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Augustin KJ, Wieruszewski PM, McLean L, Leiendecker E, Ramakrishna H. Analysis of the 2023 European Multidisciplinary Consensus Statement on the Management of Short-term Mechanical Circulatory Support of Cardiogenic Shock in Adults in the Intensive Cardiac Care Unit. J Cardiothorac Vasc Anesth 2024; 38:1786-1801. [PMID: 38862282 DOI: 10.1053/j.jvca.2024.04.035] [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] [Received: 04/19/2024] [Accepted: 04/21/2024] [Indexed: 06/13/2024]
Affiliation(s)
- Katrina Joy Augustin
- Division of Anesthesia and Critical Care Medicine, Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, MN; Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | - Patrick M Wieruszewski
- Department of Pharmacy, Mayo Clinic, Rochester, MN; Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | - Lewis McLean
- Intensive Care Unit, John Hunter Hospital, Newcastle, Australia
| | | | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Kochar A, Vallabhajosyula S, John K, Sinha SS, Esposito M, Pahuja M, Hirst C, Li S, Kong Q, Li B, Natov P, Kanwar M, Hernandez-Montfort J, Garan R, Walec K, Zazzali P, Sangal P, Ton VK, Zweck E, Kataria R, Guglin M, Vorovich E, Nathan S, Abraham J, Harwani NM, Hickey GW, Wencker D, Schwartzman AD, Khalife W, Mahr C, Kim JH, Bhimaraj A, Blumer V, Faugno A, Burkhoff D, Kapur NK. Factors associated with Acute Limb Ischemia in Cardiogenic Shock and downstream Clinical Outcomes: Insights from the Cardiogenic Shock Working Group. J Heart Lung Transplant 2024:S1053-2498(24)01705-4. [PMID: 38944132 DOI: 10.1016/j.healun.2024.06.012] [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: 01/31/2024] [Revised: 05/29/2024] [Accepted: 06/24/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND There are limited data depicting the prevalence and ramifications of acute limb ischemia (ALI) among cardiogenic shock (CS) patients. METHODS We employed data from the Cardiogenic Shock Working Group (CSWG), a consortium including 33 sites. We constructed a multi-variable logistic regression to examine the association between clinical factors and ALI, we generated another logistic regression model to ascertain the association of ALI with mortality. RESULTS There were 7,070 patients with CS and 399 (5.6%) developed ALI. Patients with ALI were more likely to be female (40.4% versus 29.4%) and have peripheral arterial disease (13.8% versus 8.3%). Stratified by maximum SCAI shock stage, the rates of ALI were stage B 0.0%, stage C 1.8%, stage D 4.1%, and stage E 10.3%. Factors associated with higher risk for ALI included: peripheral vascular disease OR 2.24 (95% CI: 1.53 - 3.23; p < 0.01) and ≥ 2 mechanical circulatory support (MCS) devices OR 1.66 (95% CI: 1.24 - 2.21, p < 0.01). ALI was highest for VA-ECMO patients (11.6%) or VA-ECMO + IABP/Impella CP (16.6%) yet use of distal perfusion catheters was less than 50%. Mortality was 38.0% for CS patients without ALI but 57.4% for CS patients with ALI. ALI was significantly associated with mortality, adjusted OR 1.40 (95% CI 1.01 - 1.95, p < 0.01). CONCLUSIONS The rate of ALI was 6% among CS patients. Factors most associated with ALI include peripheral vascular disease and multiple MCS devices. The downstream ramifications of ALI were dire with a considerably higher risk of mortality.
