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Delmas C, Barbosa H, David CH, Bouisset F, Piriou PG, Roubille F, Leick J, Pavlov M, Leurent G, Potapov EV, Linke A, Mierke J, Lanmüller P, Mangner N. Impella for the Management of Ventricular Septal Defect Complicating Acute Myocardial Infarction: A European Multicenter Registry. ASAIO J 2023; 69:e491-e499. [PMID: 37935014 DOI: 10.1097/mat.0000000000002060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
Ventricular septal defect (VSD) is a rare but severe complication of myocardial infarction (MI). Temporary mechanical circulatory support (MCS) can be used as a bridge to VSD closure, heart transplantation, or ventricular assist device. We describe the use of Impella device in this context based on a multicenter European retrospective registry (17 centers responded). Twenty-eight post-MI VSD patients were included (Impella device were 2.5 for 1 patient, CP for 20, 5.0 for 5, and unknown for 2). All patients were in cardiogenic shock with multiple organ failure (SAPS II 41 [interquantile range {IQR} = 27-53], lactate 4.0 ± 3.5 mmol/L) and catecholamine support (dobutamine 55% and norepinephrine 96%). Additional temporary MCS was used in 14 patients (50%), mainly extracorporeal life support (ECLS) (n = 9, 32%). Severe bleedings were frequent (50%). In-hospital and 1 year mortalities were 75%. Ventricular septal defect management was surgical for 36% of patients, percutaneous for 21%, and conservative for 43%. Only surgically managed patients survived (70% in-hospital survival). Type and combination of temporary MCS used were not associated with mortality (Impella alone or in combination with intra-aortic balloon pump [IABP] or ECLS, p = 0.84). Impella use in patients with post-MI VSD is feasible but larger prospective registries are necessary to further elucidate potential benefits of left ventricular unloading in this setting.
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Affiliation(s)
- Clement Delmas
- From the Intensive Cardiac Care Unit, Cardiology Department, Rangueil University Hospital, Toulouse, France
| | - Hélène Barbosa
- From the Intensive Cardiac Care Unit, Cardiology Department, Rangueil University Hospital, Toulouse, France
| | - Charles-Henri David
- Cardiovascular Surgery Department, Nantes University Hospital, Nantes, France
| | - Frédéric Bouisset
- From the Intensive Cardiac Care Unit, Cardiology Department, Rangueil University Hospital, Toulouse, France
| | | | - François Roubille
- Cardiology Department INI-CRT PhyMedExp INSERM CNRS CHU de Montpellier, Université de Montpellier, Montpellier, France
| | - Juergen Leick
- Herzzentrum Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | | | | | - Evgenij V Potapov
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité, Germany/Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Axel Linke
- Department of Internal Medicine and Cardiology, Heart Center Dresden, Technische Universität Dresden, Dresden, Germany
| | - Johannes Mierke
- Department of Internal Medicine and Cardiology, Heart Center Dresden, Technische Universität Dresden, Dresden, Germany
| | - Pia Lanmüller
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité, Germany/Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Norman Mangner
- Department of Internal Medicine and Cardiology, Heart Center Dresden, Technische Universität Dresden, Dresden, Germany
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Delmas C, Laine M, Schurtz G, Roubille F, Coste P, Leurent G, Hraiech S, Pankert M, Gonzalo Q, Dabry T, Letocart V, Loubière S, Resseguier N, Bonello L. Rationale and design of the ULYSS trial: A randomized multicenter evaluation of the efficacy of early Impella CP implantation in acute coronary syndrome complicated by cardiogenic shock. Am Heart J 2023; 265:203-212. [PMID: 37657594 DOI: 10.1016/j.ahj.2023.08.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/26/2023] [Accepted: 08/28/2023] [Indexed: 09/03/2023]
Abstract
