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Celińska-Spodar M, Załęska Kocięcka M, Kowalik I, Kołsut P, Sitkowska-Rysiak E, Szymański J, Stępińska J. Troponin T and Survival following Cardiac Surgery in Patients Supported with Extracorporeal Membrane Oxygenation for Post-Cardiotomy Shock. Diagnostics (Basel) 2023; 14:45. [PMID: 38201354 PMCID: PMC10802831 DOI: 10.3390/diagnostics14010045] [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: 11/14/2023] [Revised: 12/11/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND While troponin is an established biomarker of cardiac injury, its prognostic significance in post-cardiotomy cardiogenic shock patients supported by venoarterial extracorporeal membrane oxygenation (PCCS-VA-ECMO) remains unclear. OBJECTIVE This study aimed to assess the correlation between early post-operative troponin T levels and both short-term and long-term mortality outcomes in this cohort. METHODS We evaluated 1457 troponin T measurements from 102 PCCS-VA-ECMO patients treated from 2013 to 2018 at a specialized cardio-surgical and transplantation center. Emphasis was placed on troponin concentrations at 24-48 h post-surgery, post-VA-ECMO implantation, and peak troponin levels in relation to VA-ECMO weaning, as well as 90-day and one-year mortality. RESULTS No significant association was observed between troponin T levels post-VA-ECMO implantation and 90-day mortality (median: 1338 ng/L for overall, 1529 ng/L for survivors vs. 1294 ng/L for non-survivors; p = 0.146) or between peak troponin levels and 90-day mortality (median: 3583 ng/L for overall, 3337 ng/L for survivors vs. 3666 ng/L for non-survivors; p = 0.709). Comprehensive multivariate models showed no correlation between troponin levels and various mortality endpoints. Notably, age, procedure urgency, type, LVEF pre-surgery, Euroscore II, prior cardiac arrest, and VA-ECMO duration were not linked with troponin release. Hemodiafiltration emerged as the strongest mortality risk factor [HR 2.4]. CONCLUSIONS Isolated early Troponin T release and peak troponin T were not associated, while organ complications were linked with VA-ECMO weaning or short- and long-term prognosis. The results underscore the multi-organ implications of PCCS in determining survival.
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Affiliation(s)
- Małgorzata Celińska-Spodar
- Department of Anaesthesiology and Intensive Care, The National Institute of Cardiology, 04-628 Warsaw, Poland
| | - Marta Załęska Kocięcka
- Department of Mechanical Circulatory Support and Transplantation, Department of Heart Failure and Transplantology, The National Institute of Cardiology, 04-628 Warsaw, Poland
| | - Ilona Kowalik
- Clinical Research Support Center, The National Institute of Cardiology, 04-628 Warsaw, Poland
| | - Piotr Kołsut
- Department of Cardiac Surgery and Transplantation, The National Institute of Cardiology, 04-628 Warsaw, Poland
| | - Ewa Sitkowska-Rysiak
- Department of Anaesthesiology and Intensive Care, The National Institute of Cardiology, 04-628 Warsaw, Poland
| | - Jarosław Szymański
- Department of Cardiac Surgery and Transplantation, The National Institute of Cardiology, 04-628 Warsaw, Poland
| | - Janina Stępińska
- Department of Cardiac Intensive Care, The National Institute of Cardiology, 04-628 Warsaw, Poland
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Altshuler PJ, Pace DJ, Preston WA, Vincent SA, Shah AP, Glorioso JM, Maley WR, Frank AM, Ramirez CB, West S, Hasz R, Bodzin AS. Assessing Kidney Transplantation Using ECMO-Supported Donors Within a KDPI-Based Allocation System. Transplant Direct 2023; 9:e1521. [PMID: 37829245 PMCID: PMC10566806 DOI: 10.1097/txd.0000000000001521] [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: 05/31/2023] [Accepted: 06/16/2023] [Indexed: 10/14/2023] Open
Abstract
Background Organ donors supported by extracorporeal membrane oxygenation (ECMO) have historically been considered high-risk and are judiciously utilized. This study examines transplant outcomes using renal allografts from donors supported on ECMO for nondonation purposes. Methods Retrospective review of the Gift of Life (Pennsylvania, New Jersey, Delaware) organ procurement organization database, cross-referenced to the Organ Procurement and Transplantation Network database, assessed kidney transplants using donors supported on venoarterial (VA) and venovenous (VV) ECMO for nondonation purposes. Transplants using VA- and VV-ECMO donors were compared with Kidney Donor Profile Index (KDPI)-stratified non-ECMO donors. Regression modeling of the entire ECMO and non-ECMO populations assessed ECMO as predictive of graft survival. Additional regression of the ECMO population alone assessed for donor features associated with graft survival. Results Seventy-eight ECMO donors yielded 128 kidney transplants (VA: 80, VV: 48). Comparing outcomes using these donors to kidney transplants using organs from KDPI-stratified non-ECMO donors, VA- and VV-ECMO donor grafts conferred similar rates of delayed graft function and posttransplant renal function to KDPI-matched non-ECMO counterparts. VA-ECMO kidneys demonstrated superior graft survival compared with the lowest-quality (KDPI 86%-100%) non-ECMO kidneys and similar graft survival to KDPI <85% non-ECMO kidneys. VV-ECMO showed inferior graft survival to all but the lowest-quality (KDPI 86%-100%) non-ECMO kidneys. VV-ECMO, but not VA-ECMO, was associated with increased risk of graft loss on multivariable regression (hazard ratios-VA: 1.02, VV: 2.18). Higher KDPI, advanced age, increased body mass index, hypertension, and diabetes were identified as high-risk features of ECMO donors. Conclusions Kidney transplantation using appropriately selected ECMO donors can safely expand the donor pool. Ongoing studies are necessary to determine best practice patterns using kidneys from these donors.
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Affiliation(s)
| | - Devon J. Pace
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | | | - Sage A. Vincent
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Ashesh P. Shah
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Jaime M. Glorioso
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Warren R. Maley
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Adam M. Frank
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Carlo B. Ramirez
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Sharon West
- Gift of Life Donor Program, Philadelphia, PA
| | | | - Adam S. Bodzin
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
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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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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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Tierradentro-Garcia LO, Stern JA, Dennis R, Hwang M. Utility of Cerebral Microvascular Imaging in Infants Undergoing ECMO. CHILDREN (BASEL, SWITZERLAND) 2022; 9:1827. [PMID: 36553271 PMCID: PMC9776869 DOI: 10.3390/children9121827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/18/2022] [Accepted: 11/20/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Infants who require extracorporeal membrane oxygenation (ECMO) therapy have an increased risk of neurological complications and mortality. Microvascular imaging (MVI) is an advanced Doppler technique that allows high-resolution visualization of microvasculature in the brain. We describe the feasibility and utility of MVI for the evaluation of cerebral microvascular perfusion in patients undergoing ECMO. METHODS We retrospectively analyzed brain MVI scans of neonates undergoing ECMO. Two pediatric radiologists qualitatively assessed MVI scans to determine the presence or absence of tortuosity, symmetry, heterogeneity, engorgement, and hypoperfusion of the basal ganglia-thalamus (BGT) region, as well as the presence or absence of white matter vascular engorgement and increased peri-gyral flow in the cortex. We tested the association between the presence of the aforementioned brain MVI features and clinical outcomes. RESULTS We included 30 patients, 14 of which were male (46.7%). The time of ECMO duration was 11.8 ± 6.9 days. The most prevalent microvascular finding in BGT was lenticulostriate vessel tortuosity (26/30, 86.7%), and the most common microvascular finding in the cortex was increased peri-gyral flow (10/24, 41.7%). Cortical white matter vascular engorgement was significantly associated with the presence of any poor outcome as defined by death, seizure, and/or cerebrovascular events on magnetic resonance imaging (p = 0.03). CONCLUSION MVI is a feasible modality to evaluate cerebral perfusion in infants undergoing ECMO. Additionally, evidence of white matter vascular engorgement after ECMO cannulation could serve as a predictor of poor outcomes in this population.
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Affiliation(s)
| | - Joseph A. Stern
- Department of Pediatric Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Rebecca Dennis
- Department of Pediatric Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Misun Hwang
- Department of Pediatric Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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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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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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8
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Rali AS, Ranka S, Butcher A, Shah Z, Tonna JE, Anders MM, Brinkley MD, Siddiqi H, Punnoose L, Wigger M, Sacks SB, Pedrotty D, Ooi H, Bacchetta MD, Hoffman J, McMaster W, Balsara K, Shah AS, Menachem JN, Schlendorf KH, Lindenfeld J, Zalawadiya SK. Early Blood Pressure Variables Associated With Improved Outcomes in VA-ECLS: The ELSO Registry Analysis. JACC. HEART FAILURE 2022; 10:397-403. [PMID: 35654524 PMCID: PMC9214574 DOI: 10.1016/j.jchf.2022.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/14/2022] [Accepted: 04/01/2022] [Indexed: 06/03/2023]
Abstract
BACKGROUND As utilization of veno-arterial extracorporeal life support (VA-ECLS) in treatment of cardiogenic shock (CS) continues to expand, clinical variables that guide clinicians in early recognition of myocardial recovery and therefore, improved survival, after VA-ECLS are critical. There remains a paucity of literature on early postinitiation blood pressure measurements that predict improved outcomes. OBJECTIVES The objective of this study is to help identify early blood pressure variables associated with improved outcomes in VA-ECLS. METHODS The authors queried the ELSO (Extracorporeal Life Support Organization) registry for cardiogenic shock patients treated with VA-ECLS or venovenous arterial ECLS between 2009 and 2020. Their inclusion criteria included treatment with VA-ECLS or venovenous arterial ECLS; absence of pre-existing durable right, left, or biventricular assist devices; no pre-ECLS cardiac arrest; and no surgical or percutaneously placed left ventricular venting devices during their ECLS runs. Their primary outcome of interest was the survival to discharge during index hospitalization. RESULTS A total of 2,400 CS patients met the authors' inclusion criteria and had complete documentation of blood pressures. Actual mortality during index hospitalization in their cohort was 49.5% and survivors were younger and more likely to be Caucasian, intubated for >30 hours pre-ECLS initiation, and had a favorable baseline SAVE (Survival After Veno-arterial ECMO) score (P < 0.05 for all). Multivariable regression analyses adjusting for SAVE score, age, ECLS flow at 4 hours, and race showed that every 10-mm Hg increase in baseline systolic blood pressure (HR: 0.92 [95% CI: 0.89-0.95]; P < 0.001), and baseline pulse pressure (HR: 0.88 [95% CI: 0.84-0.91]; P < 0.001) at 24 hours was associated with a statistically significant reduction in mortality. CONCLUSIONS Early (within 24 hours) improvements in pulse pressure and systolic blood pressure from baseline are associated with improved survival to discharge among CS patients treated with VA-ECLS.
