Publications by authors named "Leonardo Salazar"

10 Publications

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Somatic Support with Veno-venous ECMO in a Pregnant Woman with Brain Death: A Case Report.

ASAIO J 2021 Mar 11. Epub 2021 Mar 11.

From the Department of Intensive Care, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia Department of Anesthesia & Critical Care, University of Iowa Hospitals & Clinics, Carver College of Medicine, Iowa City, IA Department of Pediatrics, Universidad Industrial de Santander, Bucaramanga, Colombia Department of Cardiac Surgery, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia Department of Pediatrics, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia Department of Medical Research, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia Department of Obstetrics and Gynecology, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia.

Supporting homeostasis in a pregnant woman with brain death to achieve fetal viability is called somatic support. We present a case of young pregnant woman at 21 weeks' gestation who developed acute respiratory distress syndrome secondary to influenza A H2N3 infection requiring veno-venous extracorporeal membrane oxygenation (VV ECMO) support for refractory hypoxemia. The clinical course was complicated by intracranial hemorrhage and subsequent brain death. After multidisciplinary team discussion with her family, consensus was reached to continue somatic support with VV ECMO to enable fetal development to attain extrauterine viability. The challenging clinical, ethical, and legal concerns are discussed.
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http://dx.doi.org/10.1097/MAT.0000000000001411DOI Listing
March 2021

ECMO for COVID-19: Updated 2021 Guidelines from the Extracorporeal Life Support Organization (ELSO).

ASAIO J 2021 Feb 26. Epub 2021 Feb 26.

Department of Emergency Medicine, University of Washington, USA Division of Pulmonary Critical Care and Sleep Medicine, University of Washington, USA General ICU, University Hospital of Parma, Italy Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Italy Extracorporeal Life Support Organization Texas Children's Hospital, Baylor College of Medicine Children's Medical Center of Dallas, University of Texas Southwestern Medical Center Extracorporeal Life Support Organization, President; Children's Healthcare of Atlanta, Emory University Department of Medicine, Columbia University College of Physicians and Surgeons, New York, USA Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, USA University of Michigan Department of Critical Care, Guy's and St. Thomas' NHS Foundation Trust Centre for Human & Applied Physiological Sciences, Faculty of Life Sciences & Medicine, King's College London Sorbonne Université, INSERM, Institute of Cardiometabolism and Nutrition Service de médecine intensive-réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, F-75013 PARIS, France Department of Cardio-Thoracic Surgery - Maastricht University Medical Centre - Cardiovascular Research Institute Maastricht Maastricht, The Netherlands Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany Nemours Children's Health System Congenital Heart Center, Departments of Surgery and Pediatrics, University of Florida, Gainesville, USA Intensive Care Unit, Alfred Health Melbourne, Victoria, Australia Critical Care ECMO service, King Saud Medical City - Ministry Of Health (MOH), Riyadh - Saudi Arabia. Fundación Cardiovascular de Colombia Service de Médecine Intensive-Réanimation, Institut de Cardiologie, AP-HP, Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France. Sorbonne Université, GRC n°30, GRC RESPIRE, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France. Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia National University Hospital, Singapore Department of Medicine, Columbia University College of Physicians and Surgeons, New York, USA Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, USA.

This is an updated guideline from the Extracorporeal Life Support Organization (ELSO) for the role of extracorporeal membrane oxygenation (ECMO) for patients with severe cardiopulmonary failure due to coronavirus disease 2019 (COVID-19). The great majority of COVID-19 patients (>90%) requiring ECMO have been supported using venovenous (V-V) ECMO for acute respiratory distress syndrome (ARDS). While COVID-19 ECMO run duration may be longer than in non-COVID-19 ECMO patients, published mortality appears to be similar between the two groups. However, data collection is ongoing, and there is a signal that overall mortality may be increasing. Conventional selection criteria for COVID-19-related ECMO should be used; however, when resources become more constrained during a pandemic, more stringent contraindications should be implemented. Formation of regional ECMO referral networks may facilitate communication, resource sharing, expedited patient referral, and mobile ECMO retrieval. There are no data to suggest deviation from conventional ECMO device or patient management when applying ECMO for COVID-19 patients. Rarely, children may require ECMO support for COVID-19-related ARDS, myocarditis or multisystem inflammatory syndrome in children (MIS-C); conventional selection criteria and management practices should be the standard. We strongly encourage participation in data submission to investigate the optimal use of ECMO for COVID-19.
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http://dx.doi.org/10.1097/MAT.0000000000001422DOI Listing
February 2021

Survival after Heart Transplantation for Chagas Cardiomyopathy Using a Conventional Protocol: A Ten-years Experience in a Single Center.