CONTEXT Despite 20 years of improvement in acute coronary syndromes care, patients with acute myocardial infarction complicated by cardiogenic shock (AMICS) remains a major clinical challenge with a stable incidence and mortality. While intra-aortic balloon pump (IABP) did not meet its expectations, percutaneous mechanical circulatory supports (pMCS) with higher hemodynamic support, large availability and quick implementation may improve AMICS prognosis by enabling early hemodynamic stabilization and unloading. Both interventional and observational studies suggested a clinical benefit in selected patients of the IMPELLAⓇ CP device within in a well-defined therapeutic strategy. While promising, these preliminary results are challenged by others suggesting a higher rate of complications and possible poorer outcome. Given these conflicting data and its high cost, a randomized clinical trial is warranted to delineate the benefits and risks of this new therapeutic strategy. DESIGN The ULYSS trial is a prospective randomized open label, 2 parallel multicenter clinical trial that plans to enroll patients with AMICS for whom an emergent percutaneous coronary intervention (PCI) is intended. Patients will be randomized to an experimental therapeutic strategy with pre-PCI implantation of an IMPELLAⓇ CP device on top of standard medical therapy or to a control group undergoing PCI and standard medical therapy. The primary objective of this study is to compare the efficacy of this experimental strategy by a composite end point of death, need to escalate to ECMO, long-term left ventricular assist device or heart transplantation at 1 month. Among secondary objectives 1-year efficacy, safety and cost effectiveness will be assessed. CLINICAL TRIAL REGISTRATION NCT05366452.
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Affiliation(s)
- Clement Delmas
- Department of Cardiology, Intensive Cardiac Care Unit, Rangueil University Hospital, Toulouse, France; INSERM U1048, I2MC, Toulouse, France; REICATRA, Institut Saint Jacques, Toulouse, France.
| | - Marc Laine
- Aix-Marseille Université, F-13385 Marseille, France; Intensive Care Unit, Department of Cardiology, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, F-13385 Marseille, France; Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), Marseille, France
| | - Guillaume Schurtz
- Department of Cardiology, Intensive Cardiac Care Unit, Lille University Hospital, Lille, France
| | - Francois Roubille
- PhyMedExp, Université de Montpellier, INSERM, CNRS, Cardiology Department, CHU de Montpellier, France
| | - Pierre Coste
- Cardiology Department, Bordeaux University Hospital, Pessac, France
| | - Guillaume Leurent
- Intensive Cardiac Care Unit, Cardiology Department, Rennes University Hospital, Rennes, France
| | - Sami Hraiech
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France
| | | | | | | | - Vincent Letocart
- Department of Cardiology, Nantes Université, CHU Nantes, l'institut du thorax, Nantes, France
| | - Sandrine Loubière
- Department of Epidemiology and Health Economics, APHM, Marseille, France; CEReSS-Health Service Research and Quality of Life Center, School of Medicine Aix-Marseille University Marseille France
| | - Noémie Resseguier
- Department of Epidemiology and Health Economics, APHM, Marseille, France; CEReSS-Health Service Research and Quality of Life Center, School of Medicine Aix-Marseille University Marseille France
| | - Laurent Bonello
- Aix-Marseille Université, F-13385 Marseille, France; Intensive Care Unit, Department of Cardiology, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, F-13385 Marseille, France; Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), Marseille, France
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Delmas C, Bonello L, Roubille F. For the best management, please ask for assistance! Eur J Heart Fail 2023; 25:573-575. [PMID: 36924144 DOI: 10.1002/ejhf.2826] [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: 02/23/2023] [Accepted: 03/06/2023] [Indexed: 03/18/2023] Open
Affiliation(s)