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Affiliation(s)
| | | | - Kevin John
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Campus, Falls Church, VA
| | | | - Mohit Pahuja
- University of Oklahoma Health Science Center, Oklahoma City, OK
| | - Colin Hirst
- St. Peter's Health Partners Medical Associates, Albany, NY
| | - Song Li
- Institute for Advanced Cardiac Care, Medical City Healthcare, Dallas, TX
| | - Qiuyue Kong
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | - Borui Li
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | - Peter Natov
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | - Manreet Kanwar
- Cardiovascular Instittue at Allegheny Health Network, Pittsburgh, PA
| | | | - Reshad Garan
- Beth Israel Deaconess Medical Center, Boston, MA
| | - Karol Walec
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | - Peter Zazzali
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | - Paavni Sangal
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | - Van-Khue Ton
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, MA
| | - Elric Zweck
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Rachna Kataria
- Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, RI
| | - Maya Guglin
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN
| | - Esther Vorovich
- Bluhm Cardiovascular Institute of Northwestern University, Chicago, IL
| | | | | | - Neil M Harwani
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | | | - Detlef Wencker
- Baylor Scott & White Health, Advanced Heart Failure Program Clinic, Temple, TX
| | | | | | - Claudius Mahr
- University of Washington Medical Center, Seattle, WA
| | - Ju H Kim
- Houston Methodist Research Institute, Houston, TX
| | | | - Vanessa Blumer
- Inova Heart and Vascular Institute, Inova Fairfax Campus, Falls Church, VA
| | - Anthony Faugno
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | | | - Navin K Kapur
- The Cardiovascular Center, Tufts Medical Center, Boston, MA.
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Wickramarachchi A, Burrell AJC, Joyce PR, Bellomo R, Raman J, Gregory SD, Stephens AF. Flow capabilities of arterial and drainage cannulae during venoarterial extracorporeal membrane oxygenation: A simulation model. Perfusion 2024:2676591241256502. [PMID: 38783767 DOI: 10.1177/02676591241256502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND Large cannulae can increase cannula-related complications during venoarterial extracorporeal membrane oxygenation (VA ECMO). Conversely, the ability for small cannulae to provide adequate support is poorly understood. Therefore, we aimed to evaluate a range of cannula sizes and VA ECMO flow rates in a simulated patient under various disease states. METHODS Arterial cannulae sizes between 13 and 21 Fr and drainage cannula sizes between 21 and 25 Fr were tested in a VA ECMO circuit connected to a mock circulation loop simulating a patient with severe left ventricular failure. Systemic and pulmonary hypertension, physiologically normal, and hypotension were simulated by varying systemic and pulmonary vascular resistances (SVR and PVR, respectively). All cannula combinations were evaluated against all combinations of SVR, PVR, and VA ECMO flow rates. RESULTS A 15 Fr arterial cannula combined with a 21 Fr drainage cannula could provide >4 L/min of total flow and a mean arterial pressure of 81.1 mmHg. Changes in SVR produced marked changes to all measured parameters, while changes to PVR had minimal effect. Larger drainage cannulae only increased maximum circuit flow rates when combined with larger arterial cannulae. CONCLUSION Smaller cannulae and lower flow rates could sufficiently support the simulated patient under various disease states. We found arterial cannula size and SVR to be key factors in determining the flow-delivering capabilities for any given VA ECMO circuit. Overall, our results challenge the notion that larger cannulae and high flows must be used to achieve adequate ECMO support.
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Affiliation(s)
- Avishka Wickramarachchi
- Cardio-Respiratory Engineering and Technology Laboratory, Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, VIC, Australia
| | - Aidan J C Burrell
- Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Patrick R Joyce
- Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
| | - Jaishankar Raman
- Cardiothoracic Surgery, University of Melbourne, Austin & St Vincent's Hospitals, Melbourne, VIC, Australia
| | - Shaun D Gregory
- Cardio-Respiratory Engineering and Technology Laboratory, Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, VIC, Australia
| | - Andrew F Stephens
- Cardio-Respiratory Engineering and Technology Laboratory, Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, VIC, Australia
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Boyle C, Nguyen K, Steiner J, Macon CJ, Marbach JA. Mitral Regurgitation Complicated by Cardiogenic Shock: Reassessing Risk Stratification and Therapeutic Strategies. Interv Cardiol Clin 2024; 13:191-205. [PMID: 38432762 DOI: 10.1016/j.iccl.2023.11.003] [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: 03/05/2024]
Abstract
Mitral regurgitation complicated by cardiogenic shock creates a unique and devastating risk profile for patients and poses significant difficulties for physicians who lack a comprehensive range of effective management strategies. Supportive measures such as intravenous vasodilators, intra-aortic balloon pumps, and percutaneous ventricular assist devices are often necessary to stabilize patients prior to definitive treatment with surgical mitral valve replacement or trans-catheter edge-to-edge repair. This review evaluates the evidence for the available supportive and definitive management strategies in patients with mitral regurgitation complicated by cardiogenic shock and presents a framework to aid clinicians in navigating the complex clinical decision-making process. Additionally, the authors review emerging transcatheter mitral valve replacement technologies that hold promise for expanding the therapeutic armamentarium and improving patient outcomes.