Transpl Infect Dis 2020 Dec 21:e13549. Epub 2020 Dec 21.

Cardiovascular Surgery, Fundación Cardiovascular de Colombia, Floridablanca, Santander, Colombia.

Heart transplant (HT) remains the most frequently indicated therapy for patients with end-stage heart failure that improves prognosis in Chagas cardiomyopathy (CCM). However, the lack of benznidazole therapy and availability of RT-PCR follow-up in many centers is a major limitation to perform this life-saving intervention, as there are concerns related with the risk of reactivation. We aimed to describe the outcomes of a cohort of patients with CCM that underwent HT using a conventional protocol with mycophenolate mofetil, without benznidazole prophylaxis or RT-PCR follow-up. Retrospective cohort study. Between 2008-2018, forty-three patients with CCM underwent HT. A descriptive analysis to characterize outcomes as rejection, infectious and neoplastic complications and a survival analysis were carried out. Median of follow-up was 4.3 (IR 4.28) years. Survival at one month, one year, and five years was 95%, 85% and 75%, respectively, infections being the main cause of death (60%). Reactivations occurred in only three patients (7.34%) and were not related to mortality. This cohort showed a favorable survival and a low reactivation rate without an impact on mortality. Our results suggest that performing HT in patients with CCM following conventional guidelines and recommendations for other etiologies is a safe approach.
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http://dx.doi.org/10.1111/tid.13549DOI Listing
December 2020

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

Crit Care Med 2020 03;48(3):406-414

Department of Pediatrics, Division of Neonatology, Nemours Alfred I duPont Hospital for Children, Wilmington, DE.

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.

Setting: In 2018, the Extracorporeal Life Support Organization convened the ECMOed Taskforce at two structured, face-to-face meetings of 40 healthcare practitioners and educators with expertise in caring for the extracorporeal membrane oxygenation patient and in extracorporeal membrane oxygenation education.

Patients: None.

Interventions: None.

Measurements And Main Results: The ECMOed Taskforce identified seven educational domains that would benefit from international collaborative efforts. Of primary importance, the Taskforce outlined actionable items regarding 1) the creation of a standardized extracorporeal membrane oxygenation curriculum; 2) defining criteria for an extracorporeal membrane oxygenation course as a vehicle for delivering the curriculum; 3) outlining a mechanism for evaluating the quality of educational offerings; 4) utilizing validated assessment tools in the development of extracorporeal membrane oxygenation practitioner certification; and 5) promoting high-quality educational research to guide ongoing educational and competency assessment development.

Conclusions: Significant variability and limitations in global extracorporeal membrane oxygenation education exist. In this position paper, we outline a road map for standardizing international extracorporeal membrane oxygenation education and practitioner certification. Ongoing high-quality educational research is needed to evaluate the impact of these initiatives.
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http://dx.doi.org/10.1097/CCM.0000000000004158DOI Listing
March 2020

Position paper for the organization of ECMO programs for cardiac failure in adults.

Intensive Care Med 2018 06 15;44(6):717-729. Epub 2018 Feb 15.

Division of Pulmonary, Allergy, and Critical Care, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, 622 W168th St, PH 8E, Room 101, New York, NY, 10032, USA.