- Clément Delmas
- Intensive Cardiac Care Unit, Rangueil University Hospital, Toulouse, France.,REICATRA, Institut Saint Jacques, CHU de Toulouse, Toulouse, France
| | - Laurent Bonello
- Aix-Marseille Université, Marseille, France.,Intensive Care Unit, Department of Cardiology, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France.,Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), Marseille, France
| | - François Roubille
- PhyMedExp, Université de Montpellier, INSERM, CNRS, Cardiology Department, INI-CRT, CHU de Montpellier, Montpellier, France
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Dagher O, Noly PE, Ben Ali W, Bouabdallaoui N, Geicu L, Lamanna R, Malhi P, Romero E, Ducharme A, Demers P, Lamarche Y. Extracorporeal membrane oxygenation and microaxial left ventricular assist device in cardiogenic shock: Choosing the right mechanical circulatory support to improve outcomes. JTCVS OPEN 2023; 13:200-213. [PMID: 37063130 PMCID: PMC10091281 DOI: 10.1016/j.xjon.2022.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 11/11/2022] [Accepted: 12/05/2022] [Indexed: 04/18/2023]
Abstract
Objective To evaluate the outcomes of patients supported with Impella (CP/5.0) or venoarterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock according to shock phenotype. The primary end point was 30-day survival. Methods A retrospective study of patients supported with Impella (CP/5.0) or VA-ECMO between 2010 and 2020 was performed. Patients were grouped according to 1 of 2 shock phenotypes: isolated left ventricular (LV) dysfunction versus biventricular dysfunction or multiple organ failure (MOF). The local practice favors Impella for isolated LV dysfunction and VA-ECMO for biventricular dysfunction or MOF. Results Among the 75 patients included, 17 (23%) had isolated LV dysfunction. Patients with biventricular dysfunction or MOF had a greater median lactate level compared with those with isolated LV dysfunction (7.9 [2.9-11.8] vs 3.8 [1.1-5.8] mmol/L, respectively). Among patients with isolated LV dysfunction, 30-day survival was 46% for the Impella group (n = 13) and 75% for VA-ECMO (n = 4). Among patients with biventricular dysfunction or MOF, 30-day survival was 9% for the Impella group (n = 11) and 28% for VA-ECMO (n = 47). Patients supported with Impella 5.0 had better 30-day survival compared with those supported with Impella CP, for both shock phenotypes (83% vs 14% and 14% vs 0%, respectively). Conclusions In this small cohort, patients supported with Impella for isolated LV dysfunction and VA-ECMO for biventricular dysfunction or MOF had acceptable survival at 30 days. Patients with biventricular dysfunction or MOF who were supported by Impella had the lowest survival rates. Patients with isolated LV dysfunction who were supported with VA-ECMO had good 30-day survival.
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Affiliation(s)
- Olina Dagher
- Department of Surgery, Montreal Heart Institute, Montreal, Quebec, Canada
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | | | - Walid Ben Ali
- Department of Surgery, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Nadia Bouabdallaoui
- Université de Montréal and Department of Cardiology, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Lucian Geicu
- Department of Surgery, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Roxanne Lamanna
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Pavan Malhi
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Elizabeth Romero
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Anique Ducharme
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
- Université de Montréal and Department of Cardiology, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Philippe Demers
- Department of Surgery, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Yoan Lamarche
- Department of Surgery, Montreal Heart Institute, Montreal, Quebec, Canada
- Address for reprints: Yoan Lamarche, MD, MSc, 5000 rue Bélanger Est, Montréal, Quebec, H1T 1C8, Canada.