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Affiliation(s)
- Carla Boyle
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3161 Southwest Pavilion Loop, Portland, OR 97239, USA
| | - Khoa Nguyen
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3161 Southwest Pavilion Loop, Portland, OR 97239, USA
| | - Johannes Steiner
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3161 Southwest Pavilion Loop, Portland, OR 97239, USA
| | - Conrad J Macon
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3161 Southwest Pavilion Loop, Portland, OR 97239, USA
| | - Jeffrey A Marbach
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3161 Southwest Pavilion Loop, Portland, OR 97239, USA.
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Simons J, Mees B, MacLaren G, Fraser JF, Zaaqoq AM, Cho SM, Patel BM, Brodie D, Bělohlávek J, Belliato M, Jung JS, Salazar L, Meani P, Mariani S, Di Mauro M, Yannopoulos D, Broman LM, Chen YS, Riera J, van Mook WN, Lorusso R. Evolution of distal limb perfusion management in adult peripheral venoarterial extracorporeal membrane oxygenation with femoral artery cannulation. Perfusion 2024; 39:23S-38S. [PMID: 38651584 DOI: 10.1177/02676591241236650] [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
Limb ischaemia is a clinically relevant complication of venoarterial extracorporeal membrane oxygenation (VA ECMO) with femoral artery cannulation. No selective distal perfusion or other advanced techniques were used in the past to maintain adequate distal limb perfusion. A more recent trend is the shift from the reactive or emergency management to the pro-active or prophylactic placement of a distal perfusion cannula to avoid or reduce limb ischaemia-related complications. Multiple alternative cannulation techniques to the distal perfusion cannula have been developed to maintain distal limb perfusion, including end-to-side grafting, external or endovascular femoro-femoral bypass, retrograde limb perfusion (e.g., via the posterior tibial, dorsalis pedis or anterior tibial artery), and, more recently, use of a bidirectional cannula. Venous congestion has also been recognized as a potential contributing factor to limb ischaemia development and specific techniques have been described with facilitated venous drainage or bilateral cannulation being the most recent, to reduce or avoid venous stasis as a contributor to impaired limb perfusion. Advances in monitoring techniques, such as near-infrared spectroscopy and duplex ultrasound analysis, have been applied to improve decision-making regarding both the monitoring and management of limb ischaemia. This narrative review describes the evolution of techniques used for distal limb perfusion during peripheral VA ECMO.
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Affiliation(s)
- Jorik Simons
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Barend Mees
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Vascular Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Health System, Singapore
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Akram M Zaaqoq
- Department of Anesthesiology, Division of Critical Care, University of Virginia, Charlottesville, VA, USA
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Division of Neuroscience Critical Care, Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Bhavesh M Patel
- Department of Critical Care, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Daniel Brodie
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jan Bělohlávek
- 2nd Department of Medicine - Department of Cardiovascular Medicine, General University Hospital in Prague, Prague, Czech Republic
| | - Mirko Belliato
- SC AR 2 Anestesia e Terapia Intensiva Cardiotoracica, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Jae-Seung Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University Medicine, Seoul, Republic of Korea
| | - Leonardo Salazar
- Department of Intensive Care, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia
| | - Paolo Meani
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Silvia Mariani
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- S. Gerardo Hospital is the hospital of the departmen, Monza, Italy
| | - Michele Di Mauro
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Demetris Yannopoulos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Lars Mikael Broman
- Department of Pediatric Perioperative Medicine and Intensive Care, ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Yih-Sharng Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Jordi Riera
