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Abstract
The use of Extracorporeal Life Support (ECLS) in children and adults has markedly increased during the past few years with over 4000 patients placed on ECLS every year in over 200 centers. This article focuses on updates to the physiology and mechanics of ECLS with use of magnetically levitated centrifugal pumps, hollow-fiber gas-exchange devices, and bi-caval dual-lumen catheters. We also explore controversies in management including indications, cannulation approaches, renal replacement, monitoring of anticoagulation, early ambulation, and termination of ECLS. Finally, we present changes in the systems that provide ECLS including the single-provider model and regionalization of care.
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Affiliation(s)
- Samir K Gadepalli
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan.
| | - Ronald B Hirschl
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
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202
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Shah KB, Smallfield MC, Tang DG, Malhotra R, Cooke RH, Kasirajan V. Mechanical circulatory support devices in the ICU. Chest 2015; 146:848-857. [PMID: 25180728 DOI: 10.1378/chest.13-2645] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The medical community has used implantable mechanical circulatory support devices at increasing rates for patients dying from heart failure and cardiogenic shock. Newer-generation devices offer a more durable and compact option when compared with bulky early-generation devices. This article is a succinct introduction and overview of the hemodynamic principles and complications after device implantation for ICU clinicians. We review the concepts of device physiology, clinical pearls for perioperative management, and common medical complications after device implantation.
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Affiliation(s)
- Keyur B Shah
- Division of Cardiology, Virginia Commonwealth University, Richmond, VA.
| | | | - Daniel G Tang
- Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, VA
| | - Rajiv Malhotra
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA
| | - Richard H Cooke
- Division of Cardiology, Virginia Commonwealth University, Richmond, VA
| | - Vigneshwar Kasirajan
- Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, VA
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203
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Horne D, Conway J, Rebeyka IM, Buchholz H. Mechanical circulatory support in univentricular hearts: current management. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2015; 18:17-24. [PMID: 25939838 DOI: 10.1053/j.pcsu.2015.02.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Failing single-ventricle patients have now come into focus as the next cohort where improvement in outcomes for mechanical circulatory support can be realized. There is a paucity of published patient reports or management protocols in this patient population. Increased interest exists in finding answers of how to bridge these patients to transplant. We review the current literature and describe our approach to the patient with univentricular heart needing mechanical circulatory support.
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Affiliation(s)
- David Horne
- Division of Cardiac Surgery, University of Alberta, Stollery Children׳s Hospital, Edmonton, Alberta, Canada.
| | - Jennifer Conway
- Division of Pediatric Cardiology, University of Alberta, Stollery Children׳s Hospital, Edmonton, Alberta, Canada
| | - Ivan M Rebeyka
- Division of Cardiac Surgery, University of Alberta, Stollery Children׳s Hospital, Edmonton, Alberta, Canada
| | - Holger Buchholz
- Division of Cardiac Surgery, University of Alberta, Stollery Children׳s Hospital, Edmonton, Alberta, Canada
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204
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Cornwell WK, Tarumi T, Aengevaeren VL, Ayers C, Divanji P, Fu Q, Palmer D, Drazner MH, Meyer DM, Bethea BT, Hastings JL, Fujimoto N, Shibata S, Zhang R, Markham DW, Levine BD. Effect of pulsatile and nonpulsatile flow on cerebral perfusion in patients with left ventricular assist devices. J Heart Lung Transplant 2014; 33:1295-303. [DOI: 10.1016/j.healun.2014.08.013] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 07/28/2014] [Accepted: 08/20/2014] [Indexed: 10/24/2022] Open
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205
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de Biasi AR, Manning KB, Salemi A. Science for surgeons: understanding pump thrombogenesis in continuous-flow left ventricular assist devices. J Thorac Cardiovasc Surg 2014; 149:667-73. [PMID: 25534307 DOI: 10.1016/j.jtcvs.2014.11.041] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 10/28/2014] [Accepted: 11/08/2014] [Indexed: 12/11/2022]
Affiliation(s)
- Andreas R de Biasi
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, NY
| | - Keefe B Manning
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, Pa; Department of Surgery, Penn State College of Medicine, Hershey, Pa
| | - Arash Salemi
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, NY.
