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Biancari F, Kaserer A, Perrotti A, Ruggieri VG, Cho SM, Kang JK, Dalén M, Welp H, Jónsson K, Ragnarsson S, Hernández Pérez FJ, Gatti G, Alkhamees K, Loforte A, Lechiancole A, Rosato S, Spadaccio C, Pettinari M, Mariscalco G, Mäkikallio T, Sahli SD, L'Acqua C, Arafat AA, Albabtain MA, AlBarak MM, Laimoud M, Djordjevic I, Krasivskyi I, Samalavicius R, Puodziukaite L, Alonso-Fernandez-Gatta M, Spahn DR, Fiore A. Hyperlactatemia and poor outcome After postcardiotomy veno-arterial extracorporeal membrane oxygenation: An individual patient data meta-Analysis. Perfusion 2024; 39:956-965. [PMID: 37066850 DOI: 10.1177/02676591231170978] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
INTRODUCTION Postcardiotomy veno-arterial extracorporeal membrane oxygenation (V-A-ECMO) is associated with significant mortality. Identification of patients at very high risk for death is elusive and the decision to initiate V-A-ECMO is based on clinical judgment. The prognostic impact of pre-V-A-ECMO arterial lactate level in these critically ill patients has been herein evaluated. METHODS A systematic review was conducted to identify studies on postcardiotomy VA-ECMO for the present individual patient data meta-analysis. RESULTS Overall, 1269 patients selected from 10 studies were included in this analysis. Arterial lactate level at V-A-ECMO initiation was increased in patients who died during the index hospitalization compared to those who survived (9.3 vs 6.6 mmol/L, p < 0.0001). Accordingly, in hospital mortality increased along quintiles of pre-V-A-ECMO arterial lactate level (quintiles: 1, 54.9%; 2, 54.9%; 3, 67.3%; 4, 74.2%; 5, 82.2%, p < 0.0001). The best cut-off for arterial lactate was 6.8 mmol/L (in-hospital mortality, 76.7% vs. 55.7%, p < 0.0001). Multivariable multilevel mixed-effect logistic regression model including arterial lactate level significantly increased the area under the receiver operating characteristics curve (0.731, 95% CI 0.702-0.760 vs 0.679, 95% CI 0.648-0.711, DeLong test p < 0.0001). Classification and regression tree analysis showed the in-hospital mortality was 85.2% in patients aged more than 70 years with pre-V-A-ECMO arterial lactate level ≥6.8 mmol/L. CONCLUSIONS Among patients requiring postcardiotomy V-A-ECMO, hyperlactatemia was associated with a marked increase of in-hospital mortality. Arterial lactate may be useful in guiding the decision-making process and the timing of initiation of postcardiotomy V-A-ECMO.
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Affiliation(s)
- Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
- Department of Medicine, South-Karelia Central Hospital, University of Helsinki, Lappeenranta, Finland
| | - Alexander Kaserer
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Andrea Perrotti
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Vito G Ruggieri
- Division of Cardiothoracic and Vascular Surgery, Robert Debré University Hospital, Reims, France
| | - Sung-Min Cho
- Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Jin Kook Kang
- Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, and Cardiac Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Henryk Welp
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Kristján Jónsson
- Department of Cardiac Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | | | - Giuseppe Gatti
- Cardio-Thoracic and Vascular Department, University Hospital of Trieste, Trieste, Italy
| | | | - Antonio Loforte
- Department of Cardiothoracic, Transplantation and Vascular Surgery, S. Orsola Hospital, Bologna, Italy
| | | | - Stefano Rosato
- Center for Global Health, Italian National Institute, Rome, Italy
| | | | - Matteo Pettinari
- Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, 3600 Genk, Belgium
| | - Giovanni Mariscalco
- Department of Intensive Care Medicine and Cardiac Surgery, Glenfield Hospital, Leicester, UK
| | - Timo Mäkikallio
- Department of Medicine, South-Karelia Central Hospital, University of Helsinki, Lappeenranta, Finland
| | - Sebastian D Sahli
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Camilla L'Acqua
- Anesthesia and Intensive Care Unit, Centro Cardiologico Monzino, Italy
- Anesthesia and Intensive Care Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Italy
| | - Amr A Arafat
- Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
- Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt
| | - Monirah A Albabtain
- Cardiology Clinical Pharmacy, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Mohammed M AlBarak
- Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Mohamed Laimoud
- Cardiac Surgical Intensive Care Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- Critical Care Medicine Department, Cairo University, Cairo, Egypt
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Ihor Krasivskyi
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Robertas Samalavicius
- 2nd Department of Anesthesia, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
- Clinic of Emergency Medicine, Medical Faculty, Vilnius University, Vilnius, Lithuania
| | - Lina Puodziukaite
- 2nd Department of Anesthesia, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Marta Alonso-Fernandez-Gatta
- Cardiology Department, University Hospital of Salamanca, Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain
- CIBER-CV Instituto de Salud Carlos III, Madrid, Spain
| | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Creteil, France
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Keller SP, Whitman GJR, Grant MC. Temporary Mechanical Circulatory Support after Cardiac Surgery. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00387-2. [PMID: 38955616 DOI: 10.1053/j.jvca.2024.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 05/30/2024] [Accepted: 06/11/2024] [Indexed: 07/04/2024]
Abstract
Postcardiotomy shock in the cardiac surgical patient is a highly morbid condition characterized by profound myocardial impairment and decreased systemic perfusion inadequate to meet end-organ metabolic demand. Postcardiotomy shock is associated with significant morbidity and mortality. Poor outcomes motivate the increased use of mechanical circulatory support (MCS) to restore perfusion in an effort to prevent multiorgan injury and improve patient survival. Despite growing acceptance and adoption of MCS for postcardiotomy shock, criteria for initiation, clinical management, and future areas of clinical investigation remain a topic of ongoing debate. This article seeks to (1) define critical cardiac dysfunction in the patient after cardiotomy, (2) provide an overview of commonly used MCS devices, and (3) summarize the relevant clinical experience for various MCS devices available in the literature, with additional recognition for the role of MCS as a part of a modified approach to the cardiac arrest algorithm in the cardiac surgical patient.
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Affiliation(s)
- Steven P Keller
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Glenn J R Whitman
- Department of Surgery, Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael C Grant
- Department of Surgery, Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Anesthesiology and Critical Care Medicine, Divisions of Cardiac Anesthesia and Surgical Critical, The Johns Hopkins University School of Medicine, Baltimore, MD.
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3
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Lakatos BK, Ladányi Z, Fábián A, Ehrenberger R, Turschl T, Bagyura Z, Evrard B, Vandroux D, Goudelin M, Lindner S, Britsch S, Dürschmied D, Zima E, Csikós GR, Túróczi Z, Soltész Á, Németh E, Kovács A, Édes FI, Merkely B. Non-invasive assessment of left ventricular contractility by myocardial work index in veno-arterial membrane oxygenation patients: rationale and design of the MIX-ECMO multicentre observational study. Front Cardiovasc Med 2024; 11:1399874. [PMID: 38863897 PMCID: PMC11165188 DOI: 10.3389/fcvm.2024.1399874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 05/01/2024] [Indexed: 06/13/2024] Open
Abstract
Introduction and aims Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an increasingly utilized therapeutic choice in patients with cardiogenic shock, however, high complication rate often counteracts with its beneficial cardiopulmonary effects. The assessment of left ventricular (LV) function in key in the management of this population, however, the most commonly used measures of LV performance are substantially load-dependent. Non-invasive myocardial work is a novel LV functional measure which may overcome this limitation and estimate LV function independent of the significantly altered loading conditions of VA-ECMO therapy. The Usefulness of Myocardial Work IndeX in ExtraCorporeal Membrane Oxygenation Patients (MIX-ECMO) study aims to examine the prognostic role of non-invasive myocardial work in VA-ECMO-supported patients. Methods The MIX-ECMO is a multicentric, prospective, observational study. We aim to enroll 110 patients 48-72 h after the initiation of VA-ECMO support. The patients will undergo a detailed echocardiographic examination and a central echocardiography core laboratory will quantify conventional LV functional measures and non-invasive myocardial work parameters. The primary endpoint will be failure to wean at 30 days as a composite of cardiovascular mortality, need for long-term mechanical circulatory support or heart transplantation at 30 days, and besides that other secondary objectives will also be investigated. Detailed clinical data will also be collected to compare LV functional measures to parameters with established prognostic role and also to the Survival After Veno-arterial-ECMO (SAVE) score. Conclusions The MIX-ECMO study will be the first to determine if non-invasive myocardial work has added prognostic value in patients receiving VA-ECMO support.
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Affiliation(s)
| | | | - Alexandra Fábián
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Réka Ehrenberger
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Tímea Turschl
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zsolt Bagyura
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Bruno Evrard
- Medical-Surgical ICU, Dupuytren Teaching Hospital, Limoges, France
- Inserm CIC 1435, Dupuytren Teaching Hospital, Limoges, France
| | - David Vandroux
- Cardiothoracic Intensive Care Unit, Dupuytren University Hospital, Limoges, France
- Inserm U1094, IRD U270, Univ. Limoges, CHU Limoges, EpiMaCT - Epidemiology of Chronic Diseases in Tropical Zone, Institute of Epidemiology and Tropical Neurology, OmegaHealth, Limoges, France
| | - Marine Goudelin
- Medical-Surgical ICU, Dupuytren Teaching Hospital, Limoges, France
| | - Simon Lindner
- Cardiology, Angiology, Haemostaseology, and Medical Intensive Care, Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/ Mannheim, and Centre for Cardiovascular Acute Medicine Mannheim (ZKAM), Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Simone Britsch
- Cardiology, Angiology, Haemostaseology, and Medical Intensive Care, Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/ Mannheim, and Centre for Cardiovascular Acute Medicine Mannheim (ZKAM), Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Daniel Dürschmied
- Cardiology, Angiology, Haemostaseology, and Medical Intensive Care, Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/ Mannheim, and Centre for Cardiovascular Acute Medicine Mannheim (ZKAM), Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Endre Zima
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | - Zsolt Túróczi
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Ádám Soltész
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Endre Németh
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Attila Kovács
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Department of Experimental and Surgical Techniques, Semmelweis University, Budapest, Hungary
| | | | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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Sá MP, Jacquemyn X, Hess N, Brown JA, Caldonazo T, Kirov H, Doenst T, Serna-Gallegos D, Kaczorowski D, Sultan I. Extracorporeal life support after surgical repair for acute type a aortic dissection: A systematic review and meta-analysis. Perfusion 2024:2676591241253464. [PMID: 38730556 DOI: 10.1177/02676591241253464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2024]
Abstract
BACKGROUND The use of extracorporeal life support (ECLS) in patients after surgical repair for acute type A aortic dissection (ATAAD) has not been well documented. METHODS We performed a systematic review and meta-analysis to assess the outcomes of ECLS after surgery for ATAAD with data published by October 2023 in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and the Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guidelines. The protocol was registered in PROSPERO (CRD42023479955). RESULTS Twelve observational studies met our eligibility criteria, including 280 patients. Mean age was 55.0 years and women represented 25.3% of the overall population. Although the mean preoperative left ventricle ejection fraction was 59.8%, 60.8% of patients developed left ventricle failure and 34.0% developed biventricular failure. Coronary involvement and malperfusion were found in 37.1% and 25.6%, respectively. Concomitant coronary bypass surgery was performed in 38.5% of patients. Regarding ECLS, retrograde flow (femoral) was present in 39.9% and central cannulation was present in 35.4%. In-hospital mortality was 62.8% and pooled estimate of successful weaning was 50.8%. Neurological complications, bleeding and renal failure were found in 25.9%, 38.7%, and 65.5%, respectively. CONCLUSION ECLS after surgical repair for ATAAD remains associated with high rates of in-hospital death and complications, but it still represents a chance of survival in critical situations. ECLS remains a salvage attempt and surgeons should not try to avoid ECLS at all costs after repairing an ATAAD case.
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Affiliation(s)
- Michel Pompeu Sá
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Xander Jacquemyn
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Nicholas Hess
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - James A Brown
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Tulio Caldonazo
- Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
| | - Hristo Kirov
- Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
| | - Derek Serna-Gallegos
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David Kaczorowski
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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5
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Lobdell KW, Grant MC, Salenger R. Temporary mechanical circulatory support & enhancing recovery after cardiac surgery. Curr Opin Anaesthesiol 2024; 37:16-23. [PMID: 38085881 DOI: 10.1097/aco.0000000000001332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
PURPOSE OF REVIEW This review highlights the integration of enhanced recovery principles with temporary mechanical circulatory support associated with adult cardiac surgery. RECENT FINDINGS Enhanced recovery elements and efforts have been associated with improvements in quality and value. Temporary mechanical circulatory support technologies have been successfully employed, improved, and the value of their proactive use to maintain hemodynamic goals and preserve long-term myocardial function is accruing. SUMMARY Temporary mechanical circulatory support devices promise to enhance recovery by mitigating the risk of complications, such as postcardiotomy cardiogenic shock, organ dysfunction, and death, associated with adult cardiac surgery.