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Affiliation(s)
- Aniket S Rali
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | - Sagar Ranka
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Amy Butcher
- Department of Cardiovascular Anesthesia and Critical Care, Baylor College of Medicine, Houston, Texas, USA
| | - Zubair Shah
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Marc M Anders
- Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Marshal D Brinkley
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Hasan Siddiqi
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lynn Punnoose
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mark Wigger
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Suzanne B Sacks
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dawn Pedrotty
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Henry Ooi
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew D Bacchetta
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jordan Hoffman
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William McMaster
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Keki Balsara
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan N Menachem
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelly H Schlendorf
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - JoAnn Lindenfeld
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sandip K Zalawadiya
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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9
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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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10
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Extracorporeal Membrane Oxygenation in Congenital Heart Disease. CHILDREN 2022; 9:children9030380. [PMID: 35327752 PMCID: PMC8947570 DOI: 10.3390/children9030380] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 11/24/2022]
Abstract
Mechanical circulatory support (MCS) is a key therapy in the management of patients with severe cardiac disease or respiratory failure. There are two major forms of MCS commonly employed in the pediatric population—extracorporeal membrane oxygenation (ECMO) and ventricular assist device (VAD). These modalities have overlapping but distinct roles in the management of pediatric patients with severe cardiopulmonary compromise. The use of ECMO to provide circulatory support arose from the development of the first membrane oxygenator by George Clowes in 1957, and subsequent incorporation into pediatric cardiopulmonary bypass (CPB) by Dorson and colleagues. The first successful application of ECMO in children with congenital heart disease undergoing cardiac surgery was reported by Baffes et al. in 1970. For the ensuing nearly two decades, ECMO was performed sparingly and only in specialized centers with varying degrees of success. The formation of the Extracorporeal Life Support Organization (ELSO) in 1989 allowed for the collation of ECMO-related data across multiple centers for the first time. This facilitated development of consensus guidelines for the use of ECMO in various populations. Coupled with improving ECMO technology, these advances resulted in significant improvements in ECMO utilization, morbidity, and mortality. This article will review the use of ECMO in children with congenital heart disease.
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11
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Lassus J, Tarvasmäki T, Tolppanen H. Biomarkers in cardiogenic shock. Adv Clin Chem 2022; 109:31-73. [DOI: 10.1016/bs.acc.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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12
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Boeken U, Assmann A, Beckmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan A, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Groesdonk H, Ferrari M, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel L, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Fischer S, Wiebe K, Hartog CS, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Kelm M, Ensminger S. S3 Guideline of Extracorporeal Circulation (ECLS/ECMO) for Cardiocirculatory Failure. Thorac Cardiovasc Surg 2021; 69:S121-S212. [PMID: 34655070 DOI: 10.1055/s-0041-1735490] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Udo Boeken
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Alexander Assmann
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Andreas Beckmann
- German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Karl Werdan
- Clinic for Internal Medicine III, University Hospital Halle (Saale), Martin-Luther University Halle-Wittenberg, Germany
| | - Guido Michels
- Department of Acute and Emergency Care, St Antonius Hospital Eschweiler, Eschweiler, Germany
| | - Oliver Miera
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Florian Schmidt
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Germany
| | - Stefan Klotz
- Department of Cardiac Surgery, Segeberger Kliniken, Bad Segeberg, Germany
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre, Berlin, German
| | - Kevin Pilarczyk
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Ardawan Rastan
- Department of Cardiac and Vascular Thoracic Surgery, Philipps-University Hospital Marburg, Marburg, Germany
| | - Marion Burckhardt
- Department of Health Sciences and Management; Baden-Wuerttemberg Cooperative State University (DHBW), Stuttgart, Germany
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies (AWMF), Universität Marburg, Marburg, Germany
| | - Ralf Muellenbach
- Department of Anaesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - York Zausig
- Department of Anesthesiology and Operative Intensive Care Medicine, Aschaffenburg-Alzenau Hospital, Aschaffenburg, Bavaria, Germany
| | - Nils Haake
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Heinrich Groesdonk
- Department of Intensive Care Medicine, Helios Clinic Erfurt, Erfurt, Germany
| | - Markus Ferrari
- HSK, Clinic of Internal Medicine I, Helios-Kliniken, Wiesbaden, Germany
| | - Michael Buerke
- Department of Cardiology, Angiology and Intensive Care Medicine, St. Marienkrankenhaus Siegen, Siegen, Germany
| | - Marcus Hennersdorf
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, SLK-Kliniken Heilbronn, Heilbronn, Germany
| | - Mark Rosenberg
- Klinikum Aschaffenburg-Alzenau, Medizinische Klinik 1, Aschaffenburg, Germany
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Harald Köditz
- Medical University Children's Hospital, Hannover, Germany
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St Antonius Hospital, Eschweiler, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Flemmer
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Munich, Germany
| | - Susanne Herber-Jonat
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Germany
| | - Lucas Wessel
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Dirk Buchwald
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | - Lars Krüger
- Division of Thoracic and Cardiovascular Surgery, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | - Andreas Fründ
- Department of Physiotherapy, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | | | - Stefan Fischer
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Karsten Wiebe
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Christiane S Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, and Klinik Bavaria, Kreischa
| | - Omer Dzemali
- Department of Cardiac Surgery, Triemli City hospital Zurich, Zurich, Switzerland
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Christian Schlensak
- Department of Cardio-Thoracic and Vascular Surgery, University of Tübingen, Tübingen, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig-Holstein, Lübeck, Germany
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13
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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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14
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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: 32] [Impact Index Per Article: 10.7] [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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15
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Welker C, Huang J, Ramakrishna H. Analysis of the 2020 EACTS/ELSO/STS/AATS Expert Guidelines on the Management of Adult Postcardiotomy Extracorporeal Life Support. J Cardiothorac Vasc Anesth 2021; 36:2207-2219. [PMID: 34332842 DOI: 10.1053/j.jvca.2021.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 02/07/2023]
Abstract
Extracorporeal life support (ECLS), also known as extracorporeal membrane oxygenation (ECMO), increasingly is used in postcardiotomy (PC) shock to facilitate a bridge to sustained recovery, long-term mechanical support, or heart transplantation. Given increasing prevalence and complexity of PC-ECLS, a joint expert consensus guideline was created in 2020 for management of adult PC-ECLS by the European Association for Cardio-Thoracic Surgery (EACTS), the Extracorporeal Life Support Organization (ELSO), the Society of Thoracic Surgeons (STS), and the American Association of Thoracic Surgery (AATS). The aim of this analysis was to comprehensively review the expert consensus guidelines, with particular emphasis on PC-ECLS candidacy, timing, cannula configuration, left ventricular distention, anticoagulation, ECLS weaning, and intensive care unit complications. This analysis finds the expert consensus guideline to be timely, pertinent, and clinically valuable, although there remains the need for larger clinical trials to codify best practices.
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Affiliation(s)
- Carson Welker
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Jeffrey Huang
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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16
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Makhoul M, Heuts S, Mansouri A, Taccone FS, Obeid A, Mirko B, Broman LM, Malfertheiner MV, Meani P, Raffa GM, Delnoij T, Maessen J, Bolotin G, Lorusso R. Understanding the "extracorporeal membrane oxygenation gap" in veno-arterial configuration for adult patients: Timing and causes of death. Artif Organs 2021; 45:1155-1167. [PMID: 34101843 PMCID: PMC8518076 DOI: 10.1111/aor.14006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 05/08/2021] [Accepted: 06/01/2021] [Indexed: 11/28/2022]
Abstract
Timing and causes of hospital mortality in adult patients undergoing veno‐arterial extracorporeal membrane oxygenation (V‐A ECMO) have been poorly described. Aim of the current review was to investigate the timing and causes of death of adult patients supported with V‐A ECMO and subsequently define the “V‐A ECMO gap,” which represents the patients who are successfully weaned of ECMO but eventually die during hospital stay. A systematic search was performed using electronic MEDLINE and EMBASE databases through PubMed. Studies reporting on adult V‐A ECMO patients from January 1993 to December 2020 were screened. The studies included in this review were studies that reported more than 10 adult, human patients, and no mechanical circulatory support other than V‐A ECMO. Information extracted from each study included mainly mortality and causes of death on ECMO and after weaning. Complications and discharge rates were also extracted. Sixty studies with 9181 patients were included for analysis in this systematic review. Overall mortality was 38.0% (95% confidence intervals [CIs] 34.2%‐41.9%) during V‐A ECMO support (reported by 60 studies) and 15.3% (95% CI 11.1%‐19.5%, reported by 57 studies) after weaning. Finally, 44.0% of patients (95% CI 39.8‐52.2) were discharged from hospital (reported by 60 studies). Most common causes of death on ECMO were multiple organ failure, followed by cardiac failure and neurological causes. More than one‐third of V‐A ECMO patients die during ECMO support. Additionally, many of successfully weaned patients still decease during hospital stay, defining the “V‐A ECMO gap.” Underreporting and lack of uniformity in reporting of important parameters remains problematic in ECMO research. Future studies should uniformly define timing and causes of death in V‐A ECMO patients to better understand the effectiveness and complications of this support.
