1
|
Putowski Z, Pluta MP, Rachfalska N, Krzych ŁJ, De Backer D. Sublingual Microcirculation in Temporary Mechanical Circulatory Support: A Current State of Knowledge. J Cardiothorac Vasc Anesth 2023; 37:2065-2072. [PMID: 37330330 DOI: 10.1053/j.jvca.2023.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/13/2023] [Accepted: 05/17/2023] [Indexed: 06/19/2023]
Abstract
Cardiogenic shock causes hypoperfusion within the microcirculation, leading to impaired oxygen delivery, cell death, and progression of multiple organ failure. Mechanical circulatory support (MCS) is the last line of treatment for cardiac failure. The goal of MCS is to ensure end-organ perfusion by maintaining perfusion pressure and total blood flow. However, machine-blood interactions and the nonobvious translation of global macrohemodynamics into the microcirculation suggest that the use of MCS may not necessarily be associated with improved capillary flow. With the use of hand-held vital microscopes, it is possible to assess the microcirculation at the bedside. The paucity of literature on the use of microcirculatory assessment suggests the need for an in-depth look into microcirculatory assessment within the context of MCS. The purpose of this review is to discuss the possible interactions between MCS and microcirculation, as well as to describe the research conducted in this area. Regarding sublingual microcirculation, 3 types of MCS will be discussed: venoarterial extracorporeal membrane oxygenation, intra-aortic balloon counterpulsation, and microaxial flow pumps (Impella).
Collapse
Affiliation(s)
- Zbigniew Putowski
- University Clinical Center of the Medical University of Silesia in Katowice, Katowice, Poland.
| | - Michał P Pluta
- Department of Anesthesiology and Intensive Care, Faculty of Medical Sciences, Medical University of Silesia, Katowice, Poland
| | - Natalia Rachfalska
- Department of Anesthesiology and Intensive Care, Faculty of Medical Sciences, Medical University of Silesia, Katowice, Poland
| | - Łukasz J Krzych
- Department of Anesthesiology and Intensive Care, Faculty of Medical Sciences, Medical University of Silesia, Katowice, Poland; Department of Cardiac Anaesthesia and Intensive Therapy, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| |
Collapse
|
2
|
Merdji H, Levy B, Jung C, Ince C, Siegemund M, Meziani F. Microcirculatory dysfunction in cardiogenic shock. Ann Intensive Care 2023; 13:38. [PMID: 37148451 PMCID: PMC10164225 DOI: 10.1186/s13613-023-01130-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/13/2023] [Indexed: 05/08/2023] Open
Abstract
Cardiogenic shock is usually defined as primary cardiac dysfunction with low cardiac output leading to critical organ hypoperfusion, and tissue hypoxia, resulting in high mortality rate between 40% and 50% despite recent advances. Many studies have now evidenced that cardiogenic shock not only involves systemic macrocirculation, such as blood pressure, left ventricular ejection fraction, or cardiac output, but also involves significant systemic microcirculatory abnormalities which seem strongly associated with the outcome. Although microcirculation has been widely studied in the context of septic shock showing heterogeneous alterations with clear evidence of macro and microcirculation uncoupling, there is now a growing body of literature focusing on cardiogenic shock states. Even if there is currently no consensus regarding the treatment of microcirculatory disturbances in cardiogenic shock, some treatments seem to show a benefit. Furthermore, a better understanding of the underlying pathophysiology may provide hypotheses for future studies aiming to improve cardiogenic shock prognosis.
Collapse
Affiliation(s)
- Hamid Merdji
- Intensive Care Unit, Department of Acute Medicine, University Hospital, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Bruno Levy
- Institut Lorrain du Cœur et des Vaisseaux, Medical Intensive Care Unit Brabois, Université de Lorraine, CHRU de Nancy, INSERM U1116, Nancy, France
| | - Christian Jung
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, 40225, Düsseldorf, Germany
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Martin Siegemund
- Intensive Care Unit, Department of Acute Medicine, University Hospital, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Ferhat Meziani
- Faculté de Médecine, Université de Strasbourg (UNISTRA), Strasbourg, France.
- Service de Médecine Intensive-Réanimation, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, 1, Place de L'Hôpital, 67091, Strasbourg Cedex, France.
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France.
| |
Collapse
|
3
|
Batchelor RJ, Wheelahan A, Zheng WC, Stub D, Yang Y, Chan W. Impella versus Venoarterial Extracorporeal Membrane Oxygenation for Acute Myocardial Infarction Cardiogenic Shock: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11143955. [PMID: 35887718 PMCID: PMC9317942 DOI: 10.3390/jcm11143955] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/04/2022] [Accepted: 07/06/2022] [Indexed: 01/09/2023] Open
Abstract
Objectives: Despite an increase in the use of mechanical circulatory support (MCS) devices for acute myocardial infarction cardiogenic shock (AMI-CS), there is currently no randomised data directly comparing the use of Impella and veno-arterial extra-corporeal membrane oxygenation (VA-ECMO). Methods: Electronic databases of MEDLINE, EMBASE and CENTRAL were systematically searched in November 2021. Studies directly comparing the use of Impella (CP, 2.5 or 5.0) with VA-ECMO for AMI-CS were included. Studies examining other modalities of MCS, or other causes of cardiogenic shock, were excluded. The primary outcome was in-hospital mortality. Results: No randomised trials comparing VA-ECMO to Impella in patients with AMI-CS were identified. Six cohort studies (five retrospective and one prospective) were included for systematic review. All studies, including 7093 patients, were included in meta-analysis. Five studies reported in-hospital mortality, which, when pooled, was 42.4% in the Impella group versus 50.1% in the VA-ECMO group. Impella support for AMI-CS was associated with an 11% relative risk reduction in in-hospital mortality compared to VA-ECMO (risk ratio 0.89; 95% CI 0.83–0.96, I2 0%). Of the six studies, three studies also adjusted outcome measures via propensity-score matching with reported reductions in in-hospital mortality with Impella compared to VA-ECMO (risk ratio 0.72; 95% CI 0.59–0.86, I2 35%). Pooled analysis of five studies with 6- or 12-month mortality data reported a 14% risk reduction with Impella over the medium-to-long-term (risk ratio 0.86; 95% CI 0.76–0.97, I2 0%). Conclusions: There is no high-level evidence comparing VA-ECMO and Impella in AMI-CS. In available observation studies, MCS with Impella was associated with a reduced risk of in-hospital and medium-term mortality as compared to VA-ECMO.