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Treille de Grandsaigne H, Bouisset F, Porterie J, Biendel C, Marcheix B, Lairez O, Labaste F, Elbaz M, Galinier M, Delmas C. Incidence, management, and prognosis of post-ischaemic ventricular septal defect: Insights from a 12-year tertiary centre experience. Front Cardiovasc Med 2022; 9:1066308. [PMID: 36561773 PMCID: PMC9763320 DOI: 10.3389/fcvm.2022.1066308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022] Open
Abstract
Background Among mechanical complications of acute myocardial infarction, ventricular septal defect (VSD) is uncommon but still serious. The evolution of emergency coronary revascularisation paradoxically decreased our knowledge of this disease, making it even rarer. Aim To describe ischaemic VSD incidence, management, and associated in-hospital and 1-year outcomes over a 12-years period. Methods A retrospective single-centre register of patients managed for ischaemic VSD between January 2009 and December 2020. Results Ninety-seven patients were included representing 8 patients/ years and an incidence of 0.44% of ACS managed. The majority of the patients were 73-years-old males (n = 54, 56%) with STEMI presentation (n = 75, 79%) and already presented with Q necrosis on ECG (n = 70, 74%). Forty-nine (51%) patients underwent PCI, 60 (62%) inotrope/vasopressors infusion, and 70 (72%) acute mechanical circulatory support (IABP 62%, ECMO 13%, and Impella® 3%). VSD surgical repair was performed for 44 patients (45%) and 1 patient was transplanted. In-hospital mortality was 71%, and 86% at 1 year, without significant improvement over the decade. Surgery appears to be a protective factor [0.51 (0.28-0.94) p = 0.003], whereas age [1.06 (1.03-1.09), p < 0.001] and lactate [1.16 (1.09-1.23), p < 0.001] were linked to higher 1-year mortality. None of the patients that were managed medically survived 1 year. Conclusion Post-ischaemic VSD is a rare but serious complication still associated with high mortality. Corrective surgery is associated with better survival, however, timing, patient selection, and a place for mechanical circulatory support need to be defined.
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Affiliation(s)
- Henri Treille de Grandsaigne
- Intensive Cardiac Care Unit, Rangueil University Hospital, Toulouse, France,Cardiology Department, Rangueil University Hospital, Toulouse, France
| | - Frédéric Bouisset
- Cardiology Department, Rangueil University Hospital, Toulouse, France
| | - Jean Porterie
- Cardiovascular Surgery Department, Rangueil University Hospital, Toulouse, France
| | - Caroline Biendel
- Intensive Cardiac Care Unit, Rangueil University Hospital, Toulouse, France,Cardiology Department, Rangueil University Hospital, Toulouse, France
| | - Bertrand Marcheix
- Cardiovascular Surgery Department, Rangueil University Hospital, Toulouse, France
| | - Olivier Lairez
- Cardiology Department, Rangueil University Hospital, Toulouse, France
| | - François Labaste
- Department of Anesthesiology, Intensive Care Medicine and Perioperative Medicine, Rangueil University Hospital, Toulouse, France
| | - Meyer Elbaz
- Cardiology Department, Rangueil University Hospital, Toulouse, France
| | - Michel Galinier
- Intensive Cardiac Care Unit, Rangueil University Hospital, Toulouse, France,Cardiology Department, Rangueil University Hospital, Toulouse, France
| | - Clément Delmas
- Intensive Cardiac Care Unit, Rangueil University Hospital, Toulouse, France,Cardiology Department, Rangueil University Hospital, Toulouse, France,*Correspondence: Clément Delmas
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Delmas C, Vallee L, Bouisset F, Porterie J, Biendel C, Lairez O, Crognier L, Marcheix B, Conil JM, Maury P, Minville V. Use of Percutaneous Atrioseptotosmy for Left Heart Decompression During Veno-Arterial Extracorporeal Membrane Oxygenation Support: An Observational Study. J Am Heart Assoc 2022; 11:e024642. [PMID: 36000436 PMCID: PMC9496417 DOI: 10.1161/jaha.121.024642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Left ventricular overload is frequent under veno‐arterial extracorporeal membrane oxygenation, which is associated with a worsening of the prognosis of these patients. Several left heart decompression (LHD) techniques exist. However, there is no consensus on their timing and type. We aimed to describe characteristics and outcomes of patients undergoing LHD and to compare percutaneous atrioseptostomy (PA) to other LHD techniques. Methods and Results Retrospective analysis was conducted of consecutive and prospectively collected patients supported by veno‐arterial extracorporeal membrane oxygenation for refractory cardiac arrest or cardiogenic shock between January 2015 and April 2018, with a 90‐day follow‐up in our tertiary center. Patients were divided according to the presence of LHD, and then according to its type (PA versus others). Thirty‐nine percent (n=63) of our patients (n=163) required an LHD. Patients with LHD had lower left ventricular