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Affiliation(s)
- Maged Makhoul
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands.,Cardiac Surgery Unit, Rambam Medical Centre, Haifa, Israel
| | - Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands
| | - Abdulrahman Mansouri
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands
| | - Fabio Silvio Taccone
- Department of Intensive Care Medicine, Clinique Universitaire de Bruxelles (CUB) Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Amir Obeid
- Cardiac Surgery Unit, Rambam Medical Centre, Haifa, Israel
| | - Belliato Mirko
- U.O.C. Anestesia e Rianimazione II Cardiopolmonare, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Lars Mikael Broman
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | | | - Paolo Meani
- Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Giuseppe Maria Raffa
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands.,Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
| | - Thijs Delnoij
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy.,Intensive Care Department, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Jos Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Gil Bolotin
- Cardiac Surgery Unit, Rambam Medical Centre, Haifa, Israel
| | - Roberto Lorusso
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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17
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Patangi SO, Shetty RS, Shanmugasundaram B, Kasturi S, Raheja S. Veno-arterial extracorporeal membrane oxygenation: Special reference for use in 'post-cardiotomy cardiogenic shock' - A review with an Indian perspective. Indian J Thorac Cardiovasc Surg 2021; 37:275-288. [PMID: 33191992 PMCID: PMC7647874 DOI: 10.1007/s12055-020-01051-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/14/2020] [Accepted: 09/07/2020] [Indexed: 11/16/2022] Open
Abstract
The ultimate goals of cardiovascular physiology are to ensure adequate end-organ perfusion to satisfy the local metabolic demand, to maintain homeostasis and achieve 'milieu intérieur'. Cardiogenic shock is a state of pump failure which results in tissue hypoperfusion and its associated complications. There are a wide variety of causes which lead to this deranged physiology, and one such important and common scenario is the post-cardiotomy state which is encountered in cardiac surgical units. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an important modality of managing post-cardiotomy cardiogenic shock with variable outcomes which would otherwise be universally fatal. VA-ECMO is considered as a double-edged sword with the advantages of luxurious perfusion while providing an avenue for the failing heart to recover, but with the problems of anticoagulation, inflammatory and adverse systemic effects. Optimal outcomes after VA-ECMO are heavily reliant on a multitude of factors and require a multi-disciplinary team to handle them. This article aims to provide an insight into the pathophysiology of VA-ECMO, cannulation techniques, commonly encountered problems, monitoring, weaning strategies and ethical considerations along with a literature review of current evidence-based practices.
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Affiliation(s)
- Sanjay Orathi Patangi
- Department of Anaesthesia and Intensive Care, Narayana Institute of Cardiac Sciences, 258/A Hosur Road, Bommasandra Industrial Area, Anekal Taluk, Bengaluru, Karnataka 560099 India
| | - Riyan Sukumar Shetty
- Department of Anaesthesia and Intensive Care, Narayana Institute of Cardiac Sciences, 258/A Hosur Road, Bommasandra Industrial Area, Anekal Taluk, Bengaluru, Karnataka 560099 India
| | - Balasubramanian Shanmugasundaram
- Department of Anaesthesia and Intensive Care, Narayana Institute of Cardiac Sciences, 258/A Hosur Road, Bommasandra Industrial Area, Anekal Taluk, Bengaluru, Karnataka 560099 India
| | - Srikanth Kasturi
- Department of Cardiothoracic Surgery, Narayana Institute of Cardiac Sciences, Bengaluru, India
| | - Shivangi Raheja
- Department of Cardiothoracic Surgery, Narayana Institute of Cardiac Sciences, Bengaluru, India
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18
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North M, Eckman P, Samara M, Chavez I, Schmidt C, Garberich R, Hryniewicz K. Peak troponin predicts successful weaning from VA ECMO in patients with acute myocardial infarction complicated by cardiogenic shock. Int J Artif Organs 2021; 45:68-74. [PMID: 33530814 DOI: 10.1177/0391398821991155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND In patients treated for refractory cardiogenic shock (RCS) following acute myocardial infarction (AMI), predicting successful weaning from veno-arterial extracorporeal membrane oxygenation (VA ECMO) has important implications for decision-making and prognosis. METHODS We performed a retrospective review of adult VA ECMO patients with RCS complicating AMI at our institution from 2010 to 2019. We evaluated use of peak troponin I as a predictor of successful decannulation. RESULTS Sixty-two patients were analyzed; mean age 61.1 ± 9.8 years, 73% males, 62% presented with STEMI. Forty-five patients were successfully weaned (group I). Seventeen patients did not wean (group II); seven patients received a durable LVAD, 10 died. Patients from group I had significantly lower peak troponin I (89 vs 434 ng/mL, p = 0.0001). Receiver operating characteristic curves showed a peak troponin I cutoff of 400 ng/mL correctly classified patients by weaning status 90% of the time, with associated sensitivity of 71% and specificity of 98%. With each 50 ng/mL increase in troponin I, the likelihood of weaning decreased by 33%. CONCLUSIONS Peak troponin I above 400 ng/mL may be helpful in predicting unsuccessful weaning from VA ECMO support for refractory cardiogenic shock following myocardial infarction and facilitate triage decisions regarding need for advanced therapies.
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Affiliation(s)
- Monique North
- Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Peter Eckman
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Michael Samara
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Ivan Chavez
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | | | - Ross Garberich
- Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
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Galectin-3 and sST2 as Prognosticators for Heart Failure Requiring Extracorporeal Life Support: Jack n' Jill. Biomolecules 2021; 11:biom11020166. [PMID: 33513858 PMCID: PMC7911521 DOI: 10.3390/biom11020166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 11/18/2022] Open
Abstract
Extracorporeal life support provides perfusion for patients with heart failure to allow time for recovery, function as a bridge for patients to heart transplantation, or serve as destination therapy for long term mechanical device support. Several biomarkers have been employed in attempt to predict these outcomes, but it remains to be determined which are suitable to guide clinical practice relevant to extracorporeal life support. Galectin-3 and soluble suppression of tumorigenicity-2 (sST2) are two of the more promising candidates with the greatest supporting evidence. In this review, we address the similarities and differences between galectin-3 and sST2 for prognostic prediction in adults and children with heart failure requiring extracorporeal life support and highlight the significant lack of progress in pediatric biomarker discovery and utilization.
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20
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Kim HS, Lee KJ, Ha SO, Han SJ, Park KH, Lee SH, Hwang YI, Jang SH, Park S. Brain natriuretic peptide levels predict 6-month mortality in patients with cardiogenic shock who were weaned off extracorporeal membrane oxygenation. Medicine (Baltimore) 2020; 99:e21272. [PMID: 32702916 PMCID: PMC7373502 DOI: 10.1097/md.0000000000021272] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/27/2020] [Accepted: 06/11/2020] [Indexed: 11/25/2022] Open
Abstract
There are limited data regarding the association between brain natriuretic peptide (BNP) levels obtained after weaning from extracorporeal membrane oxygenation (ECMO) and the outcomes of patients with acute coronary syndrome (ACS)-associated cardiogenic shock.We prospectively obtained data regarding patients (aged ≥ 19 years) with ACS-associated cardiogenic shock who received ECMO and were subsequently weaned off the treatment. BNP levels were collected at 5 time points: pre-ECMO implantation, post-ECMO implantation, pre-ECMO weaning, day 1 after ECMO weaning, and day 5 after ECMO weaning.Of 48 patients with ACS-related cardiogenic shock, 33 were included in this analysis. Mean patient age was 59.0 (50.0-66.5) years, and 5 patients (15.2%) were women. Eight patients had asystole/pulseless electrical activity before ECMO and 14 (42.4%) had 3-vessel disease on coronary angiography. During the 6-month follow up, 12 (36.4%) patients died. BNP levels after ECMO weaning were significantly different between 6-month survivors and non-survivors. Cox proportional hazards model revealed that BNP levels (tertiles) on days 1 and 5 after ECMO weaning were significantly associated with 6-month mortality (hazard ratio, 7.872; 95% confidence interval, 1.870-32.756; 8.658 and 1.904-39.365, respectively). According to the Kaplan-Meier curves, the first tertile had significantly longer survival compared to the third tertile for both days 1 and 5 after ECMO weaning.Post-ECMO weaning BNP levels (days 1 and 5) were significantly associated with increased 6-month mortality in patients with ACS complicated by refractory cardiogenic shock who were weaned off ECMO.