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206
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Imamura T, Kinugawa K, Fujino T, Inaba T, Maki H, Hatano M, Kinoshita O, Nawata K, Kyo S, Ono M. Aortic insufficiency in patients with sustained left ventricular systolic dysfunction after axial flow assist device implantation. Circ J 2014; 79:104-11. [PMID: 25381791 DOI: 10.1253/circj.cj-14-0944] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Predicting the occurrence of aortic insufficiency (AI) during left ventricular assist device (LVAD) support has remained unsolved. METHODS AND RESULTS We enrolled 52 patients who had received continuous flow LVAD (14 axial and 38 centrifugal pumps) and who been followed for ≥6 months between Jun 2006 and Dec 2013. Native aortic valve (AV) opening was observed in 18 patients (35%) with improved LV systolic function, and none of them had AI. On multivariate logistic regression analysis preoperative shorter heart failure duration was the only independent predictor of postoperative native AV opening (P=0.042; odds ratio [OR], 0.999). Of the remaining 34 patients (65%) with closed AV, 11 had AI with enlargement of the aortic root and narrow pulse pressure. Among those with closed AV, axial pump use (n=13) was the only significant predictor of the development of AI (P=0.042; OR, 4.950). Patients with AI had lower exercise capacity and a higher readmission rate than those without AI during 2-year LVAD support (55% vs. 8%; P<0.001). CONCLUSIONS Native AV opening during LVAD support is profoundly associated with reversal of LV systolic function, especially in patients with preoperative shorter heart failure duration. Among those in whom the native AV remains closed, low pulsatility of axial flow pump may facilitate aortic root remodeling and post-LVAD AI development that results in worse clinical outcome.
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Affiliation(s)
- Teruhiko Imamura
- Department of Therapeutic Strategy for Heart Failure, Graduate School of Medicine, University of Tokyo
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207
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Association of HeartMate II Left Ventricular Assist Device Flow Estimate with Thermodilution Cardiac Output. ASAIO J 2014; 60:513-8. [DOI: 10.1097/mat.0000000000000119] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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208
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Kirklin JK. Invited commentary. Ann Thorac Surg 2014; 98:547-8. [PMID: 25087787 DOI: 10.1016/j.athoracsur.2014.05.032] [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: 05/21/2014] [Revised: 05/21/2014] [Accepted: 05/27/2014] [Indexed: 10/25/2022]
Affiliation(s)
- James K Kirklin
- Department of Surgery, University of Alabama in Birmingham, 1530 3rd Ave S-ZRB 740, Birmingham, AL35294-0007.
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209
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Levine BD, Cornwell WK, Drazner MH. Factors Influencing the Rate of Flow Through Continuous-Flow Left Ventricular Assist Devices at Rest and With Exercise ∗. JACC-HEART FAILURE 2014; 2:331-4. [DOI: 10.1016/j.jchf.2014.03.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 03/28/2014] [Indexed: 12/17/2022]
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210
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Moazami N, Steffen RJ, Naka Y, Jorde U, Bailey S, Murali S, Camacho MT, Zucker M, Marascalco PJ, Rao V, Feldman D. Lessons learned from the first fully magnetically levitated centrifugal LVAD trial in the United States: the DuraHeart trial. Ann Thorac Surg 2014; 98:541-7. [PMID: 24928670 DOI: 10.1016/j.athoracsur.2014.04.048] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 04/07/2014] [Accepted: 04/08/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The DuraHeart is a continuous centrifugal-flow left ventricular assist device that uses active magnetic levitation for impeller positioning designed for improved hemocompatibility and durability. This study reviews the results of the US trial with specific attention to hemolysis, thrombotic complications, and pump failure. METHODS The US SUSTAIN trial was a multicenter, prospective, single-arm observational study in advanced heart failure patients listed for transplantation. Follow-up was complete in 100% of the patients at 6 months. RESULTS Sixty-three patients were enrolled at 23 centers. Forty-six patients (73%) reached the primary end points of survival to transplantation, alive on the original device at 180 days and listed for transplantation, or explant for recovery. Median duration of support was 267 days (range, 10 to 952 days) with a total support time of 46 patient-years. There was no clinical hemolysis reported during the study. Mean lactate dehydrogenase values peaked at day 4 and significantly decreased during support (435±236 U/L and 297±142 U/L on day 3 and day 180, respectively). There were no cases of pump thrombosis reported, and 3 cases of pump thrombus "in transit" (0.06 events/patient-year) were observed. There were 6 (10%) cases of magnetic levitation system failure, all secondary to cable wire fractures (0.12 events/patient-year). All patients were hemodynamically stable with the backup hydrodynamic mode. Major adverse events included gastrointestinal bleeding (0.52 events/patient-year), ischemic and hemorrhagic strokes (0.17 events/patient-year and 0.09 events/patient-year, respectively), and driveline infections (0.67 events/patient-year). CONCLUSIONS The DuraHeart demonstrated good hemocompatibility; however, the reliability of full magnetic levitation systems should be a high priority in future pump designs.
