Extracorporeal Membrane Oxygenation in a Patient With Peripartum Cardiomyopathy

Peripartum Cardiogenic Shock and Mechanical Circulatory Support

Despite remarkable improvements in the past two decades, the annual cardiovascular mortality rate has remained higher for women than for men. Pregnant women represent an underinvestigated population in clinical research, and the mechanisms of long-term cardiovascular complications in women with obstetric complications remain to be elucidated. Regarding advanced heart failure during pregnancy, interventional approaches are effective but still underutilised. Percutaneous mechanical circulatory support is a valuable option for peripartum cardiogenic shock, although its use during pregnancy is still limited. Survival rates have improved in recent years, but further emphasis on the importance of early recognition and initiation of heart failure treatment in this patient group is warranted. The aims of this review are to summarise the current literature on the implementation of mechanical circulatory support in cardiogenic shock during pregnancy and delivery and to understand the role of percutaneous ventricular assist devices in the management of such conditions.

Extracorporeal membrane oxygenation in pregnant and postpartum patients: a systematic review

PURPOSE

Information on the use of extracorporeal membrane oxygenation (ECMO) in obstetric patients is scarce. The objective was to conduct a systematic review examining ECMO use in pregnant and postpartum patients in order to identify indications leading to ECMO use and to assess mortality rates.

MATERIALS AND METHODS

PubMed, EMBASE, Cochrane Library, and SCOPUS were searched using the terms "extracorporeal membrane oxygenation" and "pregnancy" up to 1 November 2020. Case reports and case series reporting the use of ECMO in pregnancy were eligible. Data about maternal age, gestational age, diagnosis, type of ECMO, time on ECMO, pregnancy outcomes, and maternal survival were extracted from studies.

RESULTS

The search yielded 1696 citations, of which 125 were included. There were 213 obstetric patients treated with ECMO over a 30-year period. The frequency of reports increased considerably over the last decade. The majority of patients were treated in their third trimester (28.2%) or postpartum (32.9%). Most common etiologies included influenza-induced ARDS (27.7%), pulmonary embolism (13.6%), peripartum cardiomyopathy (11.7%), and infection (11.7%). Pregnancy outcomes ended with live births, either on ECMO (15.5%, 95% CI 10.6-20.4) or not on ECMO (58.3%, 95% CI 51.7-64.9), in fetal demise (8.9%, 95% CI 5.1-12.7), or in spontaneous or induced abortion on ECMO (4.2%, 95% CI 1.5-6.9) or not on ECMO (4.2%, 95% CI 1.5-6.9). Maternal survival was 79.3%.

CONCLUSION

Although women placed on ECMO had a high mortality rate, this is likely an indication of the severity of illness. Overall, ECMO appears to be a valid therapy for the temporary support of vital organs in severely ill pregnant women.

Extracorporeal Life Support in Pregnancy: A Systematic Review

Background The use of extracorporeal life support (ECLS) has expanded to include unique populations such as peripartum women. This systematic review aims to (1) quantify the number of cases and indications for ECLS in women during the peripartum period reported in the literature and (2) report maternal and fetal complications and outcomes associated with peripartum ECLS. Methods and Results This review was registered in PROSPERO (CRD42018108142). MEDLINE, Embase, and CINAHL were searched for case reports, case series, and studies reporting cases of ECLS during the peripartum period that reported one or more of the following outcomes: maternal survival, maternal complications, fetal survival, and/or fetal complications. Qualitative assessment of 221 publications evaluated the number of cases, clinical details, and maternal and fetal outcomes of ECLS during the peripartum period. There were 358 women included and 68 reported fetal outcomes in cases where the mother was pregnant at the time of cannulation. The aggregate maternal survival at 30 days was 270 (75.4%) and at 1 year was 266 (74.3%); fetal survival was 44 (64.7%). The most common indications for ECLS overall in pregnancy included acute respiratory distress syndrome 177 (49.4%), cardiac failure 67 (18.7%), and cardiac arrest 57 (15.9%). The most common maternal complications included mild to moderate bleeding 66 (18.4%), severe bleeding requiring surgical intervention 48 (13.4%), and intracranial neurologic morbidity 19 (5.3%). The most commonly reported fetal complications included preterm delivery 33 (48.5%) and neonatal intensive care unit admission 19 (27.9%). Conclusions Reported rates of survival in ECLS in pregnant and postpartum women are high and major complications relatively low.

