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Martin-Villen L, Adsuar-Gomez A, Garrido-Jimenez JM, Perez-Vela JL, Fuset-Cabanes MP. Mechanical circulatory support in cardiogenic shock patients. Med Intensiva 2024:S2173-5727(24)00230-3. [PMID: 39394008 DOI: 10.1016/j.medine.2024.09.006] [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: 07/16/2024] [Accepted: 07/22/2024] [Indexed: 10/13/2024]
Abstract
Cardiogenic shock (CS) is a highly complex clinical condition that requires a management strategy focused on early resolution of the underlying cause and the provision of circulatory support. In cases of refractory CS, mechanical circulatory support (MCS) is employed to replace the failed cardiocirculatory system, thereby preventing the development of multiorgan failure. There are various types of MCS, and patients with CS typically require devices that are either short-term (< 15 days) or intermediate-term (15-30 days). When choosing the device the underlying cause of CS, as well as the presence or absence of concomitant conditions such as failed ventricle, respiratory failure, and the intended purpose of the support should be taken into consideration. Patients with MCS require the comprehensive care indicated in complex critically ill patients with multiorgan dysfunction, with an emphasis on device monitoring and control. Different complications may arise during support management, and its withdrawal must be protocolized.
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Affiliation(s)
- Luis Martin-Villen
- Department of Intensive Care Medicine, Hospital Universitario Virgen del Rocío, Seville, Spain.
| | - Alejandro Adsuar-Gomez
- Department of Cardiovascular Surgery, Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | - Jose Luis Perez-Vela
- Department of Intensive Care Medicine, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Mari Paz Fuset-Cabanes
- Department of Intensive Care Medicine, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain
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2
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Zhang H, Wang T, Wang J, Liu G, Yan S, Teng Y, Wang J, Ji B. Different strategies in left ventricle unloading during venoarterial extracorporeal membrane oxygenation: A network meta-analysis. INTERNATIONAL JOURNAL OF CARDIOLOGY. HEART & VASCULATURE 2024; 54:101506. [PMID: 39296587 PMCID: PMC11408045 DOI: 10.1016/j.ijcha.2024.101506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Revised: 08/22/2024] [Accepted: 08/31/2024] [Indexed: 09/21/2024]
Abstract
Background Left ventricular (LV) overload is a frequent complication during VA-ECMO associated with poor outcomes. Many strategies of LV unloading have been documented but lack of evidence shows which is better. We conducted a network meta-analysis to compare different LV unloading strategies. Methods We searched databases for all published studies on LV unloading strategies during VA-ECMO. The pre-defined primary outcome was all-cause mortality. Results 45 observational studies (34235 patients) were included. The Surface Under the Cumulative Ranking values (SUCRA) demonstrated that compared to no unloading strategy (15.4 %), IABP (73.8 %), pLVAD (60.8 %), atrial septostomy (51.2 %), catheter venting (48.8 %) were all associated with decreased all-cause mortality, in which IABP and pLVAD existed statistical significance. For secondary outcomes, no unloading group had the shortest VA-ECMO duration, ICU and hospital length of stay, and the lower risk of complications compared with unloading strategies. IABP was associated with reducing VA-ECMO duration, ICU and hospital length of stay, and the risk of complications (except for hemolysis as the second best) compared with other unloading strategies. Conclusions LV unloading strategies during VA-ECMO were associated with improved survival compared to no unloading, but the tendency to increase the risk of various complications deserves more consideration.
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Affiliation(s)
- Han Zhang
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Tianlong Wang
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Jing Wang
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Gang Liu
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Shujie Yan
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Yuan Teng
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Jian Wang
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
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Zhao Y, Wang H, Cheng Y, Zhang J, Zhao L. Factors Influencing Successful Weaning From Venoarterial Extracorporeal Membrane Oxygenation: A Systematic Review. J Cardiothorac Vasc Anesth 2024; 38:2446-2458. [PMID: 38969612 DOI: 10.1053/j.jvca.2024.05.018] [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: 09/04/2023] [Revised: 05/01/2024] [Accepted: 05/11/2024] [Indexed: 07/07/2024]
Abstract
With advancements in extracorporeal life support (ECLS) technologies, venoarterial extracorporeal membrane oxygenation (VA-ECMO) has emerged as a crucial cardiopulmonary support mechanism. This review explores the significance of VA-ECMO system configuration, cannulation strategies, and timing of initiation. Through an analysis of medication management strategies, complication management, and comprehensive preweaning assessments, it aims to establish a multidimensional evaluation framework to assist clinicians in making informed decisions regarding weaning from VA-ECMO, thereby ensuring the safe and effective transition of patients.
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Affiliation(s)
- Yanlong Zhao
- Department of Cardiology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Heru Wang
- Department of Cardiology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Yihao Cheng
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Jifeng Zhang
- School of Pharmaceutical Sciences, Jilin University, Changchun, Jilin, China
| | - Lei Zhao
- Department of Cardiology, The Second Hospital of Jilin University, Changchun, Jilin, China.
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4
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Kayali F, Agbobu T, Moothathamby T, Jubouri YF, Jubouri M, Abdelhaliem A, Ghattas SNS, Rezk SSS, Bailey DM, Williams IM, Awad WI, Bashir M. Haemodynamic support with percutaneous devices in patients with cardiogenic shock: the current evidence of mechanical circulatory support. Expert Rev Med Devices 2024; 21:755-764. [PMID: 39087797 DOI: 10.1080/17434440.2024.2380330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 07/11/2024] [Indexed: 08/02/2024]
Abstract
INTRODUCTION Cardiogenic shock (CS) is a complex life-threatening condition that results from primary cardiac dysfunction, leading to persistent hypotension and systemic hypoperfusion. Among the therapeutic options for CS are various percutaneous mechanical circulatory support (MCS) devices that have emerged as an increasingly effective hemodynamic support option. Percutaneous therapies can act as short-term mechanical circulatory assistance and can be split into intra-aortic balloon pump (IABP) and non-IABP percutaneous mechanical devices. AREAS COVERED This review will evaluate the MCS value while considering the mortality rate improvements. We also aim to outline the function of pharmacotherapies and percutaneous hemodynamic MCS devices in managing CS patients to avoid the onset of end-organ dysfunction and improve both early and late outcomes. EXPERT OPINION Given the complexity, acuity and high mortality associated with CS, and despite the availability and efficacy of pharmacological management, MCS is required to achieve hemodynamic stability and improve survival. Various percutaneous MCS devices are available with varying indications and clinical outcomes. The rates of early mortality and complications were found to be comparable between the four devices, yet, IABP seemed to show the most optimal clinical profile whilst ECMO demonstrated its more long-term efficacy.
