weaning was initiated. Support flow was reduced stepwise by 10-15% every 2 to 8 hours while the circuit flow was maintained at 3.5-4.5 L/min.
  
  
  RESULTS
  The AV bridge facilitated gradual weaning in all 30 patients (median age: 66 [53-71] years; 21 males) over a median period of 25 [8-32] hours, with a median support duration of 96 [31-181] hours. During weaning, the median left ventricular ejection fraction was 25% [15-32] and the median velocity time integral of the aortic valve was 16 cm [10-23]. Through the weaning period, the mean arterial blood pressure was maintained at 70 mmHg and the activated partial thromboplastin time was 60 ± 10 seconds without additional systemic heparinization. Neither macroscopic thrombus formation in the ELS circuit during and after weaning nor clinically relevant thromboembolism was observed.
  
  
  CONCLUSIONS
  Incorporation of an AV bridge for weaning from veno-arterial ELS is safe and feasible to gradually wean patients with functional cardiac recovery without compromising the circuit integrity.
authors.affiliation: Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Centre, Maastricht, the Netherlands.
authors.forename: Z U D
authors.initials: ZU
authors.lastname: Babar
authors.affiliation: Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Centre, Maastricht, the Netherlands ajay.sharma@maastrichtuniversity.nl.
authors.forename: A S
authors.initials: AS
authors.lastname: Sharma
authors.affiliation: Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Centre, Maastricht, the Netherlands.
authors.forename: Y M
authors.initials: YM
authors.lastname: Ganushchak
authors.affiliation: Department of Cardiology, Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Centre, Maastricht, the Netherlands Intensive Care, Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Centre, Maastricht, the Netherlands.
authors.forename: T S R
authors.initials: TS
authors.lastname: Delnoij
authors.affiliation: Department of Intensive Care Medicine, University Medical Centre, Utrecht, the Netherlands.
authors.forename: D W
authors.initials: DW
authors.lastname: Donker
authors.affiliation: Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Centre, Maastricht, the Netherlands.
authors.forename: J G
authors.initials: JG
authors.lastname: Maessen
authors.affiliation: Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Centre, Maastricht, the Netherlands.
authors.forename: P W
authors.initials: PW
authors.lastname: Weerwind
mesh_terms: D000328:Adult; D000368:Aged; D001166:Arteriovenous Shunt, Surgical; D015199:Extracorporeal Membrane Oxygenation; D005260:Female; D006801:Humans; D008020:Life Support Care; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D012770:Shock, Cardiogenic / Q000601:surgery*; D014886:Weaning
keywords: arterio-venous bridge; bleeding; low-flow extracorporeal life support; thromboembolism; veno-arterial extracorporeal life support; weaning