ejection fraction, more ischemic cardiomyopathy, and no drug intoxication‐associated cardiogenic shock. PA was frequently used for LHD (41% of first‐line and 57% of second‐line LHD). PA appears safe and fast to realize (6.3 [interquartile range, 5.8–10] minutes) under fluoroscopic and echocardiographic guidance, with no acute complications. PA was associated with fewer neurological complications (12% versus 38%, P=0.02), no need to insert a second LHD (0% versus 19%, P=0.04), and higher 90‐day survival compared with other techniques (42% versus 19%, log‐rank test P=0.02), despite more sepsis (96% versus 73%, P=0.02) and blood transfusions (13.5% versus 7%, P=0.01). Multivariate analysis confirms the association between PA and 90‐day survival (hazard ratio, 2.53 [1.18–5.45], P=0.019). Conclusions LHD was frequently used for patients supported with veno‐arterial extracorporeal membrane oxygenation, especially in cases of ischemic cardiomyopathy and low left ventricular ejection fraction. PA seems to be a safe and efficient LHD technique associated with greater mid‐term survival justifying the pursuit of research on this topic.
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Affiliation(s)
- Clément Delmas
- Intensive Cardiac Care Unit Cardiology Department Rangueil University Toulouse France.,Cardiology Department Rangueil University Hospital Toulouse France
| | - Luigi Vallee
- Department of Anesthesiology, Intensive Care Medicine, and Perioperative Medicine Rangueil University Hospital Toulouse France
| | | | - Jean Porterie
- Cardiovascular Surgery Department Rangueil University Hospital Toulouse France
| | - Caroline Biendel
- Intensive Cardiac Care Unit Cardiology Department Rangueil University Toulouse France.,Cardiology Department Rangueil University Hospital Toulouse France
| | - Olivier Lairez
- Cardiology Department Rangueil University Hospital Toulouse France
| | - Laure Crognier
- Department of Anesthesiology, Intensive Care Medicine, and Perioperative Medicine Rangueil University Hospital Toulouse France
| | - Bertrand Marcheix
- Cardiovascular Surgery Department Rangueil University Hospital Toulouse France
| | - Jean-Marie Conil
- Department of Anesthesiology, Intensive Care Medicine, and Perioperative Medicine Rangueil University Hospital Toulouse France
| | - Philippe Maury
- Cardiology Department Rangueil University Hospital Toulouse France
| | - Vincent Minville
- Department of Anesthesiology, Intensive Care Medicine, and Perioperative Medicine Rangueil University Hospital Toulouse France
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Delmas C, Pernot M, Le Guyader A, Joret R, Roze S, Lebreton G. Budget Impact Analysis of Impella CP ® Utilization in the Management of Cardiogenic Shock in France: A Health Economic Analysis. Adv Ther 2022; 39:1293-1309. [PMID: 35067868 PMCID: PMC8918169 DOI: 10.1007/s12325-022-02040-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 01/05/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Early detection and treatment of cardiogenic shock (CS) is crucial to avoid irreparable multiorgan damage and mortality. Impella CP® is a novel temporary mechanical circulatory support (MCS) device associated with greater hemodynamic support and significantly fewer device-related complications compared with other MCS devices, e.g., intra-aortic balloon pumps (IABP) and venoarterial extracorporeal membrane oxygenation (VA-ECMO). The present study evaluated the budget impact of introducing Impella CP versus IABP and VA-ECMO in patients with CS following an acute myocardial infarction (MI) in France. METHODS A budget impact model was developed to compare the cost of introducing Impella CP with continuing IABP and VA-ECMO treatment from a Mandatory Health Insurance (MHI) perspective in France over a 5-year time horizon, with 700 patients with refractory CS assumed to be eligible for treatment per year. Costs associated with Impella CP and device-related complications for all interventions were captured and clinical input data were based on published sources. Scenario analyses were performed around key parameters. RESULTS Introducing Impella CP was associated with cumulative cost savings of EUR 2.7 million over 5 years, versus continuing current clinical practice with IABP and VA-ECMO. Cost savings were achieved in every year of the analysis and driven by the lower incidence of device-related complications with Impella CP, with estimated 5-year cost savings of EUR 22.4 million due to avoidance of complications. Total cost savings of more than EUR 250,000 were projected in the first year of the analysis, which increased as the market share of Impella CP was increased. Scenario analyses indicated that the findings of the analysis were robust. CONCLUSION Treatment with Impella CP in adult patients aged less than 75 years in a state of refractory CS following an MI was projected to lead to substantial cost savings from an MHI perspective in France, compared with continuing current clinical practice.
