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Bashline M, DiBridge J, Klass WJ, Morelli B, Kaczorowski D, Schmidhofer M, Horn ET, Gomez H, Ramanan R, Hickey GW, Rivosecchi RM. Outcomes of systemic bivalirudin and sodium bicarbonate purge solution for Impella 5.5. Artif Organs 2023; 47:361-369. [PMID: 36271639 DOI: 10.1111/aor.14428] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 07/09/2022] [Accepted: 10/13/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Impella 5.5 (Abiomed; Danvers, MA) (IMP5) is a commonly used, surgically implanted, tMCS device that requires systemic anticoagulation and purge solution to avoid pump failure. To avoid heparin-induced thrombocytopenia (HIT) from unfractionated heparin (UFH) use, our program has explored the utility of bivalirudin (BIV) for systemic anticoagulation and sodium bicarbonate-dextrose purge solution (SBPS) in IMP5.5. METHODS This single center, retrospective study included 34 patients supported on IMP5.5 with BIV based AC and SBPS between December 1st 2020 to December 1st 2021.The efficacy and safety end points were incidence of development of HIT, Tissue Plasminogen Activator (tPA) use for suspected pump thrombosis, stroke, and device failure as well as clinically significant bleeding. RESULTS The median duration of IMP5.5 support was 9.8 days (IQR: 6-15). Most patients were bridged to HTX (58%) followed by recovery (27%) and LVAD implantation (15%). Patients were therapeutic on bivalirudin for 64% of their IMP5.5 support. One patient (2.9%) suffered from ischemic stroke and 26.5% (9) patients developed clinically significant bleeding. tPA was administered to 7(21%) patients. One patient in the entire cohort developed HIT. CONCLUSIONS Our experience supports the use of systemic BIV and SBPS as a method to avoid heparin exposure in a patient population predisposed to the development of HIT.
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Affiliation(s)
- Michael Bashline
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Julie DiBridge
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Wyatt J Klass
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Brian Morelli
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David Kaczorowski
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mark Schmidhofer
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Edward T Horn
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hernando Gomez
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Raj Ramanan
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gavin W Hickey
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ryan M Rivosecchi
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Reza J, Mila A, Ledzian B, Sun J, Silvestry S. Incremental cost-effectiveness of extracorporeal membranous oxygenation as a bridge to cardiac transplant or left ventricular assist device placement in patients with refractory cardiogenic shock. JTCVS OPEN 2022; 11:132-145. [PMID: 36172402 PMCID: PMC9510879 DOI: 10.1016/j.xjon.2022.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/26/2022] [Accepted: 06/27/2022] [Indexed: 11/18/2022]
Abstract
Objective Emerging literature has described using venoarterial extracorporeal membranous oxygenation (ECMO) as a bridge to transplant or left ventricular assist device (LVAD) placement. We sought to identify the incremental cost-effectiveness ratio (ICER) of ECMO used as a bridge to cardiac transplant or LVAD. Methods Patients with refractory cardiogenic shock who received venoarterial ECMO and were bridged to either cardiac transplant (n = 7) or a HeartMate 3 LVAD (n = 6) placement were included. Markov modeling was used, comparing ECMO bridging with non–ECMO-bridged patients. Cohorts entered the model alive and at every 1-year cycle, were exposed to risk of death, and ran forward for 20 years after transplant or LVAD. Results Patients bridged with ECMO to cardiac transplant were stratified as group 1 whereas those bridged with ECMO to LVAD were stratified as group 2. The average ECMO run was 3 days in group 1 versus 11 days in group 2. Among group 1 patients, the ICER was $246,629 but was paired with a longer life expectancy. The ICER of group 2 patients was –$107,088 and was not paired with a longer life expectancy. The average inpatient cost for group 1 was found to be $636,023 versus $769,471 for group 2 patients. The average inpatient costs for patients not bridged to ECMO who received cardiac transplant or LVAD was $538,928 and $325,242, respectively. Conclusions Using ECMO to bridge to transplant or LVAD placement is not cost effective. However, patients bridged to transplant are paired with longer life expectancy in contrast to patients bridged to LVAD.