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Affiliation(s)
| | - Kyu Jin Lee
- Department of Pulmonary, Allergy and Critical Care Medicine
| | | | - Sang Jin Han
- Department of Cardiology, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Kyoung-Ha Park
- Department of Cardiology, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | | | - Yong Il Hwang
- Department of Pulmonary, Allergy and Critical Care Medicine
| | - Seung Hun Jang
- Department of Pulmonary, Allergy and Critical Care Medicine
| | - Sunghoon Park
- Department of Pulmonary, Allergy and Critical Care Medicine
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21
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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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Iborra-Egea O, Rueda F, García-García C, Borràs E, Sabidó E, Bayes-Genis A. Molecular signature of cardiogenic shock. Eur Heart J 2019; 41:3839-3848. [DOI: 10.1093/eurheartj/ehz783] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/16/2019] [Accepted: 10/25/2019] [Indexed: 12/24/2022] Open
Abstract
AbstractThe incidence of cardiogenic shock (CS) has increased remarkably over the past decade and remains a challenging condition with mortality rates of ∼50%. Cardiogenic shock encompasses cardiac contractile dysfunction; however, it is also a multiorgan dysfunction syndrome, often complicated by a systemic inflammatory response with severe cellular and metabolic dysregulations. Here, we review the evidence on the biochemical manifestations of CS, elaborating on current gold standard biomarkers and novel candidates from molecular signatures of CS. Glucose and lactate, both identified over a century ago, remain the only clinically used biomarkers in current predictive risk scores. Novel genomic, transcriptomic, and proteomic data are discussed, and a recently reported molecular score derived from unbiased proteomic discovery, the CS4P, which includes liver fatty acid-binding protein, beta-2-microglobulin, fructose-bisphosphate aldolase B, and SerpinG1 is comprehensively described. Recent advances in -omics technologies provide new insight into a more holistic molecular signature of CS. Thus, we need to open new diagnostic and therapeutic avenues if we aim to improve outcomes.
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Affiliation(s)
- Oriol Iborra-Egea
- Department of Cardiology, Heart Institute, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet s/n 08916, Barcelona, Spain
- Department of Medicine, CIBERCV, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ferran Rueda
- Department of Cardiology, Heart Institute, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet s/n 08916, Barcelona, Spain
- Department of Medicine, CIBERCV, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Cosme García-García
- Department of Cardiology, Heart Institute, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet s/n 08916, Barcelona, Spain
- Department of Medicine, CIBERCV, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Eva Borràs
- Proteomics Unit, Centre de Regulació Genòmica (CRG), Barcelona Institute of Science and Technology (BIST), Dr Aiguader 88, Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Dr Aiguader 88, Barcelona, Spain
| | - Eduard Sabidó
- Proteomics Unit, Centre de Regulació Genòmica (CRG), Barcelona Institute of Science and Technology (BIST), Dr Aiguader 88, Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Dr Aiguader 88, Barcelona, Spain
| | - Antoni Bayes-Genis
- Department of Cardiology, Heart Institute, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet s/n 08916, Barcelona, Spain
- Department of Medicine, CIBERCV, Universitat Autònoma de Barcelona, Barcelona, Spain
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23
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Abouelwafa M, Radwan W, Abdelfattah A, Abdelbary A, Khaled M, Samy W, Yousry M, Saeed A, Saad M. The usefulness of Veno-Arterial Extracorporeal Membranous Oxygenation in Patients with Cardiogenic Shock. Open Access Maced J Med Sci 2019; 7:1768-1773. [PMID: 31316656 PMCID: PMC6614275 DOI: 10.3889/oamjms.2019.547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/09/2019] [Accepted: 06/10/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND: Venoarterial extracorporeal membranous oxygenation is a form of temporary mechanical circulatory support that gets as a salvage technique in patients with cardiogenic shock, we intended to evaluate the effect of (VA ECMO) support on hemodynamics and lactate levels in patients with cardiogenic shock. AIM: The aim of our study is to detect the ability to introduce veno-arterial extracorporeal membranous oxygenation (VA ECMO) as a temporary extracorporeal life support system (ECLS) in our unit, demonstrate the role of ECMO in cardiogenic shock patients regarding improving hemodynamics and microcirculation, and demonstrate the complications and drawbacks in our first center experience regarding VA ECMO. MATERIAL AND METHODS: This was a single-centre observational study that included 10 patients admitted with cardiogenic shock for which VA ECMO was used as mechanical circulatory support. RESULTS: The MAP increased after initiation of the support. It was 41.8 ± 9.3 mmHg and 59.5 ± 6.8 mmHg (P = 0.005). The use of VA ECMO support was associated with a statistically significant decrease in the base deficit (-10.6 ± 4.2 and -6.3 ± 7.4, P = 0.038). The serum lactate declined from 5.9 ± 3.5 mmoL/L to 0.6 ± 4.4 mmoL/L by the use of VA ECMO; a statistically significant change (P = 0.005). CONCLUSIONS: We concluded that VA ECMO as mechanical support for patients with cardiogenic shock might improve mean arterial blood pressure, base deficit and lactate clearance.
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Affiliation(s)
| | - Waheed Radwan
- Critical Care Department, Cairo University Hospitals, Cairo, Egypt
| | - Alia Abdelfattah
- Critical Care Department, Cairo University Hospitals, Cairo, Egypt
| | - Akram Abdelbary
- Critical Care Department, Cairo University Hospitals, Cairo, Egypt
| | - Mohamed Khaled
- Critical Care Department, Cairo University Hospitals, Cairo, Egypt
| | - Wael Samy
- Critical Care Department, Cairo University Hospitals, Cairo, Egypt
| | - Mohamed Yousry
- Critical Care Department, Cairo University Hospitals, Cairo, Egypt
| | - Ahmed Saeed
- Critical Care Department, Cairo University Hospitals, Cairo, Egypt
| | - Mahmood Saad
- Critical Care Department, Cairo University Hospitals, Cairo, Egypt
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24
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Wang D, Li S, Jiang J, Yan J, Zhao C, Wang Y, Ma Y, Zeng H, Guo X, Wang H, Tang J, Zuo H, Lin L, Cui G. Chinese society of cardiology expert consensus statement on the diagnosis and treatment of adult fulminant myocarditis. SCIENCE CHINA. LIFE SCIENCES 2019; 62:187-202. [PMID: 30519877 PMCID: PMC7102358 DOI: 10.1007/s11427-018-9385-3] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 08/02/2018] [Indexed: 01/02/2023]
Abstract
Fulminant myocarditis is primarily caused by infection with any number of a variety of viruses. It arises quickly, progresses rapidly, and may lead to severe heart failure or circulatory failure presenting as rapid-onset hypotension and cardiogenic shock, with mortality rates as high as 50%-70%. Most importantly, there are no treatment options, guidelines or an expert consensus statement. Here, we provide the first expert consensus, the Chinese Society of Cardiology Expert Consensus Statement on the Diagnosis and Treatment of Fulminant Myocarditis, based on data from our recent clinical trial (NCT03268642). In this statement, we describe the clinical features and diagnostic criteria of fulminant myocarditis, and importantly, for the first time, we describe a new treatment regimen termed life support-based comprehensive treatment regimen. The core content of this treatment regimen includes (i) mechanical life support (applications of mechanical respirators and circulatory support systems, including intraaortic balloon pump and extracorporeal membrane oxygenation, (ii) immunological modulation by using sufficient doses of glucocorticoid, immunoglobulin and (iii) antiviral reagents using neuraminidase inhibitor. The proper application of this treatment regimen may and has helped to save the lives of many patients with fulminant myocarditis.
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Affiliation(s)
- Daowen Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430030, China.
| | - Sheng Li
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430030, China
| | - Jiangang Jiang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430030, China
| | - Jiangtao Yan
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430030, China
| | - Chunxia Zhao
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430030, China
| | - Yan Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430030, China
| | - Yexin Ma
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430030, China
| | - Hesong Zeng
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430030, China
| | - Xiaomei Guo
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430030, China
| | - Hong Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430030, China
| | - Jiarong Tang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430030, China
| | - Houjuan Zuo
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430030, China
| | - Li Lin
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430030, China
| | - Guanglin Cui
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430030, China
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25
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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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Yeh YC, Lee CT, Wang CH, Tu YK, Lai CH, Wang YC, Chao A, Huang CH, Cheng YJ, Chen YS. Investigation of microcirculation in patients with venoarterial extracorporeal membrane oxygenation life support. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:200. [PMID: 30121090 PMCID: PMC6098836 DOI: 10.1186/s13054-018-2081-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 05/22/2018] [Indexed: 12/14/2022]
Abstract
Background Microcirculatory dysfunction develops in both septic and cardiogenic shock patients, and it is associated with poor prognosis in patients with septic shock. Information on the association between microcirculatory dysfunction and prognosis in cardiogenic shock patients with venoarterial extracorporeal membrane oxygenation (VA-ECMO) support is limited. Methods Sublingual microcirculation images were recorded using an incident dark-field video microscope at the following time points: within 12 h (T1), 24 h (T2), 48 h (T3), 72 h (T4), and 96 h (T5) after VA-ECMO placement. If a patient could be weaned off VA-ECMO, sublingual microcirculation images were recorded before and after VA-ECMO removal. Microcirculatory parameters were compared between 28-day nonsurvivors and survivors with VA-ECMO support. In addition, the microcirculation and clinical parameters were assessed as prognostic tests of 28-day mortality, and patients were divided into three subgroups according to microcirculation parameters for survival analysis. Results Forty-eight patients were enrolled in this study. At T1, the observed heart rate, mean arterial pressure, inotropic score and lactate level of 28-day nonsurvivors and survivors did not differ significantly, but the perfused small vessel density (PSVD) and proportion of perfused vessels (PPV) were lower in the 28-day nonsurvivors than in the survivors. The PSVD and PPV were slightly superior to lactate levels in predicting 28-day mortality (area under curve of 0.68, 0.70, and 0.62, respectively). The subgroup with the lowest PSVD (< 15 mm/mm2) and PPV (< 64%) values exhibited less favorable survival compared with the other two subgroups. Conclusions Early microcirculatory parameters could be used to predict the survival of cardiogenic shock patients with VA-ECMO support. Trial registration ClinicalTrials.gov, NCT02393274. Registered on 19 March 2015.
