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Blumer V, Kanwar MK, Barnett CF, Cowger JA, Damluji AA, Farr M, Goodlin SJ, Katz JN, McIlvennan CK, Sinha SS, Wang TY. Cardiogenic Shock in Older Adults: A Focus on Age-Associated Risks and Approach to Management: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e1051-e1065. [PMID: 38406869 PMCID: PMC11067718 DOI: 10.1161/cir.0000000000001214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Cardiogenic shock continues to portend poor outcomes, conferring short-term mortality rates of 30% to 50% despite recent scientific advances. Age is a nonmodifiable risk factor for mortality in patients with cardiogenic shock and is often considered in the decision-making process for eligibility for various therapies. Older adults have been largely excluded from analyses of therapeutic options in patients with cardiogenic shock. As a result, despite the association of advanced age with worse outcomes, focused strategies in the assessment and management of cardiogenic shock in this high-risk and growing population are lacking. Individual programs oftentimes develop upper age limits for various interventional strategies for their patients, including heart transplantation and durable left ventricular assist devices. However, age as a lone parameter should not be used to guide individual patient management decisions in cardiogenic shock. In the assessment of risk in older adults with cardiogenic shock, a comprehensive, interdisciplinary approach is central to developing best practices. In this American Heart Association scientific statement, we aim to summarize our contemporary understanding of the epidemiology, risk assessment, and in-hospital approach to management of cardiogenic shock, with a unique focus on older adults.
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Akbik B, Chou LCP, Gorthi J. Extracorporeal Membrane Oxygenation in Postcardiotomy Cardiogenic Shock. Methodist Debakey Cardiovasc J 2023; 19:66-73. [PMID: 37547900 PMCID: PMC10402824 DOI: 10.14797/mdcvj.1256] [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: 05/03/2023] [Accepted: 06/15/2023] [Indexed: 08/08/2023] Open
Abstract
Postcardiotomy extracorporeal membrane oxygenation (PC-ECMO), the most frequent indication for ECMO in the United States, is increasingly used as the first-line mechanical circulatory support in patients who are refractory to conventional treatment. Despite increasing use of PC-ECMO, limited evidence is available regarding its safety, efficacy, and optimal timing for initiation and weaning. The decision to use PC-ECMO often is made in the absence of robust clinical data, leading to variability in patient selection, management, and outcomes across different institutions. This article summarizes current evidence on ECMO use in postcardiotomy cardiogenic shock and discusses its potential benefits, management, complications, and outcomes.
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Affiliation(s)
- Bassel Akbik
- Center for Critical Care, Houston Methodist, Houston, Texas, US
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Du Y, Li W, Chen Q, Shi H, Li Q, Zhang C, Zhuang Y, Li J, Tang L. Comparison of vasoactive-inotropic score, vasoactive-ventilation-renal score, and modified vasoactive-ventilation-renal score for predicting the poor prognosis after coronary artery bypass grafting. BMC Cardiovasc Disord 2023; 23:274. [PMID: 37226089 DOI: 10.1186/s12872-023-03313-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/18/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Exploring reliable prediction scoring systems is valuable for the poor prognosis of patients after coronary artery bypass grafting (CABG). Herein, we explored and compared the predictive performance of vasoactive-inotropic score (VIS), vasoactive-ventilation-renal (VVR) score, and modified VVR (M-VVR) score in the poor prognosis of patients undergoing CABG. METHODS A retrospective cohort study was performed in Affiliated Hospital of Jining Medical University, and data of 537 patients were collected from January 2019 to May 2021. The independent variables were VIS, VVR, and M-VVR. Study endpoint of interest was the poor prognosis. Association between VIS, VVR, M-VVR and poor prognosis was assessed using logistic regression analysis, and odds ratios (OR) and 95% confidence intervals (CIs) were reported. The performance of VIS, VVR, and M-VVR to predict the poor prognosis was assessed by calculating the area under the curve (AUC), and differences of the AUC of the three scoring systems were compared using DeLong test. RESULTS After adjusting gender, BMI, hypertension, diabetes, surgery methods, and left ventricular ejection fraction (LVEF), VIS (OR: 1.09, 95%CI: 1.05-1.13) and M-VVR (OR: 1.09, 95%CI: 1.06-1.12) were associated with the increased odds of poor prognosis. The AUC of M-VVR, VVR, and VIS was 0.720 (95%CI: 0.668-0.771), 0.621 (95%CI: 0.566-0.677), and 0.685 (95%CI: 0.631-0.739), respectively. DeLong test displayed that the performance of M-VVR was better than VVR (P = 0.004) and VIS (P = 0.003). CONCLUSIONS Our study found the good prediction performance of M-VVR for the poor prognosis of patients undergoing CABG, indicating that M-VVR may be a useful prediction index in the clinic.