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Affiliation(s)
- Fatima Kayali
- University Hospitals Sussex N.H.S. Foundation Trust, Sussex, UK
| | | | - Thurkga Moothathamby
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Amr Abdelhaliem
- Vascular and Endovascular Surgery, Royal Blackburn Hospital, Blackburn, UK
| | | | | | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Wael I Awad
- Department of Cardiothoracic Surgery, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Mohamad Bashir
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
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5
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Ughetto A, Eliet J, Nagot N, David H, Bazalgette F, Marin G, Kollen S, Mourad M, Zeroual N, Muller L, Gaudard P, Colson P. Early temporary mechanical circulatory support for cardiogenic shock: Real-life data from a regional cardiac assistance network. J Heart Lung Transplant 2024; 43:911-919. [PMID: 38367739 DOI: 10.1016/j.healun.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 02/09/2024] [Accepted: 02/11/2024] [Indexed: 02/19/2024] Open
Abstract
BACKGROUND Temporary mechanical circulatory support as well as multidisciplinary team approach in a regional care organization might improve survival of cardiogenic shock. No study has evaluated the relative effect of each temporary mechanical circulatory support on mortality in the context of a regional network. METHODS Prospective observational data were retrieved from patients consecutively admitted with cardiogenic shock to the intensive care units in 3 centers organized into a regional cardiac assistance network. Temporary mechanical circulatory support indication was decided by a heart team, based on the initial shock severity or if shock was refractory to medical treatment within 24 hours of admission. A propensity score for circulatory support use was used as an adjustment co-variable to emulate a target trial. The primary endpoint was in-hospital mortality. RESULTS Two hundred and forty-six patients were included in the study (median age: 59.5 years, 71.9% male): 121 received early mechanical assistance. The main etiologies were acute myocardial infraction (46.8%) and decompensated heart failure (27.2%). Patients who received early mechanical assistance had more severe conditions than other patients. Their crude in-hospital mortality was 38% and 22.4% in other patients but adjusted in-hospital mortality was not different (hazard ratio 0.91, 95% CI:0.65-1.26). Patients with mechanical assistance had a higher rate of complications than others with longer Intensive Care Unit and hospital stays. CONCLUSIONS In the conditions of a cardiac assistance regional network, in-hospital mortality was not improved by early mechanical assistance implantation. A high incidence of complications of temporary mechanical circulatory support may have jeopardized its potential benefit.
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Affiliation(s)
- Aurore Ughetto
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Jacob Eliet
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Nicolas Nagot
- Clinical Research and Epidemiology Unit, CHU Montpellier, Univ Montpellier, Montpellier, France
| | - Hélène David
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France; University of Montpellier, CNRS, INSERM, PhyMedExp, Montpellier, France
| | - Florian Bazalgette
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Grégory Marin
- Clinical Research and Epidemiology Unit, CHU Montpellier, Univ Montpellier, Montpellier, France
| | - Sébastien Kollen
- Department of Critical Care Medicine, CH Perpignan, Perpignan, France
| | - Marc Mourad
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Norddine Zeroual
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Laurent Muller
- Department of Critical Care Medicine, CHU Nîmes, University of Montpellier-Nîmes, Nîmes, France
| | - Philippe Gaudard
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France; University of Montpellier, CNRS, INSERM, PhyMedExp, Montpellier, France
| | - Pascal Colson
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France; University of Montpellier, CNRS, INSERM, Institut de Génomique Fonctionnelle, Montpellier, France.
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Lüsebrink E, Binzenhöfer L, Hering D, Villegas Sierra L, Schrage B, Scherer C, Speidl WS, Uribarri A, Sabate M, Noc M, Sandoval E, Erglis A, Pappalardo F, De Roeck F, Tavazzi G, Riera J, Roncon-Albuquerque R, Meder B, Luedike P, Rassaf T, Hausleiter J, Hagl C, Zimmer S, Westermann D, Combes A, Zeymer U, Massberg S, Schäfer A, Orban M, Thiele H. Scrutinizing the Role of Venoarterial Extracorporeal Membrane Oxygenation: Has Clinical Practice Outpaced the Evidence? Circulation 2024; 149:1033-1052. [PMID: 38527130 DOI: 10.1161/circulationaha.123.067087] [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] [Indexed: 03/27/2024]
Abstract
The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for temporary mechanical circulatory support in various clinical scenarios has been increasing consistently, despite the lack of sufficient evidence regarding its benefit and safety from adequately powered randomized controlled trials. Although the ARREST trial (Advanced Reperfusion Strategies for Patients with Out-of-Hospital Cardiac Arrest and Refractory Ventricular Fibrillation) and a secondary analysis of the PRAGUE OHCA trial (Prague Out-of-Hospital Cardiac Arrest) provided some evidence in favor of VA-ECMO in the setting of out-of-hospital cardiac arrest, the INCEPTION trial (Early Initiation of Extracorporeal Life Support in Refractory Out-of-Hospital Cardiac Arrest) has not found a relevant improvement of short-term mortality with extracorporeal cardiopulmonary resuscitation. In addition, the results of the recently published ECLS-SHOCK trial (Extracorporeal Life Support in Cardiogenic Shock) and ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock) discourage the routine use of VA-ECMO in patients with infarct-related cardiogenic shock. Ongoing clinical trials (ANCHOR [Assessment of ECMO in Acute Myocardial Infarction Cardiogenic Shock, NCT04184635], REVERSE [Impella CP With VA ECMO for Cardiogenic Shock, NCT03431467], UNLOAD ECMO [Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO, NCT05577195], PIONEER [Hemodynamic Support With ECMO and IABP in Elective Complex High-risk PCI, NCT04045873]) may clarify the usefulness of VA-ECMO in specific patient subpopulations and the efficacy of combined mechanical circulatory support strategies. Pending further data to refine patient selection and management recommendations for VA-ECMO, it remains uncertain whether the present usage of this device improves outcomes.