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Affiliation(s)
- Yu-Chang Yeh
- Department of Anesthesiology, National Taiwan University Hospital, College of Medicine, National Taiwan University, No 7, Chung Shang South Road, Taipei, Taiwan
| | - Chen-Tse Lee
- Department of Anesthesiology, National Taiwan University Hospital, College of Medicine, National Taiwan University, No 7, Chung Shang South Road, Taipei, Taiwan
| | - Chih-Hsien Wang
- Department of Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, No 7, Chung Shang South Road, Taipei, Taiwan
| | - Yu-Kang Tu
- Department of Public Health, Institute of Epidemiology & Preventive Medicine, National Taiwan University, No. 17, Xu-Zhou Road, Taipei, Taiwan
| | - Chien-Heng Lai
- Department of Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, No 7, Chung Shang South Road, Taipei, Taiwan
| | - Yin-Chin Wang
- Department of Anesthesiology, National Taiwan University Hospital, College of Medicine, National Taiwan University, No 7, Chung Shang South Road, Taipei, Taiwan
| | - Anne Chao
- Department of Anesthesiology, National Taiwan University Hospital, College of Medicine, National Taiwan University, No 7, Chung Shang South Road, Taipei, Taiwan
| | - Chi-Hsiang Huang
- Department of Anesthesiology, National Taiwan University Hospital, College of Medicine, National Taiwan University, No 7, Chung Shang South Road, Taipei, Taiwan
| | - Ya-Jung Cheng
- Department of Anesthesiology, National Taiwan University Hospital, College of Medicine, National Taiwan University, No 7, Chung Shang South Road, Taipei, Taiwan.
| | - Yih-Sharng Chen
- Department of Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, No 7, Chung Shang South Road, Taipei, Taiwan.
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Abstract
Veno-arterial extracorporeal life support (VA-ECLS) provides circulatory and respiratory stabilisation in patients with severe refractory cardiogenic shock. Although randomised controlled trials are lacking, the use of VA-ECLS is increasing and observational studies repeatedly have shown treatment benefits in well-selected patients. Current clinical challenges in VA-ECLS relate to optimal management of the individual patient on extracorporeal support given its inherent complexity. In this review article we will discuss indications, daily clinical management and complications of VA-ECLS in cardiogenic shock refractory to conventional treatment strategies.
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Akin S, Dos Reis Miranda D, Caliskan K, Soliman OI, Guven G, Struijs A, van Thiel RJ, Jewbali LS, Lima A, Gommers D, Zijlstra F, Ince C. Functional evaluation of sublingual microcirculation indicates successful weaning from VA-ECMO in cardiogenic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:265. [PMID: 29073930 PMCID: PMC5658964 DOI: 10.1186/s13054-017-1855-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 10/05/2017] [Indexed: 12/23/2022]
Abstract
Background Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly adopted for the treatment of cardiogenic shock (CS). However, a marker of successful weaning remains largely unknown. Our hypothesis was that successful weaning is associated with sustained microcirculatory function during ECMO flow reduction. Therefore, we sought to test the usefulness of microcirculatory imaging in the same sublingual spot, using incident dark field (IDF) imaging in assessing successful weaning from VA-ECMO and compare IDF imaging with echocardiographic parameters. Methods Weaning was performed by decreasing the VA-ECMO flow to 50% (F50) from the baseline. The endpoint of the study was successful VA-ECMO explantation within 48 hours after weaning. The response of sublingual microcirculation to a weaning attempt (WA) was evaluated. Microcirculation was measured in one sublingual area (single spot (ss)) using CytoCam IDF imaging during WA. Total vessel density (TVDss) and perfused vessel density (PVDss) of the sublingual area were evaluated before and during 50% flow reduction (TVDssF50, PVDssF50) after a WA and compared to conventional echocardiographic parameters as indicators of the success or failure of the WA. Results Patients (n = 13) aged 49 ± 18 years, who received VA-ECMO for the treatment of refractory CS due to pulmonary embolism (n = 5), post cardiotomy (n = 3), acute coronary syndrome (n = 2), myocarditis (n = 2) and drug intoxication (n = 1), were included. TVDssF50 (21.9 vs 12.9 mm/mm2, p = 0.001), PVDssF50 (19.7 vs 12.4 mm/mm2, p = 0.01) and aortic velocity–time integral (VTI) at 50% flow reduction (VTIF50) were higher in patients successfully weaned vs not successfully weaned. The area under the curve (AUC) was 0.99 vs 0.93 vs 0.85 for TVDssF50 (small vessels) >12.2 mm/mm2, left ventricular ejection fraction (LVEF) >15% and aortic VTI >11 cm. Likewise, the AUC was 0.91 vs 0.93 vs 0.85 for the PVDssF50 (all vessels) >14.8 mm/mm2, LVEF >15% and aortic VTI >11 cm. Conclusion This study identified sublingual microcirculation as a novel potential marker for identifying successful weaning from VA-ECMO. Sustained values of TVDssF50 and PVDssF50 were found to be specific and sensitive indicators of successful weaning from VA-ECMO as compared to echocardiographic parameters. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1855-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sakir Akin
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. .,Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.
| | - Dinis Dos Reis Miranda
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Kadir Caliskan
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Osama I Soliman
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Goksel Guven
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.,Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Ard Struijs
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Robert J van Thiel
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Lucia S Jewbali
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.,Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Alexandre Lima
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
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Advanced Age as a Predictor of Survival and Weaning in Venoarterial Extracorporeal Oxygenation: A Retrospective Observational Study. BIOMED RESEARCH INTERNATIONAL 2017; 2017:3505784. [PMID: 28484710 PMCID: PMC5397620 DOI: 10.1155/2017/3505784] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 01/16/2017] [Accepted: 03/07/2017] [Indexed: 02/07/2023]
Abstract
Background. In most reports on ECMO treatment, advanced age is classified as a contraindication to VA ECMO. We attempted to investigate whether advanced age would be a main risk factor deciding VA ECMO application and performing VA ECMO support. We determined whether advanced age should be regarded as an absolute or relative contraindication to VA ECMO and could affect weaning and survival rates of VA ECMO patients. Methods. VA ECMO was performed on 135 adult patients with primary cardiogenic shock between January 2010 and December 2014. Successful weaning was defined as weaning from ECMO followed by survival for more than 48 hours. Results. Among the 135 patients, 35 survived and were discharged uneventfully, and the remaining 100 did not survive. There were significant differences in survival between age groups, and older age showed a lower survival rate with statistical significance (P = .01). By multivariate logistic regression analysis, age was not significantly associated with in-hospital mortality (P = .83) and was not significantly associated with VA ECMO weaning (P = .11). Conclusions. Advanced age is an undeniable risk factor for VA ECMO; however, patients of advanced age should not be excluded from the chance of recovery after VA ECMO treatment.
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Biomarcadores cardiacos en el síndrome de bajo gasto cardiaco en el posoperatorio de cirugía de cardiopatías congénitas en niños. Rev Esp Cardiol (Engl Ed) 2017. [DOI: 10.1016/j.recesp.2016.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Tolppanen H, Rivas-Lasarte M, Lassus J, Sans-Roselló J, Hartmann O, Lindholm M, Arrigo M, Tarvasmäki T, Köber L, Thiele H, Pulkki K, Spinar J, Parissis J, Banaszewski M, Silva-Cardoso J, Carubelli V, Sionis A, Harjola VP, Mebazaa A. Adrenomedullin: a marker of impaired hemodynamics, organ dysfunction, and poor prognosis in cardiogenic shock. Ann Intensive Care 2017; 7:6. [PMID: 28050899 PMCID: PMC5209311 DOI: 10.1186/s13613-016-0229-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 12/20/2016] [Indexed: 12/18/2022] Open
Abstract
Background The clinical CardShock risk score, including baseline lactate levels, was recently shown to facilitate risk stratification in patients with cardiogenic shock (CS). As based on baseline parameters, however, it may not reflect the change in mortality risk in response to initial therapies. Adrenomedullin is a prognostic biomarker in several cardiovascular diseases and was recently shown to associate with hemodynamic instability in patients with septic shock. The aim of our study was to evaluate the prognostic value and association with hemodynamic parameters of bioactive adrenomedullin (bio-ADM) in patients with CS. Methods CardShock was a prospective, observational, European multinational cohort study of CS. In this sub-analysis, serial plasma bio-ADM and arterial blood lactate measurements were collected from 178 patients during the first 10 days after detection of CS. Results Both bio-ADM and lactate were higher in 90-day non-survivors compared to survivors at all time points (P < 0.05 for all). Lactate showed good prognostic value during the initial 24 h (AUC 0.78 at admission and 0.76 at 24 h). Subsequently, lactate returned normal (≤2 mmol/L) in most patients regardless of later outcome with lower prognostic value. By contrast, bio-ADM showed increasing prognostic value from 48 h and beyond (AUC 0.71 at 48 h and 0.80 at 5–10 days). Serial measurements of either bio-ADM or lactate were independent of and provided added value to CardShock risk score (P < 0.001 for both). Ninety-day mortality was more than double higher in patients with high levels of bio-ADM (>55.7 pg/mL) at 48 h compared to those with low bio-ADM levels (49.1 vs. 22.6%, P = 0.001). High levels of bio-ADM were associated with impaired cardiac index, mean arterial pressure, central venous pressure, and systolic pulmonary artery pressure during the study period. Furthermore, high levels of bio-ADM at 48 to 96 h were related to persistently impaired cardiac and end-organ function. Conclusions Bio-ADM is a valuable prognosticator and marker of impaired hemodynamics in CS patients. High levels of bio-ADM may show shock refractoriness and developing end-organ dysfunction and thus help to guide therapeutic approach in patients with CS. Study identifier of CardShock study NCT01374867 at clinicaltrials.gov Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0229-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Heli Tolppanen
- INSERM UMR-S942, Paris, France. .,Heart Center, Päijät-Häme Central Hospital, Lahti, Finland. .,Heart and Lung Center, Helsinki University and Helsinki University Hospital, Helsinki, Finland.