Extracorporeal membrane oxygenation in peripartum cardiomyopathy: A review of the ELSO Registry

AIMS

Data on the use of extracorporeal membrane oxygenation (ECMO) for cardiogenic shock in peripartum cardiomyopathy (PPCM) is limited. We queried the Extracorporeal Life Support Organization (ELSO) Registry for PPCM patients treated with ECMO in order to characterize demographic and clinical features, complications, survival, and variables associated with mortality.

METHODS AND RESULTS

This was a retrospective review of patients voluntarily entered into the ELSO Registry. De-identified data was collected on patients with a diagnosis of PPCM based on ICD-9/ICD-10 coding who received ECMO between 2007 and 2019. Collected data included demographics, ECMO mode, cannulation strategies, pre-ECMO ventilator, biochemical, and hemodynamic parameters, run duration, complications, and survival to wean off ECMO and hospital discharge. Our primary outcome measure was survival to discharge. In the final analysis, 88 veno-arterial (VA) ECMO patients were included. Overall, 72% of patients were weaned off ECMO, including 10% who were weaned to ventricular assist device or heart transplantation, and 64% survived to hospital discharge. Extracorporeal cardiopulmonary resuscitation (ECPR) was performed in 11% of patients with 60% survival. Factors associated with decreased survival included neurologic complications (p = 0.03), specifically central nervous system hemorrhage (p = 0.01).

CONCLUSION

Our review is the largest to date of PPCM patients supported with VA ECMO for cardiogenic shock. ECMO and ECPR are valuable forms of short-term mechanical circulatory support with acceptable mortality profiles for PPCM patients who remain refractory to aggressive medical management. Complications should be meticulously avoided, especially neurologic complications.

Extracorporeal Membrane Oxygenation During Adult Noncardiac Surgery and Perioperative Emergencies: A Narrative Review

Over the last decade, the use of extracorporeal membrane oxygenation (ECMO) has increased significantly. In some centers, ECMO has been deployed to manage perioperative emergencies and plays a role in facilitating high-risk thoracic, airway, and trauma surgery, which may not be feasible without ECMO support. General anesthesiologists who usually manage these cases may not be familiar with the initiation and management of patients on ECMO. This review discusses the use of ECMO in the operating room for thoracic, airway, and trauma surgery, as well as obstetric and perioperative emergencies.

Use of Impella heart pump for management of women with peripartum cardiogenic shock

Background

Percutaneous mechanical circulatory support (MCS), such as the Impella heart pump is a valuable option for cardiogenic shock (CS), although the use of Impella in CS due to peripartum cardiomyopathy (PPCM) is limited.

Objective

To assess outcomes in women with PPCM supported with an Impella device from the global catheter‐based ventricular assist device (cVAD) Registry.

Methods and Results

A total of 15 women with PPCM supported with Impella devices between November 2008 and October 2015 were included. Of the 15 women, five were treated at Hannover medical school and have been reported previously, the rest were managed at various US hospitals. The mean age was 30.0 ± 7.34 years, eight women were Caucasian, and seven were African‐American. The occurrence of PPCM was post‐delivery in eight (53.3%), at delivery in one (6.7%), and during gestation in four women (26.7%). At admission, all women had severe heart failure with a mean ejection fraction of 14.7 ± 6% and 13 women (86.7%) presented with CS. Prior to Impella, 100% were mechanically ventilated, 79% received inotropes/vasopressors, 20% supported with IABP, and 27% received veno‐arterial extracorporeal membrane oxygenation (VA ECMO) during Impella support. Two women (13.3%) died, and 13 (87.7%) survived to discharge. Eight women (53.3%) had a recovery of native heart function and six (40%) were bridged to durable left ventricular assist device (LVAD).

Conclusion

MCS with Impella devices can be successfully used as a bridge to early improvement, heart recovery, or successful implantation of durable LVAD in women with PPCM complicated by severe LV dysfunction.

Preemptive ECMO Cannulation in a Patient with Severe Left Ventricular Systolic Dysfunction Undergoing Cesarean Delivery

Obstetric patients with heart failure undergoing cesarean delivery are high risk and the perioperative care of these patients poses significant multidisciplinary challenges. In contrast to the nonobstetric patient population the potential role of mechanical circulatory support in parturients with heart failure is not well established and the use of extracorporeal membrane oxygenation (ECMO) has rarely been reported. We report the case of a super morbidly obese patient with decompensated heart failure, pulmonary hypertension, and superimposed preeclampsia undergoing preemptive ECMO cannulation for urgent cesarean delivery.