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Affiliation(s)
- Joseph Reza
- General Surgery Residency Program, AdventHealth Orlando, Orlando, Fla
- Address for reprints: Joseph Reza, MD, 3401 N. Broad St. C501. Philadelphia, PA 19140.
| | - Ashley Mila
- General Surgery Residency Program, AdventHealth Orlando, Orlando, Fla
| | - Bradford Ledzian
- AdventHealth Transplant Institute, Thoracic Transplant and Cardiovascular Surgery, AdventHealth Orlando, Orlando, Fla
| | - Jingwei Sun
- Center for Academic Research, AdventHealth Orlando, Orlando, Fla
| | - Scott Silvestry
- AdventHealth Transplant Institute, Thoracic Transplant and Cardiovascular Surgery, AdventHealth Orlando, Orlando, Fla
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Trials for Mechanical Circulatory Support Devices in Cardiogenic Shock. Am J Cardiol 2022; 179:123-125. [PMID: 35879154 DOI: 10.1016/j.amjcard.2022.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/17/2022] [Accepted: 06/22/2022] [Indexed: 11/20/2022]
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Zhou AL, Etchill EW, Giuliano KA, Shou BL, Sharma K, Choi CW, Kilic A. Bridge to transplantation from mechanical circulatory support: a narrative review. J Thorac Dis 2022; 13:6911-6923. [PMID: 35070375 PMCID: PMC8743412 DOI: 10.21037/jtd-21-832] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 08/25/2021] [Indexed: 12/12/2022]
Abstract
Objective To highlight recent developments in the utilization of mechanical circulatory support (MCS) devices as bridge-to-transplant strategies and to discuss trends in MCS use following the changes to the United Network for Organ Sharing (UNOS) heart allocation system. Background MCS devices have played an increasingly important role in the treatment of heart failure patients. Over the past several years, technological advancements have led to new developments in MCS devices and expanding indications for MCS use. In October of 2018, the UNOS heart allocation policy was revised to prioritize higher-urgency patients, including those supported with temporary MCS devices. Since then, changes in trends of MCS utilization have been observed. Methods Articles from the PubMed database regarding the use of MCS devices as bridge-to-transplant strategies were reviewed. Conclusions Over the past decade, utilization of temporary MCS devices, which include the intra-aortic balloon pump (IABP), percutaneous ventricular assist devices (pVADs), and extracorporeal membrane oxygenation (ECMO), has become increasingly common. Recent advancements in MCS include the development of pVADs that can fully unload the left ventricle (LV) as well as devices designed to provide right-sided support. Technological advancements in durable left ventricular assist devices (LVADs) have also led to improved outcomes both on the device and following heart transplantation. Following the 2018 UNOS heart allocation policy revision, the utilization of temporary MCS in advanced heart failure patients has further increased and the proportion of patients bridged directly from a temporary MCS device has exponentially risen. However, following the start of the COVID-19 pandemic, the trends have reversed, with a decrease in the percentage of patients bridged from a temporary MCS device. As long-term data following the allocation policy revision becomes available, future studies should investigate how trends in MCS use for patients with advanced heart failure continue to evolve.
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Affiliation(s)
- Alice L Zhou
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Eric W Etchill
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Katherine A Giuliano
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Kavita Sharma
- Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Chun W Choi
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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Wang Z, Yu H, Yan S, Yan H, Chen D, Dai Y, Xu Q, Zeng Z, Zhang W, Jin L. Evaluation of a Novel Left Ventricular Assist Device for Resuscitation in an Animal Model of Ventricular Fibrillation Cardiac Arrest. IEEE JOURNAL OF TRANSLATIONAL ENGINEERING IN HEALTH AND MEDICINE 2021; 10:1900107. [PMID: 34984109 PMCID: PMC8719647 DOI: 10.1109/jtehm.2021.3135445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 09/06/2021] [Accepted: 12/09/2021] [Indexed: 12/02/2022]
Abstract
We evaluated an independently developed novel percutaneous implantable left ventricular assist device for resuscitation in a pig model of ventricular fibrillation cardiac arrest. The model was established in 10 domestic pigs by blocking the anterior descending coronary artery with a balloon after anesthesia. With ventilator-assisted ventilation, the independently developed percutaneous implantable left ventricular assist device was inserted via the femoral artery to assist circulation. According to whether effective circulatory support was achieved, the pigs were randomly divided into an experimental group and a control group. The experimental group was subjected to insertion of the assist device and received continuous circulatory support. The control group underwent insertion of the assist device; however, it did not start it within 15 minutes. For all animals, if successful rescue was achieved (sinus rhythm restoration within 15 minutes and maintenance for over 5 minutes), circulatory support was stopped, and the arterial blockage was removed. If sinus rhythm was not restored within 15 minutes, electric defibrillation, adrenaline injection, and removal of the arterial blockage were performed, and circulatory support was provided until sinus rhythm recovered. A determination of failed rescue was made when sinus rhythm was not restored after 1 hour. All successfully rescued animals were fed for 1 week. There were no significant differences in baseline data between the groups. All animals underwent successful novel left ventricular assist device implantation through the femoral artery. The rescue rate was significantly higher in the experimental group than in the control group (80% vs. 0%, [Formula: see text]). All successfully rescued animals survived after 1 week of feeding, and no eating or movement abnormalities were observed. We conclude that this independently developed percutaneous implantable left ventricular assist device can be conveniently and rapidly implanted through the femoral artery and can maintain basic circulatory perfusion during resuscitation in an animal model of cardiac arrest.