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Affiliation(s)
- Enzo Lüsebrink
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Leonhard Binzenhöfer
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Daniel Hering
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Laura Villegas Sierra
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany and DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Germany (B.S.)
| | - Clemens Scherer
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Walter S Speidl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria (W.S.S.)
| | - Aitor Uribarri
- Cardiology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain. CIBER-CV (A.U.)
| | - Manel Sabate
- Interventional Cardiology Department, Hospital Clinic, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain (M.S.)
| | - Marko Noc
- Center for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia (M.N.)
| | - Elena Sandoval
- Department of Cardiovascular Surgery, Hospital Clínic, Barcelona, Spain (E.S.)
| | - Andrejs Erglis
- Latvian Centre of Cardiology, Paul Stradins Clinical University Hospital, Riga, Latvia (A.E.)
| | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy (F.P.)
| | - Frederic De Roeck
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium (F.D.R.)
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia Intensive Care, Fondazione IRCCS Policlinico San Matteo, Italy (G.T.)
| | - Jordi Riera
- Intensive Care Department, Vall d'Hebron University Hospital, and SODIR, Vall d'Hebron Research Institute, Barcelona, Spain (J.R.)
| | - Roberto Roncon-Albuquerque
- Department of Intensive Care Medicine, São João University Hospital Center, UnIC@RISE and Department of Surgery and Physiology, Faculty of Medicine of Porto, Portugal (R.R.-A.)
| | - Benjamin Meder
- Department of Cardiology, Angiology, and Pneumology, University Hospital Heidelberg, Germany (B.M.)
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen (P.L., T.R.)
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen (P.L., T.R.)
| | - Jörg Hausleiter
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Christian Hagl
- Department of Cardiac Surgery, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Germany (C.H.)
| | - Sebastian Zimmer
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, Germany (S.Z.)
| | - Dirk Westermann
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Germany (D.W.)
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France, and Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France (A.C.)
| | - Uwe Zeymer
- Klinikum der Stadt Ludwigshafen and Institut für Herzinfarktforschung, Ludwigshafen am Rhein, Germany (U.Z.)
| | - Steffen Massberg
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Andreas Schäfer
- Department of Cardiology and Angiology, Hannover Medical School, Germany (A.S.)
| | - Martin Orban
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Department of Internal Medicine/Cardiology and Leipzig Heart Science, Germany (H.T.)
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7
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Moyon Q, Triboulet F, Reuter J, Lebreton G, Dorget A, Para M, Chommeloux J, Stern J, Pineton de Chambrun M, Hékimian G, Luyt CE, Combes A, Sonneville R, Schmidt M. Venoarterial extracorporeal membrane oxygenation in immunocompromised patients with cardiogenic shock: a cohort study and propensity-weighted analysis. Intensive Care Med 2024; 50:406-417. [PMID: 38436727 DOI: 10.1007/s00134-024-07354-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/11/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE The outcomes of immunocompromised patients with cardiogenic shock treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) are seldom documented, making ECMO candidacy decisions challenging. This study aims (1) to report outcomes of immunocompromised patients treated with VA-ECMO, (2) to identify pre-ECMO predictors of 90-day mortality, (3) to assess the impact of immunodepression on 90-day mortality, and (4) to describe the main ECMO-related complications. METHODS This is a retrospective, propensity-weighted study conducted in two French experienced ECMO centers. RESULTS From January 2006 to January 2022, 177 critically ill immunocompromised patients (median (interquartile range, IQR) age 49 (32-60) years) received VA-ECMO. The main causes of immunosuppression were long-term corticosteroids/immunosuppressant treatment (29%), hematological malignancy (26%), solid organ transplant (20%), and solid tumor (13%). Overall 90-day and 1-year mortality were 70% (95% confidence interval (CI) 63-77%) and 75% (95% CI 65-79%), respectively. Older age and higher pre-ECMO lactate were independently associated with 90-day mortality. Across immunodepression causes, 1-year mortality ranged from 58% for patients with infection by human immunodeficiency virus (HIV) or asplenia, to 89% for solid organ transplant recipients. Hemorrhagic and infectious complications affected 39% and 54% of patients, while more than half the stay in intensive care unit (ICU) was spent on antibiotics. In a propensity score-weighted model comparing the 177 patients with 942 non-immunocompromised patients experiencing cardiogenic shock on VA-ECMO, immunocompromised status was independently associated with a higher 90-day mortality (odds ratio 2.53, 95% CI 1.72-3.79). CONCLUSION Immunocompromised patients undergoing VA-ECMO treatment face an unfavorable prognosis, with higher 90-day mortality compared to non-immunocompromised patients. This underscores the necessity for thorough evaluation and careful selection of ECMO candidates within this frail population.