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Affiliation(s)
- Kevin W Lobdell
- Sanger Heart & Vascular Institute, Advocate Health, Charlotte, North Carolina
| | - Michael C Grant
- Johns Hopkins University School of Medicine, Anesthesiology and Critical Care Medicine, Baltimore
| | - Rawn Salenger
- University of Maryland School of Medicine, Department of Surgery, Towson, Maryland, USA
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6
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Patel KM, Desai RG, Krishnan S. Outcomes for Patients on Peripheral Venoarterial Extracorporeal Membrane Oxygenation After 10-Year Analysis of the Extracorporeal Life Support Organization Registry-What Lessons Can Be Learned? J Cardiothorac Vasc Anesth 2024; 38:12-15. [PMID: 37838508 DOI: 10.1053/j.jvca.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 09/11/2023] [Indexed: 10/16/2023]
Affiliation(s)
- Kinjal M Patel
- Adult Cardiothoracic Anesthesiology, Cooper University Healthcare, Cooper Medical School of Rowan University, Camden, NJ.
| | - Ronak G Desai
- Adult Cardiothoracic Anesthesiology, Cooper University Healthcare, Cooper Medical School of Rowan University, Camden, NJ
| | - Sandeep Krishnan
- Adult Cardiothoracic Anesthesiology, Wayne State University School of Medicine, Pontiac, MI
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7
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Biancari F, Mäkikallio T, Loforte A, Kaserer A, Ruggieri VG, Cho SM, Kang JK, Dalén M, Welp H, Jónsson K, Ragnarsson S, Hernández Pérez FJ, Gatti G, Alkhamees K, Fiore A, Lechiancole A, Rosato S, Spadaccio C, Pettinari M, Perrotti A, Sahli SD, L'Acqua C, Arafat AA, Albabtain MA, AlBarak MM, Laimoud M, Djordjevic I, Krasivskyi I, Samalavicius R, Jankuviene A, Alonso-Fernandez-Gatta M, Wilhelm MJ, Juvonen T, Mariscalco G. Inter-institutional analysis of the outcome after postcardiotomy veno-arterial extracorporeal membrane oxygenation. Int J Artif Organs 2024; 47:25-34. [PMID: 38053227 DOI: 10.1177/03913988231214934] [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: 12/07/2023]
Abstract
INTRODUCTION Patients requiring postcardiotomy veno-arterial extracorporeal membrane oxygenation (V-A-ECMO) have a high risk of early mortality. In this analysis, we evaluated whether any interinstitutional difference exists in the results of postcardiotomy V-A-ECMO. METHODS Studies on postcardiotomy V-A-ECMO were identified through a systematic review for individual patient data (IPD) meta-analysis. Analysis of interinstitutional results was performed using direct standardization, estimation of observed/expected in-hospital mortality ratio and propensity score matching. RESULTS Systematic review of the literature yielded 31 studies. Data from 10 studies on 1269 patients treated at 25 hospitals were available for the present analysis. In-hospital mortality was 66.7%. The relative risk of in-hospital mortality was significantly higher in six hospitals. Observed versus expected in-hospital mortality ratio showed that four hospitals were outliers with significantly increased mortality rates, and one hospital had significantly lower in-hospital mortality rate. Participating hospitals were classified as underperforming and overperforming hospitals if their observed/expected in-hospital mortality was higher or lower than 1.0, respectively. Among 395 propensity score matched pairs, the overperforming hospitals had significantly lower in-hospital mortality (60.3% vs 71.4%, p = 0.001) than underperforming hospitals. Low annual volume of postcardiotomy V-A-ECMO tended to be predictive of poor outcome only when adjusted for patients' risk profile. CONCLUSIONS In-hospital mortality after postcardiotomy V-A-ECMO differed significantly between participating hospitals. These findings suggest that in many centers there is room for improvement of the results of postcardiotomy V-A-ECMO.
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Affiliation(s)
- Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
- Department of Medicine, South-Karelia Central Hospital, University of Helsinki, Helsinki, Finland
| | - Timo Mäkikallio
- Department of Medicine, South-Karelia Central Hospital, University of Helsinki, Helsinki, Finland
| | - Antonio Loforte
- Department of Cardiothoracic, Transplantation and Vascular Surgery, S. Orsola Hospital, University of Bologna, Bologna, and Department of Surgical Science, University of Turin, Turin, Italy
| | - Alexander Kaserer
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Vito G Ruggieri
- Division of Cardiothoracic and Vascular Surgery, Robert Debré University Hospital, Reims, France
| | - Sung-Min Cho
- Division of Neurosciences, Critical Care and Cardiac Surgery, Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jin Kook Kang
- Division of Neurosciences, Critical Care and Cardiac Surgery, Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Henryk Welp
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Kristján Jónsson
- Department of Cardiac Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | | | - Giuseppe Gatti
- Division of Cardiac Surgery, Cardio-Thoracic and Vascular Department, University Hospital of Trieste, Trieste, Italy
| | | | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Creteil, France
| | | | - Stefano Rosato
- Center for Global Health, Italian National Institute, Rome, Italy
| | | | - Matteo Pettinari
- Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Andrea Perrotti
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Sebastian D Sahli
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Camilla L'Acqua
- Anesthesia and Intensive Care Unit, Centro Cardiologico Monzino, Milan, Italy
- Anesthesia and Intensive Care Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Amr A Arafat
- Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
- Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt
| | - Monirah A Albabtain
- Cardiology Clinical Pharmacy, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Mohammed M AlBarak
- Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Mohamed Laimoud
- Cardiac Surgical Intensive Care Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- Critical Care Medicine Department, Cairo University, Cairo, Egypt
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Ihor Krasivskyi
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Robertas Samalavicius
- II Department of Anesthesia, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
- Clinic of Emergency Medicine, Medical Faculty, Vilnius University, Vilnius, Lithuania
| | - Agne Jankuviene
- II Department of Anesthesia, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Marta Alonso-Fernandez-Gatta
- Cardiology Department, University Hospital of Salamanca, Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain
- CIBER-CV Instituto de Salud Carlos III, Madrid, Spain
| | - Markus J Wilhelm
- Clinic for Cardiac Surgery, University Heart Center, University and University Hospital Zurich, Zurich, Switzerland
| | - Tatu Juvonen
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
- Research Unit of Surgery, Anesthesia and Intensive Care, University of Oulu, Oulu, Finland
| | - Giovanni Mariscalco
- Department of Intensive Care Medicine and Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester, Leicester, UK
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Maigrot JLA, Weiss AJ, Tong MZY, Bakaeen F, Soltesz EG. Programmatic approach to patients with advanced ischemic cardiomyopathy: Integrating microaxial support into strategies for the modern era. Artif Organs 2024; 48:6-15. [PMID: 38013239 DOI: 10.1111/aor.14678] [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: 10/04/2023] [Revised: 10/13/2023] [Accepted: 10/29/2023] [Indexed: 11/29/2023]
Abstract
Patients with advanced ischemic cardiomyopathy manifesting as left ventricular dysfunction exist along a spectrum of severity and risk, and thus decision-making surrounding optimal management is challenging. Treatment pathways can include medical therapy as well as revascularization through percutaneous coronary intervention or coronary artery bypass grafting. Additionally, temporary and durable mechanical circulatory support, as well as heart transplantation, may be optimal for select patients. Given this spectrum of risk and the complexity of treatment pathways, patients may not receive appropriate therapy given their perceived risk, which can lead to sub-satisfactory outcomes. In this review, we discuss the identification of high-risk ischemic cardiomyopathy patients, along with our programmatic approach to patient evaluation and perioperative optimization. We also discuss our strategies for therapeutic decision-making designed to optimize both short- and long-term patient outcomes.
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Affiliation(s)
- Jean-Luc A Maigrot
- Department of Thoracic and Cardiovascular Surgery, 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
| | - 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
| | - Faisal Bakaeen
- 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
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Scott EJ, Rotar E, Dahl JJ, Beller JP, Money DT, Chancellor WZ, Mehaffey JH, Morisette M, Yarboro LT, Teman NR. Discordance among assays for monitoring? Anticoagulation during extracorporeal life support. Perfusion 2023; 38:1714-1721. [PMID: 36167522 DOI: 10.1177/02676591221129741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The optimal method for monitoring of anticoagulation in patients on extracorporeal life support (ECLS) is unknown. The objective of this study was to assess the relationship between anti-factor Xa level (anti-Xa; IU/mL) and activated partial thromboplastin time (aPTT; seconds) for monitoring intravenous unfractionated heparin anticoagulation in adult ECLS patients. METHODS Charts of all adult patients cannulated for ECLS from 2015 through 2017 were reviewed and laboratory and heparin infusion data were extracted for analysis. Time matched pairs of anti-Xa and aPTT were considered concordant if both laboratory values were within the same clinically utilized range. A hierarchical logistic regression model was used to determine factors associated with discordance while accounting for patient level effects. RESULTS A total of 1016 paired anti-Xa and aPTT values from 65 patients were evaluated. 500 (49.2%) paired samples were discordant with a degree of variability on linear regression (r2 = 0.315). The aPTT fell into a higher therapeutic range compared to the anti-Xa in 31.6% and lower in 17.3%. Logistic regression demonstrated that discordance was independently associated with time from initiation of ECLS (OR 1.17 per day, p < 0.001), average heparin infusion rate (OR 1.25 per U/kg/hr, p < 0.001), and INR (OR 3.22, p < 0.001). CONCLUSIONS Nearly half of all aPTT and anti-Xa values were in discordant ranges and discordance is more likely as the time on ECLS and the INR level increase. The use of either assay in isolation to guide heparin anticoagulation may lead to misestimation of the degree of anticoagulation in complex ECLS patients.
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Affiliation(s)
- Erik J Scott
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | - Evan Rotar
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | - Jolian J Dahl
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | - Jared P Beller
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | | | - W Z Chancellor
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | - J H Mehaffey
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | | | - Leora T Yarboro
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | - Nicholas R Teman
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
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10
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Pieri M, Bonizzoni MA, Belletti A, Calabrò MG, Fominskiy E, Nardelli P, Ortalda A, Scandroglio AM. Extracorporeal Blood Purification with CytoSorb in 359 Critically Ill Patients. Blood Purif 2023; 52:759-767. [PMID: 37669640 DOI: 10.1159/000530872] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 04/17/2023] [Indexed: 09/07/2023]
Abstract
INTRODUCTION Critically ill patients with inflammatory dysregulation and organ disfunction may benefit from blood purification, although the use of this technique has not been described in large case series. We evaluated clinical outcomes and survival in high-risk intensive care unit (ICU) patients who underwent extracorporeal blood purification. METHODS 359 consecutive ICU patients treated with CytoSorb were included. RESULTS Main admission diagnoses were 120 (34%) refractory cardiac arrest under mechanical chest compression; 101 (28%) profound cardiogenic shock; 81 (23%) post-cardiotomy cardiogenic shock; and 37 (10%) respiratory failure. Fifteen patients (4%) were positive for SARS-CoV-2 infection. We observed 49% 30-day mortality, 57% ICU mortality, and 62% hospital mortality, all lower than the 71% mortality predicted by SAPS II and 68% predicted by SOFA score. Parameters of shock and organ failure, above all vasoactive inotropic score, reduced during CytoSorb treatment. Multivariable analysis identified SAPS II, lactate dehydrogenase, ICU stay duration, vasoactive inotropic score, lactates, intra-aortic counterpulsation on top of VA-ECMO, and total bilirubin as predictors of mortality. No CytoSorb-related complications occurred. CONCLUSION CytoSorb treatment was effective in reducing laboratory parameters of shock and vasoactive inotropic score with possible survival implications in a large population of critically ill patients.
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Affiliation(s)
- Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Matteo A Bonizzoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria G Calabrò
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Pasquale Nardelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Ortalda
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anna M Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
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11
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Mariani S, Heuts S, van Bussel BCT, Di Mauro M, Wiedemann D, Saeed D, Pozzi M, Loforte A, Boeken U, Samalavicius R, Bounader K, Hou X, Bunge JJH, Buscher H, Salazar L, Meyns B, Herr D, Matteucci MLS, Sponga S, MacLaren G, Russo C, Formica F, Sakiyalak P, Fiore A, Camboni D, Raffa GM, Diaz R, Wang I, Jung J, Belohlavek J, Pellegrino V, Bianchi G, Pettinari M, Barbone A, Garcia JP, Shekar K, Whitman GJR, Lorusso R. Patient and Management Variables Associated With Survival After Postcardiotomy Extracorporeal Membrane Oxygenation in Adults: The PELS-1 Multicenter Cohort Study. J Am Heart Assoc 2023; 12:e029609. [PMID: 37421269 PMCID: PMC10382118 DOI: 10.1161/jaha.123.029609] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 05/25/2023] [Indexed: 07/10/2023]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) has been increasingly used for postcardiotomy cardiogenic shock, but without a concomitant reduction in observed in-hospital mortality. Long-term outcomes are unknown. This study describes patients' characteristics, in-hospital outcome, and 10-year survival after postcardiotomy ECMO. Variables associated with in-hospital and postdischarge mortality are investigated and reported. Methods and Results The retrospective international multicenter observational PELS-1 (Postcardiotomy Extracorporeal Life Support) study includes data on adults requiring ECMO for postcardiotomy cardiogenic shock between 2000 and 2020 from 34 centers. Variables associated with mortality were estimated preoperatively, intraoperatively, during ECMO, and after the occurrence of any complications, and then analyzed at different time points during a patient's clinical course, through mixed Cox proportional hazards models containing fixed and random effects. Follow-up was established by institutional chart review or contacting patients. This analysis included 2058 patients (59% were men; median [interquartile range] age, 65.0 [55.0-72.0] years). In-hospital mortality was 60.5%. Independent variables associated with in-hospital mortality were age (hazard ratio [HR], 1.02 [95% CI, 1.01-1.02]) and preoperative cardiac arrest (HR, 1.41 [95% CI, 1.15-1.73]). In the subgroup of hospital survivors, the overall 1-, 2-, 5-, and 10-year survival rates were 89.5% (95% CI, 87.0%-92.0%), 85.4% (95% CI, 82.5%-88.3%), 76.4% (95% CI, 72.5%-80.5%), and 65.9% (95% CI, 60.3%-72.0%), respectively. Variables associated with postdischarge mortality included older age, atrial fibrillation, emergency surgery, type of surgery, postoperative acute kidney injury, and postoperative septic shock. Conclusions In adults, in-hospital mortality after postcardiotomy ECMO remains high; however, two-thirds of those who are discharged from hospital survive up to 10 years. Patient selection, intraoperative decisions, and ECMO management remain key variables associated with survival in this cohort. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03857217.
