1
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Estep JD, Nicoara A, Cavalcante J, Chang SM, Cole SP, Cowger J, Daneshmand MA, Hoit BD, Kapur NK, Kruse E, Mackensen GB, Murthy VL, Stainback RF, Xu B. Recommendations for Multimodality Imaging of Patients With Left Ventricular Assist Devices and Temporary Mechanical Support: Updated Recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr 2024; 37:820-871. [PMID: 39237244 DOI: 10.1016/j.echo.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/07/2024]
Affiliation(s)
| | | | - Joao Cavalcante
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | | | | | | | | | - Brian D Hoit
- Case Western Reserve University, Cleveland, Ohio
| | | | - Eric Kruse
- University of Chicago, Chicago, Illinois
| | | | | | | | - Bo Xu
- Cleveland Clinic, Cleveland, Ohio
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2
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Owyang CG, Rippon B, Teran F, Brodie D, Araos J, Burkhoff D, Kim J, Tonna JE. Pulmonary Artery Pressures and Mortality During Venoarterial ECMO: An ELSO Registry Analysis. Circ Heart Fail 2024; 17:e011123. [PMID: 38979607 PMCID: PMC11251849 DOI: 10.1161/circheartfailure.123.011123] [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] [Received: 08/08/2023] [Accepted: 05/16/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Systemic hemodynamics and specific ventilator settings have been shown to predict survival during venoarterial extracorporeal membrane oxygenation (ECMO). How the right heart (the right ventricle and pulmonary artery) affect survival during venoarterial ECMO is unknown. We aimed to identify the relationship between right heart function with mortality and the duration of ECMO support. METHODS Cardiac ECMO runs in adults from the Extracorporeal Life Support Organization Registry between 2010 and 2022 were queried. Right heart function was quantified via pulmonary artery pulse pressure (PAPP) for pre-ECMO and on-ECMO periods. A multivariable model was adjusted for modified Society for Cardiovascular Angiography and Interventions stage, age, sex, and concurrent clinical data (ie, pulmonary vasodilators and systemic pulse pressure). The primary outcome was in-hospital mortality. RESULTS A total of 4442 ECMO runs met inclusion criteria and had documentation of hemodynamic and illness severity variables. The mortality rate was 55%; nonsurvivors were more likely to be older, have a worse Society for Cardiovascular Angiography and Interventions stage, and have longer pre-ECMO endotracheal intubation times (P<0.05 for all) than survivors. Increasing PAPP from pre-ECMO to on-ECMO time (ΔPAPP) was associated with reduced mortality per 2 mm Hg increase (odds ratio, 0.98 [95% CI, 0.97-0.99]; P=0.002). Higher on-ECMO PAPP was associated with mortality reduction across quartiles with the greatest reduction in the third PAPP quartile (odds ratio, 0.75 [95% CI, 0.63-0.90]; P=0.002) and longer time on ECMO per 10 mm Hg (beta, 15 [95% CI, 7.7-21]; P<0.001). CONCLUSIONS Early on-ECMO right heart function and interval improvement from pre-ECMO values were associated with mortality reduction during cardiac ECMO. Incorporation of right heart metrics into risk prediction models should be considered.
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Affiliation(s)
- Clark G. Owyang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
| | - Brady Rippon
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York, USA
| | - Felipe Teran
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Joaquin Araos
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | | | - Jiwon Kim
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine/New York Presbyterian Hospital, 525 East 68th Street, New York, NY, 10021, USA
| | - Joseph E. Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA; Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT, USA
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3
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Brewer JM, Maybauer MO. Technique for Weaning From Peripheral Venopulmonary Extracorporeal Membrane Oxygenation in Combined Cardiopulmonary Failure. ASAIO J 2024:00002480-990000000-00514. [PMID: 38913958 DOI: 10.1097/mat.0000000000002251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024] Open
Abstract
Venopulmonary (VP) extracorporeal membrane oxygenation (ECMO) is a mode capable of supporting both pulmonary and right ventricular (RV) functions. Weaning patients from VP ECMO requires careful assessment of both RV and respiratory system recovery, which may occur at different rates. The weaning strategy described herein begins with weaning of respiratory ECMO support, followed by discontinuation of RV support. We also discuss situations in which the standard weaning strategy may require modification.
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Affiliation(s)
- J Michael Brewer
- From the Nazih Zuhdi Transplant Institute, Specialty Critical Care and Acute Circulatory Support Service, INTEGRIS Health Baptist Medical Center, Oklahoma City, Oklahoma
| | - Marc O Maybauer
- Division of Critical Care Medicine, Department of Anesthesiology, University of Florida, Gainesville, Florida
- Department of Anaesthesiology and Intensive Care Medicine, Philipps University, Marburg, Germany
- Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Brisbane, Australia
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4
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Ellauzi R, Erdem S, Salam MF, Kumar A, Aggarwal V, Koenig G, Aronow HD, Basir MB. Mechanical Circulatory Support Devices in Patients with High-Risk Pulmonary Embolism. J Clin Med 2024; 13:3161. [PMID: 38892871 PMCID: PMC11172824 DOI: 10.3390/jcm13113161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/22/2024] [Accepted: 05/08/2024] [Indexed: 06/21/2024] Open
Abstract
Pulmonary embolism (PE) is a common acute cardiovascular condition. Within this review, we discuss the incidence, pathophysiology, and treatment options for patients with high-risk and massive pulmonary embolisms. In particular, we focus on the role of mechanical circulatory support devices and their possible therapeutic benefits in patients who are unresponsive to standard therapeutic options. Moreover, attention is given to device selection criteria, weaning protocols, and complication mitigation strategies. Finally, we underscore the necessity for more comprehensive studies to corroborate the benefits and safety of MCS devices in PE management.
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Affiliation(s)
- Rama Ellauzi
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI 48202, USA
| | - Saliha Erdem
- Department of Internal Medicine, Detroit Medical Center, Wayne State University, Detroit, MI 48202, USA;
| | - Mohammad Fahad Salam
- Department of Internal Medicine, Michigan State University, East Lansing, MI 48502, USA;
| | - Ashish Kumar
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH 44307, USA;
| | - Vikas Aggarwal
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (V.A.); (H.D.A.)
| | - Gerald Koenig
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (V.A.); (H.D.A.)
| | - Herbert D. Aronow
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (V.A.); (H.D.A.)
| | - Mir Babar Basir
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (V.A.); (H.D.A.)
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5
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Douflé G, Dragoi L, Morales Castro D, Sato K, Donker DW, Aissaoui N, Fan E, Schaubroeck H, Price S, Fraser JF, Combes A. Head-to-toe bedside ultrasound for adult patients on extracorporeal membrane oxygenation. Intensive Care Med 2024; 50:632-645. [PMID: 38598123 DOI: 10.1007/s00134-024-07333-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/20/2024] [Indexed: 04/11/2024]
Abstract
Bedside ultrasound represents a well-suited diagnostic and monitoring tool for patients on extracorporeal membrane oxygenation (ECMO) who may be too unstable for transport to other hospital areas for diagnostic tests. The role of ultrasound, however, starts even before ECMO initiation. Every patient considered for ECMO should have a thorough ultrasonographic assessment of cardiac and valvular function, as well as vascular anatomy without delaying ECMO cannulation. The role of pre-ECMO ultrasound is to confirm the indication for ECMO, identify clinical situations for which ECMO is not indicated, rule out contraindications, and inform the choice of ECMO configuration. During ECMO cannulation, the use of vascular and cardiac ultrasound reduces the risk of complications and ensures adequate cannula positioning. Ultrasound remains key for monitoring during ECMO support and troubleshooting ECMO complications. For instance, ultrasound is helpful in the assessment of drainage insufficiency, hemodynamic instability, biventricular function, persistent hypoxemia, and recirculation on venovenous (VV) ECMO. Lung ultrasound can be used to monitor signs of recovery on VV ECMO. Brain ultrasound provides valuable diagnostic and prognostic information on ECMO. Echocardiography is essential in the assessment of readiness for liberation from venoarterial (VA) ECMO. Lastly, post decannulation ultrasound mainly aims at identifying post decannulation thrombosis and vascular complications. This review will cover the role of head-to-toe ultrasound for the management of adult ECMO patients from decision to initiate ECMO to the post decannulation phase.
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Affiliation(s)
- Ghislaine Douflé
- Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada.
- Department of Anesthesia and Pain Management, Toronto General Hospital, 585 University Avenue, Toronto, ON, M5G 2N2, Canada.
| | - Laura Dragoi
- Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada
| | - Diana Morales Castro
- Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada
| | - Kei Sato
- Critical Care Research Group, The Prince Charles Hospital, Level 3 Clinical Sciences Building, Chermside, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Dirk W Donker
- Intensive Care Center, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
- Cardiovascular and Respiratory Physiology, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Nadia Aissaoui
- Service de Médecine intensive-réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Cité, Paris, France
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada
| | - Hannah Schaubroeck
- Department of Intensive Care Medicine, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Susanna Price
- Departments of Cardiology and Intensive Care, Royal Brompton & Harefield NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Level 3 Clinical Sciences Building, Chermside, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Alain Combes
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université, Hôpital Pitié Salpêtrière, Paris, France
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
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Hermens JAJ, van Til JA, Meuwese CL, van Dijk D, Donker DW. Clinical decision making for VA ECMO weaning in patients with cardiogenic shock A formative qualitative study. Perfusion 2024; 39:39S-48S. [PMID: 38651581 DOI: 10.1177/02676591241236643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
Weaning and liberation from VA ECMO in cardiogenic shock patients comprises a complex process requiring a continuous trade off between multiple clinical parameters. In the absence of dedicated international guidelines, we hypothesized a great heterogeneity in weaning practices among ECMO centers due to a variety in local preferences, logistics, case load and individual professional experience. This qualitative study focused on the appraisal of clinicians' preferences in decision processes towards liberation from VA ECMO after cardiogenic shock while using focus group interviews in 4 large hospitals. The goal was to provide novel and unique insights in daily clinical weaning practices. As expected, we found we a great heterogeneity of weaning strategies among centers and professionals, although participants appeared to find common ground in a clinically straightforward approach to assess the feasibility of ECMO liberation at the bedside. This was shown in a preference for robust, easily accessible parameters such as arterial pulse pressure, stable cardiac index ≥2.1 L/min, VTI LVOT and 'eyeballing' LVEF.
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Affiliation(s)
- J A J Hermens
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - J A van Til
- Department of Health Technology and Services Research, University of Twente, Enschede, The Netherlands
| | - C L Meuwese
- Department of Intensive Care Medicine and Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - D van Dijk
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - D W Donker
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Cardiovascular and Respiratory Physiology, TechMed Centre, University of Twente, Enschede, The Netherlands
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7
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Zhou L, Wiley BM. Current and Future Role of Ultrasonography in the Cardiac Intensive Care Unit. Crit Care Clin 2024; 40:15-35. [PMID: 37973351 DOI: 10.1016/j.ccc.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
The contemporary practice of ultrasonography in the cardiac intensive care unit integrates the principles of echocardiography with whole-body imaging to create a more expansive paradigm of critical care ultrasonography (CCUS). This article will review the use of CCUS for diagnostic assessment, monitoring, therapeutic guidance, and prognosis.