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Affiliation(s)
- Quentin Moyon
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Félicien Triboulet
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Jean Reuter
- Assistance Publique des Hopitaux de Paris, Medical and Infectious Diseases Intensive Care Unit, Bichat Hospital, Paris Diderot University, Sorbonne Paris Cité, INSERM/Paris Diderot University, Paris, France
| | - Guillaume Lebreton
- Assistance Publique des Hopitaux de Paris, Service de Chirurgie Cardiaque, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France
| | - Amandine Dorget
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Marylou Para
- Assistance Publique Des Hopitaux de Paris, Bichat Hospital, Service de Chirurgie Cardiaque, Paris Diderot University, Sorbonne Paris Cité, INSERM/Paris Diderot University, Paris, France
| | - Juliette Chommeloux
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Jules Stern
- Assistance Publique Des Hopitaux de Paris, Department of Anesthesiology and Critical Care Medicine, Bichat Hospital, Paris Diderot University, Sorbonne Paris Cité, INSERM/Paris Diderot University, Paris, France
| | - Marc Pineton de Chambrun
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France
| | - Guillaume Hékimian
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Charles-Edouard Luyt
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
- Sorbonne Université, GRC 30, RESPIRE, Paris, France
| | - Alain Combes
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France
- Sorbonne Université, GRC 30, RESPIRE, Paris, France
| | - Romain Sonneville
- Assistance Publique des Hopitaux de Paris, Medical and Infectious Diseases Intensive Care Unit, Bichat Hospital, Paris Diderot University, Sorbonne Paris Cité, INSERM/Paris Diderot University, Paris, France
| | - Matthieu Schmidt
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France.
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France.
- Sorbonne Université, GRC 30, RESPIRE, Paris, France.
- Service de Médecine Intensive-Réanimation Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition 47, Boulevard de L'Hôpital, 75013, Paris, France.
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8
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Khan KS, Jawaid S, Memon UA, Perera T, Khan U, Farwa UE, Jindal U, Afzal MS, Razzaq W, Abdin ZU, Khawaja UA. Management of Chronic Obstructive Pulmonary Disease (COPD) Exacerbations in Hospitalized Patients From Admission to Discharge: A Comprehensive Review of Therapeutic Interventions. Cureus 2023; 15:e43694. [PMID: 37724212 PMCID: PMC10505355 DOI: 10.7759/cureus.43694] [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: 06/08/2023] [Accepted: 08/18/2023] [Indexed: 09/20/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a common and debilitating condition that often necessitates hospitalization for exacerbations. Since COPD exacerbations can cause significant morbidity and mortality, managing them is crucial for patient care. Effective management of COPD exacerbations is essential to prevent complications, as COPD exacerbations are associated with increased healthcare costs and decreased quality of life. This review aims to comprehensively discuss the management of COPD exacerbations, covering various pharmacologic and non-pharmacologic strategies. These include inhaled bronchodilators, systemic steroids, antibiotics, invasive and non-invasive ventilation, oxygen therapy, smoking cessation, immunization with pneumococcal vaccine, inhalers at discharge, pulmonary rehabilitation, long-term oxygen therapy (LTOT), ambulatory oxygen therapy, short-burst oxygen therapy, extracorporeal membrane oxygenation (ECMO), lung volume reduction surgery (LVRS), endobronchial procedures, and lung transplant. It is drawn upon various sources, including clinical studies, systemic reviews, and observational studies, to provide a comprehensive overview of current practices and identify areas for future research and innovation in managing COPD exacerbations. Addressing these areas of interest can improve patient outcomes and quality of life.
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Affiliation(s)
- Khizar S Khan
- Basic Sciences, Foundation University Medical College, Islamabad, PAK
| | - Sanyah Jawaid
- Internal Medicine, Liaquat National Hospital and Medical College, Karachi, PAK
| | - Unaib Ahmed Memon
- Internal Medicine, Liaquat University of Medical and Health Sciences, Hyderabad, PAK
| | - Tharindu Perera
- General Medicine, Grodno State Medical University, Grodno, BLR
| | - Usman Khan
- General Practice, Akhtar Saeed Medical and Dental College, Lahore, PAK
| | - Umm E Farwa
- Emergency Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | - Urmi Jindal
- Internal Medicine, KJ Somaiya Medical College, Mumbai, IND
| | | | - Waleed Razzaq
- Internal Medicine, Services Hospital Lahore, Lahore, PAK
| | - Zain U Abdin
- Medicine, District Head Quarter Hospital, Faisalabad, PAK
| | - Uzzam Ahmed Khawaja
- Pulmonary and Critical Care Medicine, Jinnah Medical and Dental College, Karachi, PAK
- Clinical and Translational Research, Dr Ferrer BioPharma, South Miami, USA
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9
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Ardito V, Sarucanian L, Rognoni C, Pieri M, Scandroglio AM, Tarricone R. Impella Versus VA-ECMO for Patients with Cardiogenic Shock: Comprehensive Systematic Literature Review and Meta-Analyses. J Cardiovasc Dev Dis 2023; 10:jcdd10040158. [PMID: 37103037 PMCID: PMC10142129 DOI: 10.3390/jcdd10040158] [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: 02/27/2023] [Revised: 03/27/2023] [Accepted: 03/27/2023] [Indexed: 04/28/2023] Open
Abstract
Impella and VA-ECMO are two possible therapeutic courses for the treatment of patients with cardiogenic shock (CS). The study aims to perform a systematic literature review and meta-analyses of a comprehensive set of clinical and socio-economic outcomes observed when using Impella or VA-ECMO with patients under CS. A systematic literature review was performed in Medline, and Web of Science databases on 21 February 2022. Nonoverlapping studies with adult patients supported for CS with Impella or VA-ECMO were searched. Study designs including RCTs, observational studies, and economic evaluations were considered. Data on patient characteristics, type of support, and outcomes were extracted. Additionally, meta-analyses were performed on the most relevant and recurring outcomes, and results shown using forest plots. A total of 102 studies were included, 57% on Impella, 43% on VA-ECMO. The most common outcomes investigated were mortality/survival, duration of support, and bleeding. Ischemic stroke was lower in patients treated with Impella compared to the VA-ECMO population, with statistically significant difference. Socio-economic outcomes including quality of life or resource use were not reported in any study. The study highlighted areas where further data collection is needed to clarify the value of complex, new technologies in the treatment of CS that will enable comparative assessments focusing both on the health impact on patient outcomes and on the financial burden for government budgets. Future studies need to fill the gap to comply with recent regulatory updates at the European and national levels.