- Department de Medicina Intensiva, Vall d'Hebron Institut de Recerca, SODIR, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Walther Nka van Mook
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
- Academy for Postgraduate Medical Training, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
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Honzawa H, Taniguchi H, Abe T, Takeuchi I, Inoue A, Hifumi T, Sakamoto T, Kuroda Y. Prophylactic distal perfusion catheter and survival in patients with out-of-hospital cardiac arrest: Secondary analysis of the SAVE-J II study. Am J Emerg Med 2024; 78:69-75. [PMID: 38237215 DOI: 10.1016/j.ajem.2024.01.009] [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: 08/02/2023] [Revised: 12/14/2023] [Accepted: 01/08/2024] [Indexed: 03/23/2024] Open
Abstract
PURPOSE The effect of a prophylactic distal perfusion catheter (DPC) after extracorporeal cardiopulmonary resuscitation (ECPR) in patients with out-of-hospital cardiac arrest (OHCA) remains unclear. Therefore, we aimed to clarify the association between prophylactic DPC and prognosis in patients with OHCA undergoing ECPR. MATERIALS AND METHODS A secondary analysis of the Study of Advanced Life Support for Ventricular Fibrillation with Extracorporeal Circulation in Japan (SAVE-J II) database was performed to compare groups of patients with and without prophylactic DPCs. A multivariate analysis of survival at discharge was performed using factors that were significant in the two-arm comparison. RESULTS A total of 2044 patients were included in the analysis after excluding those who met the exclusion criteria. Survival at discharge was observed in 548 (26.9%) patients. In total, 100 (4.9%) patients developed limb ischemia, among whom 14 (0.7%) required therapeutic intervention. Multivariate analysis showed that prophylactic DPC did not result in a significant difference in survival at discharge (odds ratio: 0.898 [0.652-1.236], p = 0.509). CONCLUSIONS The implementation of prophylactic DPC after ECPR for patients with OHCA may not contribute to survival at discharge.
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Affiliation(s)
- Hiroshi Honzawa
- Emergency Care Department, Yokohama City University Hospital, Yokohama, Japan.
| | - Hayato Taniguchi
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Takeru Abe
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Ichiro Takeuchi
- Emergency Care Department, Yokohama City University Hospital, Yokohama, Japan; Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Tetsuya Sakamoto
- Department of Emergency Medicine, Teikyo University school of Medicine, Tokyo, Japan
| | - Yasuhiro Kuroda
- Department of Emergency, Disaster and Critical Care Medicine, Kagawa University Hospital, Kagawa, Japan
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Gouchoe DA, Chaurasia S, Henn MC, Whitson BA, Mokadam NA, Mast D, Satyapriya S, Vallakati A, Ganapathi AM. Does Size Matter? The Effect of Size of Distal Perfusion Catheter on Acute Limb Ischemia: A Meta-Analysis. ASAIO J 2024:00002480-990000000-00431. [PMID: 38446827 DOI: 10.1097/mat.0000000000002178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024] Open
Abstract
Prevention of limb ischemia in patients with venoarterial extracorporeal membrane oxygenation (VA-ECMO) is primarily achieved through the use of distal perfusion catheters (DPC). Our objective was to assess the role of DPC, and specifically the size of the catheter, in reducing the incidence of acute limb ischemia (ALI) through a meta-analysis. Seventeen studies met criteria for analysis. Pooled analysis included a total of 2,040 patients, of which 904 patients received ECMO with DPC and 1,136 patients underwent ECMO without DPC. Compared with ECMO alone, ECMO with DPC, regardless of size, significantly decreased ALI (relative risk [RR]: 0.49, 95% confidence interval [CI]: 0.31-0.77; p = 0.002). When comparing reactive versus prophylactic placement of DPC, prophylactic DPC was associated with significantly decreased ALI (RR: 0.41, 95% CI: 0.24-0.71; p = 0.02). No differences in mortality (RR: 0.89, 95% CI: 0.76-1.03; p = 0.12) and bleeding events (RR: 1.43, 95% CI: 0.41-4.96; p = 0.58) were observed between the two groups. This analysis demonstrates that the placement of DPC, if done prophylactically and regardless of size, is associated with a reduced risk of ALI versus the absence of DPC placement, but is not associated with differences in mortality or bleeding events.