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Affiliation(s)
- Leon Zhou
- Department of Cardiology, Keck School of Medicine of University of Southern California, Los Angeles General Medical Center, Clinic Tower A6E108, 2051 Marengo Street, Los Angeles, CA 90033, USA
| | - Brandon M Wiley
- Department of Cardiology, Keck School of Medicine of University of Southern California, Los Angeles General Medical Center, Clinic Tower A6E108, 2051 Marengo Street, Los Angeles, CA 90033, USA.
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8
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Siriwardena M, Breeding J, Gopalakrishnan M, Jansz P, Granger EK, Jackson A, MacDonald PS, Lowe D, Buscher H, Nair P. Pulse pressure within the first 2 days of veno-arterial extracorporeal membrane oxygenation is predictive of death prior to hospital discharge, renal dysfunction requiring dialysis and pulmonary oedema. Perfusion 2023; 38:1568-1576. [PMID: 36036658 DOI: 10.1177/02676591221115935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) flows are titrated to achieve adequate perfusion while attempting to ideally maintain arterial pulse pressure (PP). We assessed risk in patients with low PP defined as <10 mmHg within the first 2 days of support. METHODS Demographics, haemodynamics, echocardiographic and radiological findings were recorded retrospectively in cases conducted between 2014 and 2016. Outcomes were hospital mortality, requirement for renal replacement therapy (RRT) and severe pulmonary oedema (PO). RESULTS Of 101 patients, 66.3% were male, mean age was 56 (range 18-71 years), mean duration of support was 6.3 days ± 4.1 days, 37.6% died prior to hospital discharge, 39.6% needed RRT and 11.9% had severe PO. Areas under the receiver operating curves of PP at 48 h for hospital mortality, RRT and severe PO were (respectively): 0.69 (95% CI 0.58-0.80, p = .001), 0.64 (95% CI 0.50-0.77, p = .044), 0.69 (95% CI 0.55-0.82, p = .009). The odds ratio for mortality, RRT, severe PO for those with low PP were (respectively) 2.8 (95% CI 1.01-7.5, p = .04), 3.1 (95% CI 1.11-8.40, p = .026), 7.6 (95% CI 2.06-27.89, p = .001). Central venous pressure, mean arterial pressure were not predictive. CONCLUSION PP during the first 2 days of support is predictive of clinically important outcomes in patients supported with VA-ECMO.
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Affiliation(s)
- Maithri Siriwardena
- Department of Intensive Care, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia
| | - Jeff Breeding
- Department of Intensive Care, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia
| | - Mani Gopalakrishnan
- Department of Intensive Care, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia
| | - Paul Jansz
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia
| | - Emily K Granger
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia
| | - Andrew Jackson
- Department of Cardiac Anaesthesia, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia
| | - Peter S MacDonald
- Cardiac Failure and Transplantation, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia
| | - David Lowe
- Department of Intensive Care, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia
| | - Hergen Buscher
- Department of Intensive Care, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
- Centre of Applied Medical Research, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia
| | - Priya Nair
- Department of Intensive Care, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia
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9
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Hermens JA, Meuwese CL, Szymanski MK, Gianoli M, van Dijk D, Donker DW. Patient-centered weaning from venoarterial extracorporeal membrane oxygenation: "A practice-oriented narrative review of literature". Perfusion 2023; 38:1349-1359. [PMID: 35939761 DOI: 10.1177/02676591221115938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Venoarterial extracorporeal membrane oxygenation (V-A ECMO) is increasingly used in cardiogenic shock for rapid stabilization and bridging towards recovery, long-term mechanical circulatory support or transplant. Although technological advances have instigated its widespread use, the complex, long-lasting ECMO care creates a significant strain on hospital staff and resources. Therefore, optimal clinical management including timely decisions on ECMO removal and further therapy are pivotal, yet require a well-structured weaning approach. Although dedicated guidelines are lacking, a variety of weaning protocols have distillated echocardiographic and hemodynamic predictors for successful weaning. Nevertheless, a strikingly high mortality up to 70% after initial successful weaning raises concerns about the validity of current weaning strategies. Here, we plead for a patient-tailored approach including a bailout strategy when weaning fails. This should account not only for left- but also right ventricular function and interdependence, as well as the temporal course of cardiac recovery in function of extracorporeal support. Patients with a high risk of weaning failure should be identified early, enabling timely transportation to an advanced heart failure center. This review summarizes predictors of successful weaning and discusses all relevant elements for a structured weaning approach with a central role for patient-specific clinical considerations and echocardiography.
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Affiliation(s)
- Jeannine Aj Hermens
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Christiaan L Meuwese
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Mariusz K Szymanski
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Monica Gianoli
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Diederik van Dijk
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Dirk W Donker
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Cardiovascular and Respiratory Physiology, TechMed Centre, University of Twente, Enschede, The Netherlands
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10
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Owyang CG, Rippon B, Teran F, Brodie D, Araos J, Burkhoff D, Kim J, Tonna JE. Pulmonary Artery Pressures and Mortality during VA ECMO: An ELSO Registry Analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.08.23293859. [PMID: 37645725 PMCID: PMC10462237 DOI: 10.1101/2023.08.08.23293859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Background Systemic hemodynamics and specific ventilator settings have been shown to predict survival during venoarterial extracorporeal membrane oxygenation (VA ECMO). While these factors are intertwined with right ventricular (RV) function, the independent relationship between RV function and survival during VA ECMO is unknown. Objectives To identify the relationship between RV function with mortality and duration of ECMO support. Methods Cardiac ECMO runs in adults from the Extracorporeal Life Support Organization (ELSO) Registry between 2010 and 2022 were queried. RV function was quantified via pulmonary artery pulse pressure (PAPP) for pre-ECMO and on-ECMO periods. A multivariable model was adjusted for Society for Cardiovascular Angiography and Interventions (SCAI) stage, age, gender, and concurrent clinical data (i.e., pulmonary vasodilators and systemic pulse pressure). The primary outcome was in-hospital mortality. Results A total of 4,442 ECMO runs met inclusion criteria and had documentation of hemodynamic and illness severity variables. The mortality rate was 55%; non-survivors were more likely to be older, have a worse SCAI stage, and have longer pre-ECMO endotracheal intubation times (P < 0.05 for all) than survivors. Improving PAPP from pre-ECMO to on-ECMO time (Δ PAPP) was associated with reduced mortality per 10 mm Hg increase (OR: 0.91 [95% CI: 0.86-0.96]; P=0.002). Increasing on-ECMO PAPP was associated with longer time on ECMO per 10 mm Hg (Beta: 15 [95% CI: 7.7-21]; P<0.001). Conclusions Early improvements in RV function from pre-ECMO values were associated with mortality reduction during cardiac ECMO. Incorporation of Δ PAPP into risk prediction models should be considered.
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Affiliation(s)
- Clark G. Owyang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
| | - Brady Rippon
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York, USA
| | - Felipe Teran
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Joaquin Araos
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | | | - Jiwon Kim
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine/New York Presbyterian Hospital, 525 East 68th Street, New York, NY, 10021, USA
| | - Joseph E. Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA; Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT, USA
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11
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Lau FM, Chan WK, Mok YT, Lai PCK, Ma SKT, Ngai CW, Sin WC, Kwok WLP, Yu KY, Chan WM, Fraser JF, Ng PY. Feasibility of pump-controlled retrograde trial off in weaning from veno-arterial ECMO in adults-A single-center case series. Artif Organs 2023. [PMID: 37012220 DOI: 10.1111/aor.14527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 12/28/2022] [Accepted: 03/20/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Various strategies of weaning V-A ECMO have been described. PCRTO is a weaning technique which involves serial decremental pump revolutions until a retrograde flow from the arterial to venous ECMO cannula is achieved. It has been reported as a feasible weaning strategy in the pediatric population, but its application in adults has not been widely reported. METHODS This was a case series including all adult patients who underwent PCRTO during weaning from V-A ECMO at a tertiary ECMO center between January 2019 and July 2021. The primary end point was the successful weaning from V-A ECMO support. RESULTS A total of 57 runs of PCRTO in 36 patients were analyzed-45 (78.9%) of the trials were concluded successfully. The median retrograde blood flow rate during PCRTO was 0.6 ± 0.2 L/min, and the median duration of each PCRTO was 180 (120-240) min. Of the 35 patients who had at least one session of successful PCRTO, 31 (88.6%) were ultimately weaned from ECMO. There were no major complications from PCRTO including systemic or circuit thrombosis. CONCLUSIONS PCRTO is a feasible strategy for assessing readiness for weaning from V-A ECMO with a low risk of adverse events and high rate of predicting eventual successful ECMO decannulation. Further investigation including comparison with alternative weaning strategies in prospective studies is required to confirm the approach.
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Affiliation(s)
- Fung Ming Lau
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, Hong Kong SAR
| | - Wai Kit Chan
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, Hong Kong SAR
| | - Yuen Tin Mok
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, Hong Kong SAR
| | - Peter Chi Keung Lai
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, Hong Kong SAR
| | - Sin Kwan Tammy Ma
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, Hong Kong SAR
| | - Chun Wai Ngai
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, Hong Kong SAR
| | - Wai Ching Sin
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, Hong Kong SAR
- Critical Care Medicine Unit, The University of Hong Kong, Hong Kong, Hong Kong SAR
| | | | - Kin Yip Yu
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, Hong Kong SAR
| | - Wai Ming Chan
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, Hong Kong SAR
| | - John F Fraser
- University of Queensland, Brisbane, Queensland, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Pauline Yeung Ng
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, Hong Kong SAR
- Critical Care Medicine Unit, The University of Hong Kong, Hong Kong, Hong Kong SAR
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12
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Chakraborty A, Majumdar HS, Das W, Chatterjee D, Sarkar K. Discontinuation of ECMO-a review with a note on Indian scenario. Indian J Thorac Cardiovasc Surg 2023; 39:1-9. [PMID: 36778721 PMCID: PMC9898693 DOI: 10.1007/s12055-022-01453-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 11/28/2022] [Accepted: 12/02/2022] [Indexed: 02/05/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) has strikingly progressed over the last 20 years in the management of adult and pediatric severe respiratory and cardiac dysfunctions refractory to conventional management. In this review, we will discuss the weaning strategies of veno-venous and veno-arterial ECMO including the bridge to recovery and bridge to transplant along with post-ECMO care. We will also discuss the futility and the management of bridge to nowhere from Indian perspectives.
