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Tomarchio E, Momigliano F, Giosa L, Collins PD, Barrett NA, Camporota L. The intricate physiology of veno-venous extracorporeal membrane oxygenation: an overview for clinicians. Perfusion 2024; 39:49S-65S. [PMID: 38654449 DOI: 10.1177/02676591241238156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
During veno-venous extracorporeal membrane oxygenation (V-V ECMO), blood is drained from the central venous circulation to be oxygenated and decarbonated by an artificial lung. It is then reinfused into the right heart and pulmonary circulation where further gas-exchange occurs. Each of these steps is characterized by a peculiar physiology that this manuscript analyses, with the aim of providing bedside tools for clinical care: we begin by describing the factors that affect the efficiency of blood drainage, such as patient and cannulae position, fluid status, cardiac output and ventilatory strategies. We then dig into the complexity of extracorporeal gas-exchange, with particular reference to the effects of extracorporeal blood-flow (ECBF), fraction of delivered oxygen (FdO2) and sweep gas-flow (SGF) on oxygenation and decarbonation. Subsequently, we focus on the reinfusion of arterialized blood into the right heart, highlighting the effects on recirculation and, more importantly, on right ventricular function. The importance and challenges of haemodynamic monitoring during V-V ECMO are also analysed. Finally, we detail the interdependence between extracorporeal circulation, native lung function and mechanical ventilation in providing adequate arterial blood gases while allowing lung rest. In the absence of evidence-based strategies to care for this particular group of patients, clinical practice is underpinned by a sound knowledge of the intricate physiology of V-V ECMO.
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Affiliation(s)
- Emilia Tomarchio
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
| | - Francesca Momigliano
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
| | - Lorenzo Giosa
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
| | - Patrick Duncan Collins
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
| | - Nicholas A Barrett
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
| | - Luigi Camporota
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
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Sciaccaluga C, Procopio MC, Potena L, Masetti M, Bernazzali S, Maccherini M, Landra F, Righini FM, Cameli M, Valente S. Right ventricular dysfunction in left ventricular assist device candidates: is it time to change our prospective? Heart Fail Rev 2024; 29:559-569. [PMID: 38329583 PMCID: PMC10942886 DOI: 10.1007/s10741-024-10387-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2024] [Indexed: 02/09/2024]
Abstract
The use of left ventricular assist devices (LVAD) has significantly increased in the last years, trying to offer a therapeutic alternative to heart transplantation, in light also to the significant heart donor shortage compared to the growing advanced heart failure population. Despite technological improvements in the devices, LVAD-related mortality is still fairly high, with right heart failure being one of the predominant predictors. Therefore, many efforts have been made toward a thorough right ventricular (RV) evaluation prior to LVAD implant, considering clinical, laboratory, echocardiographic, and invasive hemodynamic parameters. However, there is high heterogeneity regarding both which predictor is the strongest as well as the relative cut-off values, and a consensus has not been reached yet, increasing the risk of facing patients in which the distinction between good or poor RV function cannot be surely reached. In parallel, due to technological development and availability of mechanical circulatory support of the RV, LVADs are being considered even in patients with suboptimal RV function. The aim of our review is to analyze the current evidence regarding the role of RV function prior to LVAD and its evaluation, pointing out the extreme variability in parameters that are currently assessed and future prospective regarding new diagnostic tools. Finally, we attempt to gather the available information on the therapeutic strategies to use in the peri-operative phase, in order to reduce the incidence of RV failure, especially in patients in which the preoperative evaluation highlighted some conflicting results with regard to ventricular function.
