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Abrams D, Curtis JR, Prager KM, Garan AR, Hastie J, Brodie D. Ethical Considerations for Mechanical Support. Anesthesiol Clin 2019; 37:661-673. [PMID: 31677684 DOI: 10.1016/j.anclin.2019.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Extracorporeal life support can support patients with severe forms of cardiac and respiratory failure. Uncertainty remains about its optimal use owing in large part to its resource-intensive nature and the high acuity illness in supported patients. Specific issues include the identification of patients most likely to benefit, the appropriate duration of support when prognosis is uncertain, and what to do when patients become dependent on extracorporeal life support but no longer have hope for recovery or transplantation. Careful deliberation of ethical principles and potential dilemmas should be made when considering the use of extracorporeal life support in advanced cardiopulmonary failure.
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Affiliation(s)
- Darryl Abrams
- Division of Pulmonary, Allergy, and Critical Care, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH 8E, 101, New York, NY 10032, USA.
| | - J Randall Curtis
- Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359762, Seattle, WA 98104, USA
| | - Kenneth M Prager
- Division of Pulmonary, Allergy, and Critical Care, Columbia University College of Physicians and Surgeons, 161 Ft. Washington Avenue, Room 307, New York, NY 10032, USA
| | - A Reshad Garan
- Division of Cardiology, Columbia University College of Physicians and Surgeons, 177 Ft. Washington Avenue, 5th Floor, Room 5-435, New York, NY 10032, USA
| | - Jonathan Hastie
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH 5-505, New York, NY 10032, USA
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH 8E, 101, New York, NY 10032, USA
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152
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Galiè N, Palazzini M, Manes A. Extracorporeal cardiopulmonary support in acute high-risk pulmonary embolism: still waiting for solid evidence. Eur Heart J 2019; 39:4205-4207. [PMID: 30239710 DOI: 10.1093/eurheartj/ehy507] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Nazzareno Galiè
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Massimiliano Palazzini
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Alessandra Manes
- Cardiovascular and Thoracic Department, Bologna University Hospital, Bologna, Italy
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153
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Extracorporeal Life Support: The Next Step in Moderate to Severe ARDS-A Review and Meta-Analysis of the Literature. BIOMED RESEARCH INTERNATIONAL 2019; 2019:1035730. [PMID: 31662961 PMCID: PMC6791231 DOI: 10.1155/2019/1035730] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 06/10/2019] [Accepted: 09/05/2019] [Indexed: 12/21/2022]
Abstract
Despite the use of lung protective ventilation (LPV) strategies, a severe form of acute respiratory distress syndrome (ARDS) is unfortunately associated with high mortality rates, which sometimes exceed 60%. Recently, major technical improvements have been applied in extracorporeal life support (ECLS) systems, but as these techniques are costly and associated with very serious adverse events, high-quality evidence is needed before these techniques can become the “cornerstone” in the management of moderate to severe ARDS. Unfortunately, evaluation of previous randomized controlled and observational trials revealed major methodological issues. In this review, we focused on the most important clinical trials aiming at a final conclusion about the effectiveness of ECLS in moderate to severe ARDS patients. Totally, 20 published clinical studies were included in this review. Most studies have important limitations with regard to quality and design. In the 20 included studies (2,956 patients), 1,185 patients received ECLS. Of them, 976 patients received extracorporeal membrane oxygenation (ECMO) and 209 patients received extracorporeal carbon dioxide removal (ECCO2R). According to our results, ECLS use was not associated with a benefit in mortality rate in patients with ARDS. However, when restricted to higher quality studies, ECMO was associated with a significant benefit in mortality rate. Furthermore, in patients with H1N1, a potential benefit of ECLS in mortality rate was apparent. Until more high-quality data are derived, ECLS should be an option as a salvage therapy in severe hypoxemic ARDS patients.
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154
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Brodie D, Slutsky AS, Combes A. Extracorporeal Life Support for Adults With Respiratory Failure and Related Indications: A Review. JAMA 2019; 322:557-568. [PMID: 31408142 DOI: 10.1001/jama.2019.9302] [Citation(s) in RCA: 220] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE The substantial growth over the last decade in the use of extracorporeal life support for adults with acute respiratory failure reveals an enthusiasm for the technology not always consistent with the evidence. However, recent high-quality data, primarily in patients with acute respiratory distress syndrome, have made extracorporeal life support more widely accepted in clinical practice. OBSERVATIONS Clinical trials of extracorporeal life support for acute respiratory failure in adults in the 1970s and 1990s failed to demonstrate benefit, reducing use of the intervention for decades and relegating it to a small number of centers. Nonetheless, technological improvements in extracorporeal support made it safer to use. Interest in extracorporeal life support increased with the confluence of 2 events in 2009: (1) the publication of a randomized clinical trial of extracorporeal life support for acute respiratory failure and (2) the use of extracorporeal life support in patients with severe acute respiratory distress syndrome during the influenza A(H1N1) pandemic. In 2018, a randomized clinical trial in patients with very severe acute respiratory distress syndrome demonstrated a seemingly large decrease in mortality from 46% to 35%, but this difference was not statistically significant. However, a Bayesian post hoc analysis of this trial and a subsequent meta-analysis together suggested that extracorporeal life support was beneficial for patients with very severe acute respiratory distress syndrome. As the evidence supporting the use of extracorporeal life support increases, its indications are expanding to being a bridge to lung transplantation and the management of patients with pulmonary vascular disease who have right-sided heart failure. Extracorporeal life support is now an acceptable form of organ support in clinical practice. CONCLUSIONS AND RELEVANCE The role of extracorporeal life support in the management of adults with acute respiratory failure is being redefined by advances in technology and increasing evidence of its effectiveness. Future developments in the field will result from technological advances, an increased understanding of the physiology and biology of extracorporeal support, and increased knowledge of how it might benefit the treatment of a variety of clinical conditions.
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Affiliation(s)
- Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York
- Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Alain Combes
- Sorbonne Université INSERM Unité Mixte de Recherche (UMRS) 1166, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (APHP) Hôpital Pitié-Salpêtrière, Paris, France
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156
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Bonicolini E, Martucci G, Simons J, Raffa GM, Spina C, Lo Coco V, Arcadipane A, Pilato M, Lorusso R. Limb ischemia in peripheral veno-arterial extracorporeal membrane oxygenation: a narrative review of incidence, prevention, monitoring, and treatment. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:266. [PMID: 31362770 PMCID: PMC6668078 DOI: 10.1186/s13054-019-2541-3] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 07/15/2019] [Indexed: 01/27/2023]
Abstract
Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is an increasingly adopted life-saving mechanical circulatory support for a number of potentially reversible or treatable cardiac diseases. It is also started as a bridge-to-transplantation/ventricular assist device in the case of unrecoverable cardiac or cardio-respiratory illness. In recent years, principally for non-post-cardiotomy shock, peripheral cannulation using the femoral vessels has been the approach of choice because it does not need the chest opening, can be quickly established, can be applied percutaneously, and is less likely to cause bleeding and infections than central cannulation. Peripheral ECMO, however, is characterized by a higher rate of vascular complications. The mechanisms of such adverse events are often multifactorial, including suboptimal arterial perfusion and hemodynamic instability due to the underlying disease, peripheral vascular disease, and placement of cannulas that nearly occlude the vessel. The effect of femoral artery damage and/or significant reduced limb perfusion can be devastating because limb ischemia can lead to compartment syndrome, requiring fasciotomy and, occasionally, even limb amputation, thereby negatively impacting hospital stay, long-term functional outcomes, and survival. Data on this topic are highly fragmentary, and there are no clear-cut recommendations. Accordingly, the strategies adopted to cope with this complication vary a great deal, ranging from preventive placement of antegrade distal perfusion cannulas to rescue interventions and vascular surgery after the complication has manifested.This review aims to provide a comprehensive overview of limb ischemia during femoral cannulation for VA-ECMO in adults, focusing on incidence, tools for early diagnosis, risk factors, and preventive and treating strategies.