Collapse
Affiliation(s)
- Riley J. Batchelor
- Department of Cardiology, The Alfred Hospital, 55 Commercial Road, Melbourne 3004, Australia; (R.J.B.); (W.C.Z.); (D.S.)
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne 3004, Australia
| | - Andrew Wheelahan
- Department of Cardiology, Western Health, Melbourne 3004, Australia;
| | - Wayne C. Zheng
- Department of Cardiology, The Alfred Hospital, 55 Commercial Road, Melbourne 3004, Australia; (R.J.B.); (W.C.Z.); (D.S.)
| | - Dion Stub
- Department of Cardiology, The Alfred Hospital, 55 Commercial Road, Melbourne 3004, Australia; (R.J.B.); (W.C.Z.); (D.S.)
- Department of Cardiology, Western Health, Melbourne 3004, Australia;
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne 3004, Australia
| | - Yang Yang
- Intensive Care Unit, Western Health, Melbourne 3004, Australia;
| | - William Chan
- Department of Cardiology, The Alfred Hospital, 55 Commercial Road, Melbourne 3004, Australia; (R.J.B.); (W.C.Z.); (D.S.)
- Department of Cardiology, Western Health, Melbourne 3004, Australia;
- Department of Medicine, University of Melbourne, Melbourne 3052, Australia
- Correspondence: ; Tel.: +61-3-9076-3263
| |
Collapse
|
4
|
Akin S, Ince C, Struijs A, Caliskan K. Case Report: Early Identification of Subclinical Cardiac Tamponade in a Patient With a Left Ventricular Assist Device by the Use of Sublingual Microcirculatory Imaging: A New Diagnostic Imaging Tool? Front Cardiovasc Med 2022; 9:818063. [PMID: 35402532 PMCID: PMC8990877 DOI: 10.3389/fcvm.2022.818063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 02/10/2022] [Indexed: 11/13/2022] Open
Abstract
Clinical diagnosis of cardiac tamponade can be difficult in patients with continuous flow left ventricle assist devices (cf-LVADs). This is even more so because of the lack of adequate bedside echocardiographic windows. Previous studies on monitoring sublingual microcirculation showed deterioration of end-organ perfusion in patient with cardiogenic shock. In this paper we report alterations in the sublingual microcirculation in a cf-LVAD patient prior to clinical manifestation of tamponade. Our case report suggests that such real-time monitoring of the microcirculation may provide a new diagnostic modality for early recognition of cardiac tamponade.
Collapse
Affiliation(s)
- Sakir Akin
- Department of Cardiology, Unit Heart Failure, Heart Transplantation & Mechanical Circulatory Support, Erasmus Microcirculation (MC) University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
- *Correspondence: Sakir Akin
| | - Can Ince
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Ard Struijs
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Kadir Caliskan
- Department of Cardiology, Unit Heart Failure, Heart Transplantation & Mechanical Circulatory Support, Erasmus Microcirculation (MC) University Medical Center Rotterdam, Rotterdam, Netherlands
| |
Collapse
|
5
|
Möller C, Stiermaier T, Meusel M, Jung C, Graf T, Eitel I. Microcirculation in Patients with Takotsubo Syndrome-The Prospective CIRCUS-TTS Study. J Clin Med 2021; 10:2127. [PMID: 34069038 PMCID: PMC8156359 DOI: 10.3390/jcm10102127] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/25/2021] [Accepted: 05/07/2021] [Indexed: 12/17/2022] Open
Abstract
The pathophysiology of Takotsubo syndrome (TTS) is incompletely understood. A sympathetic overdrive with coronary microvascular dysfunction might play a central role. The aim of our study was to assess the status of the systemic microcirculation (MC) of patients with TTS, compared to patients with myocardial infarction (MI) and healthy subjects. The systemic microvascular function of 22 TTS patients, 20 patients with MI and 20 healthy subjects was assessed via sublingual sidestream dark-field imaging. In TTS and MI patients, measurements were performed during the acute phase (day 1, 3 and 5) and after 3 months. The measurement in healthy subjects was performed once. The assessed parameters were number of vessel crossings, number of perfused vessel crossings, proportion of perfused vessels, total vessel density and perfused vessel density. The results did not show relevant differences between the investigated groups. Some minor, albeit statistically significant, differences occurred rather randomly. The MC parameters of the TTS group did not show any relevant changes in the temporal course. A systemic microvascular dysfunction could not be identified as a contributing factor in the pathogenesis of TTS. A possible microvascular dysfunction might instead be caused by a local effect restricted to the coronary microvascular bed.
Collapse
Affiliation(s)
- Christian Möller
- Department of Cardiology, Angiology, Pulmonology, Nephrology and Intensive Care Medicine, Medical Clinic I, Leopoldina Hospital Schweinfurt, 97422 Schweinfurt, Germany;
- Department of Cardiology, Angiology and Intensive Care Medicine, Medical Clinic II, University Heart Center Lübeck, 23538 Lübeck, Germany; (T.S.); (M.M.); (T.G.)
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, 23538 Lübeck, Germany
| | - Thomas Stiermaier
- Department of Cardiology, Angiology and Intensive Care Medicine, Medical Clinic II, University Heart Center Lübeck, 23538 Lübeck, Germany; (T.S.); (M.M.); (T.G.)