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Affiliation(s)
- Silvia Mariani
- Cardio‐Thoracic Surgery Department and Cardiovascular Research Institute MaastrichtMaastrichtthe Netherlands
| | - Samuel Heuts
- Cardio‐Thoracic Surgery Department and Cardiovascular Research Institute MaastrichtMaastrichtthe Netherlands
| | - Bas C. T. van Bussel
- Department of Intensive Care Medicine and Cardiovascular Research Institute MaastrichtMaastrichtthe Netherlands
| | - Michele Di Mauro
- Cardio‐Thoracic Surgery Department and Cardiovascular Research Institute MaastrichtMaastrichtthe Netherlands
| | - Dominik Wiedemann
- Department of Cardiac SurgeryMedical University of ViennaViennaAustria
| | - Diyar Saeed
- Department of Cardiac SurgeryLeipzig Heart CenterLeipzigGermany
| | - Matteo Pozzi
- Department of Cardiac Surgery, Louis Pradel Cardiologic HospitalLyonFrance
| | - Antonio Loforte
- Division of Cardiac SurgeryIstituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliero–Universitaria di BolognaBolognaItaly
- Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Udo Boeken
- Department of Cardiac Surgery, Medical FacultyHeinrich Heine UniversityDuesseldorfGermany
| | - Robertas Samalavicius
- II Department of Anesthesiology, Centre of Anesthesia, Intensive Care and Pain ManagementVilnius University Hospital Santariskiu KlinikosVilniusLithuania
| | - Karl Bounader
- Division of Cardiothoracic and Vascular SurgeryPontchaillou University HospitalRennesFrance
| | - Xiaotong Hou
- Center for Cardiac Intensive CareBeijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical UniversityBeijingChina
| | - Jeroen J. H. Bunge
- Department of Intensive Care AdultsErasmus Medical CenterRotterdamthe Netherlands
| | - Hergen Buscher
- Department of Intensive Care Medicine, Center of Applied Medical ResearchSt Vincent’s HospitalDarlinghursNew South WalesAustralia
- University of New South WalesSydneyAustralia
| | - Leonardo Salazar
- Department of Cardiology, Fundación Cardiovascular de ColombiaBucaramangaColombia
| | - Bart Meyns
- Department of Cardiac SurgeryUniversity Hospitals Leuven and Department of Cardiovascular Sciences, University of LeuvenLeuvenBelgium
| | - Daniel Herr
- Departments of Medicine and SurgeryUniversity of MarylandBaltimoreMD
| | - Marco L. Sacha Matteucci
- Struttura Organizzativa Dipartimentale di CardiochirurgiaOspedali Riuniti ‘Umberto I–Lancisi‐Salesi’ Università Politecnica delle MarcheAnconaItaly
| | - Sandro Sponga
- Division of Cardiac Surgery, Cardiothoracic DepartmentUniversity Hospital of UdineUdineItaly
| | - Graeme MacLaren
- Cardiothoracic Intensive Care UnitNational University Heart Centre, National University HospitalSingaporeSingapore
| | - Claudio Russo
- Cardiac Surgery Unit, Cardiac Thoracic and Vascular Department, Niguarda HospitalMilanItaly
| | - Francesco Formica
- Department of Medicine and Surgery, Cardiac Surgery Clinic, San Gerardo HospitalUniversity of Milano‐BicoccaMonzaItaly
- Department of Medicine and SurgeryUniversity of Parma, Cardiac Surgery Unit, University Hospital of ParmaParmaItaly
| | - Pranya Sakiyalak
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
| | - Antonio Fiore
- Department of Cardio‐Thoracic SurgeryUniversity Hospital Henri‐Mondor, CréteilParisFrance
| | - Daniele Camboni
- Department of Cardiothoracic SurgeryUniversity Medical Center RegensburgRegensburgGermany
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic TransplantationIstituti di Ricovero e Cura a Carattere Scientifico ‐ Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione)PalermoItaly
| | - Rodrigo Diaz
- Extracorporeal Membrane Oxygenation Unit, Departamento de AnestesiaClínica Las Condes, Las CondesSantiagoChile
| | - I‐wen Wang
- Division of Cardiac Surgery, Memorial Healthcare SystemHollywoodFL
| | - Jae‐Seung Jung
- Department of Thoracic and Cardiovascular SurgeryKorea University Anam HospitalSeoulSouth Korea
| | - Jan Belohlavek
- 2nd Department of Internal Medicine, Cardiovascular Medicine General Teaching Hospital and 1st Faculty of MedicineCharles University in PraguePragueCzech Republic
| | - Vin Pellegrino
- Intensive Care Unit, The Alfred HospitalMelbourneVictoriaAustralia
| | - Giacomo Bianchi
- Ospedale del Cuore Fondazione Toscana "G. Monasterio"MassaItaly
| | - Matteo Pettinari
- Department of Cardiovascular Surgery, Ziekenhuis Oost‐LimburgGenkBelgium
| | - Alessandro Barbone
- Cardiac Surgery UnitIstituto di Ricovero e Cura a Carattere Scientifico Humanitas Research HospitalRozzanoMilanItaly
| | - José P. Garcia
- Indiana University Health Advanced Heart and Lung Care, Indiana University Methodist HospitalIndianapolisIN
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles HospitalBrisbaneAustralia
| | | | - Roberto Lorusso
- Cardio‐Thoracic Surgery Department and Cardiovascular Research Institute MaastrichtMaastrichtthe Netherlands
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12
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Lin ZW, Liu YY, Chen XH, Zheng YR, Cao H, Chen Q. Clinical effect of early enteral nutrition support on critically ill neonates with extracorporeal membrane oxygenation. BMC Pediatr 2023; 23:359. [PMID: 37442946 PMCID: PMC10339525 DOI: 10.1186/s12887-023-04171-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/02/2023] [Indexed: 07/15/2023] Open
Abstract
OBJECTIVE To investigate the feasibility and clinical outcomes of early enteral nutrition (EN) in critically ill neonates supported by extracorporeal membrane oxygenation (ECMO). METHODS We retrospectively analyzed the clinical data of 16 critically ill neonates who received ECMO support for respiratory and circulatory failure from July 2021 to December 2022 at our center. The patients were divided into two groups: the early EN group (< 24 h) and the late EN group (> 24 h). The related clinical and nutrition-related indicators between the groups were compared. RESULTS There was a significant difference in the time from ECMO treatment to the start of EN between the early EN group (9 patients, 56.2%) and the late EN group (7 patients, 43.8%) (P < 0.05). However, there were no significant differences in ECMO duration, hospitalization time, vasoactive-inotropic score (VIS), intestinal oxygen saturation, or routine stool occult blood (OB) test between the two groups (all P > 0.05). The incidence of complications such as intestinal obstruction, abdominal distension, diarrhea, and necrotizing enterocolitis (NEC) was slightly lower in the early EN group, but the differences were not statistically significant (all P > 0.05). The early EN group had a shorter time [3.6 (3.5, 5) vs. 7.5 (5.9, 8.5) d] to reach full gastrointestinal nutrition compared to the late EN group (P < 0.05). CONCLUSION Providing early nutritional support through enteral feeding to critically ill neonates receiving ECMO treatment is both safe and practical, but close monitoring of clinical and nutritional indicators is essential.
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Affiliation(s)
- Ze-Wei Lin
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Ying-Ying Liu
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Xiu-Hua Chen
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Yi-Rong Zheng
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Hua Cao
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Qiang Chen
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.
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13
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Scupakova N, Urbonas K, Jankuviene A, Puodziukaite L, Andrijauskas P, Janusauskas V, Zorinas A, Laurusonis K, Serpytis P, Samalavicius R. Extracorporeal Life Support for Cardiogenic Shock in Octogenarians: Single Center Experience. J Clin Med 2023; 12:jcm12020585. [PMID: 36675514 PMCID: PMC9860732 DOI: 10.3390/jcm12020585] [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: 11/25/2022] [Revised: 01/05/2023] [Accepted: 01/09/2023] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The age limit for the use of extracorporeal membrane oxygenation (ECMO) support for post-cardiotomy cardiac failure is not defined. The aim of the study was to evaluate the outcomes of octogenarians supported with ECMO due to cardiogenic shock. METHODS A retrospective review of consecutive elderly patients supported with ECMO during a 13-year period in a tertiary care center. Patient's demographic variables, comorbidities, perioperative data and outcomes were collected from patient medical records. Data of octogenarian patients were compared with the septuagenarian group. The main outcomes of the study was in hospital mortality, 6-month survival and 1-year survival after hospital discharge and discharge options. Multivariate logistic regression analysis was performed to identify the factors associated with hospital survival. RESULTS Eleven patients (18.3%) in the elderly group were octogenarians (aged 80 years or above), and forty-nine (81.7%) were septuagenarians (aged 70-79 years). There were no differences except age in demographic and preoperative variables between groups. Pre ECMO SAVE, SOFA, SAPS-II and inotropic scores were significantly higher in septuagenarians than octogenarians. There was no statistically significant difference in hospital mortality, 6-month survival, 1 year survival or discharge options between groups. CONCLUSIONS ECMO could be successfully used in selected octogenarian patients undergoing cardiac surgery to support a failing heart. An early decision to initiate ECMO therapy in elderly post-cardiotomy shock patients is associated with favorable outcomes.
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Affiliation(s)
- Nadezda Scupakova
- II Department of Anaesthesiology and Intensive Care, Vilnius University Hospital Santaros Klinikos, LT-08661 Vilnius, Lithuania
- Clinic of Emergency Medicine, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-08661 Vilnius, Lithuania
- Correspondence:
| | - Karolis Urbonas
- II Department of Anaesthesiology and Intensive Care, Vilnius University Hospital Santaros Klinikos, LT-08661 Vilnius, Lithuania
- Clinic of Emergency Medicine, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-08661 Vilnius, Lithuania
| | - Agne Jankuviene
- II Department of Anaesthesiology and Intensive Care, Vilnius University Hospital Santaros Klinikos, LT-08661 Vilnius, Lithuania
| | - Lina Puodziukaite
- II Department of Anaesthesiology and Intensive Care, Vilnius University Hospital Santaros Klinikos, LT-08661 Vilnius, Lithuania
| | - Povilas Andrijauskas
- II Department of Anaesthesiology and Intensive Care, Vilnius University Hospital Santaros Klinikos, LT-08661 Vilnius, Lithuania
| | - Vilius Janusauskas
- Clinic of Cardiovascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-08661 Vilnius, Lithuania
| | - Aleksejus Zorinas
- Clinic of Cardiovascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-08661 Vilnius, Lithuania
| | | | - Pranas Serpytis
- Clinic of Emergency Medicine, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-08661 Vilnius, Lithuania
- Clinic of Cardiovascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-08661 Vilnius, Lithuania
| | - Robertas Samalavicius
- II Department of Anaesthesiology and Intensive Care, Vilnius University Hospital Santaros Klinikos, LT-08661 Vilnius, Lithuania
- Clinic of Emergency Medicine, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-08661 Vilnius, Lithuania
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14
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Biancari F, Kaserer A, Perrotti A, Ruggieri VG, Cho SM, Kang JK, Dalén M, Welp H, Jónsson K, Ragnarsson S, Hernández Pérez FJ, Gatti G, Alkhamees K, Loforte A, Lechiancole A, Rosato S, Spadaccio C, Pettinari M, Fiore A, Mäkikallio T, Sahli SD, L’Acqua C, Arafat AA, Albabtain MA, AlBarak MM, Laimoud M, Djordjevic I, Krasivskyi I, Samalavicius R, Puodziukaite L, Alonso-Fernandez-Gatta M, Wilhelm MJ, Mariscalco G. Central versus Peripheral Postcardiotomy Veno-Arterial Extracorporeal Membrane Oxygenation: Systematic Review and Individual Patient Data Meta-Analysis. J Clin Med 2022; 11:jcm11247406. [PMID: 36556021 PMCID: PMC9785985 DOI: 10.3390/jcm11247406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/01/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND It is unclear whether peripheral arterial cannulation is superior to central arterial cannulation for postcardiotomy veno-arterial extracorporeal membrane oxygenation (VA-ECMO). METHODS A systematic review was conducted using PubMed, Scopus, and Google Scholar to identify studies on postcardiotomy VA-ECMO for the present individual patient data (IPD) meta-analysis. Analysis was performed according to the intention-to-treat principle. RESULTS The investigators of 10 studies agreed to participate in the present IPD meta-analysis. Overall, 1269 patients were included in the analysis. Crude rates of in-hospital mortality after central versus peripheral arterial cannulation for VA-ECMO were 70.7% vs. 63.7%, respectively (adjusted OR 1.38, 95% CI 1.08-1.75). Propensity score matching yielded 538 pairs of patients with balanced baseline characteristics and operative variables. Among these matched cohorts, central arterial cannulation VA-ECMO was associated with significantly higher in-hospital mortality compared to peripheral arterial cannulation VA-ECMO (64.5% vs. 70.8%, p = 0.027). These findings were confirmed by aggregate data meta-analysis, which showed that central arterial cannulation was associated with an increased risk of in-hospital mortality compared to peripheral arterial cannulation (OR 1.35, 95% CI 1.04-1.76, I2 21%). CONCLUSIONS Among patients requiring postcardiotomy VA-ECMO, central arterial cannulation was associated with an increased risk of in-hospital mortality compared to peripheral arterial cannulation. This increased risk is of limited magnitude, and further studies are needed to confirm the present findings and to identify the mechanisms underlying the potential beneficial effects of peripheral VA-ECMO.