| | - Mercedes Rivas-Lasarte
- INSERM UMR-S942, Paris, France.,Intensive Cardiac Care Unit, Cardiology Department, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB-SantPau, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Johan Lassus
- Heart and Lung Center, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Jordi Sans-Roselló
- Intensive Cardiac Care Unit, Cardiology Department, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB-SantPau, Universidad Autónoma de Barcelona, Barcelona, Spain
| | | | - Matias Lindholm
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Mattia Arrigo
- INSERM UMR-S942, Paris, France.,Department of Cardiology, University Heart Center, 8091, Zürich, Switzerland.,Department of Cardiology, University Hospital Zürich, 8091, Zürich, Switzerland
| | - Tuukka Tarvasmäki
- Department of Emergency Care, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Lars Köber
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Holger Thiele
- Medical Clinic II, University Hospital Schleswig-Holstein, University Heart Center Lübeck, Lübeck, Germany
| | - Kari Pulkki
- Department of Clinical Chemistry, University of Eastern Finland, Kuopio, Finland.,Eastern Finland Laboratory Centre, Kuopio, Finland
| | - Jindrich Spinar
- Department of Internal Medicine and Cardiology, University Hospital Brno, Brno, Czech Republic.,International Clinical Research Centre (ICRC), Brno, Czech Republic
| | - John Parissis
- Heart Failure Clinic and Secondary Cardiology Department, Attikon University Hospital, Athens, Greece
| | - Marek Banaszewski
- Intensive Cardiac Therapy Clinic, Institute of Cardiology, Warsaw, Poland
| | - Jose Silva-Cardoso
- Department of Cardiology, CINTESIS, Porto Medical School, São João Hospital Center, University of Porto, Porto, Portugal
| | - Valentina Carubelli
- Division of Cardiology, Department of Medical and Surgical Specialties Radiological Sciences and Public Health, University and Civil Hospital of Brescia, Brescia, Italy
| | - Alessandro Sionis
- Intensive Cardiac Care Unit, Cardiology Department, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB-SantPau, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Veli-Pekka Harjola
- Department of Emergency Care, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Alexandre Mebazaa
- INSERM UMR-S942, Paris, France.,Department of Anesthesia and Critical Care, University Hospital Saint Louis Lariboisière, APHP, Paris, France.,University Paris Diderot, Sorbonne Paris Cité, Paris, France
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Pérez-Navero JL, de la Torre-Aguilar MJ, Ibarra de la Rosa I, Gil-Campos M, Gómez-Guzmán E, Merino-Cejas C, Muñoz-Villanueva MC, Llorente-Cantarero FJ. Cardiac Biomarkers of Low Cardiac Output Syndrome in the Postoperative Period After Congenital Heart Disease Surgery in Children. ACTA ACUST UNITED AC 2016; 70:267-274. [PMID: 28137395 DOI: 10.1016/j.rec.2016.09.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 09/01/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION AND OBJECTIVES To assess the predictive value of atrial natriuretic peptide, β-type natriuretic peptide, copeptin, mid-regional pro-adrenomedullin (MR-proADM) and cardiac troponin I (cTn-I) as indicators of low cardiac output syndrome in children with congenital heart disease undergoing cardiopulmonary bypass (CPB). METHODS After corrective surgery for congenital heart disease under CPB, 117 children (aged 10 days to 180 months) were enrolled in a prospective observational pilot study during a 2-year period. The patients were classified according to whether they developed low cardiac output syndrome. Biomarker levels were measured at 2, 12, 24, and 48 hours post-CPB. The clinical data and outcome variables were analyzed by a multiple logistic regression model. RESULTS Thirty-three (29%) patients developed low cardiac output syndrome (group 1) and the remaining 84 (71%) patients were included in group 2. cTn-I levels >14 ng/mL at 2hours after CPB (OR, 4.05; 95%CI, 1.29-12.64; P=.016) and MR-proADM levels>1.5 nmol/L at 24hours following CPB (OR, 15.54; 95%CI, 4.41-54.71; P<.001) were independent predictors of low cardiac output syndrome. CONCLUSIONS Our results suggest that cTn-I at 2hours post-CPB is, by itself, an evident independent early predictor of low cardiac output syndrome. This predictive capacity is, moreover, reinforced when cTn-I is combined with MR-proADM levels at 24hours following CPB. These 2 cardiac biomarkers would aid in therapeutic decision-making in clinical practice and would also enable clinicians to modify the type of support to be used in the pediatric intensive care unit.
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Affiliation(s)
- Juan L Pérez-Navero
- Unidad de Cuidados Intensivos Pediátricos, Unidad de Gestión Clínica de Pediatría, Hospital Universitario Reina Sofía, Córdoba, Spain; Unidad de Investigación Pediátrica, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain.
| | - María José de la Torre-Aguilar
- Unidad de Investigación Pediátrica, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
| | - Ignacio Ibarra de la Rosa
- Unidad de Cuidados Intensivos Pediátricos, Unidad de Gestión Clínica de Pediatría, Hospital Universitario Reina Sofía, Córdoba, Spain; Unidad de Investigación Pediátrica, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
| | - Mercedes Gil-Campos
- Unidad de Investigación Pediátrica, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
| | - Elena Gómez-Guzmán
- Unidad de Cardiología Pediátrica, Unidad de Gestión Clínica de Pediatría, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Carlos Merino-Cejas
- Unidad de Cirugía Cardiovascular Pediátrica, Unidad de Gestión Clínica de Cirugía Cardiovascular, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - María C Muñoz-Villanueva
- Unidad de Soporte Metodológico a la Investigación, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
| | - Francisco J Llorente-Cantarero
- Unidad de Investigación Pediátrica, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
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The response of the microcirculation to mechanical support of the heart in critical illness. Best Pract Res Clin Anaesthesiol 2016; 30:511-522. [PMID: 27931654 DOI: 10.1016/j.bpa.2016.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 10/20/2016] [Indexed: 12/25/2022]
Abstract
Critical illness associated with cardiac pump failure results in reduced tissue perfusion in all organs and occurs in various conditions such as sepsis, cardiogenic shock, and heart failure. Mechanical circulatory support (MCS) devices can be used to maintain organ perfusion in patients with cardiogenic shock and decompensated chronic heart failure. However, correction of global hemodynamic parameters by MCS does not always cause a parallel improvement in microcirculatory perfusion and oxygenation of the organ systems, a condition referred to as a loss of hemodynamic coherence between macro- and microcirculation (MC). In this paper, we review the literature describing hemodynamic coherence or loss occurring during MCS of the heart. By using Embase, Medline Cochrane, Web of Science, and Google Scholar, we analyzed the literature on the response of MC and macrocirculation to MCS of the heart in critical illness. The characteristics of patients, MCS devices, and micro- and macrocirculatory parameters were very heterogenic. Short-term MCS studies (78%) described the effects of intra-aortic balloon pumps (IABPs) on the MC and macrocirculation. Improvement in MC, observed by handheld microscopy (orthogonal polarization spectral (OPS), sidestream dark-field (SDF), and Cytocam IDF imaging) in line with restored macrocirculation was found in 44% and 40% of the studies of short- and long-term MCS, respectively. In only 6 of 14 studies, hemodynamic coherence was described. It is concluded that more studies using direct visualization of the MC in short- and long-term MCS by handheld microscopy are needed, preferably randomized controlled studies, to identify the presence and clinical significance of hemodynamic coherence. It is anticipated that these further studies can enable to better identify patients who will benefit from treatment by mechanical heart support to ensure adequate organ perfusion.