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, 23538 Lübeck, Germany
| | - Moritz Meusel
- Department of Cardiology, Angiology and Intensive Care Medicine, Medical Clinic II, University Heart Center Lübeck, 23538 Lübeck, Germany; (T.S.); (M.M.); (T.G.)
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, 23538 Lübeck, Germany
| | - Christian Jung
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, 40225 Düsseldorf, Germany;
| | - Tobias Graf
- Department of Cardiology, Angiology and Intensive Care Medicine, Medical Clinic II, University Heart Center Lübeck, 23538 Lübeck, Germany; (T.S.); (M.M.); (T.G.)
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, 23538 Lübeck, Germany
| | - Ingo Eitel
- Department of Cardiology, Angiology and Intensive Care Medicine, Medical Clinic II, University Heart Center Lübeck, 23538 Lübeck, Germany; (T.S.); (M.M.); (T.G.)
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, 23538 Lübeck, Germany
| |
Collapse
|
6
|
Chioncel O, Mebazaa A. Microcirculatory Dysfunction in Acute Heart Failure. Microcirculation 2020. [DOI: 10.1007/978-3-030-28199-1_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
7
|
Successful Bridge-to-Recovery Treatment in a Young Patient with Fulminant Eosinophilic Myocarditis: Roles of a Percutaneous Ventricular Assist Device and Endomyocardial Biopsy. Case Rep Emerg Med 2019; 2019:8236735. [PMID: 31355017 PMCID: PMC6633872 DOI: 10.1155/2019/8236735] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/31/2019] [Accepted: 06/16/2019] [Indexed: 01/05/2023] Open
Abstract
Eosinophilic myocarditis (EM) is a rare condition characterized by myocardial eosinophilic infiltration due to various underlying etiologies. The patient with EM may benefit from appropriate use of mechanical circulatory support (MCS) that acts as a bridge to myocardial recovery in response to effective immunosuppressive therapy. A 16-year-old boy presented with cardiogenic shock due to fulminant myocarditis, for which a percutaneous ventricular assist device (PVAD) was immediately inserted. Based on the histological diagnosis of EM, immunosuppressive therapy was immediately commenced, leading to improvement of left-ventricular ejection fraction (27% to 47%). The PVAD was successfully removed on day 7. Cardiac magnetic resonance imaging and dual-tracer myocardial scintigraphy suggested limited extent of irreversible myocardial damage. For fulminant EM, the short-term use of PVAD, together with immunosuppressive therapy guided by an immediate histological investigation, may be an effective bridging strategy to myocardial recovery.
Collapse
|
8
|
Deitchman AR, McCurdy MT, Fargaly H, Gilani M, Sorensen EN, Mazzeffi MA. Microcirculatory Coherence in Patients with Left Ventricular Assist Devices. J Cardiothorac Vasc Anesth 2019; 33:2608-2610. [PMID: 31076298 DOI: 10.1053/j.jvca.2019.03.057] [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: 03/23/2019] [Accepted: 03/24/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Andrew R Deitchman
- University of Maryland School of Medicine, Department of Medicine, Baltimore, MD
| | - Michael T McCurdy
- University of Maryland School of Medicine, Department of Medicine, Baltimore, MD
| | - Hithem Fargaly
- University of Maryland School of Medicine, Department of Medicine, Baltimore, MD
| | - Muhammad Gilani
- University of Maryland School of Medicine, Department of Medicine, Baltimore, MD
| | | | - Michael A Mazzeffi
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD
| |
Collapse
|
9
|
Effect of Pulsatility on Microcirculation in Patients Treated with Extracorporeal Cardiopulmonary Resuscitation: A Pilot Study. ASAIO J 2017; 63:386-391. [DOI: 10.1097/mat.0000000000000492] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
|
10
|
Effect of Early Initiation of Mechanical Circulatory Support on Survival in Cardiogenic Shock. Am J Cardiol 2017; 119:845-851. [PMID: 28040188 DOI: 10.1016/j.amjcard.2016.11.037] [Citation(s) in RCA: 243] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 11/21/2016] [Accepted: 11/21/2016] [Indexed: 11/22/2022]
Abstract
The role and timing of percutaneous mechanical circulatory support (MCS) devices in the treatment of acute myocardial infarction complicated by cardiogenic shock (AMICS) are not well understood. We sought to evaluate patient characteristics and predictors of outcomes in patients presenting with AMICS supported with an axial flow percutaneous MCS device; 287 consecutive unselected patients enrolled in the catheter-based ventricular assist device registry presenting with AMICS who underwent percutaneous coronary intervention (PCI) were included in this analysis. All patients were supported with either the Impella 2.5 or Impella CP. Mean patient age was 66 ± 12.5 years, 76% were men, and mean left ventricular ejection fraction was 25 ± 12%. Before receiving MCS, 80% of patients required inotropes or vasopressors and 40% were supported with intra-aortic balloon pump; 9% of patients were under active cardiopulmonary resuscitation at the time of MCS implantation. Survival to discharge was 44%. In a multivariate analysis, early implantation of a MCS device before PCI (p = 0.04) and before requiring inotropes and vasopressors (p = 0.05) was associated with increased survival. Survival was 66% when MCS was initiated <1.25 hours from shock onset, 37% when initiated within 1.25 to 4.25 hours, and 26% when initiated after 4.25 hours (p = 0.017). Survival was 68%, 46%, 35%, 35%, and 26% for patients requiring 0, 1, 2, 3, and ≥4 inotropes before MCS support, respectively (p <0.001). In conclusion, MCS implantation early after shock onset, before initiation of inotropes or vasopressors and before PCI, is independently associated with improved survival in patients presenting with AMICS.