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Affiliation(s)
- Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, Haartmaninkatu 4, P.O. Box 340, 00029 Helsinki, Finland
- Department of Medicine, South-Karelia Central Hospital, University of Helsinki, 53130 Lappeenranta, Finland
- Correspondence:
| | - Alexander Kaserer
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland
| | - Andrea Perrotti
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, 25030 Besançon, France
| | - Vito G. Ruggieri
- Division of Cardiothoracic and Vascular Surgery, Robert Debré University Hospital, 51100 Reims, France
| | - Sung-Min Cho
- Divisions of Neurosciences, Critical Care and Cardiac Surgery, Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21201, USA
| | - Jin Kook Kang
- Divisions of Neurosciences, Critical Care and Cardiac Surgery, Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21201, USA
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, Department of Cardiac Surgery, Karolinska Institutet, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Henryk Welp
- Department of Cardiothoracic Surgery, Münster University Hospital, 48149 Münster, Germany
| | - Kristján Jónsson
- Department of Cardiac Surgery, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden
| | - Sigurdur Ragnarsson
- Department of Cardiothoracic Surgery, University of Lund, 10392 Lund, Sweden
| | | | - Giuseppe Gatti
- Division of Cardiac Surgery, Cardio-Thoracic and Vascular Department, University Hospital of Trieste, 34128 Trieste, Italy
| | | | - Antonio Loforte
- Department of Cardiothoracic, Transplantation and Vascular Surgery, S. Orsola Hospital, University of Bologna, 40138 Bologna, Italy
| | - Andrea Lechiancole
- Cardiothoracic Department, University Hospital of Udine, 33100 Udine, Italy
| | - Stefano Rosato
- Center for Global Health, Italian National Institute, 00161 Rome, Italy
| | | | - Matteo Pettinari
- Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, 3600 Genk, Belgium
| | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, 94000 Creteil, France
| | - Timo Mäkikallio
- Department of Medicine, South-Karelia Central Hospital, University of Helsinki, 53130 Lappeenranta, Finland
| | - Sebastian D. Sahli
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland
| | - Camilla L’Acqua
- Anesthesia and Intensive Care Unit, Centro Cardiologico Monzino, 20138 Milan, Italy
- Anesthesia and Intensive Care Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Amr A. Arafat
- Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh 12611, Saudi Arabia
- Cardiothoracic Surgery Department, Tanta University, Tanta 31527, Egypt
| | - Monirah A. Albabtain
- Cardiology Clinical Pharmacy, Prince Sultan Cardiac Center, Riyadh 12611, Saudi Arabia
| | - Mohammed M. AlBarak
- Intensive Care Department, Prince Sultan Cardiac Center, Riyadh 12611, Saudi Arabia
| | - Mohamed Laimoud
- Cardiac Surgical Intensive Care Department, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia
- Critical Care Medicine Department, Cairo University, Cairo 12613, Egypt
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Ihor Krasivskyi
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Robertas Samalavicius
- 2nd Department of Anesthesia, Vilnius University Hospital Santaros Klinikos, 08410 Vilnius, Lithuania
- Clinic of Emergency Medicine, Medical Faculty, Vilnius University, 03101 Vilnius, Lithuania
| | - Lina Puodziukaite
- 2nd Department of Anesthesia, Vilnius University Hospital Santaros Klinikos, 08410 Vilnius, Lithuania
| | - Marta Alonso-Fernandez-Gatta
- Cardiology Department, University Hospital of Salamanca, Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- CIBER-CV Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Markus J. Wilhelm
- Clinic for Cardiac Surgery, University Heart Center, University and University Hospital Zurich, 8091 Zurich, Switzerland
| | - Giovanni Mariscalco
- Department of Intensive Care Medicine and Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester, Leicester LE2 9QP, UK
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Kiuchi N, Seino Y, Yamamoto M, Katagiri S, Takagi S, Nomura T, Suzuki T. Postoperative prosthetic mitral valve occlusion due to left atrial thrombus during veno-arterial extracorporeal membrane oxygenation: a case report. JA Clin Rep 2022; 8:93. [PMID: 36471130 PMCID: PMC9723070 DOI: 10.1186/s40981-022-00586-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/27/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Anticoagulation using heparin is generally used to prevent thrombus formation during mechanical circulatory support, such as veno-arterial extracorporeal membrane oxygenation (VA-ECMO). However, during the early period following cardiac surgery, anticoagulation becomes more difficult due to the greater risk of critical bleeding complications. CASE PRESENTATION A 71-year-old man presented with acute prosthetic valve occlusion caused by left atrial thrombus formation and bioprosthetic valve thrombosis during peripheral VA-ECMO following mitral valve replacement (MVR) despite continuous heparin administration and loading of antiplatelet agents. The VA-ECMO flow rate decreased 10 h after the intensive care unit (ICU) admission after MVR. Exploratory transesophageal echocardiography (TEE) examination revealed a left atrial thrombus, prosthetic valve obstruction by the thrombus, and an intrapericardial hematoma. CONCLUSIONS Intracardiac thrombus formation might occur during VA-ECMO despite appropriate anticoagulation and loading of antiplatelet agents. Exploratory TEE examination was helpful in the detection of intra-atrial thrombus formation after cardiac surgery and surgical decision-making.
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Affiliation(s)
- Naoto Kiuchi
- grid.260969.20000 0001 2149 8846Department of Anesthesiology, Nihon University School of Medicine, 30-1 Kamicho Oyaguchi, Itabashi-ku, Tokyo, Japan
| | - Yusuke Seino
- grid.410818.40000 0001 0720 6587Department of Intensive Care Medicine, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan ,grid.412764.20000 0004 0372 3116Department of Anesthesiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Japan
| | - Mai Yamamoto
- grid.260969.20000 0001 2149 8846Department of Anesthesiology, Nihon University School of Medicine, 30-1 Kamicho Oyaguchi, Itabashi-ku, Tokyo, Japan
| | - Seidai Katagiri
- grid.260969.20000 0001 2149 8846Department of Anesthesiology, Nihon University School of Medicine, 30-1 Kamicho Oyaguchi, Itabashi-ku, Tokyo, Japan
| | - Shunichi Takagi
- grid.260969.20000 0001 2149 8846Department of Anesthesiology, Nihon University School of Medicine, 30-1 Kamicho Oyaguchi, Itabashi-ku, Tokyo, Japan
| | - Takeshi Nomura
- grid.410818.40000 0001 0720 6587Department of Intensive Care Medicine, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan
| | - Takahiro Suzuki
- grid.260969.20000 0001 2149 8846Department of Anesthesiology, Nihon University School of Medicine, 30-1 Kamicho Oyaguchi, Itabashi-ku, Tokyo, Japan
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16
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Pérez Vela JL, Llanos Jorge C, Duerto Álvarez J, Jiménez Rivera JJ. Clinical management of postcardiotomy shock in adults. Med Intensiva 2022; 46:312-325. [PMID: 35570187 DOI: 10.1016/j.medine.2022.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/14/2021] [Accepted: 08/21/2021] [Indexed: 06/15/2023]
Abstract
Postcardiotomy cardiogenic shock represents the most serious expression of low cardiac output syndrome after cardiac surgery. Although infrequent, it is a relevant condition due to its specific and complex pathophysiology and important morbidity-mortality. The diagnosis requires a high index of suspicion and multimodal hemodynamic monitoring, where echocardiography and the pulmonary arterial catheter play a main role. Early and multidisciplinary management should focus on the management of postoperative or mechanical complications and the optimization of determinants of cardiac output through fluid therapy or diuretic treatments, inotropic drugs and vasopressors/vasodilators and, in the absence of a response, early mechanical circulatory support. The aim of this paper is to review and update the pathophysiology, diagnosis and management of postcardiotomy cardiogenic shock.
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Affiliation(s)
- J L Pérez Vela
- Servicio de Medicina Intensiva, Hospital Universitario Doce de Octubre, Madrid, Spain.
| | - C Llanos Jorge
- Servicio de Medicina Intensiva, Hospital Quirónsalud Tenerife, Santa Cruz de Tenerife, Spain
| | - J Duerto Álvarez
- Servicio de Medicina Intensiva, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - J J Jiménez Rivera
- Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Canarias, San Cristóbal de La Laguna, Santa Cruz de Tenerife, Spain
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17
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Fuchs A, Schmucki R, Meuli L, Wendel-Garcia PD, Albrecht R, Greif R, Pietsch U. Helicopter inter-hospital transfer for patients undergoing extracorporeal membrane oxygenation: a retrospective 12-year analysis of a service system. Scand J Trauma Resusc Emerg Med 2022; 30:33. [PMID: 35526029 PMCID: PMC9077885 DOI: 10.1186/s13049-022-01018-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/13/2022] [Indexed: 12/02/2022] Open
Abstract
Background Patients undergoing extracorporeal membrane oxygenation (ECMO) are critically ill and show high mortality. Inter-hospital transfer of these patients has to be safe, with high survival rates during transport without potentially serious and life-threatening adverse events. The Swiss Air-Rescue provides 24-h/7-days per week inter-hospital helicopter transfers that include on-site ECMO cannulation if needed. This retrospective observational study describes adverse events of patients on ECMO transported by helicopter, and their associated survival. Methods All patients on ECMO with inter-hospital transfer by helicopter from start of service in February 2009 until May 2021 were included. Patients not transported by helicopter or with missing medical records were excluded. Patient demographics (age, sex) and medical history (type of and reason for ECMO), mission details (flight distance, times, primary or secondary transport), adverse events during the inter-hospital transfer, and survival of transferred patients were recorded. The primary endpoint was patient survival during transfer. Secondary endpoints were adverse events during transfer and 28-day survival. Results We screened 214 ECMO-related missions and included 191 in this analysis. Median age was 54.6 [IQR 46.1–62.0] years, 70.7% were male, and most patients had veno-arterial ECMO (56.5%). The main reasons for ECMO were pulmonary (46.1%) or cardiac (44.0%) failure. Most were daytime (69.8%) and primary missions (n = 100), median total mission time was 182.0 [143.0–254.0] min, and median transfer distance was 52.7 [33.2–71.1] km. All patients survived the transfer. Forty-four adverse events were recorded during 37 missions (19.4%), where 31 (70.5%) were medical and none resulted in patient harm. Adverse events occurred more frequently during night-time missions (59.9%, p = 0.047). Data for 28-day survival were available for 157 patients, of which 86 (54.8%) were alive. Conclusion All patients under ECMO survived the helicopter transport. Adverse events were observed for about 20% of the flight missions, with a tendency during the night-time flights, none harmed the patients. Inter-hospital transfer for patients undergoing ECMO provided by 24-h/7-d per week helicopter emergency medical service teams can be considered as feasible and safe. The majority of the patients (54.8%) were still alive after 28 days. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-022-01018-0.
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Affiliation(s)
- Alexander Fuchs
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland.
| | - Renate Schmucki
- Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Lorenz Meuli
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | | | - Roland Albrecht
- Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.,Swiss Air-Rescue (Rega), Zurich, Switzerland
| | - Robert Greif
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland.,School of Medicine, Sigmund Freud University Vienna, Vienna, Austria.,European Resuscitation Council (ERC) Research NET, Niel, Belgium
| | - Urs Pietsch
- Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.,Swiss Air-Rescue (Rega), Zurich, Switzerland.,Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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18
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Orrego R, Gaete B. Soporte extracorpóreo en shock cardiogénico con ECMO veno-arterial. REVISTA MÉDICA CLÍNICA LAS CONDES 2022. [DOI: 10.1016/j.rmclc.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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19
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DeFilippis EM, Topkara VK, Kirtane AJ, Takeda K, Naka Y, Garan AR. Mechanical Circulatory Support for Right Ventricular Failure. Card Fail Rev 2022; 8:e14. [PMID: 35516793 PMCID: PMC9062706 DOI: 10.15420/cfr.2021.11] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 11/19/2021] [Indexed: 11/29/2022] Open
Abstract
Right ventricular (RV) failure is associated with significant morbidity and mortality, with in-hospital mortality rates estimated as high as 70–75%. RV failure may occur following cardiac surgery in conjunction with left ventricular failure, or may be isolated in certain circumstances, such as inferior MI with RV infarction, pulmonary embolism or following left ventricular assist device placement. Medical management includes volume optimisation and inotropic and vasopressor support, and a subset of patients may benefit from mechanical circulatory support for persistent RV failure. Increasingly, percutaneous and surgical mechanical support devices are being used for RV failure. Devices for isolated RV support include percutaneous options, such as micro-axial flow pumps and extracorporeal centrifugal flow RV assist devices, surgically implanted RV assist devices and veno-arterial extracorporeal membrane oxygenation. In this review, the authors discuss the indications, candidate selection, strategies and outcomes of mechanical circulatory support for RV failure.