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Affiliation(s)
- Nader Moazami
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
| | - Robert J Steffen
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Columbia University, New York, New York
| | - Ulrich Jorde
- Division of Cardiology, Columbia University, New York, New York
| | - Stephen Bailey
- Division of Cardiothoracic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Srinivas Murali
- Division of Cardiology, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Margarita T Camacho
- Division of Cardiac Surgery, Newark Beth Israel Medical Center, Newark, New Jersey
| | - Mark Zucker
- Division of Cardiology, Newark Beth Israel Medical Center, Newark, New Jersey
| | | | - Vivek Rao
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto, Ontario, Canada
| | - David Feldman
- Department of Cardiology, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota
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211
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Bansal S, Sai-Sudhakar CB, Whitson BA. Outcomes of continuous flow ventricular assist devices. World J Surg Proced 2014; 4:1-8. [DOI: 10.5412/wjsp.v4.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 12/19/2013] [Accepted: 02/18/2014] [Indexed: 02/06/2023] Open
Abstract
Heart transplantation is commonplace, the supply is limited. Many exciting changes in the field of mechanical circulatory support have occurred in the past few years, including the axial flow pump. Left ventricular assist device (LVAD) therapy is ever evolving. As the use of LVAD therapy increases it is important to understand the indications, surgical considerations and outcomes.
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212
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213
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Bottrell S, Bennett M, Augustin S, Thuys C, Schultz B, Horton A, Horton S. A comparison study of haemolysis production in three contemporary centrifugal pumps. Perfusion 2014; 29:411-6. [PMID: 24406272 DOI: 10.1177/0267659113509000] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
One challenge in providing extracorporeal circulation is to supply optimal flow while minimising adverse effects, such as haemolysis. To determine if the recent generation constrained vortex pumps with their inherent design improvements would lead to reduced red cell trauma, we undertook a study comparing three devices. Utilizing a simulated short-term ventricular assist circuit primed with whole human blood, we examined changes in plasma free haemoglobin values over a six-day period. The three pumps investigated were the Maquet Rotaflow, the Levitronix PediVAS and the Medos Deltastream DP3.This study demonstrated that all three pumps produced low levels of haemolysis and are suitable for use in a clinical environment. The Levitronix PediVAS was significantly less haemolytic than either the Rotaflow (p<0.05) or the DP3 (p<0.05). There was no significant difference in plasma free haemoglobin between the Rotaflow and the DP3 (p=0.71).
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Affiliation(s)
- S Bottrell
- Perfusion Department, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - M Bennett
- Perfusion Department, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - S Augustin
- Perfusion Department, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - C Thuys
- Perfusion Department, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - B Schultz
- Perfusion Department, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - A Horton
- Perfusion Department, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - S Horton
- Perfusion Department, Royal Children's Hospital, Melbourne, Victoria, Australia Department of Paediatrics, Melbourne University, Melbourne, Victoria, Australia
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214
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Rodriguez LE, Suarez EE, Loebe M, Bruckner BA. General Surgery Considerations in the Era of Mechanical Circulatory Assist Devices. Surg Clin North Am 2013; 93:1343-57. [DOI: 10.1016/j.suc.2013.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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215
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