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Affiliation(s)
- Vittoria Ardito
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, 20136 Milan, Italy
| | - Lilit Sarucanian
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, 20136 Milan, Italy
| | - Carla Rognoni
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, 20136 Milan, Italy
| | - Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Rosanna Tarricone
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, 20136 Milan, Italy
- Department of Social and Political Science, Bocconi University, 20136 Milan, Italy
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10
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Salter BS, Gross CR, Weiner MM, Dukkipati SR, Serrao GW, Moss N, Anyanwu AC, Burkhoff D, Lala A. Temporary mechanical circulatory support devices: practical considerations for all stakeholders. Nat Rev Cardiol 2023; 20:263-277. [PMID: 36357709 PMCID: PMC9649020 DOI: 10.1038/s41569-022-00796-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/23/2022] [Indexed: 11/12/2022]
Abstract
Originally intended for life-saving salvage therapy, the use of temporary mechanical circulatory support (MCS) devices has become increasingly widespread in a variety of clinical settings in the contemporary era. Their use as a short-term, prophylactic support vehicle has expanded to include procedures in the catheterization laboratory, electrophysiology suite, operating room and intensive care unit. Accordingly, MCS device design and technology continue to develop at a rapid pace. In this Review, we describe the functionality, indications, management and complications associated with temporary MCS, together with scenario-specific utilization, goal-directed development and bioengineering of future devices. We address various considerations for the use of temporary MCS devices in both prophylactic and rescue scenarios, with input from stakeholders from various cardiovascular specialties, including interventional and heart failure cardiology, electrophysiology, cardiothoracic anaesthesiology, critical care and cardiac surgery.
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Affiliation(s)
- Benjamin S Salter
- Department of Anaesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Caroline R Gross
- Department of Anaesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Menachem M Weiner
- Department of Anaesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Srinivas R Dukkipati
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gregory W Serrao
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai, New York, NY, USA
| | - Noah Moss
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai, New York, NY, USA
| | - Anelechi C Anyanwu
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Anuradha Lala
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai, New York, NY, USA
- Department of Population Health Science and Policy, Mount Sinai, New York, NY, USA
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11
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Yoon YI, Lim JH, Lee SG, Kang PJ, Hwang GS, Ha SM, Do HY, Hong SK, Huh JW. Role of extracorporeal membrane oxygenation as a salvage therapy for liver transplantation recipients in a high-volume transplant center. Liver Transpl 2023; 29:67-79. [PMID: 36030502 DOI: 10.1002/lt.26567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 07/08/2022] [Accepted: 07/20/2022] [Indexed: 01/14/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) has been used sporadically in adult orthotopic liver transplantation (OLT) recipients for the treatment of acute cardiopulmonary failure. This retrospective study aimed to identify OLT patients who would benefit from ECMO support. We reviewed 109 OLT patients who received ECMO support for more than 24 h from January 2007 to December 2020. Among the enrolled patients, 15 (13.8%) experienced 18 ECMO-related complications and 12 (11.0%) experienced ECMO reapplication after weaning during the same hospitalization period. The successful weaning rates were 50.98% in patients who received ECMO support during the peritransplantation period (0-30 days from transplantation) and 51.72% in patients who received ECMO support in the post-OLT period (more than 30 days after OLT); 24 (47.1%) and 23 (39.7%) patients survived until hospital discharge, respectively. The 109 enrolled OLT recipients who received ECMO support during the perioperative period had a 1-year survival rate of 42.6%. Multivariate analyses identified the following as significant and independent risk factors for in-hospital mortality: ECMO treatment prior to 2011 ( p = 0.04), septic shock as the indication for ECMO treatment ( p = 0.001), and a total bilirubin level of ≥5.0 mg/dl ( p = 0.02). The outcomes of adult OLT recipients with ECMO treatment were acceptable in terms of weaning success and survival until hospital discharge. This study confirmed that ECMO treatment for OLT recipients with septic shock and elevated bilirubin levels might be associated with a higher in-hospital mortality and demonstrated the importance of a multidisciplinary ECMO team approach.
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Affiliation(s)
- Young-In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Jung-Hyeon Lim
- Department of Thoracic and Cardiovascular Surgery , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Pil-Je Kang
- Department of Thoracic and Cardiovascular Surgery , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Su-Min Ha
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Ha-Yeon Do
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Suk-Kyung Hong
- Division of Acute Care Surgery, Department of Surgery , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Jin-Won Huh
- Department of Pulmonary and Critical Care Medicine , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
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12
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Current status of adult cardiac surgery-part 2. Curr Probl Surg 2023; 60:101245. [PMID: 36642488 DOI: 10.1016/j.cpsurg.2022.101245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 10/13/2022] [Indexed: 12/13/2022]
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13
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Ganekal P, Vastrad B, Vastrad C, Kotrashetti S. Identification of biomarkers, pathways, and potential therapeutic targets for heart failure using next-generation sequencing data and bioinformatics analysis. Ther Adv Cardiovasc Dis 2023; 17:17539447231168471. [PMID: 37092838 PMCID: PMC10134165 DOI: 10.1177/17539447231168471] [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] [Indexed: 04/25/2023] Open
Abstract
BACKGROUND Heart failure (HF) is the most common cardiovascular diseases and the leading cause of cardiovascular diseases related deaths. Increasing molecular targets have been discovered for HF prognosis and therapy. However, there is still an urgent need to identify novel biomarkers. Therefore, we evaluated biomarkers that might aid the diagnosis and treatment of HF. METHODS We searched next-generation sequencing (NGS) dataset (GSE161472) and identified differentially expressed genes (DEGs) by comparing 47 HF samples and 37 normal control samples using limma in R package. Gene ontology (GO) and pathway enrichment analyses of the DEGs were performed using the g: Profiler database. The protein-protein interaction (PPI) network was plotted with Human Integrated Protein-Protein Interaction rEference (HiPPIE) and visualized using Cytoscape. Module analysis of the PPI network was done using PEWCC1. Then, miRNA-hub gene regulatory network and TF-hub gene regulatory network were constructed by Cytoscape software. Finally, we performed receiver operating characteristic (ROC) curve analysis to predict the diagnostic effectiveness of the hub genes. RESULTS A total of 930 DEGs, 464 upregulated genes and 466 downregulated genes, were identified in HF. GO and REACTOME pathway enrichment results showed that DEGs mainly enriched in localization, small molecule metabolic process, SARS-CoV infections, and the citric acid tricarboxylic acid (TCA) cycle and respiratory electron transport. After combining the results of the PPI network miRNA-hub gene regulatory network and TF-hub gene regulatory network, 10 hub genes were selected, including heat shock protein 90 alpha family class A member 1 (HSP90AA1), arrestin beta 2 (ARRB2), myosin heavy chain 9 (MYH9), heat shock protein 90 alpha family class B member 1 (HSP90AB1), filamin A (FLNA), epidermal growth factor receptor (EGFR), phosphoinositide-3-kinase regulatory subunit 1 (PIK3R1), cullin 4A (CUL4A), YEATS domain containing 4 (YEATS4), and lysine acetyltransferase 2B (KAT2B). CONCLUSIONS This discovery-driven study might be useful to provide a novel insight into the diagnosis and treatment of HF. However, more experiments are needed in the future to investigate the functional roles of these genes in HF.