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Affiliation(s)
- Doug A Gouchoe
- From the Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sameer Chaurasia
- Heritage College of Osteopathic Medicine, Ohio University, Athens, Ohio
| | - Matthew C Henn
- From the Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Bryan A Whitson
- From the Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Nahush A Mokadam
- From the Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - David Mast
- From the Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sree Satyapriya
- Division of Critical Care Medicine, Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ajay Vallakati
- Division of Cardiovascular Medicine, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Asvin M Ganapathi
- From the Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Liu ZX, Yang Y, Song HH, Liu W, Sun P, Lin CW. Impact of independent early stage extracorporeal cardiopulmonary resuscitation in the emergency department following the establishment of an extracorporeal life support team. Heliyon 2024; 10:e23411. [PMID: 38187318 PMCID: PMC10770443 DOI: 10.1016/j.heliyon.2023.e23411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 11/28/2023] [Accepted: 12/04/2023] [Indexed: 01/09/2024] Open
Abstract
Objective In this paper, we present a comprehensive overview of our experience in establishing and leading distinct extracorporeal cardiopulmonary resuscitation (ECPR)-related teams to independently handle ECPR in the early stages in the emergency department. Methods A retrospective analysis was conducted on the clinical data of 29 patients who underwent ECPR treatment in the emergency room between May 2018 and April 2022. A control group, consisting of 10 patients treated between May 2018 and September 2019 was managed using a standard rescue coordination mode. The 19 patients who received ECPR between October 2019 and April 2022 were treated by members of the department's 24-h extracorporeal life support team. We compared the implementation and operational challenges faced by the two groups, including item preparation, circuit setup, and ECPR initiation times, among other factors. Results Gender, age, cardiac arrest risk factors, and other baseline data did not significantly differ between the two groups. Extracorporeal membrane oxygenation (ECMO) pipeline prefilling time (from 35.27±10.34 to 13.46±5.32), ECPR establishment time (from 62.35±29.61 to 30.98±13.41), and item preparation time (from 16.42±9.78 to 3.19±1.49) all considerably decreased when compared to the control group. The rate of return of spontaneous circulation recovery rose from 37.50 % to 77.78 % (P < 0.05). The consequences of gastrointestinal and pulmonary bleeding were greatly reduced while ECPR was being used, and the difference was statistically significant (P < 0.05). Significant improvements were made in the ECPR weaning rate (from 25.00 % to 38.89 %) and survival rate (from 20.0 % to 36.8 %). Conclusion The establishment of a 24-h extracorporeal life support team significantly reduced the time needed for rescue during the early stage of independent setup of ECPR in the emergency department and serves as a guide for effective care of critically ill patients.
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Affiliation(s)
| | | | - Huan-Huan Song
- Department of Emergency Medicine, Aerospace Center Hospital, Beijing, 100049, China
| | - Wei Liu
- Department of Emergency Medicine, Aerospace Center Hospital, Beijing, 100049, China
| | - Peng Sun
- Department of Emergency Medicine, Aerospace Center Hospital, Beijing, 100049, China
| | - Cai-Wei Lin
- Department of Emergency Medicine, Aerospace Center Hospital, Beijing, 100049, China
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Dalton HJ, Singh R, McMullan DM. One Limb or Two? Does It Make a Difference in Femoral Venoarterial Extracorporeal Membrane Oxygenation? Crit Care Med 2024; 52:153-155. [PMID: 38095524 DOI: 10.1097/ccm.0000000000006107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Heidi J Dalton
- Heart and Vascular Institute, INOVA Fairfax Hospital, Falls Church, VA
| | - Ramesh Singh
- Cardiovascular Surgery, Heart and Vascular Surgery, INOVA Fairfax Medical Center, Falls Church, VA
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Wu X, Wang X, Luo J, Tian F, Bian J. Nursing Management of a Patient With Fulminant Myocarditis and Electrical Storm Receiving ECMO: A Case Report. Crit Care Nurse 2023; 43:22-33. [PMID: 38035616 DOI: 10.4037/ccn2023112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
INTRODUCTION Fulminant myocarditis is a devastating disease with significant mortality and complications. The care of patients with fulminant myocarditis is rarely reported. CLINICAL FINDINGS A 17-year-old female patient was admitted to the emergency department with dizziness, amaurosis fugax, and chest tightness. Initial assessment revealed elevated levels of troponin T (4.753 ng/mL), troponin I (49.540 ng/mL), creatine kinase (1306 U/L), creatine kinase-MB isoenzymes (75.71 ng/mL), lactate dehydrogenase (509 U/L), and N-terminal pro-B-type natriuretic peptide (6345 pg/mL). The patient had recurrent ventricular tachycardia and failed to maintain a sinus rhythm after multiple electrical cardioversions. DIAGNOSIS Echocardiography revealed a left ventricular ejection fraction of 34%. Magnetic resonance imaging results confirmed the diagnosis of myocarditis. INTERVENTIONS The patient received extracorporeal membrane oxygenation for 6 days, intra-aortic balloon pump support for 7 days, and mechanical ventilation for 5 days. Norepinephrine and dopamine were used to keep circulation stable, lidocaine and amiodarone were used to control heart rate, and glucocorticoids and immunoglobulins were used to modulate immunity. OUTCOMES The patient was discharged after 23 days. A month after discharge, echocardiography showed that the ejection fraction was 60%. The patient reported complete resolution of signs and symptoms of fulminant myocarditis at follow-up assessment. CONCLUSION This case report presents the activities of bedside nurses in caring for a patient with fulminant myocarditis and broadens the literature describing nursing interventions for patients with fulminant myocarditis.