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Affiliation(s)
- Clément Delmas
- Intensive Cardiac Care Unit, Cardiology Department, Rangueil University Hospital, Toulouse, France
| | - Mathieu Pernot
- Department of Cardiology and Cardiovascular Surgery, Haut-Lévèque University Hospital, Bordeaux, France
| | - Alexandre Le Guyader
- Department of Thoracic and Cardiovascular Surgery, Dupuytren University Hospital, Limoges, France
| | | | | | - Guillaume Lebreton
- Cardiac Surgery Department, Pitié-Salpétrière Hospital, Sorbonne University, Paris, France
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Welker C, Huang J, Nunez-Gil I, Villavicencio MA, Ramakrishna H. Percutaneous Right Ventricular Mechanical Circulatory Support- Analysis of Recent Data. J Cardiothorac Vasc Anesth 2022; 36:2783-2788. [DOI: 10.1053/j.jvca.2022.01.022] [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: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 11/11/2022]
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Twelve years of circulatory extracorporeal life support at the University Medical Centre Utrecht. Neth Heart J 2021; 29:394-401. [PMID: 33675521 PMCID: PMC8271054 DOI: 10.1007/s12471-021-01552-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2021] [Indexed: 01/30/2023] Open
Abstract
Introduction Circulatory extracorporeal life support (ECLS) has been performed at the University Medical Centre Utrecht for 12 years. During this time, case mix, indications, ECLS set-ups and outcomes seem to have substantially changed. We set out to describe these characteristics and their evolution over time. Methods All patients receiving circulatory ECLS between 2007 and 2018 were retrospectively identified and divided into six groups according to a 2-year period of time corresponding to the date of ECLS initiation. General characteristics plus data pertaining to comorbidities, indications and technical details of ECLS commencement as well as in-hospital, 30-day, 1‑year and overall mortality were collected. Temporal trends in these characteristics were examined. Results A total of 347 circulatory ECLS runs were performed in 289 patients. The number of patients and ECLS runs increased from 8 till a maximum of 40 runs a year. The distribution of circulatory ECLS indications shifted from predominantly postcardiotomy to a wider set of indications. The proportion of peripheral insertions with or without application of left ventricular unloading techniques substantially increased, while in-hospital, 30-day, 1‑year and overall mortality decreased over time. Conclusion Circulatory ECLS was increasingly applied at the University Medical Centre Utrecht. Over time, indications as well as treatment goals broadened, and cannulation techniques shifted from central to mainly peripheral approaches. Meanwhile, weaning success increased and mortality rates diminished. Supplementary Information The online version of this article (10.1007/s12471-021-01552-z) contains supplementary material, which is available to authorized users.