Collapse
|
11
|
Flaherty MP, Pant S, Patel SV, Kilgore T, Dassanayaka S, Loughran JH, Rawasia W, Dawn B, Cheng A, Bartoli CR. Hemodynamic Support With a Microaxial Percutaneous Left Ventricular Assist Device (Impella) Protects Against Acute Kidney Injury in Patients Undergoing High-Risk Percutaneous Coronary Intervention. Circ Res 2017; 120:692-700. [DOI: 10.1161/circresaha.116.309738] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 12/31/2016] [Accepted: 01/10/2017] [Indexed: 01/25/2023]
Abstract
Rationale:
Acute kidney injury (AKI) is common during high-risk percutaneous coronary intervention (PCI), particularly in those with severely reduced left ventricular ejection fraction. The impact of partial hemodynamic support with a microaxial percutaneous left ventricular assist device (pLVAD) on renal function after high-risk PCI remains unknown.
Objective:
We tested the hypothesis that partial hemodynamic support with the Impella 2.5 microaxial pLVAD during high-risk PCI protected against AKI.
Methods and Results:
In this retrospective, single-center study, we analyzed data from 230 patients (115 consecutive pLVAD-supported and 115 unsupported matched-controls) undergoing high-risk PCI with ejection fraction ≤35%. The primary outcome was incidence of in-hospital AKI according to AKI network criteria. Logistic regression analysis determined the predictors of AKI. Overall, 5.2% (6) of pLVAD-supported patients versus 27.8% (32) of unsupported control patients developed AKI (
P
<0.001). Similarly, 0.9% (1) versus 6.1% (7) required postprocedural hemodialysis (
P
<0.05). Microaxial pLVAD support during high-risk PCI was independently associated with a significant reduction in AKI (adjusted odds ratio, 0.13; 95% confidence intervals, 0.09–0.31;
P
<0.001). Despite preexisting CKD or a lower ejection fraction, pLVAD support protection against AKI persisted (adjusted odds ratio, 0.63; 95% confidence intervals, 0.25–0.83;
P
=0.04 and adjusted odds ratio, 0.16; 95% confidence intervals, 0.12–0.28;
P
<0.001, respectively).
Conclusions:
Impella 2.5 (pLVAD) support protected against AKI during high-risk PCI. This renal protective effect persisted despite the presence of underlying CKD and decreasing ejection fraction.
Collapse
Affiliation(s)
- Michael P. Flaherty
- From the Cardiovascular Medicine, University of Louisville School of Medicine, KY (M.P.F., S.P., T.K., S.D., J.H.L., W.R.); Internal Medicine, Sparks Regional Medical Center, Fort Smith, AR (S.V.P.); Cardiology, University of Kansas Medical Center, Kansas City (B.D.); Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO (A.C.); and Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B.)
| | - Sadip Pant
- From the Cardiovascular Medicine, University of Louisville School of Medicine, KY (M.P.F., S.P., T.K., S.D., J.H.L., W.R.); Internal Medicine, Sparks Regional Medical Center, Fort Smith, AR (S.V.P.); Cardiology, University of Kansas Medical Center, Kansas City (B.D.); Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO (A.C.); and Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B.)
| | - Samir V. Patel
- From the Cardiovascular Medicine, University of Louisville School of Medicine, KY (M.P.F., S.P., T.K., S.D., J.H.L., W.R.); Internal Medicine, Sparks Regional Medical Center, Fort Smith, AR (S.V.P.); Cardiology, University of Kansas Medical Center, Kansas City (B.D.); Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO (A.C.); and Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B.)
| | - Tyler Kilgore
- From the Cardiovascular Medicine, University of Louisville School of Medicine, KY (M.P.F., S.P., T.K., S.D., J.H.L., W.R.); Internal Medicine, Sparks Regional Medical Center, Fort Smith, AR (S.V.P.); Cardiology, University of Kansas Medical Center, Kansas City (B.D.); Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO (A.C.); and Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B.)
| | - Sujith Dassanayaka
- From the Cardiovascular Medicine, University of Louisville School of Medicine, KY (M.P.F., S.P., T.K., S.D., J.H.L., W.R.); Internal Medicine, Sparks Regional Medical Center, Fort Smith, AR (S.V.P.); Cardiology, University of Kansas Medical Center, Kansas City (B.D.); Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO (A.C.); and Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B.)
| | - John H. Loughran
- From the Cardiovascular Medicine, University of Louisville School of Medicine, KY (M.P.F., S.P., T.K., S.D., J.H.L., W.R.); Internal Medicine, Sparks Regional Medical Center, Fort Smith, AR (S.V.P.); Cardiology, University of Kansas Medical Center, Kansas City (B.D.); Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO (A.C.); and Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B.)
| | - Wasiq Rawasia
- From the Cardiovascular Medicine, University of Louisville School of Medicine, KY (M.P.F., S.P., T.K., S.D., J.H.L., W.R.); Internal Medicine, Sparks Regional Medical Center, Fort Smith, AR (S.V.P.); Cardiology, University of Kansas Medical Center, Kansas City (B.D.); Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO (A.C.); and Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B.)
| | - Buddhadeb Dawn
- From the Cardiovascular Medicine, University of Louisville School of Medicine, KY (M.P.F., S.P., T.K., S.D., J.H.L., W.R.); Internal Medicine, Sparks Regional Medical Center, Fort Smith, AR (S.V.P.); Cardiology, University of Kansas Medical Center, Kansas City (B.D.); Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO (A.C.); and Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B.)
| | - Allen Cheng
- From the Cardiovascular Medicine, University of Louisville School of Medicine, KY (M.P.F., S.P., T.K., S.D., J.H.L., W.R.); Internal Medicine, Sparks Regional Medical Center, Fort Smith, AR (S.V.P.); Cardiology, University of Kansas Medical Center, Kansas City (B.D.); Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO (A.C.); and Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B.)