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Affiliation(s)
- Xiaoxiao Wu
- Xiaoxiao Wu is a clinical nurse in the nursing department, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoyan Wang
- Xiaoyan Wang is a clinical nurse in the coronary care unit, Fuwai Hospital, Chinese Academy of Medical Sciences, Shenzhen, Guangdong, China
| | - Jinmei Luo
- Jinmei Luo is a clinical nurse in the coronary care unit, Fuwai Hospital, Chinese Academy of Medical Sciences, Shenzhen
| | - Fang Tian
- Fang Tian is a clinical head nurse in the coronary care unit, Fuwai Hospital, Chinese Academy of Medical Sciences, Shenzhen
| | - Jin Bian
- Jin Bian is a clinical head nurse in the hypertension ward, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing
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11
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Ortoleva J. Limb Ischemia in Femoral Venoarterial ECMO Patients: Cutting to the Chase? J Cardiothorac Vasc Anesth 2023; 37:2280-2281. [PMID: 37635041 DOI: 10.1053/j.jvca.2023.07.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 07/31/2023] [Indexed: 08/29/2023]
Affiliation(s)
- Jamel Ortoleva
- Department of Anesthesiology, Boston Medical Center, Boston, MA.
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12
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Sandoval Y, Basir MB, Lemor A, Lichaa H, Alasnag M, Dupont A, Hirst C, Kearney KE, Kaki A, Smith TD, Vallabhajosyula S, Kayssi A, Firstenberg MS, Truesdell AG. Optimal Large-Bore Femoral Access, Indwelling Device Management, and Vascular Closure for Percutaneous Mechanical Circulatory Support. Am J Cardiol 2023; 206:262-276. [PMID: 37717476 DOI: 10.1016/j.amjcard.2023.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 07/30/2023] [Accepted: 08/05/2023] [Indexed: 09/19/2023]
Affiliation(s)
- Yader Sandoval
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Center for Coronary Artery Disease, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Mir B Basir
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Alejandro Lemor
- Department of Cardiology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Hady Lichaa
- Ascension Saint Thomas Heart, Ascension Saint Thomas Rutherford, Murfreesboro, Tennessee
| | - Mirvat Alasnag
- Cardiac Center, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | | | - Colin Hirst
- Department of Cardiology, Ascension St. John Hospital-Detroit, Detroit, Michigan
| | | | - Amir Kaki
- Department of Cardiology, Ascension St. John Hospital-Detroit, Detroit, Michigan
| | - Timothy D Smith
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, Ohio
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina; Division of Public Health Sciences, Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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13
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Siems C, Valentine RJ, Wang Q, Duke J, Brunsvold M, Reed AB. Risk factors for lower extremity vascular complications in adult patients on veno-arterial extracorporeal membrane oxygenation. J Vasc Surg 2023; 77:1174-1181. [PMID: 36639061 DOI: 10.1016/j.jvs.2022.11.047] [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: 09/17/2022] [Revised: 11/03/2022] [Accepted: 11/14/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Utilization of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has increased significantly over the last decade. Prior studies have reported worse mortality for patients with vascular complications on VA-ECMO; however, these were limited by small sample size. The purpose of this study is to investigate predictive risk factors for vascular complications in VA-ECMO patients and their potential impact on mortality. METHODS Patients who underwent peripheral VA-ECMO from January 2011 to December 2021 were identified. Primary outcomes were lower extremity vascular complications and in-hospital mortality. Multivariate stepwise logistic regression models were used to identify predictors of vascular complications and in-hospital mortality. RESULTS A total of 605 VA-ECMO patients (25% female) were identified. The mean age was 56.3 ± 13 years, and 56 (10.4%) were black. In-hospital mortality was 63.8% (n = 386), and VA-ECMO ipsilateral vascular complications occurred in 72 patients (11.9%). Vascular surgical interventions (thromboembolectomy, fasciotomies, amputation, and surgical management of cannula bleeding) were required in 30 patients (41.7%). Same-side arterial and venous cannulas, cannula size, and absence of distal perfusion cannula did not increase risk of vascular complication. Multivariate analysis identified age (odds ratio, 0.948; 95% confidence interval, 0.909-0.988; P = .0116) and pre-existing peripheral arterial disease (odds ratio, 3.489; 95% confidence inteval, 1.146-10.624; P = .0278) as independent predictors of need for vascular surgery interventions. The mortality rate of patients who developed vascular complications was not significantly different compared with the mortality rate of those who did not develop vascular complications (61% vs 64%; P = .92). CONCLUSIONS This study represents one of the largest series to date of lower extremity vascular outcomes in patients undergoing VA-ECMO. Our results confirm the high mortality rate associated with VA-ECMO; however, vascular complications did not represent a risk factor for mortality as previously reported. Same-sided VA-ECMO cannulas, cannula size, and the presence or absence of distal perfusion cannula did not predict vascular complications. Increasing age and presence of peripheral arterial disease are independent predictors of need for vascular surgery intervention in patients on VA-ECMO.
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Affiliation(s)
- Chesney Siems
- Division of Vascular Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - R James Valentine
- Division of Vascular Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Qi Wang
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Julie Duke
- Division of Vascular Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Melissa Brunsvold
- Division of Surgical Critical Care, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Amy B Reed
- Division of Vascular Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
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14
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Walsh RW, Smith NJ, Shepherd JF, Turbati MS, Teng BQ, Brazauskas R, Joyce DL, Joyce LD, Durham L, Rossi PJ. Peripherally inserted concomitant surgical right and left ventricular support, the Propella, is associated with low rates of limb ischemia, with mortality comparable with peripheral venoarterial extracorporeal membrane oxygenation. Surgery 2023; 173:855-863. [PMID: 36435648 DOI: 10.1016/j.surg.2022.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 10/02/2022] [Accepted: 10/04/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Mechanical circulatory support effectively treats adult cardiogenic shock. Whereas cardiogenic shock confers high mortality, acute limb ischemia is a known complication of mechanical circulatory support that confers significant morbidity. We compared our novel approach to peripheral mechanical circulatory support with a conventional femoral approach, with a focus on the incidence of acute limb ischemia. METHODS This was a retrospective cohort study of patients treated with mechanical circulatory support between January 1, 2015 and December 5, 2021 at our institution. Patients receiving any femoral peripheral venoarterial extracorporeal membrane oxygenation were compared with those receiving minimally invasive, peripherally inserted, concomitant right and left ventricular assist devices. These included the Impella 5.0 (Abiomed, Danvers, MA) left ventricular assist device and the ProtekDuo (LivaNova, London, UK) right ventricular assist device used concomitantly (Propella) approach. The primary outcome was incidence of acute limb ischemia. The baseline patient characteristics, hemodynamic data, and post-mechanical circulatory support outcomes were collected. Fisher exact test and Wilcoxon rank sum test was used for the categorical and continuous variables, respectively. Kaplan-Meier curves and log-rank test were used to estimate overall survival probabilities and survival experience, respectively. RESULTS Fifty patients were treated with mechanical circulatory support at our institution for cardiogenic shock, with 13 patients supported with the novel Propella strategy and 37 with peripheral venoarterial extracorporeal membrane oxygenation. The baseline characteristics, including patient organ function and medical comorbidities, were similar among the groups. Nine patients suffered mortality in ≤48 hours of mechanical circulatory support initiation and were excluded. Twenty patients (69%) suffered acute limb ischemia in the peripheral venoarterial extracorporeal membrane oxygenation group; 0 patients receiving Propella suffered acute limb ischemia (P < .001). The percentages of patients surviving to discharge in peripheral venoarterial extracorporeal membrane oxygenation and Propella groups were 24% and 69%, respectively (P = .007). CONCLUSION Patients treated with the Propella experienced a lower incidence of acute limb ischemia compared with patients treated with peripheral venoarterial extracorporeal membrane oxygenation.