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Affiliation(s)
- Eleonora Bonicolini
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione), Palermo, Italy
| | - Gennaro Martucci
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione), Palermo, Italy.,Maastricht University, Maastricht, The Netherlands
| | - Jorik Simons
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Giuseppe M Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione), Palermo, Italy
| | | | - Valeria Lo Coco
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Antonio Arcadipane
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione), Palermo, Italy
| | - Michele Pilato
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione), Palermo, Italy
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute (CARIM), Maastricht University, Maastricht, The Netherlands. .,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.
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157
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Sin SWC, Ng PY, Ngai WCW, Lai PCK, Mok AYT, Chan RWK. Simulation training for crises during venoarterial extracorporeal membrane oxygenation. J Thorac Dis 2019; 11:2144-2152. [PMID: 31285909 DOI: 10.21037/jtd.2019.04.54] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) education, in particular with regards to crisis management during the provision of venoarterial extracorporeal membrane oxygenation (VA ECMO), is challenging due to its intrinsic characteristics-a complex, high risk, low volume clinical activity which requires dynamic decision making, interdisciplinary teamwork and communication, and rapid response. Simulation training that focuses on crisis resource management and interprofessional communication is well-suited to address these training needs. Institutional commitment to provide both capital and human resources is instrumental to the success of ECMO training programs. Future multicenter studies with standardized training curricula are required to investigate the impact of ECMO simulation training on patient outcome.
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Affiliation(s)
- Simon W C Sin
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, China.,Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Pauline Y Ng
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, China.,Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Wallace C W Ngai
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, China
| | - Peter C K Lai
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, China
| | - Andy Y T Mok
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, China
| | - Ricky W K Chan
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, China
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158
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Clinical Efficacy of Extracorporeal Cardiopulmonary Resuscitation for Adults with Cardiac Arrest: Meta-Analysis with Trial Sequential Analysis. BIOMED RESEARCH INTERNATIONAL 2019; 2019:6414673. [PMID: 31360719 PMCID: PMC6652040 DOI: 10.1155/2019/6414673] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 04/24/2019] [Accepted: 06/16/2019] [Indexed: 01/26/2023]
Abstract
Objective This meta-analysis with trial sequential analysis (TSA) compared the clinical efficacy of extracorporeal cardiopulmonary resuscitation (ECPR) with conventional CPR (CCPR) for adult patients who experienced in-hospital cardiac arrest (IHCA) or out-of-hospital CA (OHCA). Methods A literature search was used to identify eligible publications (up to 30 July 2018) from PubMed, the Cochrane Library, the ISI Web of Knowledge, and Embase. Two investigators independently conducted the literature search, study selection, data extraction, and quality evaluation. Meta-analysis and TSA were used to analyze each outcome, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to evaluate the level of evidence. The primary outcome was 30-day survival, and the secondary outcomes were 30-day neurologic outcome, 3-6 months' survival, 3-6 months' neurological outcome, 1-year survival, and 1-year neurological outcome. Results We identified 13 eligible observational studies for the final analysis. Pooled analyses showed that ECPR was associated with a significantly better 30-day survival (RR = 1.60, 95% CI = 1.25-2.06) and 30-day neurologic outcome (RR = 2.69, 95% CI = 1.63-4.46), and TSA confirmed these results. However, subgroup analysis of patients with OHCA indicated that ECPR and CCPR had similar effects on 30-day survival (RR = 1.18, 95% CI = 0.71-1.97), which was not confirmed by TSA. Analysis of OHCA patients indicated that ECPR provided a better 30-day neurological outcome (RR = 3.93, 95% CI = 1.00-15.50), but TSA did not support these results. Analysis of IHCA patients indicated that ECPR was associated with a better 30-day survival (RR 1.90, 95% CI 1.43-2.52) and 30-day neurologic outcome (RR 2.02, 95% CI 1.21-3.39), and TSA supported these results. Other subgroup analyses showed that the results were generally consistent, regardless of nation, propensity score matching, presumed etiology, whether the CA was witnessed or not, and study quality. Conclusions Relative to CCPR, ECPR improved the survival and neurological outcome of patients who had IHCA. Compared to IHCA patients, TSA could not confirm better survival and neurologic outcome of ECPR in OHCA patients, suggesting that further studies are needed. Trial Registration This trial was registered with PROSPERO (CRD42018100513) on 17 July 2018.
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159
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Flécher E, Guihaire J, Pozzi M, Ouattara A, Baudry G, Berthelot E, Beauvais F, Radu C, Dorent R, Sebbag L, Galli E, Roubille F, Damy T, Verhoye JP, Leprince P, Obadia JF, Lebreton G. Extracorporeal membrane oxygenation support in acute circulatory failure: A plea for regulation and better organization. Arch Cardiovasc Dis 2019; 112:441-449. [DOI: 10.1016/j.acvd.2019.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/18/2019] [Accepted: 04/23/2019] [Indexed: 12/28/2022]
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160
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Michels G, Wengenmayer T, Hagl C, Dohmen C, Böttiger BW, Bauersachs J, Markewitz A, Bauer A, Gräsner JT, Pfister R, Ghanem A, Busch HJ, Kreimeier U, Beckmann A, Fischer M, Kill C, Janssens U, Kluge S, Born F, Hoffmeister HM, Preusch M, Boeken U, Riessen R, Thiele H. Empfehlungen zur extrakorporalen kardiopulmonalen Reanimation (eCPR). ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2019. [DOI: 10.1007/s00398-018-0262-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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161
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Burrell AJC, Bennett V, Serra AL, Pellegrino VA, Romero L, Fan E, Brodie D, Cooper DJ, Kaye DM, Fraser JF, Hodgson CL. Venoarterial extracorporeal membrane oxygenation: A systematic review of selection criteria, outcome measures and definitions of complications. J Crit Care 2019; 53:32-37. [PMID: 31181462 DOI: 10.1016/j.jcrc.2019.05.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 04/28/2019] [Accepted: 05/22/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to systematically investigate the reporting of selection criteria and outcome measures, and to examine definitions of complications used in venoarterial extracorporeal membrane oxygenation studies (V-A ECMO). MATERIALS AND METHODS Medline, EMBASE and the Cochrane central register were searched for V-A ECMO studies from January 2005 to July 2017. Studies with ≤99 patients or without patient centered outcomes were excluded. Two reviewers independently assessed search results and undertook data extraction. RESULTS Forty-six studies met the inclusion criteria, and all were retrospective, observational studies. Inconsistent reporting of selection criteria, ECMO management and outcome measures was common. In-hospital mortality was the most common primary outcome (41% of studies), followed by 30-day mortality (11%). Bleeding was the most frequent complication reported, most commonly defined as "bleeding requiring transfusion" (median ≥ 2 Units/day). Significant variation in reporting and definitions was also evident for vascular, neurological renal and infectious complications. CONCLUSION This systematic review provides clinicians with the most commonly reported selection criteria, outcome measures and complications used in ECMO practice. However non-standardized definitions and inconsistent reporting limits their ability to inform practice. New consensus driven definitions of complications and patient centred outcomes are urgently needed.
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Affiliation(s)
- Aidan J C Burrell
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care, The Alfred Hospital, Melbourne, Australia.
| | - Victoria Bennett
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Alexis L Serra
- Division of Pulmonary, Allergy, and Critical Care, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, USA.
| | - Vincent A Pellegrino
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care, The Alfred Hospital, Melbourne, Australia.
| | - Lorena Romero
- The Ian Potter Library, The Alfred Hospital, Melbourne, Australia.
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Departments of Medicine and Physiology, Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, USA.
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care, The Alfred Hospital, Melbourne, Australia.
| | - David M Kaye
- Baker IDI Heart and Diabetes Research Institute, Melbourne, Australia.
| | - John F Fraser
- Critical Care Research Group Adult Intensive Care Service, The Prince Charles Hospital and University of Queensland, Brisbane, Australia
| | - Carol L Hodgson
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care, The Alfred Hospital, Melbourne, Australia.