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Affiliation(s)
- Ersilia M DeFilippis
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, US
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, US
| | - Ajay J Kirtane
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, US
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY, US
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY, US
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20
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Longitudinal Trends in Bleeding Complications on Extracorporeal Life Support Over the Past Two Decades—Extracorporeal Life Support Organization Registry Analysis. Crit Care Med 2022; 50:e569-e580. [PMID: 35167502 PMCID: PMC9210715 DOI: 10.1097/ccm.0000000000005466] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Data about inhospital outcomes in bleeding complications during extracorporeal life support (ECLS) have been poorly investigated. DESIGN Retrospective observational study. SETTING Patients reported in Extracorporeal Life Support Organization Registry. PATIENTS Data of 53.644 adult patients (greater than or equal to 18 yr old) mean age 51.4 ± 15.9 years, 33.859 (64.5%) male supported with single ECLS run between 01.01.2000 and 31.03.2020, and 19.748 cannulated for venovenous (V-V) ECLS and 30.696 for venoarterial (V-A) ECLS. INTERVENTIONS Trends in bleeding complications, bleeding risk factors, and mortality. MEASUREMENT AND MAIN RESULTS Bleeding complications were reported in 14.786 patients (27.6%), more often in V-A ECLS compared with V-V (30.0% vs 21.9%; p < 0.001). Hospital survival in those who developed bleeding complications was lower in both V-V ECLS (49.6% vs 66.6%; p < 0.001) and V-A ECLS (33.9 vs 44.9%; p < 0.001). Steady decrease in bleeding complications in V-V and V-A ECLS was observed over the past 20 years (coef., -1.124; p < 0.001 and -1.661; p < 0.001). No change in mortality rates was reported over time in V-V or V-A ECLS (coef., -0.147; p = 0.442 and coef., -0.195; p = 0.139).Multivariate regression revealed advanced age, ecls duration, surgical cannulation, renal replacement therapy, prone positioning as independent bleeding predictors in v-v ecls and female gender, ecls duration, pre-ecls arrest or bridge to transplant, therapeutic hypothermia, and surgical cannulation in v-a ecls. CONCLUSIONS A steady decrease in bleeding over the last 20 years, mostly attributable to surgical and cannula-site-related bleeding has been found in this large cohort of patients receiving ECLS support. However, there is not enough data to attribute the decreasing trends in bleeding to technological refinements alone. Especially reduction in cannulation site bleeding is also due to changes in timing, patient selection, and ultrasound guided percutaneous cannulation. Other types of bleeding, such as CNS, have remained stable, and overall bleeding remains associated with a persistent increase in mortality.
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21
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Abstract
OVERVIEW The use of extracorporeal membrane oxygenation (ECMO) is becoming commonplace worldwide in ICUs for the care of patients with respiratory and/or cardiac failure. Understanding the use of ECMO and the management of these complex patients will be vital to current and future clinicians as ECMO use continues to grow.
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22
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 61:1178-1185. [DOI: 10.1093/ejcts/ezac035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 12/07/2021] [Accepted: 01/15/2022] [Indexed: 11/14/2022] Open
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23
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Chen KH, Lee PS, Tsai FC, Weng LC, Yeh SL, Huang HC, Lin SS. Health-related outcomes of extracorporeal membrane oxygenation in adults: A cross-sectional study. Heart Lung 2021; 52:76-85. [PMID: 34911020 DOI: 10.1016/j.hrtlng.2021.11.008] [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] [Received: 08/15/2021] [Revised: 11/12/2021] [Accepted: 11/22/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Patients with critical illness may face challenges after hospital discharge; therapeutic outcomes of extracorporeal membrane oxygenation (ECMO) are typically measured by survival rate. However, ECMO is an integral part of treatment in critical care medicine, which requires an outcome measure beyond survival. Post-discharge health-related quality of life (HRQoL) is such an indicator. OBJECTIVES To measure HRQoL in adult patients who had previously undergone ECMO and explore influential factors related to HRQoL. METHODS This cross-sectional descriptive study used a convenience sample of patients discharged between April 2006-April 2016 after at least one month following ECMO. The study was conducted from October 2015 to October 2016, which included data collected from structured questionnaires: the Hospital Anxiety and Depression Scale, Impact of Event Scale-Revised and Short-Form Survey-36-v2. Stepwise linear regression determined predictor variables of physical and mental HRQoL. RESULTS Age of participants (N = 144) ranged from 24 to 81 years; long-term survival rate was 28.6% after a median follow-up of 1060 days (range = 44-3150 days). Mean scores for physical and mental components of HRQoL were 46.32 and 50.39, respectively. Level of HRQoL was low to moderate. Employment affected all physical components of HRQoL; depression was the main predictor for physical and mental components. Self-perceived health status and anxiety were also factors that influenced HRQoL. CONCLUSIONS Variables of employment, self-perceived health status and mental health influenced HRQoL. Early assessment of these factors by healthcare professionals can allow integration of multidimensional interventions following hospital discharge, which could improve HRQoL for patients weaned from ECMO.
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Affiliation(s)
- Kang-Hua Chen
- Associate Professor, School of Nursing, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan; Associate Research Fellow, Department of Nursing, Chang Gung Memorial Hospital, Tao-Yuan Branch, Taiwan.
| | - Pei-Shan Lee
- Surgical Intensive Care Unit, Fu Jen Catholic University Hospital, Taipei, Taiwan
| | - Feng-Chun Tsai
- Associate Professor, Department of Cardiovascular Surgery, Chang Gung Memorial Hospital and Chang Gung University, Linkou Branch, Taiwan
| | - Li-Chueh Weng
- Professor, School of Nursing, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan; Research Fellow, Department of General Surgery, Chang Gung Memorial Hospital, Linkou Branch, Taiwan
| | - Shu-Ling Yeh
- Director, Department of Nursing, Chang Gung Memorial Hospital, Tao-Yuan Branch, Taiwan; Adjunct Lecturer, Department of Nursing, Chang Gung University of Science and Technology, Tao-Yuan, Taiwan
| | - Huei-Chiun Huang
- Case Manager, Department of Cardiovascular Surgery, Chang Gung Memorial Hospital, Linkou Branch, Taiwan
| | - Shu-Siang Lin
- Clinical Nursing Teacher, Department of Nursing, Chang Gung University of Science and Technology Taiwan
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24
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McCloskey CG, Engoren MC. Transfusion and its association with mortality in patients receiving veno-arterial extracorporeal membrane oxygenation. J Crit Care 2021; 68:42-47. [PMID: 34896794 DOI: 10.1016/j.jcrc.2021.11.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 05/28/2021] [Accepted: 11/23/2021] [Indexed: 12/22/2022]
Abstract
PURPOSE Patients receiving veno-arterial Extracorporeal Membrane Oxygenation (V-A ECMO) may require transfusion due to bleeding risk and desire to optimize oxygen delivery. The purposes of this study were to determine the transfusion requirements in patients receiving V-A ECMO and to determine if transfusion was associated with hospital mortality or complications. MATERIAL AND METHODS Retrospective chart review of adult patients at University of Michigan between 1/1/2000-6/1/2017. Survivors and decedents were compared. Logistic regression was used to determine factors independently associated with mortality, hemorrhage, and ischemic events. RESULTS One hundred eighty-seven patients received V-A ECMO. Median number of red cells transfused was 9 units (interquartile range 3.5-20), platelets 4 (1-11) packs, plasma 2 (0-6) units, cryoprecipitate 0 (0,0) units. Only 69 (37%) patients survived to hospital discharge. Hemorrhage occurred in 108 (58%) patients and 27 (14%) suffered ischemic complications. Renal replacement therapy (OR 2.94, 95% confidence interval: 1.51-5.68, p < 0.001) and ECMO duration (OR 1.01, 95% confidence interval: 1.00-1.01, p = 0.005) but not transfusion, were associated with increased odds of death. CONCLUSION Most patients receiving V-A ECMO are transfused multiple units of blood products. Receipt of transfusion or having a bleeding or ischemic complication was not associated with increased mortality.
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Affiliation(s)
- Colin G McCloskey
- University of Michigan Department of Anesthesia, Division of Critical Care, 4172 Cardiovascular Center, 1500 East Medical Center Drive, SPC 5861, Ann Arbor, MI 48109, USA.
| | - Milo C Engoren
- University of Michigan Department of Anesthesia, Division of Critical Care, USA..
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25
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Cavayas YA, Noly PE, Singh G, Lamarche Y. Controversies in extracorporeal membrane oxygenation: Immediate versus watchful waiting for venoarterial extracorporeal membrane oxygenation venting. JTCVS OPEN 2021; 8:70-76. [PMID: 36004177 PMCID: PMC9390622 DOI: 10.1016/j.xjon.2021.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/15/2021] [Indexed: 11/30/2022]
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26
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Goldstein DJ, Soltesz E. High-risk cardiac surgery: Time to explore a new paradigm. JTCVS OPEN 2021; 8:10-15. [PMID: 36004162 PMCID: PMC9390359 DOI: 10.1016/j.xjon.2021.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/04/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Daniel J. Goldstein
- Department of Cardiothoracic Surgery, Montefiore Medical Center, Bronx, NY
- Address for reprints: Daniel J. Goldstein, MD, Department of Cardiothoracic Surgery, 3400 Bainbridge Ave, MAP 5 Bronx, NY 10467.
| | - Edward Soltesz
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Hospital, Cleveland, Ohio
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27
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Pérez Vela J, Llanos Jorge C, Duerto Álvarez J, Jiménez Rivera J. Manejo clínico del shock poscardiotomía en pacientes adultos. Med Intensiva 2021. [DOI: 10.1016/j.medin.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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28
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Ong CS, Etchill E, Dong J, Shou BL, Shelley L, Giuliano K, Al-Kawaz M, Ritzl EK, Geocadin RG, Kim BS, Bush EL, Choi CW, Whitman GJR, Cho SM. Neuromonitoring detects brain injury in patients receiving extracorporeal membrane oxygenation support. J Thorac Cardiovasc Surg 2021; 165:2104-2110.e1. [PMID: 34865837 DOI: 10.1016/j.jtcvs.2021.09.063] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 09/08/2021] [Accepted: 09/21/2021] [Indexed: 01/23/2023]
Abstract
OBJECTIVE There is limited evidence on standardized protocols for optimal neurological monitoring methods in patients receiving extracorporeal membrane oxygenation (ECMO). We previously introduced protocolized noninvasive multimodal neuromonitoring using serial neurological examinations, electroencephalography, transcranial Doppler ultrasound, and somatosensory evoked potentials. The purpose of this study was to examine if standardized neuromonitoring is associated with detection of acute brain injury (ABI) and improved patient outcomes. METHODS A retrospective analysis of ECMO patients who received neurocritical care consultation was performed and outcomes were reviewed. The cohort was stratified according to those who did not receive standardized neuromonitoring (era 1: 2016-2017) and those who received standardized neuromonitoring (era 2: 2017-2020). Multivariable logistic regression was used to evaluate the association between standardized neuromonitoring and ABI. RESULTS A total of 215 patients (mean age, 54 years; 60% male) underwent ECMO (71% venoarterial-ECMO) in our institution, 70 in era 1 and 145 in era 2. The proportion of patients diagnosed with ABI were 23% in era 1 and 33% in era 2 (P = .12). In multivariable logistic regression, standardized neuromonitoring (odds ratio, 2.24; 95% CI, 1.12-4.48; P = .02) and pre-ECMO cardiac arrest (odds ratio, 2.17; 95% CI, 1.14-4.14; P = .02) were independently associated with ABI. There was a greater proportion of patients with good neurological outcomes when discharged alive in era 2 (54% vs 30%; P = .04). CONCLUSIONS Standardized neuromonitoring was associated with increased ABIs in ECMO patients. Although neuromonitoring does not prevent ABI from occurring, it might prevent worsening with timely interventions (eg, anticoagulation management, optimizing oxygen delivery and blood pressure), leading to improved neurological outcomes at discharge.
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Affiliation(s)
- Chin Siang Ong
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Eric Etchill
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Jie Dong
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Benjamin L Shou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Leah Shelley
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Md
| | - Katherine Giuliano
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Mais Al-Kawaz
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Md
| | - Eva K Ritzl
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Md
| | - Romergryko G Geocadin
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Md
| | - Bo Soo Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins Hospital, Baltimore, Md
| | - Errol L Bush
- Division of General Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Chun Woo Choi
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Glenn J R Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Md.
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29
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Bossi E, Marini C, Gaetti G, Diamanti L, Alessio D, Bertoldi LF, Pappalardo F, Odone A. Efficacy and safety of Impella 5.0 in cardiogenic shock: an updated systematic review. Future Cardiol 2021; 18:253-264. [PMID: 34713720 DOI: 10.2217/fca-2021-0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: The impact on safety and efficacy outcomes of Impella 5.0 in cardiogenic shock (CS) has not been systematically assessed. Materials & methods: We conducted a systematic review of the literature (PROSPERO protocol: CRD42020164680) to critically appraise available evidence on Impella 5.0 comparative safety, efficacy and effectiveness. Results: Of 244 retrieved citations, 17 original articles met the a priori defined inclusion criteria. All included studies had a retrospective study design and, overall, reported on, respectively, 52 and 67 different safety and efficacy/effectiveness outcomes. Thirty-day survival rates ranged from 40 to 94%, myocardial recovery from 18 to 93%. Conclusion: Impella 5.0 provides a full cardiac support, it is associated with a lower rate of vascular complications, it represents a valuable bridge-to-decision and allows for resolution of intercurrent clinical conditions. As available data suggest Impella 5.0 good performance in CS of various etiologies, more solid evidence will come from much-needed large-scale all-comer registries and prospective multicenter randomized trials.