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Affiliation(s)
- Arpan Chakraborty
- Cardiac Anesthesia, Critical Care and ECMO Services, Medica Superspecialty Hospital, Kolkata, India
| | - Hirak Subhra Majumdar
- Cardiac Anesthesia, Critical Care and ECMO Services, Medica Superspecialty Hospital, Kolkata, India
| | - Writuparna Das
- Cardiac Anesthesia, Critical Care and ECMO Services, Medica Superspecialty Hospital, Kolkata, India
| | - Dipanjan Chatterjee
- Cardiac Anesthesia, Critical Care and ECMO Services, Medica Superspecialty Hospital, Kolkata, India
| | - Kunal Sarkar
- Department of Cardiac Surgery, Medica Superspecialty Hospital, Kolkata, India
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Quantitative evaluation of hemodynamic parameters by echocardiography in patients with post-cardiotomy cardiac shock supported by extracorporeal membrane oxygenation. J Cardiothorac Surg 2023; 18:1. [PMID: 36600267 PMCID: PMC9811784 DOI: 10.1186/s13019-022-02074-4] [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: 04/02/2022] [Accepted: 12/09/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND When drugs fail to reverse post-cardiotomy cardiac shock (PCS), extracorporeal membrane oxygenation (ECMO) is considered the most effective adjuvant strategy. Transthoracic echocardiography is a useful imaging modality for monitoring of cardiac hemodynamics. The aim of this study was to investigate the value of echocardiography for monitoring the left and right heart hemodynamics in PCS patients before, during, and after weaning from ECMO. METHODS Fifty-two patients were divided into successful weaning group (group A, n = 23) and non-successful weaning group (group B, n = 29). Hemodynamic parameters measured by echocardiography were collected before, during, and after ECMO. The intra-group changes and inter-group differences were retrospectively analyzed. RESULTS In group A, the central venous pressure (CVP), proximal right ventricular outflow tract (RVOT), tricuspid annular plane systolic excursion (TAPSE), velocity of tricuspid valve (TVDV), and systolic velocity of tricuspid annulus ([Formula: see text]) during ECMO were significantly lower than those before ECMO. After ECMO, left ventricular ejection fraction (LVEF), systolic velocity of mitral annulus ([Formula: see text]), and velocity-time integral of LV outflow tract (LVOT-VTI) were higher than pre-ECMO levels, and CVP, LVEF, [Formula: see text], LVOT-VTI, RVOT, TAPSE, TVDV and [Formula: see text] were higher than those during ECMO (all P < 0.05). In group B, compared to pre-ECMO, subjects exhibited decreased CVP, RVOT, TAPSE, TVDV and [Formula: see text] during ECMO. TAPSE, TVDV, and [Formula: see text] were continuously lower after ECMO, while CVP and RVOT increased after ECMO (all P < 0.05). After ECMO, LVEF, [Formula: see text], LVOT-VTI, TAPSE, TVDV and [Formula: see text] in group A were higher than those in group B (all P < 0.05). Inter-group comparison showed the LVEF and RV Tei indices of group A were significantly different than those of group B before, during, and after ECMO. CONCLUSION Quantitative assessment of both LV and RV by echocardiography is important for ECMO weaning. Patients with better LVEF and lower RV Tei index may have a better chance of successful weaning from ECMO.
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Charbonneau F, Chahinian K, Bebawi E, Lavigueur O, Lévesque É, Lamarche Y, Serri K, Albert M, Noly PE, Cournoyer A, Cavayas YA. Parameters associated with successful weaning of veno-arterial extracorporeal membrane oxygenation: a systematic review. Crit Care 2022; 26:375. [PMID: 36471408 PMCID: PMC9724323 DOI: 10.1186/s13054-022-04249-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/19/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) can be used to restore organ perfusion in patients with cardiogenic shock until native heart recovery occurs. It may be challenging, however, to determine when patients can be weaned successfully from ECMO-surviving without requiring further mechanical support or heart transplant. We aimed to systematically review the medical literature to determine the biomarkers, hemodynamic and echocardiographic parameters associated with successful weaning of VA-ECMO in adults with cardiogenic shock and to present an evidence-based weaning algorithm incorporating key findings. METHOD We systematically searched PubMed, Embase, ProQuest, Google Scholars, Web of Science and the Grey literature for pertinent original research reports. We excluded studies limited to extracorporeal cardiopulmonary resuscitation (ECPR) as the neurological prognosis may significantly alter the decision-making process surrounding the device removal in this patient population. Studies with a mixed population of VA-ECMO for cardiogenic shock or cardiac arrest were included. We excluded studies limited to patients in which ECMO was only used as a bridge to VAD or heart transplant, as such patients are, by definition, never "successfully weaned." We used the Risk of Bias Assessment tool for Non-Randomized Studies. The study was registered on the International prospective register of systematic reviews (PROSPERO CRD42020178641). RESULTS We screened 14,578 records and included 47 that met our pre-specified criteria. Signs of lower initial severity of shock and myocardial injury, early recovery of systemic perfusion, left and right ventricular recovery, hemodynamic and echocardiographic stability during flow reduction trial and/or pump-controlled retrograde trial off predicted successful weaning. The most widely used parameter was the left ventricular outflow tract velocity time integral, an indicator of stroke volume. Most studies had a moderate or high risk of bias. Heterogeneity in methods, timing, and conditions of measurements precluded any meta-analysis. CONCLUSIONS In adult patients on VA-ECMO for cardiogenic shock, multiple biomarkers, hemodynamic and echocardiographic parameters may be used to track resolution of systemic hypoperfusion and myocardial recovery in order to identify patients that can be successfully weaned.
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Affiliation(s)
- Francis Charbonneau
- Division of Critical Care, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, 5400 Boulevard Gouin Ouest, Montreal, QC, H4J 1C5, Canada
| | - Karina Chahinian
- Division of Critical Care, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, 5400 Boulevard Gouin Ouest, Montreal, QC, H4J 1C5, Canada
| | - Emmanuel Bebawi
- Division of Critical Care, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, 5400 Boulevard Gouin Ouest, Montreal, QC, H4J 1C5, Canada
| | - Olivier Lavigueur
- Division of Critical Care, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, 5400 Boulevard Gouin Ouest, Montreal, QC, H4J 1C5, Canada
| | - Émilie Lévesque
- Division of Critical Care, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, 5400 Boulevard Gouin Ouest, Montreal, QC, H4J 1C5, Canada
- Division of Critical Care, Department of Surgery, Montreal Heart Institute, Montreal, Canada
| | - Yoan Lamarche
- Division of Critical Care, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, 5400 Boulevard Gouin Ouest, Montreal, QC, H4J 1C5, Canada
- Division of Critical Care, Department of Surgery, Montreal Heart Institute, Montreal, Canada
| | - Karim Serri
- Division of Critical Care, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, 5400 Boulevard Gouin Ouest, Montreal, QC, H4J 1C5, Canada
- Division of Critical Care, Department of Surgery, Montreal Heart Institute, Montreal, Canada
| | - Martin Albert
- Division of Critical Care, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, 5400 Boulevard Gouin Ouest, Montreal, QC, H4J 1C5, Canada
- Division of Critical Care, Department of Surgery, Montreal Heart Institute, Montreal, Canada
| | - Pierre-Emmanuel Noly
- Division of Critical Care, Department of Surgery, Montreal Heart Institute, Montreal, Canada
| | - Alexis Cournoyer
- Department of Emergency Medicine, Hôpital du Sacré-Cœur de Montréal, Montreal, Canada
| | - Yiorgos Alexandros Cavayas
- Division of Critical Care, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, 5400 Boulevard Gouin Ouest, Montreal, QC, H4J 1C5, Canada.
- Division of Critical Care, Department of Surgery, Montreal Heart Institute, Montreal, Canada.
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Alonso-Fernandez-Gatta M, Merchan-Gomez S, Gonzalez-Cebrian M, Diego-Nieto A, Gonzalez-Martin J, Toranzo-Nieto I, Barrio A, Martin-Herrero F, Sanchez PL. Echocardiographic Prediction of Successful Weaning From Venoarterial Extracorporeal Membrane Oxygenation. Am J Crit Care 2022; 31:483-493. [PMID: 36316178 DOI: 10.4037/ajcc2022588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Weaning from venoarterial extracorporeal membrane oxygenation (VA-ECMO) support fails in 30% to 70% of patients. OBJECTIVE To explore the utility of echocardiographic parameters in predicting successful disconnection from VA-ECMO. METHODS Patients receiving VA-ECMO in a referral hospital were included. The relationships between echocardiographic parameters during the weaning trial and weaning success (survival > 24 hours after VA-ECMO explant and no death from cardiogenic shock, heart failure, or cardiac arrest during the hospital stay) and survival were evaluated. RESULTS Of 85 patients included, 61% had successful weaning. Parameters significantly related to weaning success were higher left ventricular ejection fraction (LVEF; 40% in patients with weaning success vs 30% in patients with weaning failure, P = .01), left ventricular outflow tract velocity time integral (15 cm vs 11 cm, P = .01), aortic valve opening in every cycle (98% vs 91% of patients, P = .01), and normal qualitative right ventricular function (60% vs 42% of patients, P = .02). The LVEF remained as an independent predictor of weaning success (hazard ratio, 0.938; 95% CI, 0.888-0.991; P = .02). An LVEF >33.4% was the optimal cutoff value to discriminate patients with successful weaning (area under the curve, 0.808; sensitivity, 93%; specificity, 72%) and was related to higher survival at discharge (60% vs 20%, P < .001). CONCLUSION Among weaning trial echocardiographic parameters, LVEF was the only independent predictor of successful VA-ECMO weaning. An LVEF >33.4% was the optimal cutoff value to discriminate patients with successful weaning and was related to final survival.
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Affiliation(s)
- Marta Alonso-Fernandez-Gatta
- Marta Alonso-Fernandez-Gatta is a cardiologist at University Hospital of Salamanca-Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain and takes part in the Centro de Investigación en Red de Enfermedades Cardio vasculares (CIBER-CV), Instituto de Salud Carlos III, Madrid, Spain
| | - Soraya Merchan-Gomez
- Soraya Merchan-Gomez is a cardiologist at University Hospital of Salamanca-IBSAL and takes part in CIBER-CV, Instituto de Salud Carlos III
| | - Miryam Gonzalez-Cebrian
- Miryam Gonzalez-Cebrian is a nursing supervisor, Cardiology Department, University Hospital of Salamanca-IBSAL
| | - Alejandro Diego-Nieto
- Alejandro Diego-Nieto is a cardiologist at University Hospital of Salamanca-IBSAL and takes part in CIBER-CV, Instituto de Salud Carlos III
| | | | - Ines Toranzo-Nieto
- Ines Toranzo-Nieto is a cardiologist at University Hospital of Salamanca-IBSAL and takes part in CIBER-CV, Instituto de Salud Carlos III
| | - Alfredo Barrio
- Alfredo Barrio is a cardiologist at University Hospital of Salamanca-IBSAL and takes part in CIBER-CV, Instituto de Salud Carlos III
| | - Francisco Martin-Herrero
- Francisco Martin-Herrero is a cardiologist at University Hospital of Salamanca-IBSAL and takes part in CIBER-CV, Instituto de Salud Carlos III
| | - Pedro L Sanchez
- Pedro L. Sanchez is head of the Cardiology Department, University Hospital of Salamanca-IBSAL, and takes part in CIBER-CV, Instituto de Salud Carlos III
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Abstract
PURPOSE OF REVIEW Right ventricular (RV) failure is increasingly recognized as a major cause of morbidity and mortality. When RV failure is refractory to medical therapy, escalation to right-sided mechanical circulatory support (MCS) should be considered. In this review, we begin by recapitulating the hemodynamics of RV failure, then we delve into current and future right-sided MCS devices and describe their hemodynamic profiles. RECENT FINDINGS The field of temporary right-sided MCS continues to expand, with evolving strategies and new devices actively under development. All right-sided MCS devices bypass the RV, with each bypass configuration conferring a unique hemodynamic profile. Devices that aspirate blood directly from the RV, as opposed to the RA or the IVC, have more favorable hemodynamics and more effective RV unloading. There has been a growing interest in single-access MCS devices which do not restrict patient mobility. Additionally, a first-of-its-kind percutaneous, pulsatile, right-sided MCS device (PERKAT RV) is currently undergoing investigation in humans. Prompt recognition of refractory RV failure and deployment of right-sided MCS can improve outcomes. The field of right-sided MCS is rapidly evolving, with ongoing efforts dedicated towards developing novel temporary devices that are single access, allow for patient mobility, and directly unload the RV, as well as more durable devices.