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Affiliation(s)
- Carlotta Sciaccaluga
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy.
| | | | - Luciano Potena
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Masetti
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sonia Bernazzali
- Department of Cardiac Surgery, University of Siena, Siena, Italy
| | | | - Federico Landra
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Francesca Maria Righini
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Serafina Valente
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
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3
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Hockstein MA, Fan E. The Roles of Venopulmonary Arterial Extracorporeal Membrane Oxygenation. Crit Care Med 2024; 52:297-306. [PMID: 37909826 DOI: 10.1097/ccm.0000000000006094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVES Concise definitive review of the use of venopulmonary arterial extracorporeal membrane oxygenation (V-PA ECMO) support in patients with cardiopulmonary failure. DATA SOURCES Original investigations identified through a PubMed search with search terms "percutaneous right ventricular assist device," "oxy-RVAD," "V-PA ECMO," and "veno-pulmonary arterial ECMO" were reviewed and evaluated for relevance. STUDY SELECTION Studies that included more than three patients supported with V-PA ECMO were included. DATA EXTRACTION Clinically relevant data from included studies, including patient-important outcomes, were summarized and discussed. DATA SYNTHESIS We identified four groups of patients where V-PA ECMO has been studied: acute respiratory distress syndrome, right ventricular dysfunction after left ventricular assist device placement, bridge to lung transplantation, and pulmonary embolism. Most identified works are small, single center, and retrospective in nature, precluding definitive conclusions regarding the efficacy of V-PA ECMO. There have been no clinical trials evaluating the efficacy of V-PA ECMO for any indication. CONCLUSIONS V-PA ECMO is a promising form of extracorporeal support for patients with right ventricular dysfunction. Future work should focus on identifying the optimal timing and populations for the use of V-PA ECMO.
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Affiliation(s)
- Maxwell A Hockstein
- Department of Emergency Medicine, MedStar Washington Hospital Center, Georgetown University School of Medicine, Washington, DC
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Georgetown University School of Medicine, Washington, DC
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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Thomas C, Tobes D, Trela K, Montes M, Cuppini C, Petty K, Saini G, Perdigao J, Song T, Dalton A, Tung A. A Case Report of Percutaneous Right Ventricular Assist Device Utilization After Cesarean Delivery in a Patient With Severe Pulmonary Arterial Hypertension. A A Pract 2023; 17:e01728. [PMID: 37975893 DOI: 10.1213/xaa.0000000000001728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Physiologic changes of pregnancy are poorly tolerated in patients with pulmonary arterial hypertension (PAH), and peripartum maternal mortality is high. We present a case of a 31-year-old G3P0020 patient at 35 weeks' gestation with severe World Health Organization group I PAH who underwent cesarean delivery followed by percutaneous right ventricular assist device placement. Risks and benefits of the mode of delivery, neuraxial versus general anesthesia, and mechanical circulatory support are reviewed.
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Affiliation(s)
- Caroline Thomas
- From the Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - Daniel Tobes
- From the Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - Kristin Trela
- From the Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - Mariana Montes
- From the Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - Candice Cuppini
- From the Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - Kyle Petty
- From the Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - Gurjit Saini
- From the Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - Joana Perdigao
- Department of Maternal and Fetal Medicine, University of Chicago, Chicago, Illinois
| | - Tae Song
- Department of Cardiac Surgery, University of Chicago, Chicago, Illinois
| | - Allison Dalton
- From the Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - Avery Tung
- From the Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
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5
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Usman AA, Cevasco M, Maybauer MO, Spelde AE, Olia S, Bermudez C, Ibrahim M, Szeto W, Vernick WJ, Gutsche JT. Oxygenated right ventricular assist device as part of veno-venopulmonary extracorporeal membrane oxygenation to support the right ventricle and pulmonary vasculature. J Cardiothorac Surg 2023; 18:134. [PMID: 37041646 PMCID: PMC10088623 DOI: 10.1186/s13019-023-02264-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/03/2023] [Indexed: 04/13/2023] Open
Abstract
COVID-19 infection can lead to severe acute respiratory distress syndrome (ARDS), right ventricular (RV) failure and pulmonary hypertension. Venovenous extracorporeal membrane oxygenation (V-V ECMO) has been used for patients with refractory hypoxemia. More recently dual-lumen right atrium to pulmonary artery oxygenated right ventricular assist devices (Oxy-RVAD) have been utilized in the severe medical refractory COVID ARDS setting. Historically, animal data has demonstrated that high continuous non-pulsatile RVAD flows, leading to unregulated and unprotected circulation through the pulmonary vessels is associated with an increased risk of pulmonary hemorrhage and increased amount of extravascular lung water. These risks are heightened in the setting of ARDS with fragile capillaries, left ventricular (LV) diastolic failure, COVID cardiomyopathy, and anticoagulation. Concurrently, due to infection, tachycardia, and refractory hypoxemia, high V-V ECMO flows to match high cardiac output are often necessary to maintain systemic oxygenation. Increase in cardiac output without a concurrent increase in VV ECMO flow will result in a higher fraction of deoxygenated blood returning to the right heart and therefore resulting in hypoxemia. Several groups have suggested using a RVAD only strategy in COVID ARDS; however, this exposes the patients to the risk of pulmonary hemorrhage. We present one of the first known cases using an RV mechanical support, partial flow pulmonary circulation, oxygenated Veno-venopulmonary (V-VP) strategy resulting in RV recovery, total renal recovery, awake rehabilitation, and recovery.