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Affiliation(s)
- Eleonora Bossi
- HTA Committee, Health Directorate, IRCCS San Raffaele Hospital, Milan, 20132, Italy.,School of Public Health, Vita-Salute San Raffaele University, Milan, 20132, Italy
| | - Claudia Marini
- Advanced Heart Failure & Mechanical Circulatory Support Program, IRCCS San Raffaele Hospital, Milan, 20132, Italy.,Department of Cardiovascular, ASST Santi Paolo e Carlo, Milan, 20142, Italy
| | - Giovanni Gaetti
- HTA Committee, Health Directorate, IRCCS San Raffaele Hospital, Milan, 20132, Italy.,School of Public Health, Vita-Salute San Raffaele University, Milan, 20132, Italy
| | - Luca Diamanti
- HTA Committee, Health Directorate, IRCCS San Raffaele Hospital, Milan, 20132, Italy
| | - Davide Alessio
- HTA Committee, Health Directorate, IRCCS San Raffaele Hospital, Milan, 20132, Italy
| | - Letizia Fausta Bertoldi
- Advanced Heart Failure & Mechanical Circulatory Support Program, IRCCS San Raffaele Hospital, Milan, 20132, Italy.,Department of Cardiovascular, Humanitas Clinical & Research Center IRCCS, Rozzano, 20089, Italy
| | - Federico Pappalardo
- Advanced Heart Failure & Mechanical Circulatory Support Program, IRCCS San Raffaele Hospital, Milan, 20132, Italy.,Department of Cardiothoracic & Vascular Anesthesia & Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, 15121, Alessandria
| | - Anna Odone
- HTA Committee, Health Directorate, IRCCS San Raffaele Hospital, Milan, 20132, Italy.,Department of Public Health, Experimental & Forensic Medicine, University of Pavia, Pavia, 27100, Italy
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30
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Zaaqoq AM, Pottash M, Ahlstrom E, Brodie D. Postcardiotomy Extracorporeal Membrane Oxygenation: Narrative Review Navigating the Ethical Issues. J Cardiothorac Vasc Anesth 2021; 36:2628-2635. [PMID: 34763977 DOI: 10.1053/j.jvca.2021.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/18/2021] [Accepted: 10/08/2021] [Indexed: 11/11/2022]
Abstract
Postcardiotomy shock (PCS) is an uncommon and life-threatening surgical complication. Extracorporeal membrane oxygenation (ECMO) is the first line of mechanical circulatory support for treating PCS when medical therapies are insufficient. Reaching a "therapeutic ceiling" or a "bridge to nowhere" is a common clinical scenario in which medical avenues for recovery have been exhausted. These situations pose emotional and ethical challenges for patients, their surrogates, and clinicians. To shed light on these ethically challenging situations in PCS and potential approaches, the authors conducted a narrative review of the literature. Publications were utilized to describe current trends in the diagnosis and management of the patient with PCS, with particular emphasis on the therapeutic ceiling for life support. Most of the recommendations came from practice parameters or expert opinions to support specific interventions. The authors proposed a stepwise multidisciplinary approach to reduce PCS-associated ethical and emotional challenges. Their proposed algorithm was based on the likelihood of the need for ECMO support based on the mortality risk stratification of cardiac surgery. They suggested focused discussions around the commencement of ECMO or other life-sustaining therapies-ideally preoperatively at the time of consent-through shared decision-making and, subsequently, proactive multidisciplinary education and updates to the surrogate decision-makers relying on realistic prognosis and consideration of the patient wishes during the ECMO run.
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Affiliation(s)
- Akram M Zaaqoq
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Georgetown University, Washington, DC; Department of Medicine, MedStar Washington Hospital Center, Georgetown University, Washington, DC.
| | - Michael Pottash
- Department of Medicine, MedStar Washington Hospital Center, Georgetown University, Washington, DC; Division of Palliative Medicine, MedStar Washington Hospital Center, Georgetown University, Washington, DC
| | - Eric Ahlstrom
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Georgetown University, Washington, DC; Department of Medicine, MedStar Washington Hospital Center, Georgetown University, Washington, DC
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York
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31
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Luo JC, Zheng WH, Meng C, Zhou H, Xu Y, Tu GW, Luo Z, Huang HB. Levosimendan to Facilitate Weaning From Cardiorespiratory Support in Critically Ill Patients: A Meta-Analysis. Front Med (Lausanne) 2021; 8:741108. [PMID: 34712681 PMCID: PMC8546177 DOI: 10.3389/fmed.2021.741108] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 09/16/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Cardiopulmonary support, as extracorporeal membrane oxygenation (ECMO) or mechanical ventilation (MV), is crucial for ICU patients. However, some of these patients are difficult to wean. Therefore, we aimed to assess the efficacy and safety of levosimendan in facilitating weaning from cardiorespiratory support in this patient population. Methods: We searched for potentially relevant articles in PubMed, Embase, China National Knowledge Infrastructure, Wanfang, and the Cochrane database from inception up to Feb 30, 2021. Studies focusing on weaning data in MV/ECMO adult patients who received levosimendan compared to controls were included. We used the Cochrane risk of bias tool or the Newcastle-Ottawa Quality Assessment Scale to evaluate the study quality. The primary outcome was the weaning rate from MV/ECMO. Secondary outcomes were mortality, duration of MV, and ICU stay. Subgroup analysis, sensitivity analysis, and publication bias were also conducted. Results: Eighteen studies with 2,274 patients were included. The quality of the included studies was low to moderate. Overall, levosimendan effectively improved weaning rates from MV/ECMO [odds ratio (OR) = 2.32; 95%CI, 1.60-3.36; P < 0.00001, I 2 = 68%]. Subgroup analyses confirmed the higher successful weaning rates in ventilated patients with low left ventricular ejection fractions (OR = 4.06; 95%CI, 2.16-7.62), patients with ECMO after cardiac surgery (OR = 2.04; 95%CI, 1.25-3.34), and patients with ECMO and cardiogenic shock (OR = 1.98; 95%CI, 1.34-2.91). However, levosimendan showed no beneficial effect on patients with MV weaning difficulty (OR = 2.28; 95%CI, 0.72-7.25). Additionally, no differences were found concerning the secondary outcomes between the groups. Conclusions: Levosimendan therapy significantly increased successful weaning rates in patients with cardiopulmonary support, especially patients with combined cardiac insufficiency. Large-scale, well-designed RCTs will be needed to define the subgroup of patients most likely to benefit from this strategy.
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Affiliation(s)
- Jing-Chao Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wen-He Zheng
- Department of Critical Care Medicine, The Second People's Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Chang Meng
- Department of Critical Care Medicine, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Hua Zhou
- Department of Critical Care Medicine, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Yuan Xu
- Department of Critical Care Medicine, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
| | - Hui-Bin Huang
- Department of Critical Care Medicine, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
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32
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Brewer JM, Tran A, Yu J, Ali MI, Poulos CM, Gates J, Gluck J, Underhill D. ECMO after cardiac surgery: a single center study on survival and optimizing outcomes. J Cardiothorac Surg 2021; 16:264. [PMID: 34538270 PMCID: PMC8451085 DOI: 10.1186/s13019-021-01638-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 08/29/2021] [Indexed: 11/10/2022] Open
Abstract
Background The study purpose is to examine survival prognostic and extracorporeal membrane oxygenation (ECMO) application outcomes at our tertiary care center.
Methods This is a retrospective analysis, January 2014 to September 2019. We analyzed 60 patients who underwent cardiac surgery and required peri-operative ECMO. All inpatients with demographic and intervention data was examined. 52 patients (86.6%) had refractory cardiogenic shock, 7 patients (11.6%) had pulmonary insufficiency, and 1 patient (1.6%) had hemorrhagic shock, all patients required either venous-arterial (VA) (n = 53, 88.3%), venous-venous (VV) (n = 5, 8.3%) or venous-arterial-venous (VAV) (n = 2, 3.3%) ECMO for hemodynamic support. ECMO parameters were analyzed and common postoperative complications were examined in the setting of survival with comorbidities. Results In-hospital mortality was 60.7% (n = 37). Patients who survived were younger (52 ± 3.3 vs 66 ± 1.5, p < 0.001) with longer hospital stays (35 ± 4.0 vs 20 ± 1.5, p < 0.03). Survivors required fewer blood products (13 ± 2.3 vs 25 ± 2.3, p = 0.02) with a net negative fluid balance (− 3.5 ± 1.6 vs 3.4 ± 1.6, p = 0.01). Cardiac re-operations worsened survival. Conclusion ECMO is a viable rescue strategy for cardiac surgery patients with a 40% survival to discharge rate. Careful attention to volume management and blood transfusion are important markers for potential survival.
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Affiliation(s)
- Jennifer M Brewer
- Department of General Surgery, University of Connecticut, 263 Farmington Ave, Farmington, CT, 06030, USA.
| | - Anthony Tran
- Department of General Surgery, University of Connecticut, 263 Farmington Ave, Farmington, CT, 06030, USA
| | - Jielin Yu
- Department of General Surgery, University of Connecticut, 263 Farmington Ave, Farmington, CT, 06030, USA
| | - M Irfan Ali
- Department of General Surgery, University of Connecticut, 263 Farmington Ave, Farmington, CT, 06030, USA
| | - Constantine M Poulos
- Department of General Surgery, University of Connecticut, 263 Farmington Ave, Farmington, CT, 06030, USA
| | - Jonathan Gates
- Division of Trauma and Acute Care Surgery, Hartford Healthcare, Hartford, USA
| | - Jason Gluck
- Department of Cardiology and Mechanical Circulatory Support, Hartford Healthcare, Hartford, USA
| | - David Underhill
- Division of Cardiac Surgery, Hartford Healthcare, Hartford, USA
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33
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Kalampokas N, Sipahi NF, Aubin H, Akhyari P, Petrov G, Albert A, Westenfeld R, Lichtenberg A, Saeed D. Postcardiotomy Veno-Arterial Extracorporeal Membrane Oxygenation: Does the Cannulation Technique Influence the Outcome? Front Cardiovasc Med 2021; 8:658412. [PMID: 34434969 PMCID: PMC8382236 DOI: 10.3389/fcvm.2021.658412] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 06/23/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may be cannulated using either central (cannulation of aorta) or peripheral (cannulation of femoral or axillary artery) access. The ideal cannulation approach for postcardiotomy cardiogenic shock (PCS) is still unknown. The aim of this study is to compare the outcome of patients with PCS who were supported with central vs. peripheral cannulation. Methods: This is a single-center retrospective data analysis including all VA-ECMO implantations for PCS from January 2011 to December 2017. The central and peripheral approaches were compared in terms of patient characteristics, intensive care unit (ICU) stay, hospitalization length, adverse event rates, and overall survival. Results: Eighty-six patients met the inclusion criteria. Twenty-eight patients (33%) were cannulated using the central approach, and 58 patients (67%) were cannulated using the peripheral approach. Forty-three patients (50%) received VA-ECMO in the operating room and 43 patients (50%) received VA-ECMO in the ICU. Central VA-ECMO group had higher EuroSCORE II (p = 0.007), longer cross-clamp time (p = 0.054), higher rate of open chest after the procedure (p < 0.001), and higher mortality rate (p = 0.02). After propensity score matching, 20 patients in each group were reanalyzed. In the matched groups, no statistically significant differences were observed in the baseline characteristics between the two groups except for a higher rate of open chests in the central ECMO group (p = 0.02). However, no significant differences were observed in the outcome and complications between the groups. Conclusions: This study showed that in postcardiotomy patients requiring VA-ECMO support, similar complication rates and outcome were observed regardless of the cannulation strategy.
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Affiliation(s)
- Nikolaos Kalampokas
- Department of Cardiovascular Surgery, University Hospital of Düsseldorf, Düsseldorf, Germany
| | - Nihat Firat Sipahi
- Department of Cardiovascular Surgery, University Hospital of Düsseldorf, Düsseldorf, Germany
| | - Hug Aubin
- Department of Cardiovascular Surgery, University Hospital of Düsseldorf, Düsseldorf, Germany
| | - Payam Akhyari
- Department of Cardiovascular Surgery, University Hospital of Düsseldorf, Düsseldorf, Germany
| | - Georgi Petrov
- Department of Cardiovascular Surgery, University Hospital of Düsseldorf, Düsseldorf, Germany
| | - Alexander Albert
- Department of Cardiovascular Surgery, University Hospital of Düsseldorf, Düsseldorf, Germany
| | - Ralf Westenfeld
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital of Düsseldorf, Düsseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiovascular Surgery, University Hospital of Düsseldorf, Düsseldorf, Germany
| | - Diyar Saeed
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
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34
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Management of Extracorporeal Membrane Oxygenation for Postcardiotomy Cardiogenic Shock. Anesthesiology 2021; 135:497-507. [PMID: 34259811 DOI: 10.1097/aln.0000000000003876] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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35
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Brahmbhatt DH, Daly AL, Luk AC, Fan E, Billia F. Liberation From Venoarterial Extracorporeal Membrane Oxygenation: A Review. Circ Heart Fail 2021; 14:e007679. [PMID: 34247519 DOI: 10.1161/circheartfailure.120.007679] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Venoarterial extracorporeal membrane oxygenation may be used for circulatory support in cardiogenic shock as a bridge to recovery, a bridge to a ventricular assist device (VAD), or a bridge to transplant. While the determination of potential exit strategies is essential before cannulation, the final determination of a patient's options may change, in part, through their in-hospital clinical course. We propose that liberation from venoarterial extracorporeal membrane oxygenation should be conceptualized as a process of discovery in the assessment of a patient's underlying clinical status and a key driver of further clinical decision-making. A trial of liberation from support should be considered when the goals of the weaning trial are well-defined and, ideally, in the absence of potentially confounding clinical factors. In this review, we will discuss readiness to wean criteria from venoarterial extracorporeal membrane oxygenation, as well as specific clinical, biochemical, and echocardiographic parameters that may prove useful in determining weaning timing and revealing the patient's underlying hemodynamic status and prognosis. The role of various cannula configurations, support devices, and pharmacological adjuncts will also be discussed. Finally, we highlight current gaps in evidence and suggest areas of future research.