| | - Carlo R. Bartoli
- From the Cardiovascular Medicine, University of Louisville School of Medicine, KY (M.P.F., S.P., T.K., S.D., J.H.L., W.R.); Internal Medicine, Sparks Regional Medical Center, Fort Smith, AR (S.V.P.); Cardiology, University of Kansas Medical Center, Kansas City (B.D.); Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO (A.C.); and Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B.)
| |
Collapse
|
12
|
The response of the microcirculation to mechanical support of the heart in critical illness. Best Pract Res Clin Anaesthesiol 2016; 30:511-522. [PMID: 27931654 DOI: 10.1016/j.bpa.2016.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 10/20/2016] [Indexed: 12/25/2022]
Abstract
Critical illness associated with cardiac pump failure results in reduced tissue perfusion in all organs and occurs in various conditions such as sepsis, cardiogenic shock, and heart failure. Mechanical circulatory support (MCS) devices can be used to maintain organ perfusion in patients with cardiogenic shock and decompensated chronic heart failure. However, correction of global hemodynamic parameters by MCS does not always cause a parallel improvement in microcirculatory perfusion and oxygenation of the organ systems, a condition referred to as a loss of hemodynamic coherence between macro- and microcirculation (MC). In this paper, we review the literature describing hemodynamic coherence or loss occurring during MCS of the heart. By using Embase, Medline Cochrane, Web of Science, and Google Scholar, we analyzed the literature on the response of MC and macrocirculation to MCS of the heart in critical illness. The characteristics of patients, MCS devices, and micro- and macrocirculatory parameters were very heterogenic. Short-term MCS studies (78%) described the effects of intra-aortic balloon pumps (IABPs) on the MC and macrocirculation. Improvement in MC, observed by handheld microscopy (orthogonal polarization spectral (OPS), sidestream dark-field (SDF), and Cytocam IDF imaging) in line with restored macrocirculation was found in 44% and 40% of the studies of short- and long-term MCS, respectively. In only 6 of 14 studies, hemodynamic coherence was described. It is concluded that more studies using direct visualization of the MC in short- and long-term MCS by handheld microscopy are needed, preferably randomized controlled studies, to identify the presence and clinical significance of hemodynamic coherence. It is anticipated that these further studies can enable to better identify patients who will benefit from treatment by mechanical heart support to ensure adequate organ perfusion.
Collapse
|
13
|
New insights into the pathophysiology of cardiogenic shock: the role of the microcirculation. Curr Opin Crit Care 2014; 19:381-6. [PMID: 23995131 DOI: 10.1097/mcc.0b013e328364d7c8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The ultimate goal of therapy for cardiogenic shock is to restore microcirculatory function and thereby restore the oxygen supply to sustain cellular function. Therapeutic measures mainly focus on improving pressure-derived macrocirculatory parameters. However, it is increasingly clear that to achieve significant progress in treatment, microcirculatory physiopathological mechanisms must be considered. RECENT FINDINGS Microcirculatory function deteriorated during cardiogenic shock and improved after treatment. Postcardiogenic shock microcirculatory disturbances, both myocardial and peripheral, were a prognostic factor for the long-term outcome. Hypothermia, whether pharmacologically or physically induced, improved postresuscitation myocardial and cerebral function, an effect associated with improved postresuscitation microcirculation. The impact of cardiogenic shock on cerebral and myocardial microcirculation could be evaluated with MRI. In severe heart failure, pharmacological interventions improved microcirculation. An assessment of the microcirculation was often performed using handheld video microscopy for direct observation of the sublingual microcirculation, which proved to be useful for evaluating the effects of interventions during cardiogenic shock. A large multicenter study on critically ill patients is now being conducted using this technique. SUMMARY Cardiogenic shock induces microcirculatory disorders that can be monitored and influenced in various manners, both pharmacologically and physically. In addition to global hemodynamic optimization, interventions must also ameliorate the microcirculation.
Collapse
|
14
|
Liu W, Mukku VK, Gilani S, Fujise K, Barbagelata A. Percutaneous Hemodynamic Support (Impella) in Patients with Advanced Heart Failure and/or Cardiogenic Shock Not Eligible to PROTECT II Trial. Int J Angiol 2014; 22:207-12. [PMID: 24436614 DOI: 10.1055/s-0033-1349167] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
PROTECT I and II trials have tested the efficacy of Impella in patents with high-risk percutaneous coronary intervention (PCI). However, patients with severe hemodynamic instability such as cardiac arrest, ST-segment elevated myocardial infarction (STEMI), or cardiogenic shock were excluded. The objective was to investigate the efficacy of Impella in sicker patient population who were not included in PROTECT trials. These patients merit high-risk PCI who had cardiogenic shock and unstable or decompensated heart failure (HF). From December 2010 to March 2012, 10 consecutive patients with extremely high surgical risk and hemodynamic instability underwent urgent PCI with Impella 2.5 support (Abiomed Inc., Danvers, MA). These patients were presented with advance HF and/or cardiogenic shock. Among the 10 included patients, 3 patients were with cardiac arrest and 1 patient was with acute myocardial infarction. All patients had successful Impella implantation and remained hemodynamically stable during high-risk PCI. Among the 10 patients 2 patients (20%) died within 1 month and 1 patient developed limb ischemia. In high-risk population nonrandomizable to PROTECT trials with advance HF/cardiogenic shock, Impella could be an important tool for hemodynamic support to PCI or could be a bridge to left ventricle assist device to achieve good recovery. Larger studies need to be conducted on this high-risk population.