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Affiliation(s)
- Asad Ali Usman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce St, 6 Silverstein Pavilion, Philadelphia, PA, USA.
| | - Marisa Cevasco
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Marc O Maybauer
- Advanced Cardiac and Critical Care, Nazih Zuhdi Transplant Institute, 24/7 Shock Service, Intergris Baptist Medical Center, Oklahoma City, OK, USA
- Department of Anaesthesiology and Intensive Care Medicine, Philipps University, Marburg, Germany
- Critical Care Research Group, The Prince Charles Hospital, The University of Queensland, Hospital cardiac Arrest, Brisbane, Australia
| | - Audrey Elizabeth Spelde
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce St, 6 Silverstein Pavilion, Philadelphia, PA, USA
| | - Salim Olia
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Christian Bermudez
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Michael Ibrahim
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Wilson Szeto
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - William J Vernick
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce St, 6 Silverstein Pavilion, Philadelphia, PA, USA
| | - Jacob T Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce St, 6 Silverstein Pavilion, Philadelphia, PA, USA
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Rodenas-Alesina E, Brahmbhatt DH, Rao V, Salvatori M, Billia F. Prediction, prevention, and management of right ventricular failure after left ventricular assist device implantation: A comprehensive review. Front Cardiovasc Med 2022; 9:1040251. [PMID: 36407460 PMCID: PMC9671519 DOI: 10.3389/fcvm.2022.1040251] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/18/2022] [Indexed: 08/26/2023] Open
Abstract
Left ventricular assist devices (LVADs) are increasingly common across the heart failure population. Right ventricular failure (RVF) is a feared complication that can occur in the early post-operative phase or during the outpatient follow-up. Multiple tools are available to the clinician to carefully estimate the individual risk of developing RVF after LVAD implantation. This review will provide a comprehensive overview of available tools for RVF prognostication, including patient-specific and right ventricle (RV)-specific echocardiographic and hemodynamic parameters, to provide guidance in patient selection during LVAD candidacy. We also offer a multidisciplinary approach to the management of early RVF, including indications and management of right ventricular assist devices in this setting to provide tools that help managing the failing RV.