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17
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Cusanno A, Aissaoui N, Minville V, Porterie J, Biendel C, Volle K, Crognier L, Conil JM, Delmas C. Predictors of weaning failure in case of VA ECMO implantation. Sci Rep 2022; 12:13842. [PMID: 35974037 PMCID: PMC9381562 DOI: 10.1038/s41598-022-18105-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 08/05/2022] [Indexed: 11/09/2022] Open
Abstract
The use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for the treatment of refractory cardiogenic shock has increased significantly. Nevertheless, early weaning may be advisable to reduce the potential for severe complications. Only a few studies focusing on ECMO weaning predictors are currently available. Our objective was to evaluate factors that may help predict failure during VA ECMO weaning. We included 57 patients on VA ECMO support previously considered suitable for weaning based on specific criteria. Clinical, haemato-chemical and echocardiographic assessment was considered before and after a "weaning test" (ECMO flow < 2 L/min for at least 60 min). ECMO removal was left to the discretion of the medical team blinded to the results. Weaning failure was defined as a patient who died or required a new VA ECMO, heart transplant or LVAD 30 days after ECMO removal. Thirty-six patients (63.2%) were successfully weaned off VA ECMO, of whom 31 (54.4%) after the first weaning test. In case of first test failure, 3 out of 7 patients could be weaned after a 2nd test and 3 out of 4 patients after a 3rd test. Pre-existing ischemic heart disease (OR 9.6 [1.1-83]), pre-test left ventricular ejection fraction (LVEF) ≤ 25% and/or post-test LVEF ≤ 40% (OR 11 [0.98-115]), post-test systolic blood pressure ≤ 120 mmHg (OR 33 [3-385]), or length of ECMO support > 7 days (OR 24 [2-269]) were predictors of weaning failure. The VA ECMO weaning test failed in less than 40% of patients considered suitable for weaning. Clinical and echocardiographic criteria, which are easily accessible by a non-expert intensivist, may help increase the probability of successful weaning.
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Affiliation(s)
- Axelle Cusanno
- Department of Anesthesia, Intensive Care and Perioperative Care Medicine, Rangueil University Hospital, Toulouse, France
| | - Nadia Aissaoui
- Medical Intensive Care Unit, Hôpital Cochin, AP-HP, Paris, France
| | - Vincent Minville
- Department of Anesthesia, Intensive Care and Perioperative Care Medicine, Rangueil University Hospital, Toulouse, France
| | - Jean Porterie
- Department of Cardiovascular Surgery, Rangueil University Hospital, Toulouse, France
| | - Caroline Biendel
- Intensive Cardiac Care Unit, Department of Cardiology, Rangueil University Hospital, Toulouse, France
| | - Kim Volle
- Department of Anesthesia, Intensive Care and Perioperative Care Medicine, Rangueil University Hospital, Toulouse, France.,Intensive Cardiac Care Unit, Department of Cardiology, Rangueil University Hospital, Toulouse, France
| | - Laure Crognier
- Department of Anesthesia, Intensive Care and Perioperative Care Medicine, Rangueil University Hospital, Toulouse, France
| | - Jean-Marie Conil
- Department of Anesthesia, Intensive Care and Perioperative Care Medicine, Rangueil University Hospital, Toulouse, France
| | - Clément Delmas
- Intensive Cardiac Care Unit, Department of Cardiology, Toulouse University Hospital, 1, avenue Jean Poulhès, TSA 50032, 31059, Toulouse Cedex 9, France.
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18
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Puerto E, Tavazzi G, Gambaro A, Cirillo C, Pecoraro A, Martín-Asenjo R, Delgado J, Bueno H, Price S. Interaction between va-ecmo and the right ventricle. Hellenic J Cardiol 2022; 68:17-24. [PMID: 35863728 DOI: 10.1016/j.hjc.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 05/29/2022] [Accepted: 07/07/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The response of the right ventricle (RV) to the hemodynamic effects of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is currently unpredictable. We hypothesized that the presence of uni- or bi-ventricular failure before implantation and the cannulation strategy may influence this interaction. We sought to assess the RV performance during VA-ECMO support and identify RV-related predictors of successful weaning. METHODS Changes of RV size and function during VA-ECMO support by echocardiography were retrospectively analyzed in 87 consecutive adult patients between February, 2008, and June, 2017. Predictors of successful weaning due to myocardial recovery were evaluated by multivariable logistic regression. RESULTS RV echocardiographic parameters did not vary significantly during VA-ECMO support, neither after stratification by type of cannulation or the presence of isolated or biventricular failure. Successful weaning was conditioned by the absence of RV dysfunction before implantation (OR, 14.7; 95%CI, 13.3-140.3; p=0.025) or in the last day of support (OR, 9.5; 95%CI, 1.6-54; p=0.011), and was favored by a total or partial recovery of RV function during the assistance (OR, 6.2; 95%CI, 1.7-22.4; p=0.005). RV improvement was more often observed in patients with acute RV failure and longer support, while VA-ECMO configuration, additional mechanical support or pharmacological therapy had no effect. CONCLUSIONS Preservation or improvement of RV function during VA-ECMO is essential for successful weaning. RV echocardiographic performance does not change significantly during VA-ECMO support and is not influenced by cannulation type or the presence of uni- or bi-ventricular failure before implantation.
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Affiliation(s)
- Elena Puerto
- Servicio de Cardiología, Hospital Universitario 12 de Octubre e Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain.
| | - Guido Tavazzi
- University of Pavia, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, Pavia, Italy; Department of Anesthesia and Intensive Care Unit, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | | | | | | | - Roberto Martín-Asenjo
- Servicio de Cardiología, Hospital Universitario 12 de Octubre e Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Juan Delgado
- Servicio de Cardiología, Hospital Universitario 12 de Octubre e Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Héctor Bueno
- Servicio de Cardiología, Hospital Universitario 12 de Octubre e Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Susanna Price
- Intensive Care Unit, Royal Brompton & Harefield NHS Foundation Trust, London, UK
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Vuthoori R, Heaney C, Lima B, Knisel A, Miller E, Kennedy K, Majure D, Stevens G, Bocchieri K, Cassiere H, Fernandez H, Maybaum S. Assessment of cardiac recovery in patients supported with venoarterial extracorporeal membrane oxygenation. ESC Heart Fail 2022; 9:2272-2278. [PMID: 35451212 PMCID: PMC9288741 DOI: 10.1002/ehf2.13892] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 02/01/2022] [Accepted: 03/03/2022] [Indexed: 11/16/2022] Open
Abstract
Aims Venoarterial extracorporeal membrane oxygenation (VA‐ECMO) is increasingly being used to support patients in cardiogenic shock (CS). Early determination of disposition is paramount, as longer durations of support have been associated with worse outcomes. We describe a stepwise, bedside weaning protocol to assess cardiopulmonary recovery during VA‐ECMO. Methods and results Over 1 year, we considered all patients on VA‐ECMO for CS for the Weaning Protocol (WP) at our centre. During the WP, patients had invasive haemodynamic monitoring, echocardiography, and blood gas analysis while flow was reduced in 1 LPM decrements. Ultimately, the circuit was clamped for 30 min, and final measures were taken. Patients were described as having durable recovery (DR) if they were free of pharmacological and mechanical support at 30 days post‐decannulation. Over 12 months, 34 patients had VA‐ECMO for CS. Fourteen patients were eligible for the WP at 4–12 days. Ten patients tolerated full flow reduction and were successfully decannulated. Twenty‐four per cent of the entire cohort demonstrated DR with no adverse events during the WP. Patients with DR had significantly higher ejection fraction, cardiac index, and smaller left ventricular size at lowest flow during the WP. Conclusions We describe a safe, stepwise, bedside weaning protocol to assess cardiac recovery during VA‐ECMO. Early identification of patients more likely to recover may improve outcomes during ECMO support.
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Affiliation(s)
- Ravi Vuthoori
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Uniondale, NY, USA
| | - Cassandra Heaney
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Uniondale, NY, USA
| | - Brian Lima
- Department of Cardiovascular and Thoracic Surgery at North Shore University Hospital, Manhasset, NY, USA
| | - Alexis Knisel
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Uniondale, NY, USA
| | - Ed Miller
- RDS2 Solutions Research Division, Stony Brook, NY, USA
| | - Kevin Kennedy
- Statistical Consultant for Northwell Health, Kansas City, MO, USA
| | - David Majure
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Uniondale, NY, USA
| | - Gerin Stevens
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Uniondale, NY, USA
| | - Karl Bocchieri
- Department of Cardiovascular and Thoracic Surgery at North Shore University Hospital, Manhasset, NY, USA
| | - Hugh Cassiere
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Uniondale, NY, USA
| | - Harold Fernandez
- Department of Cardiovascular and Thoracic Surgery at North Shore University Hospital, Manhasset, NY, USA
| | - Simon Maybaum
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Uniondale, NY, USA
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Exploration of the Utility of Speckle-Tracking Echocardiography During Mechanical Ventilation and Mechanical Circulatory Support. Crit Care Explor 2022; 4:e0666. [PMID: 35372843 PMCID: PMC8970088 DOI: 10.1097/cce.0000000000000666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This narrative review aims to discuss the potential applicability of speckle-tracking echocardiography (STE) in patients under mechanical ventilation (MV) and mechanical circulatory support (MCS). Both its benefits and limitations were considered through critical analyses of the current available evidence.