Extracorporeal membrane oxygenation (ECMO) has been used increasingly for both respiratory and cardiac failure in adult patients. Indications for ECMO use in cardiac failure include severe refractory cardiogenic shock, refractory ventricular arrhythmia, active cardiopulmonary resuscitation for cardiac arrest, and acute or decompensated right heart failure. Evidence is emerging to guide the use of this therapy for some of these indications, but there remains a need for additional evidence to guide best practices. As a result, the use of ECMO may vary widely across centers. The purpose of this document is to highlight key aspects of care delivery, with the goal of codifying the current use of this rapidly growing technology. A major challenge in this field is the need to emergently deploy ECMO for cardiac failure, often with limited time to assess the appropriateness of patients for the intervention. For this reason, we advocate for a multidisciplinary team of experts to guide institutional use of this therapy and the care of patients receiving it. Rigorous patient selection and careful attention to potential complications are key factors in optimizing patient outcomes. Seamless patient transport and clearly defined pathways for transition of care to centers capable of providing heart replacement therapies (e.g., durable ventricular assist device or heart transplantation) are essential to providing the highest level of care for those patients stabilized by ECMO but unable to be weaned from the device. Ultimately, concentration of the most complex care at high-volume centers with advanced cardiac capabilities may be a way to significantly improve the care of this patient population.
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http://dx.doi.org/10.1007/s00134-018-5064-5DOI Listing
June 2018

Telemedicine in Pediatric Critical Care: A Retrospective Study in an International Extracorporeal Membrane Oxygenation Program.

Telemed J E Health 2018 07 18;24(7):489-496. Epub 2017 Dec 18.

1 Division of Cardiac Intensive Care, Department of Critical Care Medicine, Children's Hospital of Pittsburgh of UPMC , Pittsburgh, Pennsylvania.

Introduction: Extracorporeal membrane oxygenation (ECMO) is an invaluable rescue technique for critically ill children with imminent or present cardiopulmonary collapse. However, medical team expertise to optimize results and decrease complications is scarce. Telemedicine can be used to enhance the delivery of quality interventions.

Materials And Methods: This is a retrospective review of pediatric patients assisted with ECMO in the cardiac intensive care unit (CICU) at Fundación Cardiovascular de Colombia from July 2011 to June 2015 (telemedicine) compared with similar patients from a previous period (pretelemedicine). Collected information included demographic data, cardiac diagnosis, risk adjustment for congenital heart surgery (RACHS-1), hospital mortality, CICU and hospital length of stay (LOS), ECMO type, and ECMO run hours as well as specific telemedicine information.

Results: Fifty-seven patients in the pretelemedicine and 109 in the telemedicine periods were included in the analysis. Forty-nine teleconsulted patients received 218 teleconsultations, with a recommendation for diagnostic or interventional catheterization in 38 patients (77.5%). A surgical procedure for significant residual lesions was recommended in 30 patients (61.2%). Patients in the telemedicine period were older (4.7 months vs. 1.6 months, p = 0.006), more likely to receive operating room ECMO (43.1% vs. 24.6%, p = 0.02), and had a higher proportion of patients with two-ventricle physiology (73.4% vs. 54.4%, p = 0.013). Hospital survival was higher during the telemedicine period (54.1% vs. 29.8%, p = 0.002), with a longer hospital LOS (67 days vs. 28 days, p < 0.001).

Conclusion: The implementation of telemedicine-assisted interventions in a pediatric ECMO program delivered valuable diagnostic and therapeutic advice, was associated with significant changes in selection criteria and model of care, and an increased hospital survival.
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http://dx.doi.org/10.1089/tmj.2017.0223DOI Listing
July 2018

Extracorporeal Membrane Oxygenation in Dengue, Malaria, and Acute Chagas Disease.

ASAIO J 2017 Nov/Dec;63(6):e71-e76

From the *Department of Cardiovascular Surgery and Research Center, Fundación Cardiovascular de Colombia, Floridablanca, Colombia; †Erasmus University, Rotterdam, the Netherlands; ‡Department of Pediatric Pneumology, Fundación Cardiovascular de Colombia, Floridablanca, Colombia; §Respiratory Department, Fundación Cardiovascular de Colombia, and Respiratory Health Center, Hospital Internacional de Colombia; CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; ¶Pompeu Fabra University, Barcelona, Spain; and ‖Department of Cardiology, Fundación Cardiovascular de Colombia, Floridablanca, Colombia.