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Affiliation(s)
- Prashanth Ganekal
- Department of General Medicine, Basaveshwara Medical College, Chitradurga, India
| | - Basavaraj Vastrad
- Department of Pharmaceutical Chemistry, K.L.E. College of Pharmacy, Gadag, India
| | - Chanabasayya Vastrad
- Biostatistics and Bioinformatics, Chanabasava Nilaya, #253, Bharthinagar, Dharwad 580001, India
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14
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Spartalis M, Zweiker D, Spartalis E, Iliopoulos DC, Siasos G. Hemodynamic support during catheter ablation of ventricular arrhythmias in patients with cardiogenic shock. Front Cardiovasc Med 2023; 10:1145123. [PMID: 37180778 PMCID: PMC10174244 DOI: 10.3389/fcvm.2023.1145123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 04/11/2023] [Indexed: 05/16/2023] Open
Affiliation(s)
- Michael Spartalis
- 3rd Department of Cardiology, Sotiria Thoracic Diseases General Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Correspondence: Michael Spartalis
| | - David Zweiker
- Department of Cardiology, Medical University of Graz, Graz, Austria
| | - Eleftherios Spartalis
- Laboratory of Experimental Surgery and Surgical Research “N. S. Christeas”, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Dimitrios C. Iliopoulos
- Laboratory of Experimental Surgery and Surgical Research “N. S. Christeas”, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Gerasimos Siasos
- 3rd Department of Cardiology, Sotiria Thoracic Diseases General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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15
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Duburcq T, Goutay J, Preau S, Mugnier A, Rousse N, Moussa MD, Vincentelli A, Cuny J, Parmentier-Decrucq E, Poissy J. Venoarterial Extracorporeal Membrane Oxygenation in Severe Drug Intoxication: A Retrospective Comparison of Survivors and Nonsurvivors. ASAIO J 2022; 68:907-913. [PMID: 34560717 DOI: 10.1097/mat.0000000000001583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Selecting patients most likely to benefit from venoarterial extracorporeal membrane oxygenation (V-A ECMO) to treat refractory drug-induced cardiovascular shock remains a difficult challenge for physicians. This study reported short-term survival outcomes and factors associated with mortality in V-A ECMO-treated patients for poisoning. Twenty-two patients placed on V-A ECMO after drug intoxication from January 2014 to December 2020 were retrospectively analyzed. The primary endpoint of this study was survival at hospital discharge. Univariate descriptive analysis was performed to compare survivors and nonsurvivors during hospitalization. The overall survival at hospital discharge was 45.4% (n = 10/22). Survival rate tended to be higher in patients treated for refractory shock (n = 7/10) compared with those treated for refractory cardiac arrest (n = 3/12, p = 0.08). Low-flow duration and time from admission to ECMO cannulation were shorter in survivors ( p = 0.02 and p = 0.03, respectively). Baseline characteristics before ECMO, including the class of drugs involved in the poisoning, between survivors and nonsurvivors were not statistically different except pH, bicarbonate, serum lactate, Sequential Organ Failure Assessment, and Survival After Veno-arterial-ECMO (SAVE) score. All patients with SAVE-score risk classes II/III survived whereas 85.7% (n = 12/14) of those with SAVE-score risk classes IV/V died. A lactic acid >9 mmol/L predicts mortality with a sensitivity/specificity ratio of 83.3%/100%. V-A ECMO for severe drug intoxication should be reserved for highly selected poisoned patients who do not respond to conventional therapies. Shortening the timing of V-A ECMO initiation should be a key priority in improving outcomes. Low-flow time >60min, lactic acid >9mmol/L, and SAVE-score may be good indicators of a worse prognosis.