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Affiliation(s)
- Zongtao Wang
- The First Affiliated Hospital of Guangdong Pharmaceutical UniversityGuangzhouGuangdong510008China
| | - Huiming Yu
- Hypertension Research Laboratory, Guangdong Provincial People’s HospitalDepartment of CardiologyGuangdong Cardiovascular Institute, Guangdong Academy of Medical SciencesGuangzhouGuangdong510080China
| | | | - Hong Yan
- Hypertension Research Laboratory, Guangdong Provincial People’s HospitalDepartment of CardiologyGuangdong Cardiovascular Institute, Guangdong Academy of Medical SciencesGuangzhouGuangdong510080China
| | - Danhong Chen
- Hypertension Research Laboratory, Guangdong Provincial People’s HospitalDepartment of CardiologyGuangdong Cardiovascular Institute, Guangdong Academy of Medical SciencesGuangzhouGuangdong510080China
| | - Yining Dai
- Hypertension Research Laboratory, Guangdong Provincial People’s HospitalDepartment of CardiologyGuangdong Cardiovascular Institute, Guangdong Academy of Medical SciencesGuangzhouGuangdong510080China
| | - Qichun Xu
- Hypertension Research Laboratory, Guangdong Provincial People’s HospitalDepartment of CardiologyGuangdong Cardiovascular Institute, Guangdong Academy of Medical SciencesGuangzhouGuangdong510080China
| | - Zhihuan Zeng
- The First Affiliated Hospital of Guangdong Pharmaceutical UniversityGuangzhouGuangdong510008China
| | - Wei Zhang
- The First Affiliated Hospital of Guangdong Pharmaceutical UniversityGuangzhouGuangdong510008China
| | - Lijun Jin
- Hypertension Research Laboratory, Guangdong Provincial People’s HospitalDepartment of CardiologyGuangdong Cardiovascular Institute, Guangdong Academy of Medical SciencesGuangzhouGuangdong510080China
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Lang CN, Zotzmann V, Schmid B, Kaier K, Bode C, Wengenmayer T, Staudacher DL. Utilization of transfusions and coagulation products in cardiogenic shock with and without mechanical circulatory support. J Crit Care 2021; 65:62-64. [PMID: 34090149 DOI: 10.1016/j.jcrc.2021.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/30/2021] [Accepted: 05/25/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Corinna N Lang
- Department of Cardiology and Angiology I (Heart Center Freiburg University - Bad Krozingen), Medical Center, Faculty of Medicine, University of Freiburg, Germany; Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Germany.
| | - Viviane Zotzmann
- Department of Cardiology and Angiology I (Heart Center Freiburg University - Bad Krozingen), Medical Center, Faculty of Medicine, University of Freiburg, Germany; Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Bonaventura Schmid
- Department of Emergency Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Klaus Kaier
- Institute for Medical Biometry and Statistics, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I (Heart Center Freiburg University - Bad Krozingen), Medical Center, Faculty of Medicine, University of Freiburg, Germany; Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Tobias Wengenmayer
- Department of Cardiology and Angiology I (Heart Center Freiburg University - Bad Krozingen), Medical Center, Faculty of Medicine, University of Freiburg, Germany; Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Dawid L Staudacher
- Department of Cardiology and Angiology I (Heart Center Freiburg University - Bad Krozingen), Medical Center, Faculty of Medicine, University of Freiburg, Germany; Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Germany
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Loungani RS, Fudim M, Ranney D, Kochar A, Samsky MD, Bonadonna D, Itoh A, Takayama H, Takeda K, Wojdyla D, DeVore AD, Daneshmand M. Contemporary Use of Venoarterial Extracorporeal Membrane Oxygenation: Insights from the Multicenter RESCUE Registry. J Card Fail 2021; 27:327-337. [PMID: 33347997 DOI: 10.1016/j.cardfail.2020.11.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 11/24/2020] [Accepted: 11/27/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as a life-saving therapy for patients with cardiovascular collapse, but identifying patients unlikely to benefit remains a challenge. METHODS AND RESULTS We created the RESCUE registry, a retrospective, observational registry of adult patients treated with VA-ECMO between January 2007 and June 2017 at 3 high-volume centers (Columbia University, Duke University, and Washington University) to describe short-term patient outcomes. In 723 patients treated with VA-ECMO, the most common indications for deployment were postcardiotomy shock (31%), cardiomyopathy (including acute heart failure) (26%), and myocardial infarction (17%). Patients frequently suffered in-hospital complications, including acute renal dysfunction (45%), major bleeding (41%), and infection (33%). Only 40% of patients (n = 290) survived to discharge, with a minority receiving durable cardiac support (left ventricular assist device [n = 48] or heart transplantation [n = 7]). Multivariable regression analysis identified risk factors for mortality on ECMO as older age (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.12-1.42) and female sex (OR, 1.44; 95% CI, 1.02-2.02) and risk factors for mortality after decannulation as higher body mass index (OR 1.17; 95% CI, 1.01-1.35) and major bleeding while on ECMO support (OR, 1.92; 95% CI, 1.23-2.99). CONCLUSIONS Despite contemporary care at high-volume centers, patients treated with VA-ECMO continue to have significant in-hospital morbidity and mortality. The optimization of outcomes will require refinements in patient selection and improvement of care delivery.