Collapse
Affiliation(s)
- Wei Liu
- Cardiology Department, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | | | - Syed Gilani
- Division of Cardiology, University of Texas Medical Branch, Galveston, Texas
| | - Ken Fujise
- Division of Cardiology, University of Texas Medical Branch, Galveston, Texas
| | | |
Collapse
|
15
|
Engström AE, Piek JJ, Henriques JPS. Percutaneous left ventricular assist devices for high-risk percutaneous coronary intervention. Expert Rev Cardiovasc Ther 2014; 8:1247-55. [DOI: 10.1586/erc.10.93] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
16
|
From macrohemodynamic to the microcirculation. Crit Care Res Pract 2013; 2013:892710. [PMID: 23509621 PMCID: PMC3600213 DOI: 10.1155/2013/892710] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 01/22/2013] [Accepted: 01/28/2013] [Indexed: 01/20/2023] Open
Abstract
ICU patients need a prompt normalization of macrohemodynamic parameters. Unfortunately, this optimization sometimes does not protect patients from organ failure development. Prevention or treatment of organ failure needs another target to be pursued: the microcirculatory restoration. Microcirculation is the ensemble of vessels of maximum 100 μm in diameter. Nowadays the Sidestream Dark Field (SDF) imaging technique allows its bedside investigation and a recent round-table conference established the criteria for its evaluation. First, microcirculatory derangements have been studied in sepsis: they are mainly characterized by a reduction of vessel density, an alteration of flow, and a heterogeneous distribution of perfusion. Endothelial malfunction and glycocalyx rupture were proved to be the main reasons for the observed microthrombi, capillary leakage, leukocyte rolling, and rouleaux phenomenon, even if further studies are necessary for a better explanation. Therapeutic approaches targeting microcirculation are under investigation. Microcirculatory alterations have been recently demonstrated in other diseases such as hypovolemia and cardiac failure but this issue still needs to be explored. The aim of this paper is to gather the already known information, focus the reader's attention on the importance of microvascular physiopathology in critical illness, and prompt him to actively participate to achieve a more comprehensive understanding of the issue.
Collapse
|
17
|
Percutaneous circulatory support in a patient with cardiac arrest due to acute pulmonary embolism. Clin Res Cardiol 2012; 101:1017-20. [DOI: 10.1007/s00392-012-0481-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2012] [Accepted: 05/24/2012] [Indexed: 01/17/2023]
|
18
|
Vellinga NAR, Boerma EC, Koopmans M, Donati A, Dubin A, Shapiro NI, Pearse RM, Bakker J, Ince C. Study Design of the Microcirculatory Shock Occurrence in Acutely Ill Patients (microSOAP): an International Multicenter Observational Study of Sublingual Microcirculatory Alterations in Intensive Care Patients. Crit Care Res Pract 2012; 2012:121752. [PMID: 22666566 PMCID: PMC3359769 DOI: 10.1155/2012/121752] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Accepted: 03/02/2012] [Indexed: 11/17/2022] Open
Abstract
Objective. Sublingual microcirculatory alterations are associated with an adverse prognosis in several critical illness subgroups. Up to now, single-center studies have reported on sublingual microcirculatory alterations in ICU patient subgroups, but an extensive evaluation of the prevalence of these alterations is lacking. We present the study design of an international multicenter observational study to investigate the prevalence of microcirculatory alterations in critically ill: the Microcirculatory Shock Occurrence in Acutely ill Patients (microSOAP). Methods. 36 ICU's worldwide have participated in this study aiming for inclusion of over 500 evaluable patients. To enable communication and data collection, a website, an Open Clinica 3.0 database, and image uploading software have been designed. A one-session assessment of the sublingual microcirculation using Sidestream Dark Field imaging and data collection on patient characteristics has been performed in every ICU patient >18 years, regardless of underlying disease. Statistical analysis will provide insight in the prevalence and severity of sublingual alterations, its relation to systemic hemodynamic variables, disease, therapy, and outcome. Conclusion. This study will be the largest microcirculation study ever performed. It is expected that this study will also establish a basis for future studies related to the microcirculation in critically ill.
Collapse
Affiliation(s)
- Namkje A. R. Vellinga
- Erasmus MC University Medical Center, Department of Intensive Care Adults, P.O. Box 2040–Room H625, 3000 CA Rotterdam, The Netherlands
- Medical Center Leeuwarden, Department of Intensive Care, P.O. Box 888, 8901 BR Leeuwarden, The Netherlands
| | - E. Christiaan Boerma
- Medical Center Leeuwarden, Department of Intensive Care, P.O. Box 888, 8901 BR Leeuwarden, The Netherlands
| | - Matty Koopmans
- Medical Center Leeuwarden, Department of Intensive Care, P.O. Box 888, 8901 BR Leeuwarden, The Netherlands
| | - Abele Donati
- Università Politecnica delle Marche, Department of Biomedical Science and Public Health, 60126 Ancona, Italy
| | - Arnaldo Dubin
- Sanatorio Otamendi y Miroli, Servicio de Terapia Intensiva, Azcuénaga 870, C1115AAB, Buenos Aires, Argentina
| | - Nathan I. Shapiro
- Beth Isreal Deaconess Medical Center, Department of Emergency Medicine and Center for Vascular Biology Research, 1 Deaconess Road, CC2-W, Boston, MA 02115, USA
| | - Rupert M. Pearse
- Barts and The London School of Medicine and Dentistry, London, EC1M 6BQ, London, UK
| | - Jan Bakker
- Erasmus MC University Medical Center, Department of Intensive Care Adults, P.O. Box 2040–Room H625, 3000 CA Rotterdam, The Netherlands
| | - Can Ince
- Erasmus MC University Medical Center, Department of Intensive Care Adults, P.O. Box 2040–Room H625, 3000 CA Rotterdam, The Netherlands
| |
Collapse
|
19
|
SALLISALMI M, OKSALA N, PETTILÄ V, TENHUNEN J. Evaluation of sublingual microcirculatory blood flow in the critically ill. Acta Anaesthesiol Scand 2012; 56:298-306. [PMID: 22092221 DOI: 10.1111/j.1399-6576.2011.02569.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND The microcirculation regulates the supply of oxygen and nutrients to tissues. The sublingual region is frequently used as a window to microcirculation in critically ill patients. Numerous studies have reported impaired sublingual microcirculatory flow. We hypothesized that the quality of sidestream dark field imaging (SDF) recordings could be systematically analyzed to justify the monitoring of sublingual microcirculation in interventional studies or in clinical practice. METHODS The sublingual microcirculation in critically ill patients with septic shock, open heart surgery, or alcoholic pancreatitis, and healthy subjects was recorded with a hand held SDF device by one trained investigator in observational setting. A total of 82 video recording sessions were performed and 240 video clips eligible for quality assessment were identified. Quality assessment was performed offline by two investigators independently and blinded for the origin of the video file. RESULTS Of the 240 clips, pressure artifact was detected in 86 (36%), major blood in 5 (2.1%), major saliva in 21 (8.8%) and extreme brightness causing loss of visible capillaries in 16 (6.7%) clips. The dominating vessel architecture was multiple size vessels in 228 (95%) and repeating capillary loop motif in 12 (5.0%). The mean (± SD) relative size reduction during stabilization was -6.9% (± 4.7%). Excellent technical quality was detected in 74 of 240 (30.8%) recordings. CONCLUSIONS Our findings highlight the need of a comprehensive training period and reporting of data quality before findings with SDF imaging can be accepted as surrogate end points in interventional studies or as guidance in clinical practice.