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Affiliation(s)
| | - Julien Goutay
- From the Department of Intensive Care, CHU Lille, Lille, France
| | - Sebastien Preau
- From the Department of Intensive Care, CHU Lille, Lille, France
- University of Lille, Inserm U1167, Institut Pasteur de Lille, Lille, France
| | - Agnes Mugnier
- Department of Cardiovascular Surgery, CHU Lille, Lille, France
| | - Natacha Rousse
- Department of Cardiovascular Surgery, CHU Lille, Lille, France
| | - Mouhamed D Moussa
- Cardiovascular Intensive Care Unit, CHU Lille, Lille, France
- University of Lille, Inserm U1011, Institut Pasteur de Lille, EGID, Lille, France
| | - André Vincentelli
- Department of Cardiovascular Surgery, CHU Lille, Lille, France
- University of Lille, Inserm U1011, Institut Pasteur de Lille, EGID, Lille, France
| | - Jerome Cuny
- Emergency Department and SAMU, CHU Lille, Lille, France
| | | | - Julien Poissy
- From the Department of Intensive Care, CHU Lille, Lille, France
- University of Lille, Inserm U1285, CNRS UMR 8576, Lille, France
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16
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e895-e1032. [PMID: 35363499 DOI: 10.1161/cir.0000000000001063] [Citation(s) in RCA: 761] [Impact Index Per Article: 380.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
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17
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2022; 79:e263-e421. [PMID: 35379503 DOI: 10.1016/j.jacc.2021.12.012] [Citation(s) in RCA: 920] [Impact Index Per Article: 460.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. STRUCTURE Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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18
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Hyun J, Kim AR, Lee SE, Hong JA, Kang PJ, Jung SH, Kim MS. Vasoactive-Inotropic Score as a Determinant of Timely Initiation of Venoarterial Extracorporeal Membrane Oxygenation in Patients With Cardiogenic Shock. Circ J 2022; 86:687-694. [PMID: 34759121 DOI: 10.1253/circj.cj-21-0614] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The predictive role of the vasoactive-inotropic score (VIS) for clinical outcomes after venoarterial extracorporeal membrane oxygenation (VA-ECMO) in patients with cardiogenic shock is not well known. This study investigated the predictive value of VIS on in-hospital outcomes and the determination of optimal timing for the initiation of VA-ECMO. METHODS AND RESULTS Overall, 160 patients with cardiogenic shock requiring VA-ECMO who were treated between December 2012 and August 2018 were analyzed. The in-hospital outcomes according to VIS were compared. Pre-ECMO VIS had an area under the receiver-operating characteristic curve (AUC) of 0.60 (P=0.03) for the prediction of in-hospital death. When the patients were divided into the high (≥32) and low (<32) VIS groups, the high VIS group had a higher rate of in-hospital death (P=0.002) and a lower rate of ECMO weaning (P=0.004). The difference in in-hospital death according to VIS was significant only in patients with a cardiogenic shock of non-ischemic etiology (P=0.01). Extracorporeal cardiopulmonary resuscitation (hazard ratio [HR], 1.99), age (HR, 1.02), pre-ECMO lactate (HR, 1.06), and VIS ≥32 (HR, 2.46) were independently predictive of in-hospital death. CONCLUSIONS Among patients with cardiogenic shock requiring VA-ECMO, the initiation of VA-ECMO before reaching high VIS (≥32) showed better in-hospital outcomes, suggesting that VIS may be a potential marker for determining the initiation of hemodynamic support with VA-ECMO.
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Affiliation(s)
- Junho Hyun
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine
| | - Ah-Ram Kim
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine
| | - Sang Eun Lee
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine
| | - Jung Ae Hong
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Pil Je Kang
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Min-Seok Kim
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine
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19
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Topkara VK, Sayer GT, Clerkin KJ, Wever-Pinzon O, Takeda K, Takayama H, Selzman CH, Naka Y, Burkhoff D, Stehlik J, Farr MA, Fang JC, Uriel N, Drakos SG. Recovery With Temporary Mechanical Circulatory Support While Waitlisted for Heart Transplantation. J Am Coll Cardiol 2022; 79:900-913. [PMID: 35241224 PMCID: PMC8928585 DOI: 10.1016/j.jacc.2021.12.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 11/29/2021] [Accepted: 12/06/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND The 2018 U.S. heart allocation system offers an accelerated pathway for heart transplantation to the most urgent patients. OBJECTIVES This study sought to determine whether the new allocation system resulted in lower likelihood of candidate recovery. METHODS Adult patients waitlisted for heart transplantation with temporary mechanical circulatory support at the time of initial listing between 2010 and 2020 in the United Network for Organ Sharing registry were included. Competing events of heart transplantation, waitlist death or delisting for deteriorating condition, and delisting for improved condition (candidate recovery) were analyzed in the new vs old heart allocation system. RESULTS A total of 688 patients were waitlisted with venoarterial extracorporeal membrane oxygenation or a surgical nondischargeable biventricular assist device (status 1 or old 1A). Overall, 2,237 patients were waitlisted with an intra-aortic balloon pump, a percutaneous left ventricular assist device (LVAD), or a surgical nondischargeable LVAD (status 2 or old 1A). Patients waitlisted with venoarterial extracorporeal membrane oxygenation or a nondischargeable biventricular assist device had significantly shorter median waitlist times (5 vs 31 days), higher incidence for cardiac transplantation (81.5% vs 43.0%), and lower incidence of candidate recovery (1.5% vs 7.9%) in the new vs old heart allocation system (all P < 0.05). Patients waitlisted with an intra-aortic balloon pump or percutaneous or a nondischargeable LVAD also had significantly shorter median waitlist times (8 vs 35 days), higher incidence of transplantation (88.9% vs 64.9%), and lower incidence of candidate recovery (0.2% vs 1.6%) in the new vs old heart allocation system (all P < 0.05). CONCLUSIONS Current practice of the new allocation system may not offer select temporary mechanical circulatory support patients the opportunity and adequate time to recover to the point of waitlist removal. Further research will determine which patients would benefit from urgent transplantation vs recovery strategy.