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Affiliation(s)
- Darshan H Brahmbhatt
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada (D.H.B., A.L.D., A.C.L., F.B.)
- Department of Medicine (D.H.B., A.L.D., A.C.L., F.B.), University of Toronto, ON, Canada
- National Heart & Lung Institute, Imperial College London, United Kingdom (D.H.B.)
- Ted Rogers Centre for Heart Research, Toronto, ON, Canada (D.H.B., A.C.L., F.B.)
| | - Andrea L Daly
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada (D.H.B., A.L.D., A.C.L., F.B.)
- Department of Medicine (D.H.B., A.L.D., A.C.L., F.B.), University of Toronto, ON, Canada
| | - Adriana C Luk
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada (D.H.B., A.L.D., A.C.L., F.B.)
- Department of Medicine (D.H.B., A.L.D., A.C.L., F.B.), University of Toronto, ON, Canada
- Ted Rogers Centre for Heart Research, Toronto, ON, Canada (D.H.B., A.C.L., F.B.)
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine (E.F.), University of Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON Canada (E.F., F.B.)
| | - Filio Billia
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada (D.H.B., A.L.D., A.C.L., F.B.)
- Department of Medicine (D.H.B., A.L.D., A.C.L., F.B.), University of Toronto, ON, Canada
- Ted Rogers Centre for Heart Research, Toronto, ON, Canada (D.H.B., A.C.L., F.B.)
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON Canada (E.F., F.B.)
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36
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Brisard L, Bailly A, Le Thuaut A, Bizouarn P, Lepoivre T, Nicolet J, Roussel JC, Senage T, Rozec B. Impact of early nutrition route in patients receiving extracorporeal membrane oxygenation: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2021; 46:526-537. [PMID: 34166531 DOI: 10.1002/jpen.2209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Early nutrition management in patients receiving extracorporeal membrane oxygenation (ECMO) remains controversial. Despite its potentially beneficial effect, enteral nutrition (EN) could be associated with gastrointestinal (GI) complications. Total daily energy requirements remain difficult to achieve with ECMO support. Analysis of nutrition practices could improve nutrition management of this particular population. METHODS A monocentric retrospective study of patients requiring ECMO in a cardiac surgery intensive care unit (ICU) between 2010 and 2014 with follow-up ≥6 days. Nutrition support was monitored daily until ECMO weaning. We compared patients exposed (EN group, n = 49) and unexposed (No EN group (NEN), n = 63) with EN, as well as the energy and protein intakes within 4 days after initiation of ECMO. Vital status and nosocomial infections were followed up until ICU discharge. Primary outcome was the incidence of GI intolerance and risk-factor identification. Secondary outcomes included impact of nutrition inadequacy and clinical outcome. RESULTS A total 112 patients were analyzed, representing 969 nutrition days. Median ratio of energy and protein prescribed/required daily was 81% (58-113) and 56% (36-86), respectively. GI intolerance was experienced by 53% (26 of 49) of patients in the EN group and was only associated with ECMO duration (odds ratio, 1.14: 95% CI, 1.00-1.31; P = .05). Low-energy and protein days were not associated with clinical outcomes such as nosocomial infections. CONCLUSION EN is associated with almost 50% GI intolerance without clinical benefit for patients receiving ECMO. Adequacy in energy and protein amounts did not affect clinical outcome.
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Affiliation(s)
- Laurent Brisard
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Nord Laennec, CHU Nantes, Nantes, France
| | - Arthur Bailly
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Nord Laennec, CHU Nantes, Nantes, France
| | | | - Philippe Bizouarn
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Nord Laennec, CHU Nantes, Nantes, France
| | - Thierry Lepoivre
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Nord Laennec, CHU Nantes, Nantes, France
| | - Johanna Nicolet
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Nord Laennec, CHU Nantes, Nantes, France
| | - Jean-Christian Roussel
- Department of Thoracic and Cardiovascular Surgery, PHU 2 Institut du thorax et du système nerveux, CHU Nantes, Nantes, France
| | - Thomas Senage
- Department of Thoracic and Cardiovascular Surgery, PHU 2 Institut du thorax et du système nerveux, CHU Nantes, Nantes, France
| | - Bertrand Rozec
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Nord Laennec, CHU Nantes, Nantes, France
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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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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez CA, Shah AS, D'Alessandro DA. 2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-cardiotomy Extracorporeal Life Support in Adult Patients. ASAIO J 2021; 67:e1-e43. [PMID: 33021558 DOI: 10.1097/mat.0000000000001301] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care Unit, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Milan Milojevic
- Department of Anaesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, WA, USA
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Christian A Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ashish S Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David A D'Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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39
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Alba AC, Foroutan F, Buchan TA, Alvarez J, Kinsella A, Clark K, Zhu A, Lau K, McGuinty C, Aleksova N, Francis T, Stanimirovic A, Vishram-Nielsen J, Malik A, Ross HJ, Fan E, Rac VE, Rao V, Billia F. Mortality in patients with cardiogenic shock supported with VA ECMO: A systematic review and meta-analysis evaluating the impact of etiology on 29,289 patients. J Heart Lung Transplant 2021; 40:260-268. [DOI: 10.1016/j.healun.2021.01.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 01/06/2021] [Accepted: 01/14/2021] [Indexed: 01/08/2023] Open
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40
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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez C, Shah A, D'Alessandro DA. 2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients. J Thorac Cardiovasc Surg 2021; 161:1287-1331. [PMID: 33039139 DOI: 10.1016/j.jtcvs.2020.09.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 04/03/2020] [Accepted: 04/21/2020] [Indexed: 12/26/2022]
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management, and avoidance of complications, appraisal of new approaches and ethics, education, and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Md.
| | - Milan Milojevic
- Department of Anaesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy; Department of Anaesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, Wash
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Christian Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Ashish Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - David A D'Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, Mass
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41
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Abdalghafoor T, Shoman B, Salah Omar A, Shouman Y, Almulla A. Urgent coronary artery bypass graft surgery supported by veno-arterial extracorporeal membrane oxygenation: a report of two cases. Perfusion 2021; 37:633-638. [PMID: 33789543 DOI: 10.1177/02676591211008139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Mechanical circulatory support (MCS) devices, especially veno-arterial extracorporeal membrane oxygenation (VA-ECMO) devices, are increasingly used to shore complex cardiac procedures in high-risk patients. We are reporting two cases where patients underwent coronary artery bypass grafting (CABG) under support of VA-ECMO in the setting of cardiogenic shock complicating acute myocardial infarction. The patients had different courses, but both survived the initial insult and were weaned successively from VA-ECMO. Our report indicates that VA-ECMO can be used instead of the cardiopulmonary bypass machine (CPB) to support the circulation during CABG surgery in patients with complex coronary anatomy and unstable haemodynamics. Future studies focusing on the long-term outcomes of such patients will probably help to establish the optimal management of this type of patients.
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Affiliation(s)
| | - Bassam Shoman
- Department of Cardiothoracic Anaesthesia and Intensive Care, Heart Hospital, Doha, Qatar
| | - Amr Salah Omar
- Department of Cardiothoracic Anaesthesia and Intensive Care, Heart Hospital, Doha, Qatar.,Weill Cornell Medical College in Qatar, Education City, Qatar.,Critical Care Medicine, Benis Suef University, Egypt
| | - Yasser Shouman
- Department of Cardiothoracic Anaesthesia and Intensive Care, Heart Hospital, Doha, Qatar
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Cormican DS, Elapavaluru S. Acute Neurologic Injury in VA ECMO for Post-Cardiotomy Shock: Caveat Emptor. J Cardiothorac Vasc Anesth 2021; 35:1997-1998. [PMID: 33838981 DOI: 10.1053/j.jvca.2021.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/08/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Daniel S Cormican
- Division of Cardiothoracic Anesthesiology, Division of Surgical Critical Care, Anesthesiology Institute, Allegheny Health Network, Pittsburgh, PA.
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43
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Benseghir Y, Sebestyan A, Durand M, Bennani F, Bédague D, Chavanon O. [ECMO for post cardiotomy refractory cardiogenic shock: Experience of the cardiac surgery department of the Grenoble Alpes University Hospital]. Ann Cardiol Angeiol (Paris) 2021; 70:63-67. [PMID: 33640147 DOI: 10.1016/j.ancard.2020.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/19/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The objective of our study is to detail our experience relating to ECMO implantations for post-cardiotomy refractory shock, by analyzing the pre-ECMO factors (history, type of surgery, LVEF), factors relating to ECMO (implantation time, duration) and post-ECMO factors (weaning, complications) in order to highlight those possibly associated with high mortality. METHODS This is a univariate and multivariate retrospective study of ECMO data implemented between 2011 and 2019 at the Grenoble Alpes University Hospital Center following cardiac surgery. The time to implantation of ECMO was less than 3hours (intraoperative) between 3 and 24hours (early postoperative) and between 24 and 48hours after aortic unclamping (late postoperative). Preoperative or postoperative intra-aortic balloon counterpulsation (CPBIA) could be associated. RESULTS 114 veino-arterial ECMOs were implanted for refractory cardiogenic shock after 5702 cardiac surgeries (1.9%) with a survival rate of 30.7%. The mean age of the patients was 68.6+- 10.5 years. The implantation of ECMO was performed intraoperatively in 71 patients (62.2%), early postoperatively in 22 patients (19.2%) and late postoperatively in 21 patients (18.4%). The duration of assistance was less than 48hours in 27 patients (23.6%), between 48hours and one week in 58 patients (50.9%) and more than one week in 29 patients (25.5%). Univariate analysis revealed a statistically significant association between mortality rate and male sex (P=0.002), association absent with other preoperative characteristics, delay in implantation of ECMO, installation of CPBIA, post-operative characteristics and resuscitation suites. Multivariate analysis of the entire study population demonstrated that the use of ECMO for cardio-respiratory arrest was the only independent risk factor for mortality (OR=7.57 [1.41-40, 62]). After multivariate reanalysis excluding patients with ECMO placement for cardio respiratory arrest, age, preoperative renal failure, type of procedure and EuroSCORE II were risk factors for mortality. CONCLUSION In this study, male gender, type of intervention, occurrence of cardiac arrest were significantly associated with the death rate. A study of greater power, multicentric, and with a larger sample, will have to be carried out to reach significance.
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Affiliation(s)
- Y Benseghir
- Service de chirurgie cardiaque, Pôle thorax-vaisseaux - CHU Grenoble Alpes, Grenoble, France.
| | - A Sebestyan
- Service de chirurgie cardiaque, Pôle thorax-vaisseaux - CHU Grenoble Alpes, Grenoble, France
| | - M Durand
- Réanimation cardio-vasculaire et thoracique, Pôle anesthésie-réanimation - CHU Grenoble Alpes, Grenoble, France
| | - F Bennani
- Service de chirurgie cardiaque, Pôle thorax-vaisseaux - CHU Grenoble Alpes, Grenoble, France
| | - D Bédague
- Réanimation cardio-vasculaire et thoracique, Pôle anesthésie-réanimation - CHU Grenoble Alpes, Grenoble, France
| | - O Chavanon
- Service de chirurgie cardiaque, Pôle thorax-vaisseaux - CHU Grenoble Alpes, Grenoble, France
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Abstract
Supplemental Digital Content is available in the text. We report the first U.S. experience of the recently approved micro-axial surgical heart pump for the treatment of ongoing cardiogenic shock following acute myocardial infarction (AMICGS), postcardiotomy cardiogenic shock (PCCS), cardiomyopathy including myocarditis, high-risk percutaneous coronary intervention (HRPCI), and coronary artery bypass surgery (HRCABG). Demographic, procedural, hemodynamic, and outcome data were obtained from the manufacturer’s quality database of all Impella 5.5 implants at three centers. Fifty-five patients underwent an Impella 5.5 implant for cardiomyopathy (45%), AMICGS (29%), PCCS (13%), preop CABG (5%), OPCAB (4%), and other (4%). Thirty-five patients (63.6%) were successfully weaned off device with recovery of native heart function. Eleven patients (20.0%) were bridged to another therapy, two patients (3.6%) expired while on support, and in seven patients (12.7%) care was withdrawn. Overall survival was 83.6%. There were no device-related strokes, hemolysis, or limb ischemia observed. Four patients experienced purge sidearm damage, resulting in a pump stop in two patients. The new micro-axial surgical heart pump demonstrated successful clinical and device performance in providing both full hemodynamic support and ventricular unloading for patients with AMICGS, decompensated cardiomyopathy, and high-risk cardiac procedures. In this early U.S. experience, 83.6% of patients survived to explant with 76.1% of these patients recovering native heart function.