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Affiliation(s)
- Yanping Du
- Department of Cardiac Critical Care Medicine, Affiliated Hospital of Jining Medical University, No.89 Guhuai Road, Rencheng District, 272000, Jining, P.R. China
| | - Wensu Li
- Department of Cardiac Critical Care Medicine, Affiliated Hospital of Jining Medical University, No.89 Guhuai Road, Rencheng District, 272000, Jining, P.R. China
| | - Qingjuan Chen
- Department of Cardiac Critical Care Medicine, Affiliated Hospital of Jining Medical University, No.89 Guhuai Road, Rencheng District, 272000, Jining, P.R. China
| | - Haichuan Shi
- Department of Cardiac Critical Care Medicine, Affiliated Hospital of Jining Medical University, No.89 Guhuai Road, Rencheng District, 272000, Jining, P.R. China
| | - Qiong Li
- Department of Cardiac Critical Care Medicine, Affiliated Hospital of Jining Medical University, No.89 Guhuai Road, Rencheng District, 272000, Jining, P.R. China
| | - Chunying Zhang
- Department of Cardiac Critical Care Medicine, Affiliated Hospital of Jining Medical University, No.89 Guhuai Road, Rencheng District, 272000, Jining, P.R. China
| | - Yunxu Zhuang
- Department of Cardiac Critical Care Medicine, Affiliated Hospital of Jining Medical University, No.89 Guhuai Road, Rencheng District, 272000, Jining, P.R. China
| | - Junying Li
- Department of Cardiac Critical Care Medicine, Affiliated Hospital of Jining Medical University, No.89 Guhuai Road, Rencheng District, 272000, Jining, P.R. China
| | - Li Tang
- Department of Cardiac Critical Care Medicine, Affiliated Hospital of Jining Medical University, No.89 Guhuai Road, Rencheng District, 272000, Jining, P.R. China.
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 79:e21-e129. [PMID: 34895950 DOI: 10.1016/j.jacc.2021.09.006] [Citation(s) in RCA: 618] [Impact Index Per Article: 309.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. STRUCTURE Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e18-e114. [PMID: 34882435 DOI: 10.1161/cir.0000000000001038] [Citation(s) in RCA: 160] [Impact Index Per Article: 80.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Ibrahim M, Szeto WY, Gutsche J, Weiss S, Bavaria J, Ottemiller S, Williams M, Gallagher JF, Fishman N, Cunningham R, Brady L, Brennan PJ, Acker M. Transparency, Public Reporting and a Culture of Change to Quality and Safety in Cardiac Surgery. Ann Thorac Surg 2021; 114:626-635. [PMID: 34843698 DOI: 10.1016/j.athoracsur.2021.08.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 08/17/2021] [Accepted: 08/18/2021] [Indexed: 11/17/2022]
Abstract
Academic medical centers have a duty to serve as hospitals of last resort for advanced cardiac surgical care and therefore manage patients at elevated risk of post-operative morbidity and mortality. They must also meet state and professional quality targets devised to protect the public. The tension between these imperatives can be managed by a multi-dimensional quality improvement program which aims to manage risk, optimize outcomes and exclude futile operations. We here share our approach to this process, its impact on our institution and discuss pertinent issues relevant to institutions in a similar situation.
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Affiliation(s)
- Michael Ibrahim
- Division of Cardiovascular Surgery, Penn Cardiovascular Institute, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, Penn Cardiovascular Institute, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jacob Gutsche
- Division of Cardiovascular Surgery, Penn Cardiovascular Institute, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steve Weiss
- Division of Cardiovascular Surgery, Penn Cardiovascular Institute, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph Bavaria
- Division of Cardiovascular Surgery, Penn Cardiovascular Institute, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephanie Ottemiller
- Division of Cardiovascular Surgery, Penn Cardiovascular Institute, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew Williams
- Division of Cardiovascular Surgery, Penn Cardiovascular Institute, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jo Fante Gallagher
- Division of Cardiovascular Surgery, Penn Cardiovascular Institute, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Neil Fishman
- Division of Cardiovascular Surgery, Penn Cardiovascular Institute, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Regina Cunningham
- Division of Cardiovascular Surgery, Penn Cardiovascular Institute, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Luann Brady
- Division of Cardiovascular Surgery, Penn Cardiovascular Institute, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patrick J Brennan
- Division of Cardiovascular Surgery, Penn Cardiovascular Institute, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Acker
- Division of Cardiovascular Surgery, Penn Cardiovascular Institute, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Fertouk M, Gordon A, Pevni D, Ziv-Baran T, Sela O, Mohr R, Farkash A, Kramer A, Teich N, Nesher N, Ben-Gal Y. Early and late outcomes of single versus bilateral internal thoracic artery revascularization for patients in critical condition. PLoS One 2021; 16:e0255740. [PMID: 34352035 PMCID: PMC8341519 DOI: 10.1371/journal.pone.0255740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 07/22/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The optimal surgical approach for critically ill patients with complex coronary disease remains uncertain. We compared outcomes of bilateral internal thoracic artery (BITA) versus single ITA (SITA) revascularization in critical patients. METHODS We evaluated 394 consecutive critical patients with multi-vessel disease who underwent CABG during 1996-2001. Outcomes measured were early mortality, strokes, myocardial-infarctions, sternal infections, revisions for bleeding, and late survival. The critical preoperative state was acknowledged concisely by one or more of the following: preoperative ventricular tachycardia/fibrillation, aborted sudden cardiac death, or the need for mechanical ventilation or for preoperative insertion of intra-aortic-balloon counter-pulsation. RESULTS During the study period, 193 of our patients who underwent SITA and 201 who underwent BITA were in critical condition. The SITA group was older (mean 68.0 vs. 63.3 years, p = 0.001) and higher proportions were females (28.5% vs. 18.9% p = 0.025), after recent-MI (69.9% vs. 57.2% p = 0.009) and with left-main disease (38.3% vs. 49.3% p = .029); the median logistic EuroSCORE was higher (0.2898 vs. 0.1597, p<0.001). No statistically significant differences were observed between the SITA and BITA groups in 30-day mortality; and in rates of early CVA, MI and sternal infections (13.0% vs. 8.5%, p = 0.148; 4.1% vs. 6.0%, p = 0.49; 6.7% vs. 4.5%, p = 0.32 and 2.1% vs. 2.5%, p>0.99, respectively). Long-term survival (median follow-up of 15 years, interquartile-range: 13.57-15) was better in the BITA group (median 14.39 vs. 9.31± 0.9 years, p = 0.001). Propensity-score matching (132 matched pairs) also yielded similar early outcomes and improved long-term survival (median follow-up of 15 years, interquartile-range: 13.56-15) for the BITA group (median 12.49±1.71 vs. 7.63±0.99 years, p = 0.002). In multivariable analysis, BITA revascularization was found to be a predictor for improved survival (hazard-ratio of 0.419, 95%CI 0.23-0.76, p = 0.004). CONCLUSIONS This study demonstrated long-term survival benefit for BITA revascularization in patients in a critical pre-operative state who presented for surgical revascularization.