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21
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Zhu Y, Bao Y, Zheng K, Zhou W, Zhang J, Sun R, Deng Y, Xia L, Liu Y. Quantitative assessment of right ventricular size and function with multiple parameters from artificial intelligence-based three-dimensional echocardiography: A comparative study with cardiac magnetic resonance. Echocardiography 2022; 39:223-232. [PMID: 35034377 DOI: 10.1111/echo.15292] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 12/11/2021] [Accepted: 12/26/2021] [Indexed: 01/25/2023] Open
Abstract
AIMS This study aimed to explore the validation and the diagnostic value of multiple right ventricle (RV) volumes and functional parameters derived from a novel artificial intelligence (AI)-based three-dimensional echocardiography (3DE) algorithm compared to cardiac magnetic resonance (CMR). METHODS AND RESULTS A total of 51 patients with a broad spectrum of clinical diagnoses were finally included in this study. AI-based RV 3DE was performed in a single-beat HeartModel mode within 24 hours after CMR. In the entire population, RV volumes and right ventricular ejection fraction (RVEF) measured by AI-based 3DE showed statistically significant correlations with the corresponding CMR analysis (p < 0.05 for all). However, the Bland-Altman plots indicated that these parameters were slightly underestimated by AI-based 3DE. Based on CMR derived RVEF < 45% as RV dysfunction, end-systolic volume (ESV), end-systolic volume index (ESVi), stroke volume (SV), and RVEF showed great diagnostic performance in identifying RV dysfunction, as well as some non-volumetric parameters, including tricuspid annular systolic excursion (TAPSE), fractional area change (FAC), and free-wall longitudinal strains (LS) (p < 0.05 for all). The cutoff value was 43% for RVEF with a sensitivity of 94% and specificity of 67%. CONCLUSION AI-based 3DE could provide rapid and accurate quantitation of the RV volumes and function with multiple parameters. Both volumetric and non-volumetric measurements derived from AI-based 3DE contributed to the identification of the RV dysfunction.
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Affiliation(s)
- Ying Zhu
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuwei Bao
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kangchao Zheng
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Zhou
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jun Zhang
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ruiying Sun
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Youbin Deng
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liming Xia
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yani Liu
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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22
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Elliott A, Dahyia G, Kalra R, Alexy T, Bartos J, Kosmopoulos M, Yannopoulos D. Extracorporeal Life Support for Cardiac Arrest and Cardiogenic Shock. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2021.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The rising incidence and recognition of cardiogenic shock has led to an increase in the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). As clinical experience with this therapy has increased, there has also been a rapid growth in the body of observational and randomized data describing the clinical and logistical considerations required to institute a VA-ECMO program with successful clinical outcomes. The aim of this review is to summarize this contemporary data in the context of four key themes that pertain to VA-ECMO programs: the principles of patient selection; basic hemodynamic and technical principles underlying VA-ECMO; contraindications to VA-ECMO therapy; and common complications and intensive care considerations that are encountered in the setting of VA-ECMO therapy.
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Affiliation(s)
- Andrea Elliott
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Garima Dahyia
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Rajat Kalra
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Tamas Alexy
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Jason Bartos
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Marinos Kosmopoulos
- Department of Medicine, Division of Cardiology, Center for Resuscitation Medicine, University of Minnesota, Minneapolis, MN
| | - Demetri Yannopoulos
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
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23
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Venoarterial Extracorporeal Membrane Oxygenation Weaning in Refractory Cardiogenic Shock-Echocardiographic Guidance May Improve Success. J Am Soc Echocardiogr 2021; 35:134-135. [PMID: 34695549 DOI: 10.1016/j.echo.2021.10.007] [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: 09/06/2021] [Revised: 10/10/2021] [Accepted: 10/13/2021] [Indexed: 11/22/2022]
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24
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Roscoe A, Zochios V. Echocardiography in Weaning Right Ventricular Mechanical Circulatory Support: Are We Measuring the Right Stuff? J Cardiothorac Vasc Anesth 2021; 36:362-366. [PMID: 34688542 DOI: 10.1053/j.jvca.2021.09.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 09/27/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Andrew Roscoe
- Department of Anesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anesthesia, National Heart Centre Singapore, Singapore.
| | - Vasileios Zochios
- Department of Critical Care Medicine and ECMO Unit, University Hospitals of Leicester National Health Service Trust, Glenfield Hospital, Leicester, United Kingdom.
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25
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Cole SP, Martinez-Acero N, Peterson A, Von Homeyer P, Gebhardt B, Nicoara A. Imaging for Temporary Mechanical Circulatory Support Devices. J Cardiothorac Vasc Anesth 2021; 36:2114-2131. [PMID: 34740543 DOI: 10.1053/j.jvca.2021.09.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 09/04/2021] [Accepted: 09/20/2021] [Indexed: 11/11/2022]
Abstract
Heart failure is an important cause of mortality and morbidity in the world. Changes in organ allocation for solid thoracic (lung and heart) transplantation has increased the number of patients on mechanical circulatory support. Temporary mechanical support devices include devices tht support the circulation directly or indirectly such as extracorporeal membrane oxygenation (ECMO) and temporary support for right-sided failure, left-sided failure or biventricular failure. Most often, these devices are placed percutaneously and require either guidance with echocardiography, continuous radiography (fluoroscopy) or both. Furthermore, these devices need imaging in the intensive care unit to confirm continued accurate placement. This review contains the imaging views and nuances of the temporary assist devices (including ECMO) at the time of placement and the complications that can be associated with each individual device.
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Affiliation(s)
- Sheela Pai Cole
- Clinical Professor, Department of Anesthesiology, Perioperative and Pain medicine, Stanford University, Palo Alto, CA 94305.
| | - Natalia Martinez-Acero
- Associate Physician, Cardiac Anesthesiology and Critical Care, Kaiser Permanente, Santa Clara, CA.
| | - Ashley Peterson
- Clinical Assistant Professor, Department of Anesthesiology, Perioperative and Pain medicine, Stanford University, Palo Alto, CA 94305.
| | - Peter Von Homeyer
- Associate Professor, Department of Anesthesiology, University of Washington, Seattle, WA 98195.
| | | | - Alina Nicoara
- Associate Professor, Department of Anesthesiology, Duke University, Raleigh, NC 27708.
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26
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Trahanas JM, Li SS, Crowley JC, Ton VK, Funamoto M, Cudemus Deseda GA, Villavicencio MA, D'Alessandro DA. How to Turn It Down: The Evidence and Opinions Behind Adult Venoarterial Extracorporeal Membrane Oxygenation Weaning. ASAIO J 2021; 67:964-972. [PMID: 34477569 DOI: 10.1097/mat.0000000000001375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Adequate and durable recovery in patients supported with venoarterial (VA) extracorporeal membrane oxygenation (ECMO) can be challenging to predict. Extracorporeal membrane oxygenation weaning is the process by which the ECMO flows are decreased to assess if a patient is ready for decannulation. The optimal strategies for deciding who to wean and how to wean VA ECMO remain undefined. A retrospective literature review was performed to understand the evidence supporting current practices in ECMO weaning and in particular patient selection and methods. Most published work and expert opinions agree that once the underlying process has resolved, the minimum required physiologic parameters for weaning from ECMO include: hemodynamic stability and cardiac pulsatility, adequate lung function to support oxygenation and ventilation, and evidence of recovered end organ function. Echocardiography is universally used to assess cardiac function during the weaning process. Currently, there is no consensus regarding who is eligible to wean or how to wean ECMO in adults. We have reviewed the literature to summarize the evidence and expert opinions behind VA ECMO weaning, and give an example of the protocol used at our center. We believe this protocol optimizes patient selection for weaning and helps to predict successful decannulation.
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Affiliation(s)
- John M Trahanas
- From the Department of Surgery, Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Selena S Li
- From the Department of Surgery, Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Jerome C Crowley
- Department of Anesthesia, Division of Critical Care and Pain Management, Massachusetts General Hospital, Boston, Massachusetts
| | - Van-Khue Ton
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Masaki Funamoto
- From the Department of Surgery, Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Gaston A Cudemus Deseda
- Department of Anesthesia, Division of Critical Care and Pain Management, Massachusetts General Hospital, Boston, Massachusetts
| | - Mauricio A Villavicencio
- From the Department of Surgery, Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - David A D'Alessandro
- From the Department of Surgery, Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
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27
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Randhawa VK, Al-Fares A, Tong MZY, Soltesz EG, Hernandez-Montfort J, Taimeh Z, Weiss AJ, Menon V, Campbell J, Cremer P, Estep JD. A Pragmatic Approach to Weaning Temporary Mechanical Circulatory Support: A State-of-the-Art Review. JACC-HEART FAILURE 2021; 9:664-673. [PMID: 34391743 DOI: 10.1016/j.jchf.2021.05.011] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/13/2021] [Indexed: 11/27/2022]
Abstract
Temporary mechanical circulatory support (TMCS) provides short-term support to patients with or at risk of refractory cardiogenic shock. Although indications, contraindications, and complications of TMCS may guide device selection, optimal strategies for device weaning and explant remain poorly defined. Under the revised adult heart allocation policy implemented by the United Nations for Organ Sharing in October 2018, rejustification of heart transplant listing status includes demonstrating TMCS dependency with attempted device wean trials. However, standardized device-specific weaning and explant protocols have not been proposed or evaluated. This review highlights when to use percutaneous TMCS in cardiogenic shock, with a focus on weaning and explant considerations. Terminology for important concepts that guide device escalation, de-escalation, and explantation have been defined. Clinical, hemodynamic, metabolic, and imaging features have been defined, which can guide a tailored approach to TMCS weaning and explant based on the approach used at the Cleveland Clinic. A narrative review of published studies that have reported TMCS weaning protocols and survey results of member centers from CS-MCS working group centers is also provided. Future research is needed to better understand optimal timing and implementation of standardized protocols to achieve successful TMCS weaning and explant.
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Affiliation(s)
- Varinder Kaur Randhawa
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Abdulrahman Al-Fares
- Kuwait Extracorporeal Life Support Program, Ministry of Health, Kuwait City, Kuwait; Department of Anesthesia and Critical Care Medicine, Al-Amiri Hospital, Kuwait City, Kuwait
| | - Michael Z Y Tong
- Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jaime Hernandez-Montfort
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, Florida, USA
| | - Ziad Taimeh
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Aaron J Weiss
- Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Venu Menon
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Joseph Campbell
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Paul Cremer
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jerry D Estep
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
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28
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Ellouze O, Soudry Faure A, Radhouani M, Abou‐Arab O, Besnier E, Moussa M, Cransac A, Ksiazek E, Fischer M, Mertes PM, Bouhemad B, Guinot PG. Levosimendan in venoarterial ECMO weaning. Rational and design of a randomized double blind multicentre trial. ESC Heart Fail 2021; 8:3339-3347. [PMID: 34145993 PMCID: PMC8318420 DOI: 10.1002/ehf2.13427] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 04/25/2021] [Accepted: 05/02/2021] [Indexed: 12/15/2022] Open
Abstract
AIMS Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used in circulatory failure. The main indications are cardiogenic shock, post-cardiotomy cardiac failure, and refractory cardiac arrest. However, VA-ECMO weaning is particularly challenging, and weaning failure is reported to be as high as 50%, with increased related mortality. Levosimendan is a novel long acting effect inodilator used in cardiogenic shock and terminal heart failure decompensation. Levosimendan use in VA-ECMO patients seems to reduce weaning failure regardless of the initial aetiology and to reduce mortality when administrated early after VA-ECMO initiation. However, studies are limited to retrospective analyses and reported case series. The aim of the WEANILEVO trial is to evaluate whether administration of levosimendan before VA-ECMO weaning is associated with a reduced rates of weaning failure and recourse to other temporary circulatory support. METHODS AND RESULTS WEANILEVO is a randomized, prospective, multicentre, double-blind, parallel-group, controlled trial. One hundred eighty patients will be enrolled if they had acute circulatory heart failure treated with VA-ECMO and for whom weaning is expected within 48 h. The study drugs are either levosimendan (0.2 μg/kg/min for 24 h) or a placebo. The primary endpoint of the trial is the absence of VA-ECMO weaning, recourse to another VA-ECMO, or other temporary circulatory assistance or death within 7 days of VA-ECMO weaning. CONCLUSIONS Levosimendan use in VA-ECMO appears to be beneficial for reducing weaning failure and mortality. The results of WEANILEVO should significantly influence decisions regarding the use of levosimendan for VA-ECMO weaning.