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162
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Ørbo MC, Karlsen SF, Pedersen EP, Hermansen SE, Rønning PB, Nergaard KA, Naesheim T, Myrmel T. Health-related quality of life after extracorporeal membrane oxygenation: a single centre's experience. ESC Heart Fail 2019; 6:701-710. [PMID: 31066213 PMCID: PMC6676289 DOI: 10.1002/ehf2.12433] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 02/22/2019] [Indexed: 12/31/2022] Open
Abstract
Aims The aims of this study were to evaluate health‐related quality of life (HRQL) among patients treated with extracorporeal membrane oxygenation (ECMO) in northern Norway over a period of 27 years (1988–2015) and to identify variables related to HRQL. Methods and results A retrospective inquiry of the ECMO registry at the University Hospital of North Norway identified 74 ECMO‐treated patients (mean age 49 years, 65% males). Acute cardiac failure was the dominant indication (58%), and venoarterial ECMO was the dominant mode of treatment (87%). Mortality for discharged patients was recorded on 20 September 2016. Thirty (41%) survivors were identified. Twenty‐three survivors were eligible for the survey and received a set of questionnaires at home. The main outcome measure was HRQL as measured with the 36‐item Short‐Form health survey (SF‐36) (RAND Short Form‐36 v1.2). Other questionnaires covered demographic information, problems with functioning in usual daily activities (such as hobbies, household chores, family, or work), employment status, and psychological distress. The survey was completed by 20 (87%) survivors (mean age = 49 years, 12 men). Indications for ECMO treatment (VA = 90%) had been respiratory failure (25%), cardiac failure (60%), and extracorporeal cardiopulmonary resuscitation (15%). The average time since ECMO treatment was 6.5 years. Seventy‐five percent reported mental HRQL (SF‐36 Mental Component Summary, mean = 43, SD = 5) or physical HRQL (SF‐36 Physical Component Summary, mean = 43, SD = 4.5) within the normal range (T = 50 ± 10) in comparison with age‐matched population data from national norms. Half of the responders reported problems on the SF‐36 subscales general health and role physical. Seventy percent reported problems on the SF‐36 subscale role emotional. All but one responder lived independently without any organized care, and 90% reported no problems related to basic self‐care. Half of those in working age had returned to work after ECMO treatment. Forty percent of the responders reported some degree of restrictions in usual daily activities, problems with mobility (35%), anxiety/depression (35%), or pain/discomfort (55%). Significant univariate associations were observed for poorer HRQL and higher reports of psychological distress, pain, and experiencing restrictions in usual everyday activities. Improved HRQL was significantly related to an extended time since ECMO treatment. Conclusions Our survey indicates an overall positive long‐term HRQL outcome for our ECMO survivors. A subset reported problems with functioning and HRQL. Future research should focus on identification of the survivors at risk for poor recovery who may benefit from rehabilitation interventions.
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Affiliation(s)
- Marte Christine Ørbo
- Department of Cardiothoracic and Vascular Surgery, Heart and Lung Clinic, University Hospital of North Norway, Tromsø, Norway
| | - Sidsel Fredheim Karlsen
- Department of Cardiology, Heart and Lung Clinic, University Hospital of North Norway, Tromsø, Norway
| | - Ellinor Phillips Pedersen
- Department of Cardiothoracic and Vascular Surgery, Heart and Lung Clinic, University Hospital of North Norway, Tromsø, Norway
| | - Stig Eggen Hermansen
- Department of Cardiothoracic and Vascular Surgery, Heart and Lung Clinic, University Hospital of North Norway, Tromsø, Norway
| | - Per Bjørnerud Rønning
- Department of Cardiology, Heart and Lung Clinic, University Hospital of North Norway, Tromsø, Norway
| | - Kathrine Aas Nergaard
- Division of Surgical Medicine and Intensive Care, Clinic of Emergency Medical Services, University Hospital of North Norway, Tromsø, Norway
| | - Torvind Naesheim
- Division of Surgical Medicine and Intensive Care, Clinic of Emergency Medical Services, University Hospital of North Norway, Tromsø, Norway.,Institute of Clinical Medicine, University of Tromsø, The Arctic University of Norway, Tromsø, Norway
| | - Truls Myrmel
- Department of Cardiothoracic and Vascular Surgery, Heart and Lung Clinic, University Hospital of North Norway, Tromsø, Norway.,Institute of Clinical Medicine, University of Tromsø, The Arctic University of Norway, Tromsø, Norway
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163
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van den Brink FS, van Tooren R, Sonker U, Klein P, Waanders F, Zivelonghi C, Eefting FD, Scholten E, Ten Berg JM. Veno arterial-extra corporal membrane oxygenation for the treatment of cardiac failure in patients with infective endocarditis. Perfusion 2019; 34:613-617. [PMID: 31027458 DOI: 10.1177/0267659119842807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Surgery for infective endocarditis imposes great challenges in post-operative circulatory and pulmonary support but the role of veno-arterial extra-corporal membrane oxygenation in this respect is unclear. METHODS All patients undergoing veno-arterial extra-corporal membrane oxygenation after infective endocarditis surgery were analysed for age, gender, medical history, microorganisms, clinical outcome, complications and surgical procedure. RESULTS Between 2012 and 2016, 13 patients received veno-arterial extra-corporal membrane oxygenation following infective endocarditis surgery. The median age was 62 years (33-73) and 8/13 were male. Previous cardiac surgery was present in nine patients. Surgery for infective endocarditis consisted of a Bentall procedure in 10 patients, 2 of which received concomitant mitral valve surgery and 2 received concomitant coronary artery bypass graft. Valvular surgery alone was performed in three patients. Mortality on veno-arterial extra-corporal membrane oxygenation was 62% (8/13). Mortality during intensive care unit stay was 77% (10/13). Survival to discharge was 23% (3/13). One patient reached the 1 year survival point. Two patients who survived to discharge have not yet reached the 1 year survival point. Patient-related complications occurred in 54% (7/13) of patients and consisted of haemorrhage at the cannula site in four patients, leg ischaemia in one patient, haemorrhage at another site in one patient and infection of the cannula in one patient. Extra-corporal membrane oxygenation hardware-related complications occurred in one case consisting of clot formation in the oxygenator. CONCLUSION Veno-arterial extra-corporal membrane oxygenation in post-cardiotomy patients who were operated on for infective endocarditis is feasible, but outcome is poor.
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Affiliation(s)
- Floris S van den Brink
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Cardiology, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Rob van Tooren
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Uday Sonker
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Patrick Klein
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Frans Waanders
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Carlo Zivelonghi
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Frank D Eefting
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Erik Scholten
- Department of Intensive Care, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Jurrien M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
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164
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DeMartino ES, Braus NA, Sulmasy DP, Bohman JK, Stulak JM, Guru PK, Fuechtmann KR, Singh N, Schears GJ, Mueller PS. Decisions to Withdraw Extracorporeal Membrane Oxygenation Support: Patient Characteristics and Ethical Considerations. Mayo Clin Proc 2019; 94:620-627. [PMID: 30853261 PMCID: PMC10893957 DOI: 10.1016/j.mayocp.2018.09.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 08/20/2018] [Accepted: 09/24/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To describe the prevalence and context of decisions to withdraw extracorporeal membrane oxygenation (ECMO), with an ethical analysis of issues raised by this technology. PATIENTS AND METHODS We retrospectively reviewed medical records of adults treated with ECMO at Mayo Clinic in Rochester, Minnesota, from January 1, 2010, through December 31, 2014, from whom ECMO was withdrawn and who died within 24 hours of ECMO separation. RESULTS Of 235 ECMO-supported patients, we identified 62 (26%) for whom withdrawal of ECMO was requested. Of these 62 patients, the indication for ECMO initiation was bridge to transplant for 8 patients (13%), bridge to mechanical circulatory support for 3 (5%), and bridge to decision for 51 (82%). All the patients were supported with other life-sustaining treatments. No patient had decisional capacity; for all the patients, consensus to withdraw ECMO was jointly reached by clinicians and surrogates. Eighteen patients (29%) had a do-not-resuscitate order at the time of death. CONCLUSION For most patients who underwent treatment withdrawal eventually, ECMO had been initiated as a bridge to decision rather than having an established liberation strategy, such as transplant or mechanical circulatory support. It is argued that ethically, withdrawal of treatment is sometimes better after the prognosis becomes clear, rather than withholding treatment under conditions of uncertainty. This rationale provides the best explanation for the behavior observed among clinicians and surrogates of ECMO-supported patients. The role of do-not-resuscitate orders requires clarification for patients receiving continuous resuscitative therapy.