Collapse
Affiliation(s)
- M. SALLISALMI
- Intensive Care Units; Division of Anaesthesia and Intensive Care Medicine; Helsinki University Hospital; Helsinki; Finland
| | - N. OKSALA
- Division of Vascular Surgery; Department of Surgery; Medical School; University of Tampere and Tampere University Hospital; Tampere; Finland
| | - V. PETTILÄ
- Intensive Care Units; Division of Anaesthesia and Intensive Care Medicine; Helsinki University Hospital; Helsinki; Finland
| | - J. TENHUNEN
- Critical Care Medicine Research Group; Department of Intensive Care Medicine; Tampere University Hospital; Tampere; Finland
| |
Collapse
|
20
|
Martinez CA, Badheka AO, O’Neill WW. Hemodynamic support in high-risk percutaneous coronary interventions and cardiogenic shock. Interv Cardiol 2012. [DOI: 10.2217/ica.11.98] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
21
|
The role of percutaneous circulatory assist devices in acute myocardial infarction and high-risk percutaneous coronary intervention in the 21st century. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2011; 12:237-42. [DOI: 10.1016/j.carrev.2010.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Accepted: 10/11/2010] [Indexed: 11/19/2022]
|
22
|
|
23
|
Treu CM, Lupi O, Bottino DA, Bouskela E. Sidestream dark field imaging: the evolution of real-time visualization of cutaneous microcirculation and its potential application in dermatology. Arch Dermatol Res 2010; 303:69-78. [DOI: 10.1007/s00403-010-1087-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Revised: 09/22/2010] [Accepted: 09/24/2010] [Indexed: 02/04/2023]
|
24
|
Percutaneous left ventricular assist devices during cardiogenic shock and high-risk percutaneous coronary interventions. Curr Cardiol Rep 2010; 11:369-76. [PMID: 19709497 DOI: 10.1007/s11886-009-0051-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Left ventricular assist devices were developed to support the function of a failing left ventricle. Owing to recent technological improvements, ventricular assist devices can be placed by percutaneous implantation techniques, which offer the advantage of fast implantation in the setting of acute left ventricular failure. This article reviews the growing evidence supporting the clinical use of left ventricular assist devices. Specifically, we discuss the use of left ventricular assist devices in patients with cardiogenic shock, in patients with acute ST-elevation myocardial infarction without shock, and during high-risk percutaneous coronary interventions.
Collapse
|
25
|
The role of vasoactive agents in the resuscitation of microvascular perfusion and tissue oxygenation in critically ill patients. Intensive Care Med 2010; 36:2004-18. [PMID: 20811874 PMCID: PMC2981743 DOI: 10.1007/s00134-010-1970-x] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2009] [Accepted: 07/02/2010] [Indexed: 12/19/2022]
Abstract
Purpose The clinical use of vasoactive drugs is not only intended to improve systemic hemodynamic variables, but ultimately to attenuate derangements in organ perfusion and oxygenation during shock. This review aims (1) to discuss basic physiology with respect to manipulating vascular tone and its effect on the microcirculation, and (2) to provide an overview of available clinical data on the relation between vasoactive drugs and organ perfusion, with specific attention paid to recent developments that have enabled direct in vivo observation of the microcirculation and concepts that have originated from it. Methods A MedLine search was conducted for clinical articles in the English language over the last 15 years pertainig to shock, sepsis, organ failure, or critically ill patients in combination with vasoactive drugs and specific variables of organ perfusion/oxygenation (e.g., tonometry, indocyanine clearance, laser Doppler, and sidestream dark field imaging). Results Eighty original papers evaluating the specific relationship between organ perfusion/oxygenation and the use of vasoactive drugs were identified and are discussed in light of physiological theory of vasomotor tone. Conclusions Solid clinical data in support of the idea that increasing blood pressure in shock improves microcirculatory perfusion/oxygenation seem to be lacking, and such a concept might not be in line with physiological theory of microcirculation as a low-pressure vascular compartment. In septic shock no beneficial effect on microcirculatory perfusion above a mean arterial pressure of 65 mmHg has been reported, but a wide range in inter-individual effect seems to exist. Whether improvement of microcirculatory perfusion is associated with better patient outcome remains to be elucidated.