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Affiliation(s)
- Michal Fertouk
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Amit Gordon
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dmitry Pevni
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Tomer Ziv-Baran
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Orr Sela
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Rephael Mohr
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ariel Farkash
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Amir Kramer
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nadav Teich
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nachum Nesher
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yanai Ben-Gal
- Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- * E-mail: ,
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8
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Hung DQ, Minh NT, Vo HL, Hien NS, Tuan NQ. Impact of Pre-, Intra-and Post-Operative Parameters on In-Hospital Mortality in Patients Undergoing Emergency Coronary Artery Bypass Grafting: A Scarce Single-Center Experience in Resource-Scare Setting. Vasc Health Risk Manag 2021; 17:211-226. [PMID: 34040381 PMCID: PMC8139717 DOI: 10.2147/vhrm.s303726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/21/2021] [Indexed: 11/23/2022] Open
Abstract
Background In-hospital mortality after emergency coronary artery bypass grafting (CABG) remains an important issue that has needed considerable attention in recent years as the mortality rate is still high and prevention factors are not yet optimal. Our study presents the first largest cohort of emergency CABG from one large institution in Vietnam with the primary aim of comparing a large variety of pre-, intra-and post-operative parameters between in-hospital mortality patients and in-hospital survival patients and investigate risk factors of in-hospital mortality in patients undergoing emergency CABG. Methods We conducted a retrospective evaluation of prospectively collected data in patients undergoing emergency CABG at the Hanoi Heart Hospital (Hanoi, Vietnam) from January 1, 2017, to December 31, 2019. Primary outcome variable was in-hospital mortality. Results A total of 71 patients were included in final analysis. The mean age of the cohort was 68.68 years (± 9.28, range 38-86). The mean weight, height and body mass index were 54.35 kg (± 9.17, range 37-77), 158.96 (±7.64, range 145-179) and 21.48 kg/m2 (±3.08, range 13.59-30.08), respectively. In-hospital mortality rate was 9.86%. Preoperative risk factors for in-hospital mortality included diabetes, decreased ejection fraction (EF), EF below 30%, cardiogenic shock, elevated systolic pulmonary artery pressure (PAP), elevated NT-ProBNP, and Euroscore II. Without grafting with left internal thoracic artery, and prolonged cardiopulmonary bypass (CPB) time were increased intraoperative factors for in-hospital mortality risk. In-hospital mortality's postoperative risk factors were found to be postextubation respiratory failure requiring mechanical ventilation, ventricular fibrillation, dialysis-requiring acute renal failure, pneumonia, bacterial sepsis, gastrointestinal bleeding, and prolonged mechanical ventilation time. Significant predictors determining in-hospital mortality were known as prolonged CPB time in surgery and postoperative ventricular fibrillation. Conclusion Our hospital mortality rate after emergency CABG was relatively high. An optimal preventive strategy in emergency CABG management should target significant factors combined with other previously identified risk factors to reduce in-hospital mortality.
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Affiliation(s)
- Doan Quoc Hung
- Hanoi Medical University, Hanoi, 100000, Vietnam.,Department of Cardiovascular and Thoracic Surgery, Viet Duc University Hospital, Hanoi, 100000, Vietnam
| | | | | | | | - Nguyen Quang Tuan
- Hanoi Medical University, Hanoi, 100000, Vietnam.,Bach Mai Hospital, Hanoi, 100000, Vietnam
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Smith NJ, Ramamurthi A, Joyce LD, Durham LA, Kohmoto T, Joyce DL. Temporary mechanical circulatory support prevents the occurrence of a low-output state in high-risk coronary artery bypass grafting: A case series. J Card Surg 2021; 36:864-871. [PMID: 33428241 DOI: 10.1111/jocs.15309] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 11/27/2020] [Accepted: 12/28/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Coronary artery bypass grafting (CABG) is a durable treatment for coronary artery disease. Left ventricular dysfunction (LVD) (a division of cardiothoracic surgery) (ejection fraction < 35%) significantly elevates perioperative risk for patients pursuing surgical revascularization. Periprocedural support with temporary mechanical circulatory support (tMCS) has shown benefit in this patient population. METHODS Four patients with ischemic cardiomyopathy and LVD underwent CABG at our institution between 2017 and 2018. Each patient received perioperative ventricular support using a microaxial tMCS device (Impella 5.0®). The occurrence of a postoperative low-output state (LOS) was assessed for as well as postoperative morbidity and mortality, device-specific complications, and tMCS support duration. RESULTS All patients survived to device explant without device-related complications. Two patients required reoperation for nondevice-related bleeding. All patients were without an LOS at 24 h postoperatively with cardiac indices of 2.9-3.6 L/min/m2 , normalized serum lactate, and vasoactive-inotrope scores of 0-12.0. There was a notably high incidence of acute renal failure (50%), which was observed in patients with preoperative cardiogenic shock. One patient died 10 days after the device explant. Of the three patients that survived to discharge, two were alive at the most recent follow-up. Postoperative device support varied widely (0-500 h). CONCLUSION Perioperative tMCS may be a viable strategy for preventing postoperative LOS in high-risk CABG patients with a low complication rate and acceptable morbidity. The application of microaxial tMCS devices in CABG is an area that warrants further investigation to delineate its impact on perioperative outcomes and potentially expand the indications for such devices.