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Affiliation(s)
- Eduard Rodenas-Alesina
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
- Department of Cardiology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Darshan H. Brahmbhatt
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Vivek Rao
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
| | - Marcus Salvatori
- Department of Anesthesia, University Health Network, Toronto, ON, Canada
| | - Filio Billia
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
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7
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Usman AA, Spelde AE, Olia SE, Cevasco M, Bermudez C, Haddle J, Ibrahim M, Szeto W, Vernick W, Gutsche J. First-in-man successful use of the SPECTRUM percutaneous dual-stage right ventricle and right atrium to pulmonary artery ventricular assist device. J Card Surg 2022; 37:3403-3407. [PMID: 35870174 PMCID: PMC9444884 DOI: 10.1111/jocs.16753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/03/2022] [Accepted: 06/20/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Over the past decade, several minimally invasive mechanical support devices have been introduced into clinical practice to support the right ventricle (RV). Percutaneous cannulas are easy to insert, minimally invasive, and treat acute RV failure rapidly. In December 2021, the Food and Drug Administration approved a new 31 French dual lumen single cannula for use as a right ventricular assist device. AIMS Descirbe the use of the new dual lumen percutaneous right ventricular assist device (RVAD) cannula. MATERIAL AND METHODS Deployment of the RVAD can be done surgically or percutaneously. This cannula, manufactured by Spectrum, is dual staged. It has inflow ports positioned both in the right atrium (RA) as well as the RV for maximal drainage of the right heart. The distal end of the cannula which includes the outflow port is positioned in the pulmonary artery (PA). RESULTS Deployment of the Spectrum RVAD can be done percutaneously with transesophageal and flouroscopy guidence. Cannulation requires requisite wire skills in order to navigate into the main pulmonary artery. Utilization of this cannula can be done in acute RV failure secondary to ischemia, post cardiotomy shock, acute respiratory failure or other causes of isolated RV failure. DISCUSSION The dual stage drainage design optimizes venous drainage as well as limits suck-down events. Theoretically, direct RV decompression also decreases RV dilation and wall tension, and facilitates improved transmural pressure gradient to reduce RV strain. CONCLUSION Here we describe the first-in-man successful use of the dual-stage RA and RV to PA Spectrum cannula in a patient with severe COVID acute respiratory distress syndrome and acute right ventricular failure, bridged to recovery.
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Affiliation(s)
- Asad A Usman
- Department of Anesthesiology and Critical Care, Philadelphia, Pennsylvania, USA
| | - Audrey E Spelde
- Department of Anesthesiology and Critical Care, Philadelphia, Pennsylvania, USA
| | - Salim E Olia
- Department of Surgery, Division of Cardiovascular Surgery
| | - Marisa Cevasco
- Department of Surgery, Division of Cardiovascular Surgery
| | | | - John Haddle
- Department of Surgery, Division of Cardiovascular Surgery
| | | | - Wilson Szeto
- Department of Surgery, Division of Cardiovascular Surgery
| | - William Vernick
- Department of Anesthesiology and Critical Care, Philadelphia, Pennsylvania, USA
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, Philadelphia, Pennsylvania, USA
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8
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El Banayosy AM, El Banayosy A, Brewer JM, Mihu MR, Chidester JM, Swant LV, Schoaps RS, Sharif A, Maybauer MO. The ProtekDuo for percutaneous V-P and V-VP ECMO in patients with COVID-19 ARDS. Int J Artif Organs 2022; 45:1006-1012. [PMID: 36085584 PMCID: PMC9465053 DOI: 10.1177/03913988221121355] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The ProtekDuo with oxygenator mimics veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) in veno-pulmonary (V-P) configuration. We have recently developed a new configuration by utilizing a 25 Fr multistage femoral venous drainage cannula and by returning oxygenated blood through both lumina of the double lumen ProtekDuo cannula (V-VP configuration), thereby creating partial right ventricular bypass and oxygenated blood flow of up to seven LPM. We investigated our experience with V-P and V-VP ECMO in patients suffering from COVID-19 acute respiratory distress syndrome (ARDS). METHODS Single center, retrospective observational study. RESULTS Of nine patients, one was initiated on V-A, two on V-P, and six on V-V ECMO. All patients were reconfigured to V-P and five patients in addition had V-VP ECMO configuration. All patients had at least one and up to three circuit exchanges. Patients were on ECMO support between 20 and 122 (55 ± 29) days, were in ICU between 46 and 161 (78 ± 40) days with a total hospital length of stay between 35 and 171 (82 ± 42) days. Six of nine (67%) patients could successfully be weaned off ECMO, survived, and were discharged. CONCLUSION The ProtekDuo cannula in V-P configuration provides ECMO blood flow while reducing RV flow, wall-stress and dilatation, as well as oxygen consumption. The V-VP configuration is useful to provide high blood flows of up to seven LPM of oxygenated blood, and partial RV support without over-circulating the pulmonary vascular bed. Our results show that V-P and V-VP ECMO configurations are feasible, have good outcome and are without complications.