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Affiliation(s)
- Erin S DeMartino
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN.
| | - Nicholas A Braus
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN
| | - Daniel P Sulmasy
- Department of Medicine, Georgetown University, Washington, DC; Department of Philosophy, Georgetown University, Washington, DC; Kennedy Institute of Ethics, Georgetown University, Washington, DC
| | - J Kyle Bohman
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Pramod K Guru
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | | | | | - Gregory J Schears
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Paul S Mueller
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN; Division of General Internal Medicine, Mayo Clinic, Rochester, MN
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165
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Merkle J, Azizov F, Fatullayev J, Weber C, Maier J, Eghbalzadeh K, Sabashnikov A, Pfister R, Wahlers T, Michels G. Monitoring of adult patient on venoarterial extracorporeal membrane oxygenation in intensive care medicine. J Thorac Dis 2019; 11:S946-S956. [PMID: 31183174 DOI: 10.21037/jtd.2018.10.29] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Nowadays high-tech medical assist device therapy is a crucial part of intensive care medicine. Especially, management of circulatory assist device systems poses an increasing challenge for intensive care medicine. So far, autonomous recommendations for monitoring of extracorporeal life support systems in the form of guidelines or position papers are lacking. The purpose of this paper was to present an orientation guide on this important topic.
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Affiliation(s)
- Julia Merkle
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Farid Azizov
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Javid Fatullayev
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Carolyn Weber
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Johanna Maier
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Roman Pfister
- Department of Cardiology, University Hospital of Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Guido Michels
- Department of Cardiology, University Hospital of Cologne, Cologne, Germany
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166
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Dzierba AL, Abrams D, Muir J, Brodie D. Ventilatory and Pharmacotherapeutic Strategies for Management of Adult Patients on Extracorporeal Life Support. Pharmacotherapy 2019; 39:355-368. [DOI: 10.1002/phar.2230] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Amy L. Dzierba
- Department of Pharmacy NewYork‐Presbyterian Hospital New York New York
| | - Darryl Abrams
- Division of Pulmonary, Allergy and Critical Care Columbia University College of Physicians and Surgeons/NewYork‐Presbyterian Hospital New York New York
| | - Justin Muir
- Department of Pharmacy NewYork‐Presbyterian Hospital New York New York
| | - Daniel Brodie
- Division of Pulmonary, Allergy and Critical Care Columbia University College of Physicians and Surgeons/NewYork‐Presbyterian Hospital New York New York
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167
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Kjaergaard B, Kristensen JH, Sindby JE, de Neergaard S, Rasmussen BS. Extracorporeal membrane oxygenation in life-threatening massive pulmonary embolism. Perfusion 2019; 34:467-474. [DOI: 10.1177/0267659119830014] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Introduction: In massive pulmonary embolism (PE) with circulatory collapse or with cardiac arrest, treatment can be difficult. Often, the diagnosis is unclear, and the time to treatment is crucial. Our institution has had an out-of-hospital team intended for the treatment of accidental hypothermia with extra corporeal membrane oxygenation (ECMO) since 2004. The team has occasionally been involved in patients suffering massive PE. Methods: We were called to 38 patients with PE, but two were assessed as untreatable. Seventeen were treated with cardiopulmonary resuscitation followed by veno-arterial ECMO. Nineteen were prepared for ECMO with sheaths in the femoral vessels and were intensively observed during diagnosis and treatment. Five of these patients later progressed to ECMO due to cardiac arrest during treatment with thrombolytic medication. Most of the patients were treated with heparin and thrombolytic medication, but if the medications were contraindicated, they were treated with either surgical thrombectomy or only with heparin awaiting spontaneous thrombolysis. Results: Of the 36 patients we intended to treat, 25 (69%) survived one month and 20 survived one year (56%). Of the 22 patients treated with ECMO, 11 survived one month (50%) and 10 survived one year (45%). Discussion: The treatment could have been more uniform. It seems reasonable to build up a PE alert team with ECMO capability to take care of patients with massive PE. Conclusion: The treatment of thrombolytic medications in massive PE is risky, but if the patient is treated or prepared for ECMO, it can be lifesaving.
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Affiliation(s)
- Benedict Kjaergaard
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | | | - Jesper Eske Sindby
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Susanne de Neergaard
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Bodil Steen Rasmussen
- Department of Anaesthesiology and Intensive Medicine, Aalborg University Hospital, Aalborg, Denmark
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168
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Wang L, Yang F, Wang X, Xie H, Fan E, Ogino M, Brodie D, Wang H, Hou X. Predicting mortality in patients undergoing VA-ECMO after coronary artery bypass grafting: the REMEMBER score. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:11. [PMID: 30635022 PMCID: PMC6330483 DOI: 10.1186/s13054-019-2307-y] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 01/02/2019] [Indexed: 12/20/2022]
Abstract
Background Prediction scoring systems for coronary artery bypass grafting (CABG) patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) have not yet been reported. This study was designed to develop a predictive score for in-hospital mortality for cardiogenic shock patients who received VA-ECMO after isolated CABG. Methods Retrospective cohort study of consecutive CABG patients supported with VA-ECMO (n = 166) at the Beijing Anzhen Hospital between February 2004 and March 2017. Results One hundred and six patients (64%) could be weaned from VA-ECMO, and 74 patients (45%) survived to hospital discharge. On the basis of multivariable logistic regression analyses, the pRedicting mortality in patients undergoing veno-arterial Extracorporeal MEMBrane oxygenation after coronary artEry bypass gRafting (REMEMBER) score was created with six pre-ECMO parameters: older age, left main coronary artery disease, inotropic score > 75, CK-MB > 130 IU/L, serum creatinine > 150 umol/L, and platelet count < 100 × 109/L. Four risk classes, namely class I (REMEMBER score 0–13), class II (14–19), class III (20–25), and class IV (> 25) with their corresponding mortality (13%, 55%, 70%, and 94%, respectively), were identified. The area under the receiver operating characteristic curve 0.85(95% CI 0.79–0.91) for the REMEMBER score was better than those for the SOFA, SAVE, EuroSCORE, and ENCOURAGE scores in this population. Conclusions The REMEMBER score might help clinicians at bedside to predict in-hospital mortality for patients receiving VA-ECMO after isolated CABG for refractory cardiogenic shock. Prospective studies are needed to externally validate this scoring system. Electronic supplementary material The online version of this article (10.1186/s13054-019-2307-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Liangshan Wang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Feng Yang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xiaomeng Wang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Haixiu Xie
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mark Ogino
- Division of Neonatology, Nemours/Alfred I. DuPont Hospital for Children, Wilmington, Delaware, USA
| | - Daniel Brodie
- Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA
| | - Hong Wang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China.