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Affiliation(s)
- Nathan J Smith
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Adhitya Ramamurthi
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lyle D Joyce
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lucian A Durham
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Takushi Kohmoto
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - David L Joyce
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Mariscalco G, Salsano A, Fiore A, Dalén M, Ruggieri VG, Saeed D, Jónsson K, Gatti G, Zipfel S, Dell'Aquila AM, Perrotti A, Loforte A, Livi U, Pol M, Spadaccio C, Pettinari M, Ragnarsson S, Alkhamees K, El-Dean Z, Bounader K, Biancari F, Dashey S, Yusuff H, Porter R, Sampson C, Harvey C, Settembre N, Fux T, Amr G, Lichtenberg A, Jeppsson A, Gabrielli M, Reichart D, Welp H, Chocron S, Fiorentino M, Lechiancole A, Netuka I, De Keyzer D, Strauven M, Pälve K. Peripheral versus central extracorporeal membrane oxygenation for postcardiotomy shock: Multicenter registry, systematic review, and meta-analysis. J Thorac Cardiovasc Surg 2020; 160:1207-1216.e44. [DOI: 10.1016/j.jtcvs.2019.10.078] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 10/04/2019] [Accepted: 10/04/2019] [Indexed: 12/13/2022]
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Ibrahim M, Spelde AE, Gutsche JT, Cevasco M, Bermudez CA, Desai ND, Szeto WY, Atluri P, Acker MA, Williams ML. Coronary Artery Bypass Grafting in Cardiogenic Shock: Decision-Making, Management Options, and Outcomes. J Cardiothorac Vasc Anesth 2020; 35:2144-2154. [PMID: 33268279 DOI: 10.1053/j.jvca.2020.09.108] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/13/2020] [Accepted: 09/14/2020] [Indexed: 11/11/2022]
Abstract
Coronary artery bypass grafting is a highly efficacious mode of myocardial revascularization that reduces mortality from ischemic heart disease. The patient presenting after acute myocardial infarction in cardiogenic shock presents a unique challenge. Early revascularization is proven to reduce mortality, but many questions remain, including the optimal mode and extent of revascularization, the role of mechanical circulatory support, and which patients are candidates for surgical intervention. Unprecedented attention to the outcomes of cardiac surgery means decisions about the management of the acute myocardial infarction in cardiogenic shock patients are influenced by risk aversion. The authors here review this topic to arm the reader with a comprehensive understanding of the literature to better guide surgical decision-making and perioperative management.
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Affiliation(s)
- Michael Ibrahim
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA.
| | - Audrey E Spelde
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Christian A Bermudez
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Michael A Acker
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Matthew L Williams
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
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12
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Kowalewski M, Raffa GM, Zieliński K, Alanazi M, Gilbers M, Heuts S, Natour E, Bidar E, Schreurs R, Delnoij T, Driessen R, Sels JW, van de Poll M, Roekaerts P, Meani P, Maessen J, Suwalski P, Lorusso R. The impact of Centre's heart transplant status and volume on in-hospital outcomes following extracorporeal membrane oxygenation for refractory post-cardiotomy cardiogenic shock: a meta-analysis. BMC Cardiovasc Disord 2020; 20:10. [PMID: 31918663 PMCID: PMC6950870 DOI: 10.1186/s12872-019-01317-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 12/23/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Postcardiotomy cardiogenic shock (PCS) that is refractory to inotropic support remains a major concern in cardiac surgery and is almost universally fatal unless treated with mechanical support. While reported mortality rates on ECMO vary from center to center, aim of the current report is assess if the outcomes differ between centres according to volume and heart transplantation status. METHODS A systematic search was performed according to PRISMA statement using PubMed/Medline databases between 2010 and 2018. Relevant articles were scrutinized and included in the meta-analysis only if reporting in-hospital/30-day mortality and heart transplantation status of the centre. Paediatric and congenital heart surgery-related studies along with those conducted in the setting of veno-venous ECMO for respiratory distress syndrome were excluded. Differences were assessed by means of subgroup meta-analysis and meta-regression. RESULTS Fifty-four studies enrolling N = 4421 ECMO patients were included. Of those, 6 series were performed in non-HTx centres (204 pts.;4.6%). Overall 30-day survival (95% Confidence Intervals) was 35.3% (32.5-38.2%) and did not statistically differ between non-HTx: 33.3% (26.8-40.4%) and HTx centres: 35.7% (32.7-38.8%); Pinteraction = 0.531. There was no impact of centre volume on survival as well: ßcoef = 0.0006; P = 0.833. No statistical differences were seen between HTx and non-HTx with respect to ECMO duration, limb complications, reoperations for bleeding, kidney injury and sepsis. There were however significantly less neurological complications in the HTx as compared to non-HTx centres: 11.9% vs 19.5% respectively; P = 0.009; an inverse relationship was seen for neurologic complications in centres performing more ECMOs annually ßcoef = - 0.0066; P = 0.031. Weaning rates and bridging to HTx and/or VADs were higher in HTx facilities. CONCLUSIONS There was no apparent difference in survival after ECMO implantation for refractory PCS according to centre's ECMO volume and transplantation status. Potentially different risk profiles of patients in these centres must be taken account for before definite conclusions are drawn.