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Biancari F, Perrotti A, Ruggieri VG, Mariscalco G, Dalén M, Dell'Aquila AM, Jónsson K, Ragnarsson S, Di Perna D, Bounader K, Gatti G, Juvonen T, Alkhamees K, Yusuff H, Loforte A, Lechiancole A, Chocron S, Pol M, Spadaccio C, Pettinari M, De Keyzer D, Fiore A, Welp H. Five-year survival after post-cardiotomy veno-arterial extracorporeal membrane oxygenation. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:595-601. [PMID: 33580776 DOI: 10.1093/ehjacc/zuaa039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 11/08/2020] [Indexed: 12/12/2022]
Abstract
AIMS Veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) support for post-cardiotomy cardiogenic shock (PCS) after adult cardiac surgery is associated with satisfactory hospital survival. However, data on long-term survival of these critically ill patients are scarce. METHODS AND RESULTS Between January 2010 and March 2018, 665 consecutive patients received VA-ECMO for PCS at 17 cardiac surgery centres and herein we evaluated their 5-year survival. The mean follow-up of this cohort was 1.7 ± 2.7 years (for hospital survivors, 4.6 ± 2.5 years). In this cohort, 240 (36.1%) patients survived to hospital discharge. Five-year survival of all patients was 27.7%. The PC-ECMO score was predictive of 5-year survival in these patients (0 point, 50.9%; 1 point, 44.9%; 2 points, 40.0%; 3 points, 34.7%; 4 points, 21.0%; 5 points, 17.6%; ≥6 points, 10.7%; P < 0.0001). Age was among factors independently associated with late survival, patients >70 years old having a remarkably poor 5-year survival (<60 years: 39.2%; 60-69 years: 29.9%; 70-79 years: 12.3%; ≥80 years: 13.0%, P < 0.0001). Implantation of a ventricular assist device or heart transplant was performed in 3.2% of patients and their 5-year survival was 42.9% (for heart transplant, 63.6%). CONCLUSION Veno-arterial extracorporeal membrane oxygenation for PCS is associated with satisfactory 5-year survival in young patients without critical pre-ECMO conditions. The use of VA-ECMO for PCS in patients >70 years should be considered only after a judicious scrutiny of patient's life expectancy. Future studies should evaluate whether satisfactory mid-term survival of these patients translates into a good functional outcome. TRIAL REGISTRATION Clinicaltrials.gov-NCT03508505.
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Affiliation(s)
- Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, Haartmaninkatu 4 P.O. Box 340, 00029 Helsinki, Finland.,Research Unit of Surgery, Anesthesiology and Critical Care, Faculty of Medicine, University of Oulu, Oulu, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Andrea Perrotti
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Vito G Ruggieri
- Division of Cardiothoracic and Vascular Surgery, Robert Debré University Hospital, Reims, France
| | - Giovanni Mariscalco
- Department of Intensive Care Medicine and Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester, Leicester, UK
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Department of Cardiac Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Angelo M Dell'Aquila
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Kristján Jónsson
- Department of Cardiac Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Dario Di Perna
- Division of Cardiothoracic and Vascular Surgery, Robert Debré University Hospital, Reims, France
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Giuseppe Gatti
- Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy
| | - Tatu Juvonen
- Heart and Lung Center, Helsinki University Hospital, Haartmaninkatu 4 P.O. Box 340, 00029 Helsinki, Finland.,Research Unit of Surgery, Anesthesiology and Critical Care, Faculty of Medicine, University of Oulu, Oulu, Finland
| | | | - Hakeem Yusuff
- Department of Intensive Care Medicine and Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester, Leicester, UK
| | - Antonio Loforte
- Department of Cardiothoracic, Transplantation and Vascular Surgery, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | | | - Sidney Chocron
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Marek Pol
- Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, UK
| | - Matteo Pettinari
- Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Dieter De Keyzer
- Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Antonio Fiore
- Department of Cardiothoracic Surgery, Henri Mondor University Hospital, AP-HP, Paris-Est University, Créteil, France
| | - Henryk Welp
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
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Menon PR, Flo Forner A, Marin-Cuartas M, Lehmann S, Saeed D, Ginther A, Borger MA, Ender J. 30-Day perioperative mortality following venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock in patients with normal preoperative ejection fraction. Interact Cardiovasc Thorac Surg 2021; 32:817-824. [DOI: 10.1093/icvts/ivaa323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 10/15/2020] [Accepted: 11/03/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
Assessment of early outcomes in patients with normal preoperative left ventricular ejection fraction (LVEF) in whom venoarterial extracorporeal membrane oxygenation (VA-ECMO) was implanted for postcardiotomy cardiogenic shock (PCCS) during the first postoperative 48 h.
METHODS
Retrospective single-centre analysis in adult patients with normal LVEF, who received VA-ECMO support for PCCS from May 1998 to May 2018. The primary outcome was 30-day perioperative mortality during the index hospitalization.
RESULTS
A total of 62 125 adult patients underwent cardiac surgery at our institution during the study period. Among them, 173 patients (0.3%) with normal preoperative LVEF required VA-ECMO for PCCS. Among them, 71 (41.1%) patients presented PCCS due to coronary malperfusion and in 102 (58.9%) patients, no evident cause was found for PCCS. Median duration of VA-ECMO support was 5 days (interquartile range 2–8 days). A total of 135 (78.0%) patients presented VA-ECMO-related complications and the overall 30-day perioperative mortality was 57.8%. Independent predictors of mortality were: lactate level just before VA-ECMO implantation [odds ratio (OR) 1.27; P < 0.001], major bleeding during VA-ECMO (OR 3.76; P = 0.001), prolonged cardiopulmonary bypass time (OR 1.01; P < 0.001) and female gender (OR 4.87; P < 0.001).
CONCLUSIONS
Mortality rates of VA-ECMO in PCCS patients are high, even in those with preoperative normal LVEF. Coronary problems are an important cause of PCCS; however, the aetiology remains unknown in the vast majority of the cases. The implantation of VA-ECMO before development of tissue hypoperfusion and the control of VA-ECMO-associated complications are the most important prognostic factors in PCCS patients. Lactate levels may help guide timing of VA-ECMO implantation and define the extent of therapeutic effort.
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Affiliation(s)
- Priya R Menon
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig, Germany
| | - Anna Flo Forner
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig, Germany
| | - Mateo Marin-Cuartas
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - Sven Lehmann
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - Diyar Saeed
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - André Ginther
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - Michael A Borger
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - Jörg Ender
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig, Germany
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47
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Guariento A, Piekarski BL, Doulamis IP, Blitzer D, Ferraro AM, Harrild DM, Zurakowski D, Del Nido PJ, McCully JD, Emani SM. Autologous mitochondrial transplantation for cardiogenic shock in pediatric patients following ischemia-reperfusion injury. J Thorac Cardiovasc Surg 2020; 162:992-1001. [PMID: 33349443 DOI: 10.1016/j.jtcvs.2020.10.151] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 10/09/2020] [Accepted: 10/27/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To report outcomes in a pilot study of autologous mitochondrial transplantation (MT) in pediatric patients requiring postcardiotomy extracorporeal membrane oxygenation (ECMO) for severe refractory cardiogenic shock after ischemia-reperfusion injury (IRI). METHODS A single-center retrospective study of patients requiring ECMO for postcardiotomy cardiogenic shock following IRI between May 2002 and December 2018 was performed. Postcardiotomy IRI was defined as coronary artery compromise followed by successful revascularization. Patients undergoing revascularization and subsequent MT were compared with those undergoing revascularization alone (Control). RESULTS Twenty-four patients were included (MT, n = 10; Control, n = 14). Markers of systemic inflammatory response and organ function measured 1 day before and 7 days following revascularization did not differ between groups. Successful separation from ECMO-defined as freedom from ECMO reinstitution within 1 week after initial separation-was possible for 8 patients in the MT group (80%) and 4 in the Control group (29%) (P = .02). Median circumferential strain immediately following IRI but before therapy was not significantly different between groups. Immediately following separation from ECMO, ventricular strain was significantly better in the MT group (-23.0%; range, -20.0% to -28.8%) compared with the Control group (-16.8%; range, -13.0% to -18.4%) (P = .03). Median time to functional recovery after revascularization was significantly shorter in the MT group (2 days vs 9 days; P = .02). Cardiovascular events were lower in the MT group (20% vs 79%; P < .01). Cox regression analysis showed higher composite estimated risk of cardiovascular events in the Control group (hazard ratio, 4.6; 95% confidence interval, 1.0 to 20.9; P = .04) CONCLUSIONS: In this pilot study, MT was associated with successful separation from ECMO and enhanced ventricular strain in patients requiring postcardiotomy ECMO for severe refractory cardiogenic shock after IRI.
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Affiliation(s)
- Alvise Guariento
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Breanna L Piekarski
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Ilias P Doulamis
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - David Blitzer
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Alessandra M Ferraro
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - David M Harrild
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - David Zurakowski
- Department of Anesthesiology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Pedro J Del Nido
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - James D McCully
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Sitaram M Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass.
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48
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Toivonen F, Biancari F, Dalén M, Dell'Aquila AM, Jónsson K, Fiore A, Mariscalco G, El-Dean Z, Gatti G, Zipfel S, Perrotti A, Bounader K, Alkhamees K, Loforte A, Lechiancole A, Pol M, Spadaccio C, Pettinari M, De Keyzer D, Welp H, Lichtenberg A, Saeed D, Ruggieri VG, Ragnarsson S. Neurologic Injury in Patients Treated With Extracorporeal Membrane Oxygenation for Postcardiotomy Cardiogenic Shock. J Cardiothorac Vasc Anesth 2020; 35:2669-2680. [PMID: 33262035 DOI: 10.1053/j.jvca.2020.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/01/2020] [Accepted: 11/02/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate the frequency, predictors, and outcomes of neurologic injury in adults treated with postcardiotomy extracorporeal membrane oxygenation (PC-ECMO). DESIGN A retrospective multicenter registry study. SETTING Twenty-one European institutions where cardiac surgery is performed. PARTICIPANTS A total of 781 adult patients who required PC-ECMO during 2010 to 2018 were divided into patients with neurologic injury (NI) and patients without neurologic injury (NNI). MEASUREMENTS AND MAIN RESULTS Baseline and operative data, in-hospital outcomes, and long-term survival were compared between the NI and the NNI groups. Predictors of neurologic injury were identified. A subgroup analysis according to the type of neurologic injury was performed. Overall, NI occurred in 19% of patients in the overall series, but the proportion of patients with NI ranged from 0% to 65% among the centers. Ischemic stroke occurred in 84 patients and hemorrhagic stroke in 47 patients. Emergency procedure was the sole independent predictor of NI. In-hospital mortality was higher in the NI group than in the NNI group (79% v 61%, p < 0.001). The one-year survival was lower in the NI group (17%) compared with the NNI group (37%). Long-term survival did not differ between patients with ischemic stroke and those with hemorrhagic stroke. CONCLUSION Neurologic injury during PC-ECMO is common and associated with a dismal prognosis. There is considerable interinstitutional variation in the proportion of neurologic injury in PC-ECMO-treated adults. Well-known risk factors for stroke are not associated with neurologic injury in this setting.
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Affiliation(s)
- Fanni Toivonen
- Department of Cardiothoracic Surgery, Skane University Hospital and Lund University, Lund, Sweden
| | - Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland; Research Unit of Surgery, Anesthesiology and Critical Care, Faculty of Medicine, University of Oulu, Oulu, Finland; Department of Surgery, University of Turku, Turku, Finland
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, Department of Cardiac Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Angelo M Dell'Aquila
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Kristján Jónsson
- Department of Cardiac Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Antonio Fiore
- Department of Cardiothoracic Surgery, Henri Mondor University Hospital, AP-HP, Paris-Est University, Créteil, France
| | - Giovanni Mariscalco
- Department of Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Zein El-Dean
- Department of Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Giuseppe Gatti
- Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy
| | | | - Andrea Perrotti
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | | | - Antonio Loforte
- Department of Cardiothoracic, Transplantation and Vascular Surgery, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | | | - Marek Pol
- Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Matteo Pettinari
- Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Dieter De Keyzer
- Department of Cardiovascular Surgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Henryk Welp
- Department of Cardiovascular Surgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiovascular Surgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Diyar Saeed
- Department of Cardiovascular Surgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Vito G Ruggieri
- Division of Cardiothoracic and Vascular Surgery, Robert Debré University Hospital, Reims, France
| | - Sigurdur Ragnarsson
- Department of Cardiothoracic Surgery, Skane University Hospital and Lund University, Lund, Sweden.
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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez CA, Shah AS, D’Alessandro DA. 2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients. Eur J Cardiothorac Surg 2020; 59:12-53. [DOI: 10.1093/ejcts/ezaa283] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 04/03/2020] [Accepted: 04/21/2020] [Indexed: 12/13/2022] Open
Abstract
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Milan Milojevic
- Department of Anaesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, WA, USA
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Christian A Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ashish S Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David A D’Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez CA, Shah AS, D'Alessandro DA. 2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-Cardiotomy Extracorporeal Life Support in Adult Patients. Ann Thorac Surg 2020; 111:327-369. [PMID: 33036737 DOI: 10.1016/j.athoracsur.2020.07.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 12/16/2022]
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Center, Maastricht University Medical Center, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands.
| | - Glenn Whitman
- Cardiac Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Maryland
| | - Milan Milojevic
- Department of Anesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, Washington
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Christian A Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ashish S Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David A D'Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
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