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Affiliation(s)
- Ahmed M El Banayosy
- Nazih Zuhdi Transplant Institute, Advanced Cardiac and Critical Care, 24/7 Shock Service, Intergris Baptist Medical Center, Oklahoma City, OK, USA
| | - Aly El Banayosy
- Nazih Zuhdi Transplant Institute, Advanced Cardiac and Critical Care, 24/7 Shock Service, Intergris Baptist Medical Center, Oklahoma City, OK, USA
| | - Joseph M Brewer
- Nazih Zuhdi Transplant Institute, Advanced Cardiac and Critical Care, 24/7 Shock Service, Intergris Baptist Medical Center, Oklahoma City, OK, USA
| | - Mircea R Mihu
- Nazih Zuhdi Transplant Institute, Advanced Cardiac and Critical Care, 24/7 Shock Service, Intergris Baptist Medical Center, Oklahoma City, OK, USA
| | - Jaclyn M Chidester
- Nazih Zuhdi Transplant Institute, Advanced Cardiac and Critical Care, 24/7 Shock Service, Intergris Baptist Medical Center, Oklahoma City, OK, USA
| | - Laura V Swant
- Nazih Zuhdi Transplant Institute, Advanced Cardiac and Critical Care, 24/7 Shock Service, Intergris Baptist Medical Center, Oklahoma City, OK, USA
| | - Robert S Schoaps
- Nazih Zuhdi Transplant Institute, Advanced Cardiac and Critical Care, 24/7 Shock Service, Intergris Baptist Medical Center, Oklahoma City, OK, USA
| | - Ammar Sharif
- Nazih Zuhdi Transplant Institute, Advanced Cardiac and Critical Care, 24/7 Shock Service, Intergris Baptist Medical Center, Oklahoma City, OK, USA
| | - Marc O Maybauer
- Nazih Zuhdi Transplant Institute, Advanced Cardiac and Critical Care, 24/7 Shock Service, Intergris Baptist Medical Center, Oklahoma City, OK, USA.,Critical Care Research Group, Prince Charles Hospital, University of Queensland, Brisbane, QLD, Australia.,Department of Anaesthesiology and Intensive Care Medicine, Philipps University, Marburg, Germany.,Department of Medicine/Cardiology, Oklahoma State University Health Science Center, Tulsa, OK, USA
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9
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Spelde AE, Hernandez-Morgan ME, Augoustides JG. Advances in Mechanical Support for Right Ventricular Failure. J Cardiothorac Vasc Anesth 2022; 36:3289-3291. [PMID: 35644749 PMCID: PMC9774046 DOI: 10.1053/j.jvca.2022.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 04/24/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Audrey E. Spelde
- Department of Anesthesiology & Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Marisa E Hernandez-Morgan
- Department of Anesthesiology & Perioperative Medicine, University of California Los Angeles, Los Angeles, CA
| | - John G.T. Augoustides
- Department of Anesthesiology & Critical Care, University of Pennsylvania, Philadelphia, PA
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10
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Patel S, Angelidis IK, Malsin ES, Smith S, Pawale A, Budd AN. Inhaled Tranexamic Acid for the Management of Hemoptysis in a Patient With Right and Left Ventricular Assist Devices: A Case Report. A A Pract 2022; 16:e01604. [PMID: 35917204 DOI: 10.1213/xaa.0000000000001604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The use of mechanical circulatory support (MCS) devices continues to expand in cases of refractory cardiogenic shock. Bleeding is one of the most common complications associated with MCS, and management can be challenging due to need for systemic anticoagulation. Significant hemoptysis can be a devastating complication. We describe a case of a patient supported by a right ventricular assist device with an oxygenator and a left ventricular assist device who developed pulmonary hemorrhage that was successfully treated with nebulized tranexamic acid (TXA). Following a 5-day treatment course, bleeding resolved, no adverse side effects were noted, and systemic anticoagulation was resumed.