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Suleiman T, Scott A, Tong D, Khanna V, Kunadian V. Contemporary device management of cardiogenic shock following acute myocardial infarction. Heart Fail Rev 2021; 27:915-925. [PMID: 33655387 DOI: 10.1007/s10741-021-10088-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2021] [Indexed: 11/28/2022]
Abstract
Despite advances in the overall management of acute myocardial infarction (AMI), cardiogenic shock in the setting of AMI (CS-AMI) continues to be associated with poor patient outcomes. There are multiple devices that can be used in CS-AMI to support the failing circulation, although their utility in improving outcomes as compared with conventional pharmacotherapy of vasopressors and inotropes remains to be established. This contemporary review provides an update on the evidence base for each of these techniques. In CS-AMI, acute thrombotic occlusion of a major epicardial artery leads to hypoxia and myocardial ischaemia in the territory subtended by that vessel. The resultant regional dysfunction in myocardial contractility can severely compromise stroke volume and result in acute circulatory failure, systemic hypoperfusion, lactic acidosis, multi-organ failure and ultimately death.
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Affiliation(s)
- Tariq Suleiman
- Department of Respiratory Medicine, Royal Sussex County Hospital, Brighton & Sussex University Hospitals NHS Foundation Trust, Brighton, UK.
| | - Alexander Scott
- Department of Anaesthesia and Intensive Care Medicine, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - David Tong
- PG Diploma Clinical Trials, Faculty of Medical Sciences, Institute of Cellular Medicine, Newcastle University, 4th Floor William Leech Building, Newcastle upon Tyne, NE2 4HH, UK
| | - Vikram Khanna
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Vijay Kunadian
- PG Diploma Clinical Trials, Faculty of Medical Sciences, Institute of Cellular Medicine, Newcastle University, 4th Floor William Leech Building, Newcastle upon Tyne, NE2 4HH, UK. .,Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
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Affiliation(s)
- Tanveer Rab
- Interventional Cardiology, Andreas Gruentzig Center, Emory University School of Medicine, Atlanta, Georgia.
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Mortality Risk Factors for Cardiac Arrest Prior to Venoarterial Extracorporeal Membrane Oxygenation. Crit Care Med 2020; 48:e155. [PMID: 31939818 DOI: 10.1097/ccm.0000000000004028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Akin S, Caliskan K, Soliman O, Muslem R, Guven G, van Thiel RJ, Struijs A, Gommers D, Zijlstra F, Bakker J, Dos Reis Miranda D. A novel mortality risk score predicting intensive care mortality in cardiogenic shock patients treated with veno-arterial extracorporeal membrane oxygenation. J Crit Care 2019; 55:35-41. [PMID: 31689611 DOI: 10.1016/j.jcrc.2019.09.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/16/2019] [Accepted: 09/16/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Mortality after veno-arterial extracorporeal membrane oxygenation (VA-ECMO) implantation remains a major problem in patients with cardiogenic shock. Our objective was to assess the utility of the SOFA score in combination with markers of right ventricular (RV) dysfunction in predicting mortality in the ICU. MATERIALS AND METHODS Data were retrospectively obtained from all adult patients (n=103) who were treated with VA-ECMO between November 2004 and January 2016. The primary outcome of this study was ICU mortality after VA-ECMO implantation. Using the clinical, demographic and echocardiographic data, we developed a novel mortality risk score, the SOFA-RV score, which combine RV-function to the SOFA score at the time of VA-ECMO implantation. RESULTS Out of 103 patients, 37 (36%) died in the ICU. The median duration of VA-ECMO support was 7 days [IQR 4-11], mean age 49 ± 16 years, and 54% were male. SOFA-RV score has an AUC of 0.70, and was significantly better than SOFA alone (AUC of 0.57) in predicting ICU mortality. In addition, SAVE and MELD scores were not able to predict ICU mortality. CONCLUSION Adding RV-function to the existing SOFA score improves significantly the prediction of ICU mortality in patients on VA-ECMO. Dedicated evaluation of RV function in patients with VA-ECMO is therefore recommended.