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Affiliation(s)
- Mariusz Kowalewski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, Warsaw, Poland.
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht, Netherlands.
- Cardiothoracic Research Centre, Innovative Medical Forum, Bydgoszcz, Poland.
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, ISMETT-IRCCS, Palermo, Italy
| | | | - Musab Alanazi
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht, Netherlands
| | - Martijn Gilbers
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht, Netherlands
| | - Sam Heuts
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht, Netherlands
| | - Ehsan Natour
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht, Netherlands
| | - Elham Bidar
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht, Netherlands
| | - Rick Schreurs
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht, Netherlands
| | - Thijs Delnoij
- Cardiology Department, Maastricht University Medical Centre, Maastricht, Netherlands
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Rob Driessen
- Cardiology Department, Maastricht University Medical Centre, Maastricht, Netherlands
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Jan-Willem Sels
- Cardiology Department, Maastricht University Medical Centre, Maastricht, Netherlands
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Marcel van de Poll
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Paul Roekaerts
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Paolo Meani
- Cardiology Department, Maastricht University Medical Centre, Maastricht, Netherlands
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Jos Maessen
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht, Netherlands
| | - Piotr Suwalski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht, Netherlands
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Operative Koronarrevaskularisation im akuten Myokardinfarkt. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2019. [DOI: 10.1007/s00398-019-0326-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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14
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Kowalewski M, Raffa G, Zieliński K, Meani P, Alanazi M, Gilbers M, Heuts S, Natour E, Bidar E, Schreurs R, Delnoij T, Driessen R, Sels JW, van de Poll M, Roekaerts P, Maessen J, Suwalski P, Lorusso R. Baseline surgical status and short-term mortality after extracorporeal membrane oxygenation for post-cardiotomy shock: a meta-analysis. Perfusion 2019; 35:246-254. [PMID: 31469037 DOI: 10.1177/0267659119865122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE While reported mortality rates on post-cardiotomy extracorporeal membrane oxygenation vary from center to center, impact of baseline surgical status (elective/urgent/emergency/salvage) on mortality is still unknown. METHODS A systematic search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement using PubMed/Medline databases until March 2018 using the keywords "postcardiotomy," "cardiogenic shock," "extracorporeal membrane oxygenation," and "extracorporeal life support." Relevant articles were scrutinized and included in the meta-analysis only if reporting in-hospital/30-day mortality and baseline surgical status. The correlations between mortality and percentage of elective/urgent/emergency cases were investigated. Inference analysis of baseline status and extracorporeal membrane oxygenation complications was conducted as well. RESULTS Twenty-two studies (conducted between 1993 and 2017) enrolling N = 2,235 post-cardiotomy extracorporeal membrane oxygenation patients were found. Patients were mostly of non-emergency status (65.2%). Overall in-hospital/30-day mortality event rate (95% confidence intervals) was 66.7% (63.3-69.9%). There were no differences in in-hospital/30-day mortality with respect to baseline surgical status in the subgroup analysis (test for subgroup differences; p = 0.406). Similarly, no differences between mortality in studies enrolling <50 versus ⩾50% of emergency/salvage cases was found: respective event rates were 66.9% (63.1-70.4%) versus 64.4% (57.3-70.8%); p = 0.525. Yet, there was a significant positive association between increasing percentage of emergency/salvage cases and rates of neurological complications (p < 0.001), limb complications (p < 0.001), and bleeding (p = 0.051). Incidence of brain death (p = 0.099) and sepsis (p = 0.134) was increased as well. CONCLUSION Other factors than baseline surgical status may, to a higher degree, influence the mortality in patients treated with extracorporeal membrane oxygenation for post-cardiotomy cardiogenic shock. Baseline status, however, strongly influences the complication occurrence while on extracorporeal membrane oxygenation.