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Affiliation(s)
- Shamik Patel
- From the Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Anesthesiology, Northwestern Medicine, Chicago, Illinois
| | - Ioannis K Angelidis
- Department of Anesthesiology
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Elizabeth S Malsin
- From the Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Pulmonary and Critical Care Medicine, Northwestern Medicine, Chicago, Illinois
| | - Sean Smith
- From the Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Pulmonary and Critical Care Medicine, Northwestern Medicine, Chicago, Illinois
| | - Amit Pawale
- Department of Cardiac Surgery, Washington University, St. Louis, Missouri
| | - Ashley N Budd
- From the Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Anesthesiology, Northwestern Medicine, Chicago, Illinois
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11
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Panholzer B, Pilarczyk K, Huenges K, Aldinger C, Friedrich C, Nowak-Göttl U, Cremer J, Haneya A. Severe Pulmonary Bleeding after Assist Device Implantation: Incidence, Risk Factors and Prognostic Impact. J Clin Med 2022; 11:jcm11071908. [PMID: 35407516 PMCID: PMC8999887 DOI: 10.3390/jcm11071908] [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: 01/18/2022] [Revised: 03/03/2022] [Accepted: 03/21/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Continuous flow left ventricular assist devices (CF-LVAD) improve survival in patients with advanced heart failure but confer risk of bleeding complications. Whereas pathophysiology and risk factors for many bleeding complications are well investigated, the literature lacks reports about pulmonary bleeding. Therefore, it was the aim of the present study to assess incidence, risk factors, and clinical relevance of pulmonary bleeding episodes after LVAD implantation. Methods: We retrospectively analyzed our institutional database of 125 consecutive patients who underwent LVAD implantation between 2008 and 2017. Demographic and clinical variables related to bleeding were collected. The primary endpoint was incidence of severe pulmonary bleeding (SPB). Results: Nine out of 125 patients suffered from SPB during the postoperative course (7.2%) 11 days after surgery in the median. None of them had a known history of lung disease or bleeding disorder. History of prior myocardial infarction (0% vWD. 42.2%, p = 0.012) and ischemic cardiomyopathy (25.0% vs. 50.0%, p = 0.046) were less frequent in the SBP group. Concomitant aortic valve replacement was more common in the group with SPB (33.3% versus 7.0%, p = 0.034). Surgical (blood loss 9950 vs. 3800 mL, p = 0.012) as well as ear-nose-throat (ENT) bleedings (33% vs. 4.6%, p = 0.015) were observed more frequently in patients with SPB. SPB was associated with a complicated postoperative course with a higher incidence of acute kidney failure (100% versus 36.7%, p = 0.001) and delirium (44.4% versus 14.8%, p = 0.045); a higher need for red blood cell (26 packs versus 7, p < 0.001), fresh frozen plasma (18 units versus 6, p = 0.002), and platelet transfusion (8 pools versus 1, p = 0.001); longer ventilation time (1206 versus 171 h, p = 0.001); longer ICU-stay (58 versus 13 days, p = 0.002); and higher hospital mortality (66.7% vs. 29%, p = 0.029). Conclusion: SPB is a rare but serious complication after LVAD implantation and is significantly associated with higher morbidity and mortality. The pathophysiology and potential risk factors are unknown but may include coagulation disorders and frequent suctioning or empiric bronchoscopy causing airway irritation.
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Affiliation(s)
- Bernd Panholzer
- Department of Cardiovascular Surgery, University of Schleswig-Holstein, 24105 Kiel, Germany; (B.P.); (K.H.); (C.A.); (C.F.); (J.C.); (A.H.)
| | - Kevin Pilarczyk
- Department of Intensive Care Medicine, Imland Klinik Rendsburg, 24768 Rendsburg, Germany
- Correspondence: ; Tel.: +49-431-5002-8193
| | - Katharina Huenges
- Department of Cardiovascular Surgery, University of Schleswig-Holstein, 24105 Kiel, Germany; (B.P.); (K.H.); (C.A.); (C.F.); (J.C.); (A.H.)
| | - Charlotte Aldinger
- Department of Cardiovascular Surgery, University of Schleswig-Holstein, 24105 Kiel, Germany; (B.P.); (K.H.); (C.A.); (C.F.); (J.C.); (A.H.)