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Kara A, Akin S, Dos Reis Miranda D, Struijs A, Caliskan K, van Thiel RJ, Dubois EA, de Wilde W, Zijlstra F, Gommers D, Ince C. Microcirculatory assessment of patients under VA-ECMO. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:344. [PMID: 27776535 PMCID: PMC5078964 DOI: 10.1186/s13054-016-1519-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 09/30/2016] [Indexed: 12/03/2022]
Abstract
Background Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an effective technique for providing emergency mechanical circulatory support for patients with cardiogenic shock. VA-ECMO enables a rapid restoration of global systemic organ perfusion, but it has not been found to always show a parallel improvement in the microcirculation. We hypothesized in this study that the response of the microcirculation to the initiation of VA-ECMO might identify patients with increased chances of intensive care unit (ICU) survival. Methods Twenty-four patients were included in this study. Sublingual microcirculation measurements were performed using the CytoCam-IDF (incident dark field) imaging device. Microcirculatory measurements were performed at baseline, after VA-ECMO insertion (T1), 48–72 h after initiation of VA-ECMO (T2), 5–6 days after (T3), 9–10 days after (T4), and within 24 h of VA-ECMO removal. Results Of the 24 patients included in the study population, 15 survived and 9 died while on VA-ECMO. There was no significant difference between the systemic global hemodynamic variables at initiation of VA-ECMO between the survivors and non-survivors. There was, however, a significant difference in the microcirculatory parameters of both small and large vessels at all time points between the survivors and non-survivors. Perfused vessel density (PVD) at baseline (survivor versus non-survivor, 19.21 versus 13.78 mm/mm2, p = 0.001) was able to predict ICU survival on initiation of VA-ECMO; the area under the receiver operating characteristic curve (ROC) was 0.908 (95 % confidence interval 0.772–1.0). Conclusion PVD of the sublingual microcirculation at initiation of VA-ECMO can be used to predict ICU mortality in patients with cardiogenic shock. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1519-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Atila Kara
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. .,Department of Intensive Care, Hacettepe University Faculty of Medicine, Ankara, Turkey. .,Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.
| | - Sakir Akin
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.,Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Dinis Dos Reis Miranda
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Ard Struijs
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Kadir Caliskan
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Robert J van Thiel
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Eric A Dubois
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Wouter de Wilde
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
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Pozzi M, Banfi C, Grinberg D, Koffel C, Bendjelid K, Robin J, Giraud R, Obadia JF. Veno-arterial extracorporeal membrane oxygenation for cardiogenic shock due to myocarditis in adult patients. J Thorac Dis 2016; 8:E495-502. [PMID: 27499982 DOI: 10.21037/jtd.2016.06.26] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Myocarditis is an inflammatory disease of the heart muscle with established histological, immunological and immunohistochemical diagnostic criteria. Different triggers could be advocated as possible etiologies of myocarditis such as viral and non-viral infections, medications, systemic autoimmune diseases and toxic reactions. The spectrum of clinical presentations of myocarditis is broad and varies from subclinical asymptomatic courses to refractory cardiogenic shock. The prognosis of patients with myocarditis depends mainly on the severity of clinical presentation. In particular, myocarditis patients developing cardiogenic shock refractory to optimal maximal medical treatment may benefit from the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as a temporary mechanical circulatory support (MCS). The aim of the present report is to offer a review of the most important articles of the literature showing the results of VA-ECMO in the specific setting of cardiogenic shock due to myocarditis in adult patients.
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Affiliation(s)
- Matteo Pozzi
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Claude Bernard University, Lyon, France
| | - Carlo Banfi
- Division of Cardiovascular Surgery, Geneva University Hospitals, Faculty of Medicine, University of Geneva, Geneva Hemodynamic Research Group, Geneva, Switzerland
| | - Daniel Grinberg
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Claude Bernard University, Lyon, France
| | - Catherine Koffel
- Department of Anesthesia and ICU, "Louis Pradel" Cardiologic Hospital, Claude Bernard University, Lyon, France
| | - Karim Bendjelid
- Intensive Care Service, Geneva University Hospitals, Faculty of Medicine, University of Geneva, Geneva Hemodynamic Research Group, Geneva, Switzerland
| | - Jacques Robin
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Claude Bernard University, Lyon, France
| | - Raphaël Giraud
- Intensive Care Service, Geneva University Hospitals, Faculty of Medicine, University of Geneva, Geneva Hemodynamic Research Group, Geneva, Switzerland
| | - Jean François Obadia
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Claude Bernard University, Lyon, France
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Abstract
OBJECTIVES In this review, we discuss the physiology, pathophysiology, and clinical role of troponin, lactate, and B-type natriuretic peptide in the assessment and management of children with critical cardiac disease. DATA SOURCE MEDLINE, PubMed. CONCLUSION Lactate, troponin, and B-type natriuretic peptide continue to be valuable biomarkers in the assessment and management of critically ill children with cardiac disease. However, the use of these markers as a single measurement is handicapped by the wide variety of clinical scenarios in which they may be increased. The overall trend may be more useful than any single level with a persistent or rising value of more importance than an elevated initial value.
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Tran BG, De La Cruz K, Grant S, Meltzer J, Benharash P, Dave R, Ardehali A, Shemin R, Depasquale E, Nsair A. Temporary Venoarterial Extracorporeal Membrane Oxygenation: Ten-Year Experience at a Cardiac Transplant Center. J Intensive Care Med 2016; 33:288-295. [DOI: 10.1177/0885066616654451] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: Advances in extracorporeal membrane oxygenation (ECMO) have enabled rapid deployment in a wide range of clinical settings. We report our experience with venoarterial (VA) ECMO in adult patients over 10 years and aim to identify predictors of mortality. Design: This is a retrospective analysis of all adult patients undergoing VA ECMO at a tertiary care center from January 1, 2004, to December 31, 2013. Results: A total of 224 consecutive cases were reviewed. Eighty (35.7%) patients survived to discharge and 144 (64.3%) patients died. Patients requiring ECMO for heart transplant graft failure had lower mortality (51.6%) compared to all other etiologies (69.1%; P = .02). Forty-two percent (94 of the 224) of the patients required cardiopulmonary resuscitation (CPR) preceding ECMO and had higher rate of in-hospital mortality (74.5%) compared with patients without cardiac arrest (56.9%; P = .01). Patients with less than 30 minutes of CPR had a mortality rate of 40.0% compared to 91.4% for CPR > 30 minutes ( P = .001). In all, 24.1% of patients (54 of the 224) experienced ECMO-associated complications without significant increase in mortality, and 22.3% (50 of the 224) of the patients were transitioned to ventricular assist devices (VADs) or transplant. Patients bridged to a VAD including left ventricular assist devices and biventricular assist devices had a mortality rate of 56.1% versus 22.2% when bridged directly to transplant ( P = .01). Paradoxically, patients with an ejection fraction (EF) > 35% had a higher mortality compared to patients with an EF < 35% (75.3% vs 49.4%, respectively, P = .001). Conclusion: Extracorporeal membrane oxygenation in patients with heart transplant graft failure had the best outcome. In patients who had cardiac arrest, prolonged CPR > 30 minutes was associated with very high mortality. Paradoxically, patients with EF > 35% had a higher mortality than patients with EF < 35%, likely reflecting patients with diastolic heart failure or noncardiac causes necessitating ECMO. For transplant candidates, direct bridge from ECMO to transplant could achieve a very good outcome.
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Affiliation(s)
- Bao G. Tran
- Department of Cardiology, University of California, Los Angeles, CA, USA
| | - Kim De La Cruz
- Department of Surgery, University of California, Los Angeles, CA, USA
| | - Stuart Grant
- Department of Surgery, University of California, Los Angeles, CA, USA
| | - Joseph Meltzer
- Department of Anesthesiology, University of California, Los Angeles, CA, USA
| | - Peyman Benharash
- Department of Surgery, University of California, Los Angeles, CA, USA
| | - Ravi Dave
- Department of Cardiology, University of California, Los Angeles, CA, USA
| | - Abbas Ardehali
- Department of Surgery, University of California, Los Angeles, CA, USA
| | - Richard Shemin
- Department of Surgery, University of California, Los Angeles, CA, USA
| | - Eugene Depasquale
- Department of Cardiology, University of California, Los Angeles, CA, USA
| | - Ali Nsair
- Department of Cardiology, University of California, Los Angeles, CA, USA
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Lorusso R, Centofanti P, Gelsomino S, Barili F, Di Mauro M, Orlando P, Botta L, Milazzo F, Actis Dato G, Casabona R, Casali G, Musumeci F, De Bonis M, Zangrillo A, Alfieri O, Pellegrini C, Mazzola S, Coletti G, Vizzardi E, Bianco R, Gerosa G, Massetti M, Caldaroni F, Pilato E, Pacini D, Di Bartolomeo R, Marinelli G, Sponga S, Livi U, Mauro R, Mariscalco G, Beghi C, Miceli A, Glauber M, Pappalardo F, Russo CF. Venoarterial Extracorporeal Membrane Oxygenation for Acute Fulminant Myocarditis in Adult Patients: A 5-Year Multi-Institutional Experience. Ann Thorac Surg 2015; 101:919-26. [PMID: 26518372 DOI: 10.1016/j.athoracsur.2015.08.014] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 07/31/2015] [Accepted: 08/07/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute fulminant myocarditis (AFM) may represent a life-threatening event, characterized by rapidly progressive cardiac compromise that ultimately leads to refractory cardiogenic shock or cardiac arrest. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides effective cardiocirculatory support in this circumstance, but few clinical series are available about early and long-term results. Data from a multicenter study group are reported which analyzed subjects affected by AFM and treated with VA-ECMO during a 5-year period. METHOD From hospital databases, 57 patients with diagnoses of AFM treated with VA-ECMO in the past 5 years were found and analyzed. Mean age was 37.6 ± 11.8 years; 37 patients were women. At VA-ECMO implantation, cardiogenic shock was present in 38 patients, cardiac arrest in 12, and severe hemodynamic instability in 7. A peripheral approach was used with 47 patients, whereas 10 patients had a central implantation or other access. RESULTS Mean VA-ECMO support was 9.9 ± 19 days (range, 2 to 24 days). Cardiac recovery with ECMO weaning was achieved in 43 patients (75.5%), major complications were observed in 40 patients (70.1%), and survival to hospital discharge occurred in 41 patients (71.9%). After hospital discharge (median follow-up, 15 months) there were 2 late deaths. The 5-year actual survival was 65.2% ± 7.9%, with recurrent self-recovering myocarditis observed in 2 patients (at 6 and 12 months from the first AFM event), and 1 heart transplantation. CONCLUSIONS Cardiopulmonary support with VA-ECMO provides an invaluable tool in the treatment of AFM, although major complications may characterize the hospital course. Long-term outcome appears favorable with rare episodes of recurrent myocarditis or cardiac-related events.