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169
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Wang L, Xing Z. Short‐term outcomes of intra‐aortic balloon pump combined with venoarterial extracorporeal membrane oxygenation: A systematic review and meta‐analysis. Artif Organs 2019; 43:561-568. [PMID: 30485466 DOI: 10.1111/aor.13397] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 10/14/2018] [Accepted: 11/19/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Li Wang
- Department of Anesthesiology The First Affiliated Hospital of Hebei North College Hebei People’s Republic of China
| | - Zhen Xing
- Department of Anesthesiology The First Affiliated Hospital of Hebei North College Hebei People’s Republic of China
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170
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Ortuno S, Delmas C, Diehl JL, Bailleul C, Lancelot A, Naili M, Cholley B, Pirracchio R, Aissaoui N. Weaning from veno-arterial extra-corporeal membrane oxygenation: which strategy to use? Ann Cardiothorac Surg 2019; 8:E1-E8. [PMID: 30854330 DOI: 10.21037/acs.2018.08.05] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Refractory cardiogenic shock patients may be rescued by veno-arterial extracorporeal membrane oxygenation (VA ECMO). After a few days of mechanical assistance, the device can sometimes be successfully removed if the patient has partially or fully recovered from the condition that required the use of ECMO. The percentage of patients with refractory cardiogenic shock who are successfully weaned from ECMO varies from 31% to 76%. Weaning does not mean survival, because 20% to 65% of patients weaned from VA ECMO support do not survive to hospital discharge. The high death rate after successful weaning shows that many questions remain unresolved in this field. In this review, we will discuss the various factors influencing survival and a successful weaning from VA ECMO, in addition to weaning approaches proposed in the literature. Based on this information, we will propose a strategy to optimize the weaning process.
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Affiliation(s)
- Sofia Ortuno
- Department of Intensive Care Cnit, Hôpital Européen Georges Pompidou (HEGP) Assistance Publique-Hôpitaux de Paris (APHP) and Université Paris Descartes, Paris, France
| | - Clément Delmas
- Intensive Cardiac Care Unit, Rangueil University, Toulouse, France
| | - Jean-Luc Diehl
- Department of Intensive Care Cnit, Hôpital Européen Georges Pompidou (HEGP) Assistance Publique-Hôpitaux de Paris (APHP) and Université Paris Descartes, Paris, France
| | - Clotilde Bailleul
- Department of Intensive Care Cnit, Hôpital Européen Georges Pompidou (HEGP) Assistance Publique-Hôpitaux de Paris (APHP) and Université Paris Descartes, Paris, France
| | - Aymeric Lancelot
- Department of Intensive Care Cnit, Hôpital Européen Georges Pompidou (HEGP) Assistance Publique-Hôpitaux de Paris (APHP) and Université Paris Descartes, Paris, France
| | - Mahassen Naili
- Department of Cardiology, Hôpital Européen Georges Pompidou, APHP, Paris, France
| | - Bernard Cholley
- Department of Anesthesiology and Intensive Care, Paris, Hôpital Européen Georges Pompidou, APHP, Université Paris-Descartes, Paris, France
| | - Romain Pirracchio
- Department of Anesthesiology and Intensive Care, Paris, Hôpital Européen Georges Pompidou, APHP, Université Paris-Descartes, Paris, France
| | - Nadia Aissaoui
- Department of Intensive Care Cnit, Hôpital Européen Georges Pompidou (HEGP) Assistance Publique-Hôpitaux de Paris (APHP) and Université Paris Descartes, Paris, France.,Paris-Cardiovascular-Research-Center, INSERM U970, Paris, France
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171
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Abrams D, Garan AR, Brodie D. Awake and fully mobile patients on cardiac extracorporeal life support. Ann Cardiothorac Surg 2019; 8:44-53. [PMID: 30854311 DOI: 10.21037/acs.2018.08.03] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Early mobilization of critically ill patients is increasingly being recognized as not only safe and feasible, but also as a potential means of optimizing outcomes in the intensive care unit (ICU). With the rapidly expanding use of extracorporeal life support (ECLS) for severe cardiopulmonary failure, there is a growing interest in the application of early mobilization to this patient population, which has been shown to be safe and feasible in select patient populations. However, some patients receiving ECLS support may benefit more than others. For instance, early mobilization may be particularly beneficial in patients awaiting heart or lung transplantation, as maintenance of physical conditioning may be an important component of a patient's transplant candidacy. The ability to engage critically ill patients in active physical therapy and early mobilization necessarily involves minimization of sedation and is often further facilitated by a strategy that favors endotracheal extubation. Whether an awake, extubated and mobile strategy can be applied in any given patient is often dictated by the severity of the underlying disease and the amount of extracorporeal support required. Additionally, whether this approach is superior to usual care, which patients might benefit or be harmed, and which patient characteristics are most likely to predict success of this strategy, are areas of ongoing investigation.
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Affiliation(s)
- Darryl Abrams
- Division of Pulmonary, Allergy, and Critical Care, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, USA
| | - A Reshad Garan
- Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, USA
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, USA
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172
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Lo Coco V, Lorusso R, Raffa GM, Malvindi PG, Pilato M, Martucci G, Arcadipane A, Zieliński K, Suwalski P, Kowalewski M. Clinical complications during veno-arterial extracorporeal membrane oxigenation in post-cardiotomy and non post-cardiotomy shock: still the achille's heel. J Thorac Dis 2018; 10:6993-7004. [PMID: 30746245 DOI: 10.21037/jtd.2018.11.103] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is life-saving for potentially reversible heart failure and respiratory injuries not responsive to conventional therapies. Technological innovations have produced over the years significant improvements in ECMO devices (pump, cannula design and oxygenator) and have allowed a better risk/benefit profile. Alongside with recognized advantages in the treatment of very sick patients, ECMO remains an invasive procedure for mechanical circulatory support (MCS) and it is associated with complications that strongly influence the prognosis. Current review was designed to provide a comprehensive outline on ECMO complications, analyzing risk factors and strategies of management, focusing on adult population undergoing veno-arterial ECMO (VA-ECMO) therapy.
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Affiliation(s)
- Valeria Lo Coco
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Giuseppe M Raffa
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | | | - Michele Pilato
- Department of the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Gennaro Martucci
- Department of Anaesthesia and Intensive Care, IRCCS-ISMETT, Palermo, Italy
| | - Antonio Arcadipane
- Department of Anaesthesia and Intensive Care, IRCCS-ISMETT, Palermo, Italy
| | | | - Piotr Suwalski
- Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior in Warsaw, Poland.,Clinical Department of Cardiac Surgery, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Mariusz Kowalewski
- Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior in Warsaw, Poland.,Cardiothoracic Research Centre, Innovative Medical Forum, Bydgoszcz, Poland
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173
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Tipograf Y, Liou P, Oommen R, Agerstrand C, Abrams D, Brodie D, Bacchetta M. A decade of interfacility extracorporeal membrane oxygenation transport. J Thorac Cardiovasc Surg 2018; 157:1696-1706. [PMID: 30655061 DOI: 10.1016/j.jtcvs.2018.09.139] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 08/17/2018] [Accepted: 09/22/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Extracorporeal membrane oxygenation (ECMO) is used to provide support for patients with cardiopulmonary failure. Best available medical management often fails in these patients and referring hospitals have no further recourse for escalating care apart from transfer to a tertiary facility. In severely unstable patients, the only option might be to use ECMO to facilitate safe transport. This study aimed to examine the characteristics and outcomes of patients transported while receiving ECMO. METHODS Statistical analysis was performed on data gathered retrospectively from the electronic medical records of adult patients transported while receiving ECMO to Columbia University Medical Center between January 1, 2008, and December 31, 2017. RESULTS Two hundred sixty five adult patients were safely transported while receiving ECMO with no transport-related complications that adversely affected outcomes. Transport distance ranged from 0.2 to 7084 miles with a median distance of 16.9 miles. One hundred eighty-three (69%) received on veno-venous, 72 (27%) veno-arterial, and 10 (3.8%) veno-venous arterial or veno-arterial venous configurations. Two hundred ten (79%) cannulations were performed at our institution at the referring hospital. Sixty-four percent of patients transported while receiving ECMO survived to hospital discharge. CONCLUSIONS Interfacility transport during ECMO was shown to be safe and effective with minimal complications and favorable outcomes when performed at an experienced referral center using stringently applied protocols.