Extracorporeal membrane oxygenation (ECMO) is widely used in acute respiratory distress syndrome (ARDS) and myocarditis. Severe vector-mediated diseases may be complicated by ARDS or myocarditis, which are both associated with a high mortality rate. We present six cases of severe dengue, malaria, and acute Chagas disease that were treated with ECMO from September 2007 to September 2015. Patients included two pediatric and four adults (aged 12-48). Survival to decannulation was 83% and to discharge was 66%. Overall, the mean duration on ECMO was 25.4 days. We conclude that ECMO treatment can be beneficial in patients with severe dengue, malaria, and acute Chagas disease, if complicated by pulmonary or cardiac complications.
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http://dx.doi.org/10.1097/MAT.0000000000000474DOI Listing
May 2018

Setting Up an ECMO Program in a South American Country: Outcomes of the First 104 Pediatric Patients.

World J Pediatr Congenit Heart Surg 2015 Jul;6(3):374-81

Department of Pediatric Cardiovascular Surgery and Research Center, Fundación Cardiovascular de Colombia, Floridablanca, Santander, Colombia.

Background: Less than 1% of the extracorporeal life support organization (ELSO) registry patients are from South America. Extracorporeal membrane oxygenation (ECMO) is an expensive therapy not only in terms of direct financial cost but also with respect to technical and human resources. Finding a successful ECMO model that developing countries can afford is critical to the expansion of therapy to include the availability of this technology for patients in the developing world.

Methods: We retrospectively studied the first 104 pediatric ECMO patients in the Fundacion Cardiovascular de Colombia between May 2007 and May 2013. We collected the ELSO registry data from electronic medical records to determine the survival rate, mortality risk factors, and complications in pediatric patients who received ECMO support for cardiac failure, respiratory failure, or ECMO for extracorporeal cardiopulmonary resuscitation in the setting of refractory cardiopulmonary resuscitation. We describe our model of ECMO care regarding staff, training process, care protocol, ECMO circuit, and costs.

Results: Of 104 patients, 82 were diagnosed with congenital heart disease. Of those, 50 had biventricular and 32 had univentricular physiology, with a significantly higher survival rate at discharge in the biventricular group (44% vs 18.7%, odds ratio [OR] 3.6, 95% confidence interval [CI] = 1.28-10.52, P = .01). Pediatric patients with a cardiac indication had survival rates of 76.3% at weaning and 52.6% at discharge, which is roughly comparable to those reported by the ELSO in 2013. Univentricular physiology, ECPR, severe pre-ECMO acidosis, ECMO-associated renal failure, and duration of ECMO support were factors associated with increased mortality.

Conclusion: Despite limited availability of technical and economic resources, ECMO therapy can be done successfully in a developing country. A model of care based on nurses as ECMO specialists, supported by a multidisciplinary team, is cost-effective.
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http://dx.doi.org/10.1177/2150135115589788DOI Listing
July 2015

[High risk infective endocarditis embolism during pregnancy: Medical or surgical management?].

Arch Cardiol Mex 2013 Jul-Sep;83(3):209-13

Clínica de Falla Cardíaca, Fundación Cardiovascular de Colombia, Floridablanca, Santander, Colombia; Departamento de Ecocardiografía, Fundación Cardiovascular de Colombia, Floridablanca, Santander, Colombia. Electronic address:

A 22-year-old pregnant woman was seen at 14 weeks of pregnancy for infective endocarditis with a vegetation of 15 mm and wide mobility, which affected the native mitral valve accompanied by severe valvular insufficiency. Antibiotic treatment was given for 4 weeks despite the embolism risk. Due to persistence of vegetation size and after considering the fetal and maternal risk, the surgical procedure was favored. We decided to perform valvuloplasty and removal of lesion at 18 weeks of pregnancy. Fetal protection techniques were used and a bioprosthesis was placed before attempting a repair. The postoperative follow-up was satisfactory, achieving a successful birth by cesarean section at 30 weeks.
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http://dx.doi.org/10.1016/j.acmx.2013.04.012DOI Listing
January 2015