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Affiliation(s)
- Omar Ellouze
- Department of Anesthesia and Critical CareUniversity Hospital of DijonDijonFrance
| | | | - Mohamed Radhouani
- Department of Anesthesia and Critical CareUniversity Hospital of DijonDijonFrance
| | - Osama Abou‐Arab
- Department of Anesthesia and Critical CareUniversity Hospital of AmiensAmiensFrance
| | - Emmanuel Besnier
- Department of Anesthesia and Critical CareUniversity Hospital of RouenRouenFrance
| | - Mouhamed Moussa
- Department of Anesthesia and Critical CareUniversity Hospital of LilleLilleFrance
| | - Amélie Cransac
- Department of PharmacyUniversity Hospital of DijonDijonFrance
| | - Elea Ksiazek
- Direction of Clinical ResearchUniversity Hospital of DijonDijonFrance
| | | | - Paul Michel Mertes
- Department of Anesthesia and Critical CareUniversity Hospital of StrasbourgStrasbourgFrance
| | - Belaid Bouhemad
- Department of Anesthesia and Critical CareUniversity Hospital of DijonDijonFrance
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29
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Sciaccaluga C, Mandoli GE, Ghionzoli N, Anselmi F, Dini CS, Righini F, Cesareo F, D'Ascenzi F, Focardi M, Valente S, Cameli M. Risk stratification in cardiogenic shock: a focus on the available evidence. Heart Fail Rev 2021; 27:1105-1117. [PMID: 34263413 PMCID: PMC9197897 DOI: 10.1007/s10741-021-10140-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2021] [Indexed: 11/25/2022]
Abstract
Cardiogenic shock is a clinical syndrome which is defined as the presence of primary cardiac disorder that results in hypotension together with signs of organ hypoperfusion in the state of normovolaemia or hypervolaemia. It represents a complex life-threatening condition, characterized by a high mortality rate, that requires urgent diagnostic assessment as well as treatment; therefore, it is of paramount important to advocate for a thorough risk stratification. In fact, the early identification of patients that could benefit the most from more aggressive and invasive approaches could facilitate a more efficient resource allocation. This review attempts to critically analyse the current evidence on prognosis in cardiogenic shock, focusing in particular on clinical, laboratoristic and echocardiographic prognostic parameters. Furthermore, it focuses also on the available prognostic scores, highlighting the strengths and the possible pitfalls. Finally, it provides insights into future direction that could be followed in order to ameliorate risk stratification in this delicate subset of patients.
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Affiliation(s)
- C Sciaccaluga
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy.
| | - G E Mandoli
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | - N Ghionzoli
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | - F Anselmi
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | - C Sorini Dini
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | - F Righini
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | - F Cesareo
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | - F D'Ascenzi
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | - M Focardi
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | - S Valente
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | - M Cameli
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
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30
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Brahmbhatt DH, Daly AL, Luk AC, Fan E, Billia F. Liberation From Venoarterial Extracorporeal Membrane Oxygenation: A Review. Circ Heart Fail 2021; 14:e007679. [PMID: 34247519 DOI: 10.1161/circheartfailure.120.007679] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Venoarterial extracorporeal membrane oxygenation may be used for circulatory support in cardiogenic shock as a bridge to recovery, a bridge to a ventricular assist device (VAD), or a bridge to transplant. While the determination of potential exit strategies is essential before cannulation, the final determination of a patient's options may change, in part, through their in-hospital clinical course. We propose that liberation from venoarterial extracorporeal membrane oxygenation should be conceptualized as a process of discovery in the assessment of a patient's underlying clinical status and a key driver of further clinical decision-making. A trial of liberation from support should be considered when the goals of the weaning trial are well-defined and, ideally, in the absence of potentially confounding clinical factors. In this review, we will discuss readiness to wean criteria from venoarterial extracorporeal membrane oxygenation, as well as specific clinical, biochemical, and echocardiographic parameters that may prove useful in determining weaning timing and revealing the patient's underlying hemodynamic status and prognosis. The role of various cannula configurations, support devices, and pharmacological adjuncts will also be discussed. Finally, we highlight current gaps in evidence and suggest areas of future research.
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Affiliation(s)
- Darshan H Brahmbhatt
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada (D.H.B., A.L.D., A.C.L., F.B.)
- Department of Medicine (D.H.B., A.L.D., A.C.L., F.B.), University of Toronto, ON, Canada
- National Heart & Lung Institute, Imperial College London, United Kingdom (D.H.B.)
- Ted Rogers Centre for Heart Research, Toronto, ON, Canada (D.H.B., A.C.L., F.B.)
| | - Andrea L Daly
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada (D.H.B., A.L.D., A.C.L., F.B.)
- Department of Medicine (D.H.B., A.L.D., A.C.L., F.B.), University of Toronto, ON, Canada
| | - Adriana C Luk
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada (D.H.B., A.L.D., A.C.L., F.B.)
- Department of Medicine (D.H.B., A.L.D., A.C.L., F.B.), University of Toronto, ON, Canada
- Ted Rogers Centre for Heart Research, Toronto, ON, Canada (D.H.B., A.C.L., F.B.)
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine (E.F.), University of Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON Canada (E.F., F.B.)
| | - Filio Billia
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada (D.H.B., A.L.D., A.C.L., F.B.)
- Department of Medicine (D.H.B., A.L.D., A.C.L., F.B.), University of Toronto, ON, Canada
- Ted Rogers Centre for Heart Research, Toronto, ON, Canada (D.H.B., A.C.L., F.B.)
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON Canada (E.F., F.B.)
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31
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Cardiac intensive care management of high-risk percutaneous coronary intervention using the venoarterial ECMO support. Heart Fail Rev 2021; 25:833-846. [PMID: 31677013 DOI: 10.1007/s10741-019-09862-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The emerging concept of high-risk percutaneous coronary intervention (HR-PCI) has required the adoption of a multidisciplinary team approach. Venoarterial ECMO (VA-ECMO) has been introduced as a temporary mechanical circulatory support (MCS) for HR-PCI patients in order to provide an adequate systemic perfusion during the procedure. Both patient's complexity and technological evolutions have catalyzed the development of critical care cardiology; however, ECMO therapy faces several challenges. Indeed, the management of patients on ECMO remains complex; moreover, the lack of specific recommendation for HR-PCI patients further complicates the management of these patients. In this narrative review, we give a reappraisal for the management of HR-PCI patients supported with VA-ECMO according to the available data published in current literature.
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32
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Abstract
PURPOSE OF REVIEW Cardiogenic shock (CS) therapy involving catecholamines, inotropes, fluids and revascularization is often insufficient, and short-term mortality remains 50%. Different treatment algorithms and mechanical circulatory support devices (MCS) have been increasingly used in the treatment of CS. Coronavirus disease 2019 (COVID-19) pandemic is a major challenge faced by intensive care medicine providers inevitably influencing also CS management. RECENT FINDINGS There is a lack of prospective data as well as international consensus regarding CS classification, patient risk stratification, and MCS use. Veno-arterial extracorporeal membrane oxygenation is considered the first line MCS in refractory CS and Impella the MCS of choice for the left ventricle unloading. Several ongoing randomized trials will provide much-needed evidence for MCS use in the coming years. COVID-19 infection is associated with several cardiovascular disorders complicated by CS and more data regarding the prevalence and mortality of CS during COVID-19 infection are needed. SUMMARY This review summarizes current trends in the use of MCS in CS and discusses differences in CS management during the COVID-19 pandemic. Careful patient selection, early MCS initiation, and comprehensive intensive care by experienced team is key to successful outcome in patients with refractory CS.
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Affiliation(s)
- Daniel Rob
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
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33
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Echocardiographic Predictors of Successful Extracorporeal Membrane Oxygenation Weaning After Refractory Cardiogenic Shock. J Am Soc Echocardiogr 2021; 34:414-422.e4. [DOI: 10.1016/j.echo.2020.12.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 12/07/2020] [Accepted: 12/07/2020] [Indexed: 12/23/2022]
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34
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Sawada K, Kawakami S, Murata S, Nishimura K, Tahara Y, Hosoda H, Nakashima T, Kataoka Y, Asaumi Y, Noguchi T, Sugimachi M, Fujita T, Kobayashi J, Yasuda S. Predicting Parameters for Successful Weaning from Veno-Arterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock. ESC Heart Fail 2020; 8:471-480. [PMID: 33264500 PMCID: PMC7835592 DOI: 10.1002/ehf2.13097] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/24/2020] [Accepted: 10/23/2020] [Indexed: 11/23/2022] Open
Abstract
Aims Percutaneous veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) is utilized for patients with cardiogenic shock or cardiac arrest. However, the procedure protocol for weaning from VA‐ECMO has not been well established. The present study aimed to determine the usefulness of echocardiographic and pulmonary artery catheter parameters for predicting successful weaning from VA‐ECMO in patients with refractory cardiogenic shock. Methods and results We retrospectively studied 50 patients who were hospitalized and supported by VA‐ECMO for >48 h between January 2013 and March 2017. Patients successfully weaned from VA‐ECMO without reintroduction of VA‐ECMO or left ventricular assist device implantation were defined as 30 day survivors. Echocardiographic and pulmonary artery catheter parameters were evaluated when ECMO flow was limited to a maximum of 1.5–2.0 L/min. Twenty‐four patients were successfully weaned from VA‐ECMO, whereas 26 were not. Fractional shortening, corrected left ventricular ejection time (LVETc, defined as LVET divided by the square root of heart rate), left ventricular outflow tract velocity time integral, and LVETc divided by pulmonary artery wedge pressure (PAWP) were significantly larger in the 30 day survivor groups. Multivariable analysis revealed LVETc∕PAWP as a significant independent predictor of successful weaning (LVETc∕PAWP, odds ratio 0.82, 95% confidence interval 0.71–0.94, P = 0.005). Receiver operating characteristic curve analysis revealed 15.9 as the optimal LVETc∕PAWP for predicting successful weaning (area under the curve 0.82). Conclusions The present findings indicate that LVETc∕PAWP is a potential predictor of successful weaning from VA‐ECMO.