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Affiliation(s)
- Mariusz Kowalewski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, Warsaw, Poland
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- Cardiothoracic Research Centre, Innovative Medical Forum, Bydgoszcz, Poland
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, ISMETT-IRCCS, Palermo, Italy
| | | | - Paolo Meani
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Musab Alanazi
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Martijn Gilbers
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ehsan Natour
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Elham Bidar
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Rick Schreurs
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Thijs Delnoij
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Rob Driessen
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jan Willem Sels
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Marcel van de Poll
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Paul Roekaerts
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jos Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Piotr Suwalski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Roberto Lorusso
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
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Kim Y, Cho YH, Yang JH, Sung K, Lee YT, Kim WS, Lee H, Cho SH. Outcomes of Coronary Artery Bypass Grafting after Extracorporeal Life Support in Patients with Cardiac Arrest or Cardiogenic Shock. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2019; 52:70-77. [PMID: 31089443 PMCID: PMC6493258 DOI: 10.5090/kjtcs.2019.52.2.70] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 12/28/2022]
Abstract
Background Extracorporeal life support (ECLS) is used as a bridge to revascularization in high-risk patients with ischemic heart disease. We reviewed our experiences of coronary artery bypass grafting (CABG) after ECLS in patients with cardiac arrest or refractory cardiogenic shock. Methods We retrospectively reviewed 4,616 patients who underwent CABG at our institution between May 2006 and February 2017. We identified patients who underwent CABG following ECLS for cardiogenic shock or cardiac arrest. Twenty-three patients (0.5% of all CABG cases) were enrolled in the analysis. Their median age was 65 years (Q1-Q3, 58-77 years). Nine patients (39.1%) were diagnosed with ST-elevation myocardial infarction. Mechanical complications after acute myocardial infarction, including acute mitral regurgitation, left ventricular rupture, and ventricular septal defect, occurred in 9 patients (39.1%). Results The median time from cardiopulmonary resuscitation to ECLS initiation was 25 minutes (Q1-Q3, 18.5-28.5 minutes). Conventional CABG was performed in 10 patients (43.5%) who underwent concomitant intracardiac procedures. Postoperative ECLS was required in 16 patients (69.5%). The rate of successful ECLS weaning was 91.3% (n=21). There were 6 early mortalities (26.1%). Conclusion CABG after ECLS was very rare in real-world circumstances. Although the early mortality rate was high, the risk of mortality may be acceptable under such devastating circumstances.
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Affiliation(s)
- Younghwan Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang-Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji-Hyuk Yang
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Tak Lee
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wook Sung Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Heemoon Lee
- Department of Thoracic and Cardiovascular Surgery, Sejong Hospital, Bucheon, Korea
| | - Su Hyun Cho
- Extracorporeal Perfusion Team, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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16
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Iannacone EM, Girardi LN. Commentary: Quality reporting for salvage cardiac surgery-A deeper dive is needed. J Thorac Cardiovasc Surg 2019; 159:201-202. [PMID: 30879721 DOI: 10.1016/j.jtcvs.2019.02.030] [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: 02/05/2019] [Accepted: 02/07/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Erin M Iannacone
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, NY
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, NY.
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17
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Chancellor WZ, Mehaffey JH, Beller JP, Krebs ED, Hawkins RB, Yount K, Fonner CE, Speir AM, Quader MA, Rich JB, Yarboro LT, Teman NR, Ailawadi G. Current quality reporting methods are not adequate for salvage cardiac operations. J Thorac Cardiovasc Surg 2019; 159:194-200.e1. [PMID: 30826101 PMCID: PMC6660423 DOI: 10.1016/j.jtcvs.2019.01.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 12/19/2018] [Accepted: 01/15/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Outcomes in cardiac surgery are benchmarked against national Society of Thoracic Surgeons (STS) data and include patients undergoing elective, urgent, emergent, and salvage operations. This practice relies on accurate risk adjustment to avoid risk-averse behavior. We hypothesize that the STS risk calculator does not adequately characterize the risk of salvage operations because of their heterogeneity and infrequent occurrence. METHODS Data on all cardiac surgery patients with an STS predicted risk score (2002-2017) were extracted from a regional database of 19 cardiac surgery centers. Patients were stratified according to operative status for univariate analysis. Observed-to-expected (O:E) ratios for mortality and composite morbidity/mortality were calculated and compared among elective, urgent, emergent, and salvage patients. RESULTS A total of 76,498 patients met inclusion criteria. The O:E mortality ratios for elective, urgent, and emergent cases were 0.96, 0.98, and 0.93, respectively (all P values > .05). However, mortality rate was significantly higher than expected for salvage patients (O:E ratio, 1.41; P = .04). Composite morbidity/mortality rate was lower than expected in elective (O:E ratio, 0.81; P = .0001) and urgent (O:E ratio, 0.93; P = .0001) cases but higher for emergent (O:E ratio, 1.13; P = .0006) and salvage (O:E ratio, 1.24; P = .01). O:E ratios for salvage mortality were highly variable among each of the 19 centers. CONCLUSIONS The current STS risk models do not adequately predict outcomes for salvage cardiac surgery patients. On the basis of these results, we recommend more detailed reporting of salvage outcomes to avoid risk aversion in these potentially life-saving operations.
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Affiliation(s)
- William Z Chancellor
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - J Hunter Mehaffey
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va; Center for Health Policy, University of Virginia, Charlottesville, Va
| | - Jared P Beller
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - Elizabeth D Krebs
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - Robert B Hawkins
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va; Center for Health Policy, University of Virginia, Charlottesville, Va
| | - Kenan Yount
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | | | - Alan M Speir
- INOVA Heart and Vascular Institute, Falls Church, Va
| | - Mohammed A Quader
- Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, Va
| | - Jeffrey B Rich
- Virginia Cardiac Services Quality Initiative, Virginia Beach, Va
| | - Leora T Yarboro
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - Nicholas R Teman
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va.