Collapse
|
26
|
|
27
|
Martin DS, Goedhart P, Vercueil A, Ince C, Levett DZH, Grocott MPW. Changes in sublingual microcirculatory flow index and vessel density on ascent to altitude. Exp Physiol 2010; 95:880-91. [PMID: 20418348 DOI: 10.1113/expphysiol.2009.051656] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We hypothesized that ascent to altitude would result in reduced sublingual microcirculatory flow index (MFI) and increased vessel density. Twenty-four subjects were studied using sidestream dark-field imaging, as they ascended to 5300 m; one cohort remained at this altitude (n = 10), while another ascended higher (maximum 8848 m; n = 14). The MFI, vessel density and grid crossings (GX; an alternative density measure) were calculated. Total study length was 71 days; images were recorded at sea level (SL), Namche Bazaar (3500 m), Everest base camp (5300 m), the Western Cwm (6400 m), South Col (7950 m) and departure from Everest base camp (5300 m; 5300 m-b). Peripheral oxygen saturation (SpO2), heart rate and blood pressure were also recorded. Compared with SL, altitude resulted in reduced sublingual MFI in small (<25 microm; P < 0.0001) and medium vessels (26-50 microm; P = 0.006). The greatest reduction in MFI from SL was seen at 5300 m-b; from 2.8 to 2.5 in small vessels and from 2.9 to 2.4 in medium-sized vessels. The density of vessels <25 microm did not change during ascent, but those >25 microm rose from 1.68 (+/- 0.43) mm mm(-2) at SL to 2.27 (+/- 0.57) mm mm(-2) at 5300 m-b (P = 0.005); GX increased at all altitudes (P < 0.001). The reduction in MFI was greater in climbers than in those who remained at 5300 m in small and medium-sized vessels (P = 0.017 and P = 0.002, respectively). At 7950 m, administration of supplemental oxygen resulted in a further reduction of MFI and increase in vessel density. Thus, MFI was reduced whilst GX increased in the sublingual mucosa with prolonged exposure to hypoxia and was exaggerated in those exposed to extreme altitude.
Collapse
Affiliation(s)
- Daniel S Martin
- UCL Centre for Altitude, Space and Extreme Environment Medicine, Portex Unit, Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK.
| | | | | | | | | | | | | |
Collapse
|
28
|
Jacobshagen C, Pelster T, Pax A, Horn W, Schmidt-Schweda S, Unsöld BW, Seidler T, Wagner S, Hasenfuss G, Maier LS. Effects of mild hypothermia on hemodynamics in cardiac arrest survivors and isolated failing human myocardium. Clin Res Cardiol 2010; 99:267-76. [PMID: 20130890 PMCID: PMC2858797 DOI: 10.1007/s00392-010-0113-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Accepted: 01/11/2010] [Indexed: 12/19/2022]
Abstract
Post-cardiac arrest myocardial dysfunction is a common phenomenon after return of spontaneous circulation (ROSC) and contributes to hemodynamic instability and low survival rates after cardiac arrest. Mild hypothermia for 24 h after ROSC has been shown to significantly improve neurologic recovery and survival rates. In the present study we investigate the influence of therapeutic hypothermia on hemodynamic parameters in resuscitated patients and on contractility in failing human myocardium. We analyzed hemodynamic data from 200 cardiac arrest survivors during the hypothermia period. The initial LVEF was 32.6 +/- 1.2% indicating a significantly impaired LV function. During hypothermia induction, the infusion rate of epinephrine could be significantly reduced from 9.1 +/- 1.3 microg/min [arrival intensive care unit (ICU) 35.4 degrees C] to 4.6 +/- 1.0 microg/min (34 degrees C) and 2.8 +/- 0.5 microg/min (33 degrees C). The dobutamine and norepinephrine application rates were not changed significantly. The mean arterial blood pressure remained stable. The mean heart rate significantly decreased from 91.8 +/- 1.7 bpm (arrival ICU) to 77.3 +/- 1.5 bpm (34 degrees C) and 70.3 +/- 1.4 bpm (33 degrees C). In vitro we investigated the effect of hypothermia on isolated ventricular muscle strips from explanted failing human hearts. With decreasing temperature, the contractility increased to a maximum of 168 +/- 23% at 27 degrees C (n = 16, P < 0.05). Positive inotropic response to hypothermia was accompanied by moderately increased rapid cooling contractures as a measure of sarcoplasmic reticulum (SR) Ca(2+) content, but can be elicited even when the SR Ca(2+) release is blocked in the presence of ryanodine. Contraction and relaxation kinetics are prolonged with hypothermia, indicating increased Ca(2+) sensitivity as the main mechanism responsible for inotropy. In conclusion, mild hypothermia stabilizes hemodynamics in cardiac arrest survivors which might contribute to improved survival rates in these patients. Mechanistically, we demonstrate that hypothermia improves contractility in failing human myocardium most likely by increasing Ca(2+)-sensitivity.
Collapse
Affiliation(s)
- Claudius Jacobshagen
- Department of Cardiology und Pneumology, Heart Center, Georg-August-University, Robert-Koch-Strasse 40, 37075, Göttingen, Germany.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Aqel RA, Hage FG, Iskandrian AE. Improvement of myocardial perfusion with a percutaneously inserted left ventricular assist device. J Nucl Cardiol 2010; 17:158-60. [PMID: 19685267 DOI: 10.1007/s12350-009-9127-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2009] [Revised: 07/09/2009] [Accepted: 07/12/2009] [Indexed: 10/20/2022]
Affiliation(s)
- Raed A Aqel
- Division of Cardiovascular Disease, University of Alabama at Birmingham, BDB 383, 1530 3rd AVE S, Birmingham, AL 35294-0007, USA.
| | | | | |
Collapse
|
30
|
Tuseth V, Nordrehaug JE. Role of percutaneous left ventricular assist devices in preventing cerebral ischemia. Interv Cardiol 2009. [DOI: 10.2217/ica.09.27] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|