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Affiliation(s)
- Yuliya Tipograf
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - Peter Liou
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - Roy Oommen
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - Cara Agerstrand
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Darryl Abrams
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Daniel Brodie
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Matthew Bacchetta
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tenn.
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174
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Fernández-Mondéjar E, Fuset-Cabanes MP, Grau-Carmona T, López-Sánchez M, Peñuelas Ó, Pérez-Vela JL, Pérez-Villares JM, Rubio-Muñoz JJ, Solla-Buceta M. The use of ECMO in ICU. Recommendations of the Spanish Society of Critical Care Medicine and Coronary Units. Med Intensiva 2018; 43:108-120. [PMID: 30482406 DOI: 10.1016/j.medin.2018.09.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 09/26/2018] [Accepted: 09/30/2018] [Indexed: 02/07/2023]
Abstract
The use of extracorporeal membrane oxygenation systems has increased significantly in recent years; given this reality, the Spanish Society of Critical Intensive Care Medicine and Coronary Units (SEMICYUC) has decided to draw up a series of recommendations that serve as a framework for the use of this technique in intensive care units. The three most frequent areas of extracorporeal membrane oxygenation systems use in our setting are: as a cardiocirculatory support, as a respiratory support and for the maintenance of the abdominal organs in donors. The SEMICYUC appointed a series of experts belonging to the three working groups involved (Cardiological Intensive Care and CPR, Acute Respiratory Failure and Transplant work group) that, after reviewing the existing literature until March 2018, developed a series of recommendations. These recommendations were posted on the SEMICYUC website to receive suggestions from the intensivists and finally approved by the Scientific Committee of the Society. The recommendations, based on current knowledge, are about which patients may be candidates for the technique, when to start it and the necessary infrastructure conditions of the hospital centers or, the conditions for transfer to centers with experience. Although from a physiopathological point of view, there are clear arguments for the use of extracorporeal membrane oxygenation systems, the current scientific evidence is weak, so studies are needed that define more precisely which patients benefit most from the technique and when they should start.
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Affiliation(s)
- E Fernández-Mondéjar
- Servicio de Medicina Intensiva, Hospital Universitario Virgen de las Nieves, Granada, España; Instituto de Investigación Biosanitaria IBS, Granada, España.
| | - M P Fuset-Cabanes
- Servicio de Medicina Intensiva, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - T Grau-Carmona
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España
| | - M López-Sánchez
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Ó Peñuelas
- Servicio de Medicina Intensiva, Hospital Universitario de Getafe, Getafe, Madrid, España; CIBER de Enfermedades Respiratorias, CIBERES, Madrid, España
| | - J L Pérez-Vela
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España
| | - J M Pérez-Villares
- Servicio de Medicina Intensiva, Hospital Universitario Virgen de las Nieves, Granada, España; Instituto de Investigación Biosanitaria IBS, Granada, España
| | - J J Rubio-Muñoz
- Servicio de Medicina Intensiva, Hospital Universitario Puerta de Hierro, Madrid, España
| | - M Solla-Buceta
- Servicio de Medicina Intensiva, Complejo Hospitalario Universitario, La Coruña, España
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175
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Focus on extracorporeal life support. Intensive Care Med 2018; 44:2251-2253. [PMID: 30465069 DOI: 10.1007/s00134-018-5465-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 11/12/2018] [Indexed: 01/19/2023]
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176
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Danial P, Hajage D, Nguyen LS, Mastroianni C, Demondion P, Schmidt M, Bouglé A, Amour J, Leprince P, Combes A, Lebreton G. Percutaneous versus surgical femoro-femoral veno-arterial ECMO: a propensity score matched study. Intensive Care Med 2018; 44:2153-2161. [PMID: 30430207 DOI: 10.1007/s00134-018-5442-z] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 10/31/2018] [Indexed: 12/13/2022]
Abstract
PURPOSE Femoral artery surgical cannulation is the reference for venoarterial extracorporeal membrane oxygenation (VA-ECMO) in adults. However, the less invasive percutaneous approach has been associated with lower rates of complications. This retrospective study compared complication rates and overall survival in a large series of patients who received surgical or percutaneous peripheral VA-ECMO. METHODS All consecutive patients implanted with VA-ECMO between January 2015 and December 2017 in a high ECMO-volume university hospital were included. Surgical cannulation was the only approach until late 2016 after which the percutaneous approach became the first line strategy. Propensity score framework analyzes were used to compare outcomes of percutaneous and surgical groups while controlling for confounders. RESULTS Among the 814 patients who received VA-ECMO (485 surgical and 329 percutaneous), propensity-score matching selected 266 unique pairs of patients with similar characteristics. Percutaneous cannulation was associated with fewer local infections (16.5% versus 27.8%, p = 0.001), similar rates of limb ischemia (8.6% versus 12.4%, p = 0.347) and sensory-motor complications (2.6% versus 2.3%, p = 0.779) and improved 30-day survival (63.8% versus 56.3%, p = 0.034). However, more vascular complications following decannulation (14.7% versus 3.4%, p < 0.001), mainly persistent bleeding requiring surgical revision (9.4% vs. 1.5%, p < 0.001), occurred after percutaneous cannulation. CONCLUSIONS Compared to the surgical approach, percutaneous cannulation for peripheral VA-ECMO was associated with fewer local infections, similar rates of ischemia and sensory-motor complications and improved 30-day survival. The higher rate of vascular complications following decannulation suggests that improvements in cannula removal techniques are needed to further improve patients' outcomes after percutaneous cannulation.
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Affiliation(s)
- Pichoy Danial
- Department of Cardiovascular and Thoracic Surgery, Institute of Cardiology, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University, 47-83, Boulevard de l'hopital, Paris, 75013, France
| | - David Hajage
- Sorbonne Université, AP-HP, Hôpital Pitié-Salpêtrière, Département Biostatistique Santé Publique Et Information Médicale, Unité de Recherche Clinique PSL-CFX, Centre de Pharmacoépidémiologie (Cephepi), CIC-1421, Paris, France
| | - Lee S Nguyen
- Department of Cardiovascular and Thoracic Surgery, Institute of Cardiology, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University, 47-83, Boulevard de l'hopital, Paris, 75013, France
| | - Ciro Mastroianni
- Department of Cardiovascular and Thoracic Surgery, Institute of Cardiology, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University, 47-83, Boulevard de l'hopital, Paris, 75013, France
| | - Pierre Demondion
- Department of Cardiovascular and Thoracic Surgery, Institute of Cardiology, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University, 47-83, Boulevard de l'hopital, Paris, 75013, France
| | - Matthieu Schmidt
- Medical Intensive Care Unit, Institute of Cardiology, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Paris, France
| | - Adrien Bouglé
- Department of Anesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Paris, France
| | - Julien Amour
- Department of Anesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Paris, France
| | - Pascal Leprince
- Department of Cardiovascular and Thoracic Surgery, Institute of Cardiology, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University, 47-83, Boulevard de l'hopital, Paris, 75013, France
| | - Alain Combes
- Medical Intensive Care Unit, Institute of Cardiology, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Paris, France
| | - Guillaume Lebreton
- Department of Cardiovascular and Thoracic Surgery, Institute of Cardiology, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University, 47-83, Boulevard de l'hopital, Paris, 75013, France.
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177
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Franchineau G, Luyt CE, Combes A, Schmidt M. Ventilator-associated pneumonia in extracorporeal membrane oxygenation-assisted patients. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:427. [PMID: 30581835 DOI: 10.21037/atm.2018.10.18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) provides a circulatory and/or respiratory assistance in case of refractory cardiogenic shock or acute respiratory distress syndrome (ARDS). Due to their extreme critical illness, these patients usually require prolonged mechanical ventilation, which is an inherent risk of ventilator-associated pneumonia (VAP). Although microorganisms responsible of VAP on ECMO are similar to those found in non-ECMO patients, classical suspicion criteria of VAP are no longer relevant on ECMO. Frequent severe chest X-Ray impairments, and poor specificity of the classical biomarkers on ECMO make VAP diagnosis challenging. In addition, significant drug pharmacokinetic modifications by the device may lead to low plasmatic antibiotic concentration and potential treatment failure. Consequently, rate of treatment failure and relapse appear high in that population (up to 30%), with significant impact on mortality and on the ECMO duration.