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Wang L, Wang H, Hou X. Clinical Outcomes of Adult Patients Who Receive Extracorporeal Membrane Oxygenation for Postcardiotomy Cardiogenic Shock: A Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth 2018; 32:2087-2093. [DOI: 10.1053/j.jvca.2018.03.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Indexed: 12/12/2022]
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19
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Unmittelbare operative Myokardrevaskularisation nach Reanimation. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2018. [DOI: 10.1007/s00398-018-0237-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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20
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Khorsandi M, Dougherty S, Bouamra O, Pai V, Curry P, Tsui S, Clark S, Westaby S, Al-Attar N, Zamvar V. Extra-corporeal membrane oxygenation for refractory cardiogenic shock after adult cardiac surgery: a systematic review and meta-analysis. J Cardiothorac Surg 2017; 12:55. [PMID: 28716039 PMCID: PMC5512816 DOI: 10.1186/s13019-017-0618-0] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 07/10/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Postcardiotomy cardiogenic shock (PCCS) refractory to inotropic support and intra-aortic balloon pump (IABP) occurs rarely but is almost universally fatal without mechanical circulatory support. In this systematic review and meta-analysis we looked at the evidence behind the use of veno-arterial extra-corporeal membrane oxygenation (VA ECMO) in refractory PCCS from a patient survival rate and determinants of outcome viewpoint. METHODS A systematic review was performed in January 2017 using PubMed (with no defined time period) using the keywords "postcardiotomy", "cardiogenic shock", "extracorporeal membrane oxygenation" and "cardiac surgery". We excluded papers pertaining to ECMO following paediatric cardiac surgery, medical causes of cardiogenic shock, as well as case reports, review articles, expert opinions, and letters to the editor. Once the studies were collated, a meta-analysis was performed on the proportion of survivors in those papers that met the inclusion criteria. Meta-regression was performed for the most commonly reported adverse prognostic indicators (API). RESULTS We identified 24 studies and a cumulative pool of 1926 patients from 1992 to 2016. We tabulated the demographic data, including the strengths and weaknesses for each of the studies, outcomes of VA ECMO for refractory PCCS, complications, and APIs. All the studies were retrospective cohort studies. Meta-analysis of the moderately heterogeneous data (95% CI 0.29 to 0.34, p < 0.01, I 2 = 60%) revealed overall survival rate to hospital discharge of 30.8%. Some of the commonly reported APIs were advanced age (>70 years, 95% CI -0.057 to 0.001, P = 0.058), and long ECMO support (95% CI -0.068 to 0.166, P = 0.412). Postoperative renal failure, high EuroSCORE (>20%), diabetes mellitus, obesity, rising lactate whilst on ECMO, gastrointestinal complications had also been reported. CONCLUSION Haemodynamic support with VA ECMO provides a survival benefit with reasonable intermediate and long-term outcomes. Many studies had reported advanced age, renal failure and prolonged VA ECMO support as the most likely APIs for VA ECMO in PCCS. EuroSCORE can be utilized to anticipate the need for prophylactic perioperative VA ECMO in the high-risk category. APIs can be used to aid decision-making regarding both the institution and weaning of ECMO for refractory PCCS.
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Affiliation(s)
- Maziar Khorsandi
- Department of Cardiac Surgery and Transplantation, Golden Jubilee National Hospital, Glasgow, UK.
| | | | - Omar Bouamra
- Medical Statistics, Trauma, Audit & Research Network, University of Manchester, Salford Royal NHS foundation trust, Manchester, UK
| | - Vasudev Pai
- Department of Cardiovascular and Thoracic Surgery, Kasturba Medical College, Manipal University, Manipal, India
| | - Philip Curry
- Department of Cardiac Surgery and Transplantation, Golden Jubilee National Hospital, Glasgow, UK
| | - Steven Tsui
- Department of Cardiac Surgery and Transplantation, Papworth hospital, Cambridge, UK
| | - Stephen Clark
- Department of Cardiac surgery and Transplantation, Freeman hospital, Newcastle, UK
| | - Stephen Westaby
- Department of Cardiac Surgery, Oxford Heart Center, John Radcliffe Hospital, Oxford, UK
| | - Nawwar Al-Attar
- Department of Cardiac Surgery and Transplantation, Golden Jubilee National Hospital, Glasgow, UK
| | - Vipin Zamvar
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
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21
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Davierwala PM, Leontyev S, Verevkin A, Rastan AJ, Mohr M, Bakhtiary F, Misfeld M, Mohr FW. Temporal Trends in Predictors of Early and Late Mortality After Emergency Coronary Artery Bypass Grafting for Cardiogenic Shock Complicating Acute Myocardial Infarction. Circulation 2017; 134:1224-1237. [PMID: 27777292 DOI: 10.1161/circulationaha.115.021092] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 07/26/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiogenic shock after acute myocardial infarction is an indication for emergent coronary artery bypass grafting in patients not amenable to percutaneous coronary intervention. Our study aimed to evaluate and identify risk factors for early and long-term outcomes in such patients. METHODS A total of 508 patients who underwent coronary artery bypass grafting for cardiogenic shock complicating acute myocardial infarction between January 2000 and June 2014 were divided into 3 time cohorts: 2000 to 2004 (n=204), 2005 to 2009 (n=166), and 2010 to 2014 (n=138). Predictors of in-hospital mortality for each time cohort and long-term mortality for all patients were identified by logistic and Cox regression analyses, respectively. RESULTS Mean age was 68.3±9.8 years. Of the 508 patients, 78.5% had 3-vessel and 47.1% had left main disease. Left ventricular function <30% was observed in 44.1% of patients, with 30.4%, 37.9%, 52.9%, and 3.1% requiring preoperative resuscitation, ventilation, intra-aortic balloon pump, and extracorporeal membrane oxygenation support, respectively. Overall in-hospital mortality was 33.7%; declined from 42.2% to 30.7% to 24.6%, respectively, for the 3 time cohorts (P=0.02); and was independently predicted by serum lactate >4 mmol/L (odds ratio [OR], 4.78; 95% confidence interval, 2.88-7.95; P<0.0001), ST-segment-elevation myocardial infarction (OR, 2.10; 95% confidence interval, 1.36-3.26; P=0.001), age >75 years (OR, 2.01; 95% confidence interval, 1.06-3.85; P=0.03), and left ventricular ejection fraction <30% (OR, 1.83; 95% confidence interval, 1.15-2.91; P=0.01). Cumulative survival was 42.6±2.0% and 33.4±2.0% at 5 and 10 years, respectively, and correspondingly improved to 64.3±3.0% and 49.8±3.0% in hospital survivors. Serum lactate >4 mmol/L (OR, 2.2; P<0.0001), incremental age (OR, 1.05; P<0.0001), New York Heart Association class IV (OR, 1.33; P=0.02), diabetes mellitus (OR, 1.39; P=0.005), and preoperative inotropic (OR, 2.61; P=0.001) and extracorporeal membrane oxygenation (OR, 1.68; P=0.05) support predicted late mortality. CONCLUSIONS Emergency coronary artery bypass grafting in patients with acute myocardial infarction complicated by cardiogenic shock is associated with a high in-hospital mortality, which showed a significant decline with time. Hospital survivors have good long-term outcomes, which demonstrate the beneficial effect of surgical revascularization. Preoperative serum lactate >4 mmol/L is a strong predictor of both early and late mortality.