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Affiliation(s)
- Sakir Akin
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Intensive Care, Haga Teaching Hospital, The Hague, the Netherlands.
| | - Kadir Caliskan
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Osama Soliman
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Rahatullah Muslem
- Department of Cardiothoracic surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Goksel Guven
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Robert J van Thiel
- Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Ard Struijs
- Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Diederik Gommers
- Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Felix Zijlstra
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Jan Bakker
- Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Division of Pulmonary, Allergy, and Critical Care, Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, USA; Department of Pulmonary and Critical Care, Langone Medical Center, New York University, New York, USA; Department of Intensive Care, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Dinis Dos Reis Miranda
- Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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14
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Karami M, den Uil CA, Ouweneel DM, Scholte NTB, Engström AE, Akin S, Lagrand WK, Vlaar APJ, Jewbali LS, Henriques JPS. Mechanical circulatory support in cardiogenic shock from acute myocardial infarction: Impella CP/5.0 versus ECMO. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2019; 9:164-172. [DOI: 10.1177/2048872619865891] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Short-term mechanical circulatory support devices are increasingly used in cardiogenic shock after acute myocardial infarction. As no randomised evidence is available, the choice between high-output Impella or extra-corporeal membrane oxygenation (ECMO) is still a matter of debate. Real-life data are necessary to assess adverse outcomes and to help guide the treatment decision between the different devices. The purpose of this study was to compare characteristics and clinical outcomes of Impella CP/5.0 with ECMO support in patients with cardiogenic shock from myocardial infarction. Methods: A retrospective, two-centre study was performed on all cardiogenic shock from myocardial infarction patients with Impella CP/5.0 or ECMO support, from 2006 until 2018. The primary outcome was 30-day mortality. Potential baseline imbalance between the groups was adjusted using inverse probability treatment weighting, and survival analysis was performed with an adjusted log-rank test. Secondarily, the occurrence of device-related complications (limb ischaemia, access site-related bleeding, access site-related infection) was evaluated. Results: A total of 128 patients were included (Impella, N=90; ECMO, N=38). The 30-day mortality was similar for both groups (53% vs. 49%, P=0.30), also after adjustment for potential baseline imbalance between the groups (weighted log-rank P=0.16). Patients with Impella support had significantly fewer device-related complications than patients treated with ECMO (respectively, 17% vs. 40%, P<0.01). Conclusions: Patients treated with Impella CP/5.0 or ECMO for cardiogenic shock after myocardial infarction did not differ in 30-day mortality. More device-related complications occurred with ECMO compared to Impella support.
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Affiliation(s)
- Mina Karami
- Department of Cardiology, Heart Center, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Corstiaan A den Uil
- Department of Intensive Care, Erasmus University Rotterdam, The Netherlands
- Department of Cardiology, Erasmus University Rotterdam, The Netherlands
| | - Dagmar M Ouweneel
- Department of Cardiology, Heart Center, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Niels TB Scholte
- Department of Intensive Care, Erasmus University Rotterdam, The Netherlands
| | - Annemarie E Engström
- Department of Intensive Care, Erasmus University Rotterdam, The Netherlands
- Department of Cardiology, Erasmus University Rotterdam, The Netherlands
| | - Sakir Akin
- Department of Intensive Care, Haga Teaching Hospital, The Hague, The Netherlands
| | - Wim K Lagrand
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Alexander PJ Vlaar
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Lucia S Jewbali
- Department of Intensive Care, Erasmus University Rotterdam, The Netherlands
- Department of Cardiology, Erasmus University Rotterdam, The Netherlands
| | - José PS Henriques
- Department of Cardiology, Heart Center, Amsterdam UMC, University of Amsterdam, The Netherlands
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15
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Standardized Team-Based Care for Cardiogenic Shock. J Am Coll Cardiol 2019; 73:1659-1669. [DOI: 10.1016/j.jacc.2018.12.084] [Citation(s) in RCA: 214] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 12/12/2018] [Accepted: 12/21/2018] [Indexed: 11/23/2022]
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16
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Outcomes of patients with right ventricular failure requiring short-term hemodynamic support with the Impella RP device. J Heart Lung Transplant 2018; 37:1448-1458. [DOI: 10.1016/j.healun.2018.08.001] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 06/25/2018] [Accepted: 08/01/2018] [Indexed: 11/22/2022] Open
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17
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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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