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Affiliation(s)
- Guillaume Franchineau
- Sorbonne Universités, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris, France.,Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris, France
| | - Charles Edouard Luyt
- Sorbonne Universités, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris, France.,Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris, France
| | - Alain Combes
- Sorbonne Universités, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris, France.,Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris, France
| | - Matthieu Schmidt
- Sorbonne Universités, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris, France.,Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris, France
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178
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Extracorporeal life support in the emergency department: A narrative review for the emergency physician. Resuscitation 2018; 133:108-117. [PMID: 30336233 DOI: 10.1016/j.resuscitation.2018.10.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/08/2018] [Accepted: 10/11/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Extracorporeal life support (ECLS) describes the use of blood perfusion devices to provide advanced cardiac or respiratory support. Advances in percutaneous vascular cannula insertion, centrifugal pump technologies, and the miniaturization of extracorporeal devices have simplified ECLS. The intention of this discussion is to review the role of ECLS as a potential rescue method for emergency department (ED) clinicians in critical clinical scenarios and to focus on the prerequisites for managing an ECLS program in an ED setting. DISCUSSION Possible indications for ECLS cannulation in the ED include ongoing circulatory arrest, shock or refractory hypoxemia and pulmonary embolism with refractory shock. Severe trauma, foreign body obstruction, hypothermia and near drowning are situations in which patients may potentially benefit from ECLS. Early stabilization in the ED can provide a time window for a diagnostic workup and/or urgent procedures, including percutaneous coronary intervention, rewarming or damage control surgery in trauma. The use of ECLS is resource intensive and can be associated with a high risk of complications, especially when performed without previous training. Therefore, ECLS should only be used when the underlying problem is potentially reversible, and the resources are available to address the etiology of organ dysfunction. CONCLUSION Emergent ECLS has a role in the ED for selected indications in the face of life-threatening conditions. ECLS provides a bridge to recovery, definitive therapy, intervention or surgery. ECLS program requires an appropriately trained staff (physicians, nurses and ECLS specialists), equipment resources and logistical planning.
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179
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Roncon-Albuquerque R, Gaião S, Figueiredo P, Príncipe N, Basílio C, Mergulhão P, Silva S, Honrado T, Cruz F, Pestana M, Oliveira G, Meira L, França A, Almeida-Sousa JP, Araújo F, Paiva JA. An integrated program of extracorporeal membrane oxygenation (ECMO) assisted cardiopulmonary resuscitation and uncontrolled donation after circulatory determination of death in refractory cardiac arrest. Resuscitation 2018; 133:88-94. [PMID: 30321624 DOI: 10.1016/j.resuscitation.2018.10.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/10/2018] [Accepted: 10/11/2018] [Indexed: 10/28/2022]
Abstract
AIM To assess the feasibility of an integrated program of extracorporeal cardiopulmonary resuscitation (ECPR) and uncontrolled donation after circulatory determination of death (uDCDD) in refractory cardiac arrest (rCA). METHODS Single center, prospective, observational study of selected patients with in-hospital (IHCA) and out-of-hospital (OHCA) rCA occurring in an urban area of ∼1.5 million inhabitants, between October-2016 and May-2018. 65 year old or younger patients without significant bleeding or comorbidities with witnessed nonasystolic cardiac arrests were triaged to ECPR if they had a reversible cause and high quality CPR lasting < 60 min. Otherwise they were considered for uDCDD after a ten minute no touch period using normothermic regional perfusion. RESULTS 58 patients were included, of which 41 (71%) were OHCA and 18 (31%) had ECPR initiated. Median age was 52 (IQR 45-56) years. Cannulation was successful in 49/58 (84%) cases. Compared to ECPR, patients referred for uDCDD were more frequently OHCA (90 vs. 28%), had bystander CPR (28 vs. 83%) and prolonged low-flow period (40 (35-50) vs. 60 (49-78) min). Survival to hospital discharge with full neurological recovery (cerebral performance category 1) occurred in 6/18 (33%) ECPR patients. uDCDD resulted in transplantation of 44 kidneys. CONCLUSIONS An integrated program for rCA consisting of a formal pathway to uDCDD referral in ECPR ineligible patients is feasible. ECPR-referred patients had a reasonable survival with full neurologic recovery. Successful kidney transplantation was achieved with uDCDD.
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Affiliation(s)
- Roberto Roncon-Albuquerque
- Department of Emergency and Intensive Care Medicine, São João Hospital Centre, Porto, Portugal; Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Portugal.
| | - Sérgio Gaião
- Department of Emergency and Intensive Care Medicine, São João Hospital Centre, Porto, Portugal; Department of Medicine, Faculty of Medicine, University of Porto, Portugal
| | - Paulo Figueiredo
- Department of Infectious Diseases, São João Hospital Centre, Porto, Portugal
| | - Nuno Príncipe
- Department of Emergency and Intensive Care Medicine, São João Hospital Centre, Porto, Portugal
| | - Carla Basílio
- Department of Emergency and Intensive Care Medicine, São João Hospital Centre, Porto, Portugal
| | - Paulo Mergulhão
- Department of Emergency and Intensive Care Medicine, São João Hospital Centre, Porto, Portugal; Department of Medicine, Faculty of Medicine, University of Porto, Portugal
| | - Sofia Silva
- Department of Emergency and Intensive Care Medicine, São João Hospital Centre, Porto, Portugal
| | - Teresa Honrado
- Department of Emergency and Intensive Care Medicine, São João Hospital Centre, Porto, Portugal
| | - Francisco Cruz
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Portugal; Department of Urology, São João Hospital Centre, Porto, Portugal; i3S: Instituto de Investigação e Inovação em Saúde, Portugal
| | - Manuel Pestana
- Department of Medicine, Faculty of Medicine, University of Porto, Portugal; Department of Nephrology, São João Hospital Centre, Porto, Portugal; Nephrology and Infectious Diseases R&D Group, Instituto de Investigação e Inovação em Saúde (INEB-i3S), Universidade do Porto, Portugal
| | - Gerardo Oliveira
- Department of Medicine, Faculty of Medicine, University of Porto, Portugal; Organ Donation and Transplant Coordination Office, São João Hospital Centre, Porto, Portugal
| | - Luis Meira
- National Institute of Medical Emergency, Portugal
| | - Ana França
- Portuguese Institute for Blood and Transplantation, Portugal
| | | | | | - José-Artur Paiva
- Department of Emergency and Intensive Care Medicine, São João Hospital Centre, Porto, Portugal; Department of Medicine, Faculty of Medicine, University of Porto, Portugal
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180
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Spies C, Laufs U, Hagendorff A, Metze M. Case report: panic attacks as symptom of aortic regurgitation and aneurysm. Clin Res Cardiol 2018; 108:448-451. [PMID: 30242467 DOI: 10.1007/s00392-018-1370-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 09/05/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Christian Spies
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstraße 20, 04103, Leipzig, Germany.