| | - Christine Friedrich
- Department of Cardiovascular Surgery, University of Schleswig-Holstein, 24105 Kiel, Germany; (B.P.); (K.H.); (C.A.); (C.F.); (J.C.); (A.H.)
| | - Ulrike Nowak-Göttl
- Institute of Clinical Chemistry, University of Schleswig-Holstein, 24105 Kiel, Germany;
| | - Jochen Cremer
- Department of Cardiovascular Surgery, University of Schleswig-Holstein, 24105 Kiel, Germany; (B.P.); (K.H.); (C.A.); (C.F.); (J.C.); (A.H.)
| | - Assad Haneya
- Department of Cardiovascular Surgery, University of Schleswig-Holstein, 24105 Kiel, Germany; (B.P.); (K.H.); (C.A.); (C.F.); (J.C.); (A.H.)
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12
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Lo Coco V, De Piero ME, Massimi G, Chiarini G, Raffa GM, Kowalewski M, Maessen J, Lorusso R. Right ventricular failure after left ventricular assist device implantation: a review of the literature. J Thorac Dis 2021; 13:1256-1269. [PMID: 33717597 PMCID: PMC7947472 DOI: 10.21037/jtd-20-2228] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Right ventricular failure (RVF) following left ventricular assist device (LVAD) implantation remains a major complication which may significantly impair patient outcome. The genesis of RVF is, however, multifactorial, and the mechanisms underlying such a condition have not been fully elucidated, making its prevention challenging and the course not always predictable. Although preoperative risks factors can be associated with RV impairment, the physiologic changes after the LV support, can still hamper the function of the RV. Current medical treatment options are limited and sometimes, patients with a severe post-LVAD RVF may be unresponsive to pharmacological therapy and require more aggressive treatment, such as temporary RV support. We retrieved 11 publications which we assessed and divided in groups based on the RV support [extracorporeal membrane oxygenation (ECMO), right ventricular assist device (RVAD), TandemHeart with ProtekDuo cannula]. The current review comprehensively summarizes the main studies of the literature with particular attention to the RV physiology and its changes after the LVAD implantation, the predictors and prognostic score as well as the different modalities of temporary mechanical cardio-circulatory support, and its effects on patient prognosis for RVF in such a setting. In addition, it provides a decision making of the pre-, intra and post-operative management in high- and moderate- risk patients.
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Affiliation(s)
- Valeria Lo Coco
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Maria Elena De Piero
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands.,Department of Anesthesia/Intensive Care, San Giovanni, Turin, Italy
| | - Giulio Massimi
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands.,Department of Cardiac Surgery, Circolo Hospital, University of Insurbia, Varese, Italy
| | - Giovanni Chiarini
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands.,Division of Anesthesiology, Intensive Care and Emergency medicine, Spedali Civili University, Brescia, Italy
| | - Giuseppe M Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
| | - Mariusz Kowalewski
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands.,Thoracic Research Centre, Collegium Medicum, Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Jos Maessen
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
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13
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Raina A, Patarroyo-Aponte M. Prevention and Treatment of Right Ventricular Failure During Left Ventricular Assist Device Therapy. Crit Care Clin 2018; 34:439-452. [PMID: 29907275 DOI: 10.1016/j.ccc.2018.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Left ventricular assist devices (LVAD) are increasingly used for the treatment of end-stage heart failure. Right ventricular (RV) failure after LVAD implantation is an increasingly common clinical problem, occurring in patients early after continuous flow LVAD implant. RV failure is associated with a substantial increase in post-LVAD morbidity and mortality. RV failure can be predicted using preoperative hemodynamic, clinical, and echocardiographic variables and a variety of risk prediction algorithms. However, RV failure may also develop due to unanticipated intraoperative or perioperative factors. Early recognition and treatment are critical in terms of mitigating the impact of RV failure on post-LVAD outcomes.
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Affiliation(s)
- Amresh Raina
- Cardiovascular Institute, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212-4772, USA.
| | - Maria Patarroyo-Aponte
- Cardiovascular Institute, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212-4772, USA
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