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Affiliation(s)
- Kenichiro Sawada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.,Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Shoji Kawakami
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Shunsuke Murata
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshio Tahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Hayato Hosoda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Takahiro Nakashima
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Yu Kataoka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.,Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Masaru Sugimachi
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.,Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.,Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
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Bachmann KF, Zwicker L, Nettelbeck K, Casoni D, Heinisch PP, Jenni H, Haenggi M, Berger D. Assessment of Right Heart Function during Extracorporeal Therapy by Modified Thermodilution in a Porcine Model. Anesthesiology 2020; 133:879-891. [PMID: 32657798 DOI: 10.1097/aln.0000000000003443] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Veno-arterial extracorporeal membrane oxygenation therapy is a growing treatment modality for acute cardiorespiratory failure. Cardiac output monitoring during veno-arterial extracorporeal membrane oxygenation therapy remains challenging. This study aims to validate a new thermodilution technique during veno-arterial extracorporeal membrane oxygenation therapy using a pig model. METHODS Sixteen healthy pigs were centrally cannulated for veno-arterial extracorporeal membrane oxygenation, and precision flow probes for blood flow assessment were placed on the pulmonary artery. After chest closure, cold boluses of 0.9% saline solution were injected into the extracorporeal membrane oxygenation circuit, right atrium, and right ventricle at different extracorporeal membrane oxygenation flows (4, 3, 2, 1 l/min). Rapid response thermistors in the extracorporeal membrane oxygenation circuit and pulmonary artery recorded the temperature change. After calculating catheter constants, the distributions of injection volumes passing each circuit were assessed and enabled calculation of pulmonary blood flow. Analysis of the exponential temperature decay allowed assessment of right ventricular function. RESULTS Calculated blood flow correlated well with measured blood flow (r2 = 0.74, P < 0.001). Bias was -6 ml/min [95% CI ± 48 ml/min] with clinically acceptable limits of agreement (668 ml/min [95% CI ± 166 ml/min]). Percentage error varied with extracorporeal membrane oxygenation blood flow reductions, yielding an overall percentage error of 32.1% and a percentage error of 24.3% at low extracorporeal membrane oxygenation blood flows. Right ventricular ejection fraction was 17 [14 to 20.0]%. Extracorporeal membrane oxygenation flow reductions increased end-diastolic and end-systolic volumes with reductions in pulmonary vascular resistance. Central venous pressure and right ventricular ejection fractions remained unchanged. End-diastolic and end-systolic volumes correlated highly (r2 = 0.98, P < 0.001). CONCLUSIONS Adapted thermodilution allows reliable assessment of cardiac output and right ventricular behavior. During veno-arterial extracorporeal membrane oxygenation weaning, the right ventricle dilates even with stable function, possibly because of increased venous return. EDITOR’S PERSPECTIVE
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Ak K. Assessment of the right ventricular function under venoarterial ECMO: a challenging issue. Ann Thorac Surg 2020; 114:354-355. [PMID: 33161016 DOI: 10.1016/j.athoracsur.2020.08.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 08/01/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Koray Ak
- Marmara University Faculty of Medicine, Department of Cardiovascular Surgery, Marmara Universitesi Pendik Egitim ve Arastırma Hastanesi, Ustkaynarca Pendik Istanbul, Turkey.
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Sertic F, Bermudez C, Rame JE. Venoarterial Extracorporeal Membrane Oxygenation as a Bridge to Recovery or Bridge to Heart Replacement Therapy in Refractory Cardiogenic Shock. Curr Heart Fail Rep 2020; 17:341-349. [DOI: 10.1007/s11897-020-00495-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 01/16/2023]
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Ju MH, Lim MH, Lee SY, Lee CH, Je HG. Early experience of pump-controlled retrograde trial off for weaning from veno-arterial extracorporeal membrane oxygenation in adult patients with cardiogenic shock. Perfusion 2020; 36:401-406. [DOI: 10.1177/0267659120941328] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Introduction: Pump-controlled retrograde trial off has recently been introduced as an effective method for weaning from veno-arterial extracorporeal membrane oxygenation in pediatric patients. However, studies on pump-controlled retrograde trial off in adults are still lacking. Thus, this study aimed to examine the outcomes of pump-controlled retrograde trial off for weaning from veno-arterial extracorporeal membrane oxygenation in adult patients. Methods: Between January 2018 and July 2019, 87 consecutive adult patients underwent veno-arterial extracorporeal membrane oxygenation support, of whom 47 (54.0%) underwent pump-controlled retrograde trial off for weaning from extracorporeal membrane oxygenation and were enrolled in this study. The pump-controlled retrograde trial off results, extracorporeal membrane oxygenation reapplication rate, and clinical outcomes were analyzed. Results: Of the 47 patients, 38 (80.9%) were weaned from veno-arterial extracorporeal membrane oxygenation on the first attempt of pump-controlled retrograde trial off, 5 (10.6%) on the second attempt, and 4 (8.5%) on the third attempt. Three patients were converted to venovenous extracorporeal membrane oxygenation by desaturation but had stable blood pressure during pump-controlled retrograde trial off. No extracorporeal membrane oxygenation reapplication was performed within 3 days after removal, and two patients underwent veno-arterial extracorporeal membrane oxygenation during follow-up. No complications associated with pump-controlled retrograde trial off occurred during the weaning process, including thromboembolic events. Five in-hospital deaths (10.6%) occurred after weaning from extracorporeal membrane oxygenation. Conclusion: Pump-controlled retrograde trial off is an effective method to safely wean from veno-arterial extracorporeal membrane oxygenation in adult patients. It is simple and can be easily implemented without additional invasive procedures and may help prevent deterioration of the cardiovascular system after weaning from veno-arterial extracorporeal membrane oxygenation.
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Affiliation(s)
- Min Ho Ju
- Department of Cardiovascular and Thoracic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Mi Hee Lim
- Department of Cardiovascular and Thoracic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Soo Yong Lee
- Cardiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Chee-Hoon Lee
- Department of Cardiovascular and Thoracic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyung Gon Je
- Department of Cardiovascular and Thoracic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
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Tohme J, Piat C, Aissat N, Lebreton G, Duceau B, Charfeddine A, Baptiste A, Bouglé A. Weaning-Related Shock in Patients With ECMO: Incidence, Mortality, and Predisposing Factors. J Cardiothorac Vasc Anesth 2020; 35:41-47. [PMID: 32828655 DOI: 10.1053/j.jvca.2020.07.069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 07/22/2020] [Accepted: 07/23/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Venoarterial extracorporeal membrane oxygenation (VA-ECMO) commonly is used to manage refractory cardiogenic shock after cardiac surgery, with 31% to 76% of patients successfully weaned off their ECMO. However, it is associated with high mortality rates, and 20% to 65% of weaned patients do not survive to hospital discharge. This study aimed to assess the incidence of ECMO weaning-related shock, the risk factors, and prognosis in the intensive care unit (ICU). DESIGN Retrospective observational cohort study. SETTING Surgical ICU of Cardiology Institute of Pitié-Salpêtrière University Hospital (Paris-France). PARTICIPANTS Patients who were assisted with a peripheral VA-ECMO from January 2015 to December 2017 were included. Patients with venovenous, central, or right ECMO were excluded. MEASUREMENTS The authors collected data on patients' characteristics, during and after surgery. The indications for VA-ECMO implantation were ventricular dysfunction, primary graft dysfunction, and refractory cardiac arrest. Weaning-related shock was defined as the need to introduce or increase the dose of catecholamine at ECMO explantation or in the following week. RESULTS After weaning off VA-ECMO, 56 of 146 patients (38.4%) presented weaning-related shock: 55% were septic shocks, 12.5 % were caused by right ventricle failure, and 7.1% by hemorrhage. ICU mortality was 42% versus 8% in patients who did not present shock. Multivariate analysis showed that patients with pulmonary hypertension and those with norepinephrine before weaning were more likely to develop shock. CONCLUSION ECMO weaning-related shock is frequent in patients with refractory cardiogenic shock after cardiac surgery. This is most commonly caused by sepsis and causes higher mortality rates, calling for further evaluation.
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Affiliation(s)
- Joanna Tohme
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Camille Piat
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Nadia Aissat
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Guillaume Lebreton
- Sorbonne Université, UMR INSERM 1166, IHU ICAN, AP-HP, Department of Cardio-Vascular and Thoracic Surgery, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Baptiste Duceau
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Ahmed Charfeddine
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Amandine Baptiste
- AP-HP, Hôpital Pitié-Salpêtrière, Département Biostatistique Santé Publique Et Information Médicale, Unité de Recherche Clinique PSL-CFX, Centre de Pharmacoépidémiologie (Cephepi), CIC-1421, Paris, France
| | - Adrien Bouglé
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France.
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The Venoarterial Extracorporeal Membrane Oxygenation Weaning Checklist. A A Pract 2020; 14:e01199. [PMID: 32392020 PMCID: PMC7190048 DOI: 10.1213/xaa.0000000000001199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Supplemental Digital Content is available in the text. Venoarterial extracorporeal membrane oxygenation (vaECMO) is a well-established treatment option for severe cardiogenic shock of various etiologies. Although trials have explored weaning strategies, a brief and conclusive overview is lacking. We present the different aspects of weaning and provide an evidence- and experienced-based guide for clinicians managing patients under vaECMO in the preweaning, weaning, and postweaning phases.
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Hemodynamic Aspects of Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiac Support: A Worldwide Survey. ASAIO J 2020; 66:489-496. [DOI: 10.1097/mat.0000000000001024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Right ventricular three-dimensional echocardiography: the current status and future perspectives. J Echocardiogr 2020; 18:149-159. [PMID: 32239383 DOI: 10.1007/s12574-020-00468-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 03/23/2020] [Indexed: 12/18/2022]
Abstract
This review focused on right ventricular (RV) three-dimensional echocardiography (3DE) and discussed the following agenda. First, we summarized the clinical RV anatomy and function-related RV3DE use followed by the explanations about 3DSTE image acquisition, including pitfall. Next, we reviewed the reliability and feasibility of RV volume and RV ejection fraction measurements during the last decade. Besides, we described the techniques that might overcome the dropout images at RV anterior and out tract including the current limitations. Finally, speckle tracking echocardiography by RV3DE and novel RV shape assessment were reviewed. This review will help you get comprehensive information on the current status and future perspectives of RV3DE.
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Lüsebrink E, Stremmel C, Stark K, Joskowiak D, Czermak T, Born F, Kupka D, Scherer C, Orban M, Petzold T, von Samson-Himmelstjerna P, Kääb S, Hagl C, Massberg S, Peterss S, Orban M. Update on Weaning from Veno-Arterial Extracorporeal Membrane Oxygenation. J Clin Med 2020; 9:E992. [PMID: 32252267 PMCID: PMC7230450 DOI: 10.3390/jcm9040992] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/18/2020] [Accepted: 03/27/2020] [Indexed: 01/14/2023] Open
Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary cardiac and respiratory support and has emerged as an established salvage intervention for patients with hemodynamic compromise or shock. It is thereby used as a bridge to recovery, bridge to permanent ventricular assist devices, bridge to transplantation, or bridge to decision. However, weaning from VA-ECMO differs between centers, and information about standardized weaning protocols are rare. Given the high mortality of patients undergoing VA-ECMO treatment, it is all the more important to answer the many questions still remaining unresolved in this field Standardized algorithms are recommended to optimize the weaning process and determine whether the VA-ECMO can be safely removed. Successful weaning as a multifactorial process requires sufficient recovery of myocardial and end-organ function. The patient should be considered hemodynamically stable, although left ventricular function often remains impaired during and after weaning. Echocardiographic and invasive hemodynamic monitoring seem to be indispensable when evaluating biventricular recovery and in determining whether the VA-ECMO can be weaned successfully or not, whereas cardiac biomarkers may not be useful in stratifying those who will recover. This review summarizes the strategies of weaning of VA-ECMO and discusses predictors of successful and poor weaning outcome.