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Affiliation(s)
- Piroze M Davierwala
- From Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany (P.M.D., S.L., A.V., F.B., M. Misfeld, F.W.M.); Department of Cardiovascular Surgery, Heart and Circulatory Center, Rotenburg an der Fulda, Germany (A.J.R.); and Medizinische Klinik II, Sana Kliniken, Lübeck, Germany (M. Mohr).
| | - Sergey Leontyev
- From Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany (P.M.D., S.L., A.V., F.B., M. Misfeld, F.W.M.); Department of Cardiovascular Surgery, Heart and Circulatory Center, Rotenburg an der Fulda, Germany (A.J.R.); and Medizinische Klinik II, Sana Kliniken, Lübeck, Germany (M. Mohr)
| | - Alexander Verevkin
- From Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany (P.M.D., S.L., A.V., F.B., M. Misfeld, F.W.M.); Department of Cardiovascular Surgery, Heart and Circulatory Center, Rotenburg an der Fulda, Germany (A.J.R.); and Medizinische Klinik II, Sana Kliniken, Lübeck, Germany (M. Mohr)
| | - Ardawan J Rastan
- From Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany (P.M.D., S.L., A.V., F.B., M. Misfeld, F.W.M.); Department of Cardiovascular Surgery, Heart and Circulatory Center, Rotenburg an der Fulda, Germany (A.J.R.); and Medizinische Klinik II, Sana Kliniken, Lübeck, Germany (M. Mohr)
| | - Matthias Mohr
- From Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany (P.M.D., S.L., A.V., F.B., M. Misfeld, F.W.M.); Department of Cardiovascular Surgery, Heart and Circulatory Center, Rotenburg an der Fulda, Germany (A.J.R.); and Medizinische Klinik II, Sana Kliniken, Lübeck, Germany (M. Mohr)
| | - Farhad Bakhtiary
- From Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany (P.M.D., S.L., A.V., F.B., M. Misfeld, F.W.M.); Department of Cardiovascular Surgery, Heart and Circulatory Center, Rotenburg an der Fulda, Germany (A.J.R.); and Medizinische Klinik II, Sana Kliniken, Lübeck, Germany (M. Mohr)
| | - Martin Misfeld
- From Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany (P.M.D., S.L., A.V., F.B., M. Misfeld, F.W.M.); Department of Cardiovascular Surgery, Heart and Circulatory Center, Rotenburg an der Fulda, Germany (A.J.R.); and Medizinische Klinik II, Sana Kliniken, Lübeck, Germany (M. Mohr)
| | - Friedrich W Mohr
- From Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany (P.M.D., S.L., A.V., F.B., M. Misfeld, F.W.M.); Department of Cardiovascular Surgery, Heart and Circulatory Center, Rotenburg an der Fulda, Germany (A.J.R.); and Medizinische Klinik II, Sana Kliniken, Lübeck, Germany (M. Mohr)
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Joffre J, Preda G, Arrivé L, Maury E. Fatal Aortic Dissection during Extracorporeal Membrane Oxygenation Axillary Cannulation Confirmed by Postmortem Computed Tomography Angiography. Am J Respir Crit Care Med 2017; 195:953-954. [PMID: 28277737 DOI: 10.1164/rccm.201609-1923im] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Jérémie Joffre
- 1 Medical Intensive Care Unit, and.,2 INSERM U970, Cardiovascular Research Center, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Lionel Arrivé
- 3 Department of Radiology, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France; and
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23
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Santarpino G, Fischlein T, Biancari F. Emergency CABG: The Importance of Definition Criteria. Ann Thorac Surg 2016; 102:674-5. [PMID: 27449433 DOI: 10.1016/j.athoracsur.2016.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 03/01/2016] [Accepted: 03/02/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Giuseppe Santarpino
- Department of Cardiac Surgery, Paracelsus Medical University, Breslauerstrasse 201-90471, Nuremberg, Germany.
| | - Theodor Fischlein
- Department of Cardiac Surgery, Paracelsus Medical University, Breslauerstrasse 201-90471, Nuremberg, Germany
| | - Fausto Biancari
- Department of Cardiac Surgery, University of Oulu, Oulu, Finland
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