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Affiliation(s)
- Roberto Lorusso
- Cardiac Surgery Unit, Spedali Civili Hospital, Brescia, Italy.
| | | | - Sandro Gelsomino
- Cardiovascular Research Centre, Careggi Hospital, Florence, Italy
| | - Fabio Barili
- Cardiac Surgery Unit, S. Anna Hospital, Cuneo, Italy
| | | | - Parise Orlando
- Cardiovascular Research Centre, Careggi Hospital, Florence, Italy
| | - Luca Botta
- Cardiac Surgery Unit, Niguarda Hospital, Milan, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Gino Gerosa
- Cardiac Surgery Unit, University Hospital, Padua, Italy
| | | | | | | | | | | | | | | | | | | | - Giovanni Mariscalco
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, United Kingdom
| | | | - Antonio Miceli
- Pasquinucci Hospital Fondazione Monasterio, Massa, Italy
| | - Mattia Glauber
- Pasquinucci Hospital Fondazione Monasterio, Massa, Italy
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Schrimpf C, Gillmann HJ, Sahlmann B, Meinders A, Larmann J, Wilhelmi M, Aper T, Rustum S, Lichtinghagen R, Theilmeier G, Teebken OE. Renal function interferes with copeptin in prediction of major adverse cardiac events in patients undergoing vascular surgery. PLoS One 2015; 10:e0123093. [PMID: 25875814 PMCID: PMC4395325 DOI: 10.1371/journal.pone.0123093] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 02/27/2015] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE Precise perioperative risk stratification is important in vascular surgery patients who are at high risk for major adverse cardiovascular events (MACE) peri- and postoperatively. In clinical practice, the patient's perioperative risk is predicted by various indicators, e.g. revised cardiac index (RCRI) or modifications thereof. Patients suffering from chronic kidney disease (CKD) are stratified into a higher risk category. We hypothesized that Copeptin as a novel biomarker for hemodynamic stress could help to improve the prediction of perioperative cardiovascular events in patients undergoing vascular surgery including patients with chronic kidney disease. METHODS 477 consecutive patients undergoing abdominal aortic, peripheral arterial or carotid surgery from June 2007 to October 2012 were prospectively enrolled. Primary endpoint was 30-day postoperative major adverse cardiovascular events (MACE). RESULTS 41 patients reached the primary endpoint, including 63.4% aortic, 26.8% carotid, and 9.8% peripheral surgeries. Linear regression analysis showed that RCRI (P< .001), pre- (P< .001), postoperative Copeptin (P< .001) and Copeptin level change (P= .001) were associated with perioperative MACE, but CKD remained independently associated with MACE and Copeptin levels. Multivariate regression showed that increased Copeptin levels added risk predictive information to the RCRI (P= .003). Especially in the intermediate RCRI categories was Copeptin significantly associated with the occurrence of MACE. (P< .05 Kruskal Wallis test). Subdivision of the study cohort into CKD stages revealed that preoperative Copeptin was significantly associated with CKD stages (P< .0001) and preoperative Copeptin measurements could not predict MACE in patients with more severe CKD stages. CONCLUSION Preoperative Copeptin loses its risk predictive potential for perioperative MACE in patients with chronic kidney disease undergoing vascular surgery.
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Affiliation(s)
- Claudia Schrimpf
- Division of Vascular & Endovascular Surgery, Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Hans-Joerg Gillmann
- Department for Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Bianca Sahlmann
- Department for Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Antje Meinders
- Department for Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Jan Larmann
- Department for Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Mathias Wilhelmi
- Division of Vascular & Endovascular Surgery, Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Thomas Aper
- Division of Vascular & Endovascular Surgery, Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Saad Rustum
- Division of Vascular & Endovascular Surgery, Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Ralf Lichtinghagen
- Department for Clinical Chemistry, Hannover Medical School, Hannover, Germany
| | - Gregor Theilmeier
- Department for Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Omke E. Teebken
- Division of Vascular & Endovascular Surgery, Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- * E-mail:
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Rüffer A, Münch F, Potapov S, Purbojo A, Toka O, Dodge-Khatami A, Dittrich S, Cesnjevar RA. Troponin I levels in extracorporeal membrane oxygenation following congenital heart surgery. World J Pediatr Congenit Heart Surg 2015; 5:229-35. [PMID: 24668970 DOI: 10.1177/2150135113510007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Correlating postcardiotomy extracorporeal membrane oxygenation (ECMO) troponin I (TnI) levels and outcomes. METHODS Between January 2006 and August 2010, 34 patients needed postcardiotomy ECMO for low cardiac output. Bailout ECMO was required either after unsuccessful weaning from bypass (n = 17, 50%), postoperatively from prolonged hemodynamic failure (n = 8, 23.5%), or following resuscitation (n = 9, 26.5%). The TnI levels were measured following surgery or resuscitation during 10 days and compared between survivors (group I) and non-survivors (group II). RESULTS Median support duration was seven days (range: 0-31). Surgery involving hypoplastic aortic arch repair (Norwood palliation; n = 7, 20.6%, or biventricular repair; n = 11, 32.4%) led to most ECMO runs. Successful weaning from ECMO and hospital survival were 76.5% and 50%, respectively. In group I, peak TnI levels were reached by 24 hours postoperatively, comparable to levels in group II (36 ± 34 vs 49 ± 38 ng/mL; P = .98). However, in group II, TnI levels formed a plateau by the second postoperative day, whereas group I showed a steep decline in TnI levels, suggesting myocardial recovery (P = .028). All patients (n = 4) who reached or maintained peak TnI levels at 48 hours died. On days 8, 9 and 10, TnI levels were significantly higher in group II (P = .024, .019, and .013, respectively). CONCLUSIONS Postcardiotomy ECMO was most commonly required after aortic arch repair. In the absence of ongoing myocardial insult due to ECMO hardware issues, coronary insufficiency or residual lesions, plateau TnI levels at 48 hours may seem to indicate an unfavorable outcome due to irreversible myocardial damage.
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Affiliation(s)
- André Rüffer
- Department of Pediatric Cardiac Surgery, University Hospital Erlangen, Erlangen, Germany
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Iversen K, Gøtze JP, Dalsgaard M, Nielsen H, Boesgaard S, Bay M, Kirk V, Nielsen OW, Køber L. Risk stratification in emergency patients by copeptin. BMC Med 2014; 12:80. [PMID: 24884642 PMCID: PMC4053286 DOI: 10.1186/1741-7015-12-80] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 04/10/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rapid risk stratification is a core task in emergency medicine. Identifying patients at high and low risk shortly after admission could help clinical decision-making regarding treatment, level of observation, allocation of resources and post discharge follow-up. The purpose of the present study was to determine short-, mid- and long-term mortality by plasma measurement of copeptin in unselected admitted patients. METHOD Consecutive patients >40-years-old admitted to an inner-city hospital were included. Within the first 24 hours after admission, a structured medical interview was conducted and self-reported medical history was recorded. All patients underwent a clinical examination, an echocardiographic evaluation and collection of blood for later measurement of risk markers. RESULTS Plasma for copeptin measurement was available from 1,320 patients (average age 70.5 years, 59.4% women). Median follow-up time was 11.5 years (range 11.0 to 12.0 years). Copeptin was elevated (that is, above the 97.5 percentile in healthy individuals).Mortality within the first week was 2.7% (17/627) for patients with elevated copeptin (above the 97.5 percentile, that is, >11.3 pmol/L) compared to 0.1% (1/693) for patients with normal copeptin concentrations (that is, ≤11.3 pmol/L) (P <0.01). Three-month mortality was 14.5% (91/627) for patients with elevated copeptin compared to 3.2% (22/693) for patients with normal copeptin. Similar figures for one-year mortality and for the entire observation period were 27.6% (173/627) versus 8.7% (60/693) and 82.9% (520/527) versus 57.5% (398/693) (P <0.01 for both), respectively.Using multivariable Cox regression analyses shows that elevated copeptin was significantly and independently related to short-, mid- and long-term mortality. Adjusted hazard ratios were 2.4 for three-month mortality, 1.9 for one-year mortality and 1.4 for mortality in the entire observation period. CONCLUSIONS In patients admitted to an inner-city hospital, copeptin was strongly associated with short-, mid- and long-term mortality. The results suggest that rapid copeptin measurement could be a useful tool for both disposition in an emergency department and for mid- and long-term risk assessment.
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Affiliation(s)
- Kasper Iversen
- Departments of Cardiology and Endocrinology, Hillerød Hospital, Hillerød, Denmark.
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Stephens R, Fan E. Choosing wisely - when to mend a broken heart with ECMO? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:112. [PMID: 24602370 PMCID: PMC4059487 DOI: 10.1186/cc13736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Refractory cardiac shock in the cardiac surgical intensive care unit confers significant morbidity and mortality. Extracorporeal membrane oxygenation (ECMO) has become a common intervention for refractory cardiogenic shock when other therapies have failed. However, it is difficult to predict who will benefit from this costly, resource-intensive, but potentially life-saving technology. Here, we discuss the utility of a novel biomarker, serum butylcholinesterase, in determining survival in patients supported with ECMO following cardiac surgery.
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