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Affiliation(s)
- Enzo Lüsebrink
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Christopher Stremmel
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Konstantin Stark
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Dominik Joskowiak
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Thomas Czermak
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Frank Born
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Danny Kupka
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Clemens Scherer
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Mathias Orban
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Tobias Petzold
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Patrick von Samson-Himmelstjerna
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Stefan Kääb
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Steffen Massberg
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Sven Peterss
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Martin Orban
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
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Krishnan S, Schmidt GA. Hemodynamic monitoring in the extracorporeal membrane oxygenation patient. Curr Opin Crit Care 2020; 25:285-291. [PMID: 30865613 DOI: 10.1097/mcc.0000000000000602] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Hemodynamic monitoring in ECMO patients requires familiarity with the underlying pathophysiology and circulatory mechanics of extracorporeal flow. This review discusses the various monitoring modalities relevant to the management of patients on venovenous ECMO (VV ECMO) and venoarterial (VA ECMO). We emphasize tools to judge the adequacy of perfusion, predict the response to fluid boluses, measure right ventricular function, assess left ventricular distention (for VA ECMO), and monitor the process of weaning from ECMO. We emphasize how differences between VV ECMO and VA ECMO are reflected in distinct approaches to monitoring. RECENT FINDINGS Point-of-care ultrasound and near-infrared spectroscopy can play a significant role in monitoring of global and regional perfusion. SUMMARY Recent literature in hemodynamic monitoring of ECMO patients is discussed, with comparison of VV ECMO and VA ECMO. Many common monitoring tools lack validity during ECMO: by taking into account the unique physiology of the ECMO circulation, selected methods can aid in the care of these complex patients.
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Affiliation(s)
| | - Gregory A Schmidt
- Division of Pulmonary Diseases, Critical Care, and Occupational Medicine, University of Iowa, Iowa City, USA
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Desai SR, Hwang NC. Strategies for Left Ventricular Decompression During Venoarterial Extracorporeal Membrane Oxygenation - A Narrative Review. J Cardiothorac Vasc Anesth 2020; 34:208-218. [DOI: 10.1053/j.jvca.2019.08.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 07/26/2019] [Accepted: 08/17/2019] [Indexed: 01/21/2023]
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Contemporary Comprehensive Monitoring of Veno-arterial Extracorporeal Membrane Oxygenation Patients. Can J Cardiol 2019; 36:291-299. [PMID: 31924449 DOI: 10.1016/j.cjca.2019.10.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 10/17/2019] [Accepted: 10/30/2019] [Indexed: 01/09/2023] Open
Abstract
The use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) has increased substantially over the past few decades. Today's clinicians now have a powerful means with which to salvage a growing population of patients at risk for cardiopulmonary collapse. At the same time, patients supported with VA ECMO have become increasingly more complex. The successful use of VA ECMO depends not only on selecting the appropriate patients, but also on effectively navigating a potential torrent of device- and patient-related complications until ECMO is no longer needed. A multitude of monitoring tools are now available to help the treatment team determine the adequacy of care, to detect problems, and to anticipate recovery. Monitoring with devices such as the Swan-Ganz catheter, transthoracic and transesophageal echocardiography, chest radiography, and near-infrared spectroscopy can provide useful information to complement routine clinical care. Leveraging data derived from the ECMO circuit itself also can be instrumental in both evaluating the sufficiency of support and troubleshooting complications. Each of these tools, however, has its own unique sets of limitations and liabilities. A thorough understanding of these risks and benefits is critical to the contemporary care of the individual managed with VA ECMO. In addition, more research is needed to establish optimal evidence-based care pathways and best-practice principles for using these devices to improve patient outcomes.
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Lai HJ, Huang KC, Liang YC, Chien KL, Lee MJ, Hsieh ST, Chao CC, Yang CC. Cardiac manifestations and prognostic implications of hereditary transthyretin amyloidosis associated with transthyretin Ala97Ser. J Formos Med Assoc 2019; 119:693-700. [PMID: 31521469 DOI: 10.1016/j.jfma.2019.08.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/23/2019] [Accepted: 08/26/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The cardiac manifestations of late-onset hereditary transthyretin amyloidosis with p.A97S variant have not been extensively studied, and the prognostic factors remain unclear. METHODS The clinical profile, echocardiography, and ECG of patients diagnosed with ATTR p.A97S polyneuropathy between 2000 and 2016 were retrospectively collected. 67 patients with ATTR p.A97S were collected. RESULTS A total of 82% of patients met the criteria for left ventricular (LV) hypertrophy. Reduced global longitudinal strain (GLS) was noted in 42.1% of patients, and 14% of patients had a relative apical sparing pattern. A low voltage pattern in the ECG was observed in 31.3% of patients, while 64.2% presented with a pseudoinfarction pattern. End-systolic LV inner dimension (HR: 2.25 (95% CI: 1.01-5.01), p = 0.048), reduced GLS (HR: 5.26 (1.08-25.0), p = 0.039), relative apical longitudinal strain (RALS>1, HR: 8.57 (1.69-43.3), p = 0.009), increased E/A ratio (HR: 6.51 (1.17-36.4), p = 0.033), and increased QRS duration (HR: 1.02 (1.00-1.04), p = 0.05) were correlated with reduced survival in univariate analysis. Multivariate analysis revealed reduced RALS was significantly correlated with reduced survival (HR: 13.00 (1.81-93.45), p = 0.011). CONCLUSION Our findings reveal that ATTR p.A97S is a cardiomyopathy as well as a polyneuropathic syndrome. Routine use of more contemporary echocardiographic techniques are recommended to identify cardiac amyloidosis and provide prognostic information.
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Affiliation(s)
- Hsing-Jung Lai
- Department of Neurology, National Taiwan University Hospital, Taiwan; National Taiwan University Hospital, Jin-Shan Branch, Taiwan
| | - Kuan-Chih Huang
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan; Division of Cardiology, Heart Center, Cheng- Hsin General Hospital, Taipei, Taiwan
| | - Yun-Chieh Liang
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taiwan
| | - Kuo-Liong Chien
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taiwan; Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taiwan
| | - Ming-Jen Lee
- Department of Neurology, National Taiwan University Hospital, Taiwan
| | - Sung-Tsang Hsieh
- Department of Neurology, National Taiwan University Hospital, Taiwan
| | - Chi-Chao Chao
- Department of Neurology, National Taiwan University Hospital, Taiwan
| | - Chih-Chao Yang
- Department of Neurology, National Taiwan University Hospital, Taiwan.
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48
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Kado Y, Miyamoto T, Fukamachi K, Karimov JH. Update on the management and associated challenges of adult patients treated with veno-arterial extracorporeal membrane oxygenation. Expert Rev Med Devices 2019; 16:483-491. [DOI: 10.1080/17434440.2019.1614439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Yuichiro Kado
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland, OH, USA
| | - Takuma Miyamoto
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland, OH, USA
| | - Kiyotaka Fukamachi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland, OH, USA
| | - Jamshid H. Karimov
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland, OH, USA
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49
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Ortuno S, Delmas C, Diehl JL, Bailleul C, Lancelot A, Naili M, Cholley B, Pirracchio R, Aissaoui N. Weaning from veno-arterial extra-corporeal membrane oxygenation: which strategy to use? Ann Cardiothorac Surg 2019; 8:E1-E8. [PMID: 30854330 DOI: 10.21037/acs.2018.08.05] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Refractory cardiogenic shock patients may be rescued by veno-arterial extracorporeal membrane oxygenation (VA ECMO). After a few days of mechanical assistance, the device can sometimes be successfully removed if the patient has partially or fully recovered from the condition that required the use of ECMO. The percentage of patients with refractory cardiogenic shock who are successfully weaned from ECMO varies from 31% to 76%. Weaning does not mean survival, because 20% to 65% of patients weaned from VA ECMO support do not survive to hospital discharge. The high death rate after successful weaning shows that many questions remain unresolved in this field. In this review, we will discuss the various factors influencing survival and a successful weaning from VA ECMO, in addition to weaning approaches proposed in the literature. Based on this information, we will propose a strategy to optimize the weaning process.
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Affiliation(s)
- Sofia Ortuno
- Department of Intensive Care Cnit, Hôpital Européen Georges Pompidou (HEGP) Assistance Publique-Hôpitaux de Paris (APHP) and Université Paris Descartes, Paris, France
| | - Clément Delmas
- Intensive Cardiac Care Unit, Rangueil University, Toulouse, France
| | - Jean-Luc Diehl
- Department of Intensive Care Cnit, Hôpital Européen Georges Pompidou (HEGP) Assistance Publique-Hôpitaux de Paris (APHP) and Université Paris Descartes, Paris, France
| | - Clotilde Bailleul
- Department of Intensive Care Cnit, Hôpital Européen Georges Pompidou (HEGP) Assistance Publique-Hôpitaux de Paris (APHP) and Université Paris Descartes, Paris, France
| | - Aymeric Lancelot
- Department of Intensive Care Cnit, Hôpital Européen Georges Pompidou (HEGP) Assistance Publique-Hôpitaux de Paris (APHP) and Université Paris Descartes, Paris, France
| | - Mahassen Naili
- Department of Cardiology, Hôpital Européen Georges Pompidou, APHP, Paris, France
| | - Bernard Cholley
- Department of Anesthesiology and Intensive Care, Paris, Hôpital Européen Georges Pompidou, APHP, Université Paris-Descartes, Paris, France
| | - Romain Pirracchio
- Department of Anesthesiology and Intensive Care, Paris, Hôpital Européen Georges Pompidou, APHP, Université Paris-Descartes, Paris, France
| | - Nadia Aissaoui
- Department of Intensive Care Cnit, Hôpital Européen Georges Pompidou (HEGP) Assistance Publique-Hôpitaux de Paris (APHP) and Université Paris Descartes, Paris, France.,Paris-Cardiovascular-Research-Center, INSERM U970, Paris, France
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50
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Mensch J, Flynn BC. Echocardiographic Assessment of Biventricular Function in 249 Patients During the Peri-Extracorporeal Membrane Oxygenation Period: Procedural and Ethical Questions. J Cardiothorac Vasc Anesth 2018; 33:1331-1333. [PMID: 30448071 DOI: 10.1053/j.jvca.2018.10.020] [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: 10/09/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Jason Mensch
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Brigid C Flynn
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
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