Peripartum Cardiomyopathy: Current Options for Treatment and Cardiovascular Support

Peripartum cardiomyopathy is a rare form of acute heart failure but the major cause of all deaths in pregnant patients with heart failure. Improved survival rates in recent years, however, emphasize the importance of early recognition and initiation of heart failure treatment. This article, therefore, attempts to raise awareness among cardiac and obstetric anesthesiologists as well as intensivists of this often fatal diagnosis. This review summarizes theories of the pathophysiology and outcome of peripartum cardiomyopathy. Based on the most recent literature, it further outlines diagnostic criteria and treatment options including medical management, mechanical circulatory support devices, and heart transplantation. Earlier recognition of this rare condition and a new generation of mechanical circulatory devices has contributed to the improved outcome. More frequently, patients in cardiogenic shock who fail medical management are successfully bridged to recovery on extracorporeal circulatory devices or survive with a long-lasting implantable ventricular assist device. The outcome of transplanted patients with peripartum cardiomyopathy, however, is worse compared to other recipients of heart transplants and warrants further investigation in the future.

Veno-venous ECMO as a safe bridge to recovery in a patient with severe peripartum cardiomyopathy – learning from errors

Peripartum cardiomyopathy (PPCM) is a rare disorder of unknown etiology and pathogenesis. The most important tool for diagnostic confirmation is transthoracic echocardiography. The recommended management of PPCM in pregnancy is summarized by the European Society of Cardiology Heart Failure Guidelines. Few data exist on the treatment of patients with fulminant PPCM and the need for extracorporeal membrane oxygenation (ECMO) in this context. We report on a young multiparous woman with cardiogenic shock caused by severe PPCM who was successfully, but atypically, supported with veno-venous ECMO as a bridge to recovery immediately after the birth of her third child.

Discoveries in peripartum cardiomyopathy

The past decade has seen remarkable gains for outcomes in peripartum cardiomyopathy (PPCM), one of the leading causes of maternal mortality and morbidity in the USA and many other countries, including the high-incidence areas of Haiti and South Africa. This review article emphasizes the importance of continuing the process of increasing awareness of PPCM and presents details of this evolving picture, including important discoveries that point the way to full recovery for almost all PPCM subjects. In addition, new interventions will be highlighted, which may facilitate recovery. Numerous studies have demonstrated that when the diagnosis of PPCM is made with LVEF > 0.30, the probability is that recovery to LVEF ≥ 0.50 will occur in the overwhelming majority of subjects. PPCM patients diagnosed with severely depressed systolic function (LVEF < 0.30) and a remodeled left ventricle with greater dilatation (LVEDd ≥ 60mm) are least likely to reach the outcome recovery goals. These are the patients with the greatest need for newer interventional strategies.

Anesthetic experience using extracorporeal membrane oxygenation for cesarean section in the patient with peripartum cardiomyopathy: a case report

Peripartum cardiomyopathy is a rare form of cardiomyopathy that is associated with significant mortality. It can cause a cardiac arrest during cesarean section even though the patient does not have any previous symptom and sign. The most important thing of anesthesia in this patient is an optimization of hemodynamic and respiratory status. We report the successful general anesthesia using of extracorporeal membrane oxygenation for cesarean section in a 34-year-old woman with fulminant peripartum cardiomyopathy.

Peripartum cardiomyopathy: moving towards a more central role of genetics

Peripartum cardiomyopathy (PCM) is a relatively rare disease with potentially devasting consequences requiring prompt identification and correct treatment. Overall prognosis is good in majority of the cases, although some patients may progress to irreversible heart failure. Early diagnosis is important and effective treatment reduces mortality rates and increases the chance of complete recovery of ventricular systolic function. The aetiology and pathogenesis seems to be multifactorial and poorly understood, with the available literature rather conflicting. In recent years, there has been increased interest in the role played by genetic predisposition in the development of PCM. It probably develops as a result of a complex interaction of pregnancy-associated factors and genetic factors and recently there have been many observations pointing out the central role played by a genetic predisposition. The direct and indirect observations on genetic susceptibility may offer new insights into the pathogenesis of PCM. However, larger studies are needed before advising routine genetic testing in these patients.