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Andreas Hagendorff
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Michael Metze
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
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181
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Recommendations for extracorporeal cardiopulmonary resuscitation (eCPR): consensus statement of DGIIN, DGK, DGTHG, DGfK, DGNI, DGAI, DIVI and GRC. Clin Res Cardiol 2018; 108:455-464. [DOI: 10.1007/s00392-018-1366-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 08/30/2018] [Indexed: 11/27/2022]
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182
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Monaco F, Belletti A, Bove T, Landoni G, Zangrillo A. Extracorporeal Membrane Oxygenation: Beyond Cardiac Surgery and Intensive Care Unit: Unconventional Uses and Future Perspectives. J Cardiothorac Vasc Anesth 2018; 32:1955-1970. [DOI: 10.1053/j.jvca.2018.03.031] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Indexed: 02/06/2023]
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183
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Holmberg MJ, Geri G, Wiberg S, Guerguerian AM, Donnino MW, Nolan JP, Deakin CD, Andersen LW. Extracorporeal cardiopulmonary resuscitation for cardiac arrest: A systematic review. Resuscitation 2018; 131:91-100. [PMID: 30063963 DOI: 10.1016/j.resuscitation.2018.07.029] [Citation(s) in RCA: 175] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 07/19/2018] [Accepted: 07/25/2018] [Indexed: 01/21/2023]
Abstract
AIM To assess the use of extracorporeal cardiopulmonary resuscitation (ECPR), compared with manual or mechanical cardiopulmonary resuscitation (CPR), for out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) in adults and children. METHODS The PRISMA guidelines were followed. We searched Medline, Embase, and Evidence-Based Medicine Reviews for randomized clinical trials and observational studies published before May 22, 2018. The population included adult and pediatric patients with OHCA and IHCA of any origin. Two investigators reviewed studies for relevance, extracted data, and assessed risk of bias using the ROBINS-I tool. Outcomes included short-term and long-term survival and favorable neurological outcome. RESULTS We included 25 observational studies, of which 15 studies were in adult OHCA, 7 studies were in adult IHCA, and 3 studies were in pediatric IHCA. There were no studies in pediatric OHCA. No randomized trials were included. Results from individual studies were largely inconsistent, although several studies in adult and pediatric IHCA were in favor of ECPR. The risk of bias for individual studies was overall assessed to be critical, with confounding being the primary source of bias. The overall quality of evidence was assessed to be very low. Heterogeneity across studies precluded any meaningful meta-analyses. CONCLUSIONS There is inconclusive evidence to either support or refute the use of ECPR for OHCA and IHCA in adults and children. The quality of evidence across studies is very low.
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Affiliation(s)
- Mathias J Holmberg
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, Bygning J, Plan 1, 8200 Aarhus N, Denmark; Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215, USA
| | - Guillaume Geri
- Medical Intensive Care Unit, Assistance Publique Hôpitaux de Paris, Ambroise Paré Hospital, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France; Versailles Saint Quentin University, INSERM UMR1018, Team 5 Kidney & Heart, 78000 Versailles, France
| | - Sebastian Wiberg
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215, USA; Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Anne-Marie Guerguerian
- Department of Critical Care Medicine, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, 555 University Ave, Toronto, ON M5G 1X8, Canada
| | - Michael W Donnino
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215, USA
| | - Jerry P Nolan
- Bristol Medical School, University of Bristol, 69 St Michael's Hill, Bristol BS2 8DZ, UK
| | - Charles D Deakin
- NIHR Southampton Respiratory Biomedical Research Unit, Southampton, SO16 6YD, UK
| | - Lars W Andersen
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, Bygning J, Plan 1, 8200 Aarhus N, Denmark; Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215, USA.
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185
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Michels G, Wengenmayer T, Hagl C, Dohmen C, Böttiger BW, Bauersachs J, Markewitz A, Bauer A, Gräsner JT, Pfister R, Ghanem A, Busch HJ, Kreimeier U, Beckmann A, Fischer M, Kill C, Janssens U, Kluge S, Born F, Hoffmeister HM, Preusch M, Boeken U, Riessen R, Thiele H. Empfehlungen zur extrakorporalen kardiopulmonalen Reanimation (eCPR). Med Klin Intensivmed Notfmed 2018; 113:478-486. [DOI: 10.1007/s00063-018-0452-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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186
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Nolan JP, Berg RA, Callaway CW, Morrison LJ, Nadkarni V, Perkins GD, Sandroni C, Skrifvars MB, Soar J, Sunde K, Cariou A. The present and future of cardiac arrest care: international experts reach out to caregivers and healthcare authorities. Intensive Care Med 2018; 44:823-832. [DOI: 10.1007/s00134-018-5230-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 05/12/2018] [Indexed: 12/24/2022]
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187
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Donker DW, Meuwese CL, Braithwaite SA, Broomé M, van der Heijden JJ, Hermens JA, Platenkamp M, de Jong M, Janssen JG, Balík M, Bělohlávek J. Echocardiography in extracorporeal life support: A key player in procedural guidance, tailoring and monitoring. Perfusion 2018; 33:31-41. [DOI: 10.1177/0267659118766438] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Extracorporeal life support (ECLS) is a mainstay of current practice in severe respiratory, circulatory or cardiac failure refractory to conventional management. The inherent complexity of different ECLS modes and their influence on the native pulmonary and cardiovascular system require patient-specific tailoring to optimize outcome. Echocardiography plays a key role throughout the ECLS care, including patient selection, adequate placement of cannulas, monitoring, weaning and follow-up after decannulation. For this purpose, echocardiographers require specific ECLS-related knowledge and skills, which are outlined here.
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Affiliation(s)
- Dirk W. Donker
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Christiaan L. Meuwese
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sue A. Braithwaite
- Department of Anaesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Michael Broomé
- ECMO Department, Karolinska University Hospital, Stockholm, Sweden
- Anaesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
- School of Technology and Health, Royal Institute of Technology, Stockholm, Sweden
| | - Joris J. van der Heijden
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jeannine A. Hermens
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marc Platenkamp
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Michel de Jong
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jacqueline G.D. Janssen
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Martin Balík
- Department of Anaesthesiology, Resuscitation and Intensive Medicine, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Jan Bělohlávek
- 2nd Department of Medicine, Department of Cardiovascular Medicine, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
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188
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Mebazaa A, Combes A, van Diepen S, Hollinger A, Katz JN, Landoni G, Hajjar LA, Lassus J, Lebreton G, Montalescot G, Park JJ, Price S, Sionis A, Yannopolos D, Harjola VP, Levy B, Thiele H. Management of cardiogenic shock complicating myocardial infarction. Intensive Care Med 2018; 44:760-773. [DOI: 10.1007/s00134-018-5214-9] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 05/05/2018] [Indexed: 02/08/2023]
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189
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Affiliation(s)
- Matthieu Schmidt
- Sorbonne Université, UPMC Univ Paris 06, INSERM, UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651, Paris Cedex 13, France.,Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651, Paris Cedex 13, France
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, ON, Canada.,Interdepartmental Division of Critical Care, Departments of Medicine, Anesthesia and Interdisciplinary, Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Research Institute, Toronto, ON, Canada.,Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA.
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190
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Truesdell AG, Tehrani B, Singh R, Desai S, Saulino P, Barnett S, Lavanier S, Murphy C. 'Combat' Approach to Cardiogenic Shock. Interv Cardiol 2018; 13:81-86. [PMID: 29928313 DOI: 10.15420/icr.2017:35:3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The incidence of cardiogenic shock is rising, patient complexity is increasing and patient survival has plateaued. Mirroring organisational innovations of elite military units, our multidisciplinary medical specialists at the INOVA Heart and Vascular Institute aim to combine the adaptability, agility and cohesion of small teams across our large healthcare system. We advocate for widespread adoption of our 'combat' methodology focused on: increased disease awareness, early multidisciplinary shock team activation, group decision-making, rapid initiation of mechanical circulatory support (as appropriate), haemodynamic-guided management, strict protocol adherence, complete data capture and regular after action reviews, with a goal of ending preventable death from cardiogenic shock.
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Affiliation(s)
- Alexander G Truesdell
- Virginia Heart, Falls Church VA, USA.,INOVA Heart and Vascular Institute, Falls Church VA, USA
| | - Behnam Tehrani
- INOVA Heart and Vascular Institute, Falls Church VA, USA
| | - Ramesh Singh
- INOVA Heart and Vascular Institute, Falls Church VA, USA
| | - Shashank Desai
- INOVA Heart and Vascular Institute, Falls Church VA, USA
| | | | - Scott Barnett
- INOVA Heart and Vascular Institute, Falls Church VA, USA
| | | | - Charles Murphy
- INOVA Heart and Vascular Institute, Falls Church VA, USA
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