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Affiliation(s)
- Richard W Walsh
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Nathan J Smith
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - John F Shepherd
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Mia S Turbati
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Bi Qing Teng
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI
| | - Ruta Brazauskas
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI
| | - David L Joyce
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Lyle D Joyce
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Lucian Durham
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Peter J Rossi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.
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15
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Vinogradsky A, Kurlansky P, Ning Y, Kirschner M, Beck J, Brodie D, Kaku Y, Fried J, Takeda K. Continuous near-infrared reflectance spectroscopy monitoring to guide distal perfusion can minimize limb ischemia surgery for patients requiring femoral venoarterial extracorporeal life support. J Vasc Surg 2023; 77:1495-1503. [PMID: 36603665 DOI: 10.1016/j.jvs.2022.12.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 12/26/2022] [Accepted: 12/28/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Patients requiring femoral venoarterial (VA) extracorporeal life support (ECLS) are at risk of distal lower limb hypoperfusion and ischemia of the cannulated leg. In the present study, we evaluated the effect of using continuous noninvasive lower limb oximetry with near-infrared reflectance spectroscopy (NIRS) to detect tissue hypoxia and guide distal perfusion catheter (DPC) placement on the rates of leg ischemia requiring surgical intervention. METHODS We performed a retrospective analysis of patients who had undergone femoral VA-ECLS at our institution from 2010 to 2014 (pre-NIRS era) and 2017 to 2021 (NIRS era). Patients who had undergone cannulation during the 2015 to 2016 transition era were excluded. The baseline characteristics, short-term outcomes, and ischemic complications requiring surgical intervention (eg, fasciotomy, thrombectomy, amputation, exploration) were compared across the two cohorts. RESULTS Of the 490 patients included in the present study, 141 (28.8%) and 349 (71.2%) had undergone cannulation before and after the routine use of NIRS to direct DPC placement, respectively. The patients in the NIRS cohort had had a greater incidence of hyperlipidemia (53.7% vs 41.1%; P = .015) and hypertension (71.4% vs 60%; P = .020) at baseline, although they were less likely to have been supported with an intra-aortic balloon pump before ECLS cannulation (26.9% vs 37.6%; P = .026). These patients were also more likely to have experienced cardiac arrest (22.9% vs 7.8%; P ≤ .001) and a pulmonary cause (5.2% vs 0.7%; P = .04) as an indication for ECLS, with ECLS initiated less often for acute myocardial infarction (15.8% vs 34%; P ≤ .001). The patients in the NIRS cohort had had a smaller arterial cannula size (P ≤ .001) and a longer duration of ECLS support (5 vs 3.25 days; P ≤ .001) but significantly lower rates of surgical intervention for limb ischemia (2.6% vs 8.5%; P = .007) despite comparable rates of DPC placement (49.1% vs 44.7%; P = .427), with only two patients (1.1%) not identified by NIRS ultimately requiring surgical intervention. CONCLUSIONS The use of a smaller arterial cannula (≤15F) and continuous NIRS monitoring to guide selective insertion of DPCs could be a valid and effective strategy associated with a reduced incidence of ischemic events requiring surgical intervention.
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Affiliation(s)
- Alice Vinogradsky
- Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Paul Kurlansky
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Yuming Ning
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Michael Kirschner
- Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - James Beck
- Department of Cardiovascular Perfusion, Columbia University Irving Medical Center, New York, NY
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Yuji Kaku
- Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Justin Fried
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Koji Takeda
- Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY.
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