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Affiliation(s)
- Rahul S Loungani
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina.
| | - Marat Fudim
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Dave Ranney
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Ajar Kochar
- Division of Cardiology, Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Marc D Samsky
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Desiree Bonadonna
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Akinobu Itoh
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Hiroo Takayama
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York
| | - Koji Takeda
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York
| | - Daniel Wojdyla
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Adam D DeVore
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Mani Daneshmand
- Department of Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
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Vasopressors and Inotropes as Predictors of Mortality in Acute Severe Cardiogenic Shock Treated With the Impella Device. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 31:71-75. [PMID: 33309042 DOI: 10.1016/j.carrev.2020.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/24/2020] [Accepted: 12/01/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Vasopressors and inotropes are the primary pharmacologic agents in the management of cardiogenic shock. Increased use of these agents in the setting of cardiogenic shock treated with the Impella is associated with increased mortality. This study evaluates the use of vasopressors and inotropes as predictors of mortality in patients treated with the Impella for acute cardiogenic shock. METHODS This retrospective study included 276 patients treated with the Impella 2.5, Impella CP, or Impella 5.0 from March 2011 to January 2020 at a single, tertiary referral center for acute cardiogenic shock. RESULTS All-cause in-hospital mortality was 44.6%. Mortality significantly increased with escalating use of vasopressors and inotropes, with the most significant increase in mortality from use of 2 agents to the use of 3 agents (8.1% vs 39.7%, p < 0.001). There was no difference in mortality whether dobutamine or milrinone was used (44.4% vs 35.7%, p = 0.41); there was increased mortality with use of multiple inotropes. Patients treated with only vasopressors had increased mortality compared to those treated with a combination of agents that included 1 inotrope. CONCLUSIONS The escalating need for vasopressors and inotropes and particular combinations of these agents are significant predictors of mortality that may help determine whether the Impella or higher level of support is more appropriate to treat acute cardiogenic shock.
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Trends, Outcomes, and Predictors of Revascularization in Cardiogenic Shock. Am J Cardiol 2020; 125:328-335. [PMID: 31784052 DOI: 10.1016/j.amjcard.2019.10.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 10/20/2019] [Accepted: 10/28/2019] [Indexed: 12/19/2022]
Abstract
Cardiogenic shock (CS) carries high mortality and morbidity. Early revascularization is an important strategy in management of these patients. We sought to determine the outcomes and predictors of revascularization among patients with CS. Patients with CS and acute myocardial infarction were identified using the National Inpatient Sample (NIS) data from January 2002 to December 2014 using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Subsequently, patients who underwent revascularization were then selected. A total of 118,618 patients with CS were identified. Out of these, about 55,735 (47%) patients underwent revascularization. Mean age of patients who underwent revascularization was lower when compared with patients not who underwent revascularization (66.40 vs 72.24 years, p < 0.01). Patients who underwent revascularization had lower mortality when compared with patients not who underwent revascularization (25.1% vs 52.2%, p < 0.01). Extracorporeal membrane oxygenation and mechanical circulatory support devices were often utilized more in patients who underwent revascularization. Overall, we found modest increased trend of revascularization over our study years with decline in mortality. Female gender, weekend admission, drug abuse, pulmonary hypertension, anemia, renal failure, neurological disorders, malignancy were associated with lower odds of revascularization. In conclusion, in this large nationally represented US population sample of CS patients, we found revascularization rate of about 47% with improvement in overall mortality over our study years.
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