Clinical characteristics of peripartum cardiomyopathy in the United States: diagnosis, prognosis, and management

Peripartum cardiomyopathy is a pregnancy-associated myocardial disease characterized by the development of heart failure due to marked left ventricular systolic dysfunction. Although the disease is relatively uncommon, its incidence is increasing, and it can be associated with important and lasting morbidity and with mortality. Peripartum cardiomyopathy seems to affect women in different parts of the world but with considerable differences in clinical presentation. The purposes of this review are to describe the clinical profile of peripartum cardiomyopathy in the United States and to provide recommendations for the diagnosis and the management of this disease.

Acute and critically ill peripartum cardiomyopathy and 'bridge to' therapeutic options: a single center experience with intra-aortic balloon pump, extra corporeal membrane oxygenation and continuous-flow left ventricular assist devices

INTRODUCTION

Peripartum cardiomyopathy (PPCM) patients refractory to medical therapy and intra-aortic balloon pump (IABP) counterpulsation or in whom weaning from these therapies is impossible, are candidates for a left ventricular assist device (LVAD) as a bridge to recovery or transplant. Continuous-flow LVADs are smaller, have a better long-term durability and are associated with better outcomes. Extra corporeal membrane oxygenation (ECMO) can be used as a temporary support in patients with refractory cardiogenic shock. The aim of this study was to evaluate the efficacy and safety of mechanical support in acute and critically ill PPCM patients.

METHODS

This was a retrospective search of the patient database of the Ghent University hospital (2000 to 2010).

RESULTS

Six PPCM-patients were treated with mechanical support. Three patients presented in the postpartum period and three patients at the end of pregnancy. All were treated with IABP, the duration of IABP support ranged from 1 to 13 days. An ECMO was inserted in one patient who presented with cardiogenic shock, multiple organ dysfunction syndrome and a stillborn baby. Two patients showed partial recovery and could be weaned off the IABP. Four patients were implanted with a continuous-flow LVAD (HeartMate II, Thoratec Inc.), including the ECMO-patient. Three LVAD patients were successfully transplanted 78, 126 and 360 days after LVAD implant; one patient is still on the transplant waiting list. We observed one peripheral thrombotic complication due to IABP and five early bleeding complications in three LVAD patients. One patient died suddenly two years after transplantation.

CONCLUSIONS

In PPCM with refractory heart failure IABP was safe and efficient as a bridge to recovery or as a bridge to LVAD. ECMO provided temporary support as a bridge to LVAD, while the newer continuous-flow LVADs offered a safe bridge to transplant.

Veno-arterial extracorporeal membrane oxygenation for high-risk cardiac catheterisation procedures

Extracorporeal membrane oxygenation (ECMO) provides circulatory or respiratory support, or both, to patients with severe but potentially reversible cardiac or respiratory failure refractory to standard therapy. The use of ECMO in the paediatric cardiac surgical population is established. Likewise, the use of ECMO for severe adult respiratory failure has recently been established and has been the subject of recent clinical trials. However, its use as a means of cardiac support in the adult population is not routine in clinical practice. We herein review the indications, technical procedure, complications and outcomes of extracorporeal membrane oxygenation as pertinent to cardiac disease in general, and specifically, to catheter-based interventions. We describe two cases of high-risk cardiac catheterisation laboratory procedures performed with veno-arterial ECMO support in adult patients who were deemed to be at unacceptably high risk for conventional open-heart surgery and cardiopulmonary bypass.

Peripartum cardiomyopathy: an intriguing challenge. Case report with literature review

Peripartum cardiomyopathy is a relatively rare disease, which can have devasting consequences and should be promptly identified and correctly treated. Overall prognosis is good in majority of the cases, although some patients may progress to irreversible heart failure. Early diagnosis is important and effective treatment reduces mortality rates and increases the chance of complete recovery of ventricular systolic function.We report of an interesting case with a favourable outcome and discuss about the clinical presentation, therapy and outcome of this condition.

Successful treatment of peripartum cardiomyopathy with extracorporeal membrane oxygenation

A 24-year-old female developed heart failure within four months of delivering her first child. Echocardiogram revealed a moderately dilated left ventricle with severely reduced systolic function. She continued to decompensate, requiring intubation and inotropic support. When the use of an intra-aortic balloon pump failed to stabilize the patient, the decision was made to place her on ECMO. The circuit consisted of a Quadrox D membrane oxygenator and a CentriMag® centrifugal pump. After 11 days of support, the patient met the weaning criteria and was successfully removed from ECMO. She was discharged one month after her admission. The new technology available allows for ECMO to be considered as an earlier option for the treatment and management of these patients as a bridge to recovery.