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Affiliation(s)
- Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA.
| | - Gabriel T Sayer
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Kevin J Clerkin
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Omar Wever-Pinzon
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah and Salt Lake Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Hiroo Takayama
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Daniel Burkhoff
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Josef Stehlik
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah and Salt Lake Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Maryjane A Farr
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - James C Fang
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah and Salt Lake Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah and Salt Lake Veterans Affairs Medical Center, Salt Lake City, Utah, USA
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20
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Loforte A, Comentale G, Botta L, Gliozzi G, Cavalli GG, Mariani C, Pilato E, Suarez SM, Pacini D. How Would the Authors Treat Their Own Temporary Left Ventricular Failure With Mechanical Circulatory Support? J Cardiothorac Vasc Anesth 2021; 36:1238-1250. [PMID: 34785126 DOI: 10.1053/j.jvca.2021.10.020] [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: 03/29/2021] [Revised: 09/23/2021] [Accepted: 10/15/2021] [Indexed: 12/28/2022]
Abstract
In the last 20 years, mechanical circulatory supports (MCS) have overturned completely the outcomes and the clinical recovery of patients with isolated acute left ventricle failure (iALVF). This usually occurs more frequently than right-sided heart failure or biventricular dysfunction, and it mainly is caused by acute myocardial infarction. The primary role of MCS is to restore the tissue metabolism to preserve the vital organs' function but, on the other hand, they also have to relieve the workload stress on the heart. In this way, they allow not only the heart to recover from the acute event, but MCS also can stabilize the patient toward cardiac transplantation. The short-term MCS devices currently used in clinical practice are the intraaortic balloon pump, the Impella (Abiomed, Danvers, MA), and venoarterial extracorporeal membrane oxygenation (VA-ECMO), but the choice of the right and tailored device for each patient, as well as the timing to use it, is actually one of the most debated topics of MCS management.
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Affiliation(s)
- Antonio Loforte
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, ALMA Mater Studiorum University of Bologna, Bologna, Italy.
| | - Giuseppe Comentale
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, ALMA Mater Studiorum University of Bologna, Bologna, Italy; Division of Cardiac Surgery, Department of Advanced Biomedical Sciences, University of Naples 'Federico II', Naples, Italy
| | - Luca Botta
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, ALMA Mater Studiorum University of Bologna, Bologna, Italy
| | - Gregorio Gliozzi
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, ALMA Mater Studiorum University of Bologna, Bologna, Italy
| | - Giulio Giovanni Cavalli
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, ALMA Mater Studiorum University of Bologna, Bologna, Italy
| | - Carlo Mariani
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, ALMA Mater Studiorum University of Bologna, Bologna, Italy
| | - Emanuele Pilato
- Division of Cardiac Surgery, Department of Advanced Biomedical Sciences, University of Naples 'Federico II', Naples, Italy
| | - Sofia Martin Suarez
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, ALMA Mater Studiorum University of Bologna, Bologna, Italy
| | - Davide Pacini
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, ALMA Mater Studiorum University of Bologna, Bologna, Italy
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21
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Montero S, Huang F, Rivas-Lasarte M, Chommeloux J, Demondion P, Bréchot N, Hékimian G, Franchineau G, Persichini R, Luyt CÉ, Garcia-Garcia C, Bayes-Genis A, Lebreton G, Cinca J, Leprince P, Combes A, Alvarez-Garcia J, Schmidt M. Awake venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:585-594. [PMID: 33822901 DOI: 10.1093/ehjacc/zuab018] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 02/08/2021] [Accepted: 03/11/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Venoarterial-extracorporeal membrane oxygenation (VA-ECMO) is currently one of the first-line therapies for refractory cardiogenic shock (CS), but its applicability is undermined by the high morbidity associated with its complications, especially those related to mechanical ventilation (MV). We aimed to assess the prognostic impact of keeping patients in refractory CS awake at cannulation and during the VA-ECMO run. METHODS A 7-year database of patients given peripheral VA-ECMO support was used to conduct a propensity-score (PS)-matched analysis to balance their clinical profiles. Patients were classified as 'awake ECMO' or 'non-awake ECMO', respectively, if invasive MV was used during ≤50% or >50% of the VA-ECMO run. Primary outcomes included ventilator-associated pneumonia and ECMO-related complication rates, and secondary outcomes were 60-day and 1-year mortality. A multivariate logistic-regression analysis was used to identify whether MV at cannulation was independently associated with 60-day mortality. RESULTS Among 231 patients included, 91 (39%) were 'awake' and 140 (61%) 'non-awake'. After PS-matching adjustment, the 'awake ECMO' group had significantly lower rates of pneumonia (35% vs. 59%, P = 0.017), tracheostomy, renal replacement therapy, and less antibiotic and sedative consumption. This strategy was also associated with reduced 60-day (20% vs. 41%, P = 0.018) and 1-year mortality rates (31% vs. 54%, P = 0.021) compared to the 'non-awake' group, respectively. Lastly, MV at ECMO cannulation was independently associated with 60-day mortality. CONCLUSION An 'awake ECMO' management in VA-ECMO-supported CS patients is feasible, safe, and associated with improved short- and long-term outcomes.
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Affiliation(s)
- Santiago Montero
- Acute Cardiovascular Care Unit, Cardiology, Hospital Germans Trias i Pujol, Departament de Medicina, Universitat Autònoma de Barcelona, Spain.,Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France
| | - Florent Huang
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France
| | - Mercedes Rivas-Lasarte
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIb-SantPau, CIBERCV, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juliette Chommeloux
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France
| | - Pierre Demondion
- Thoracic and Cardiovascular Department, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France
| | - Nicolas Bréchot
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France
| | - Guillaume Hékimian
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France
| | - Guillaume Franchineau
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France
| | - Romain Persichini
- Medical-Surgical Intensive Care Unit, CHU de La Réunion, Felix-Guyon Hospital, Saint Denis, La Réunion, France
| | - Charles-Édouard Luyt
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France
| | - Cosme Garcia-Garcia
- Acute Cardiovascular Care Unit, Cardiology, Hospital Germans Trias i Pujol, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Antoni Bayes-Genis
- Acute Cardiovascular Care Unit, Cardiology, Hospital Germans Trias i Pujol, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Guillaume Lebreton
- Thoracic and Cardiovascular Department, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France
| | - Juan Cinca
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIb-SantPau, CIBERCV, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Pascal Leprince
- Thoracic and Cardiovascular Department, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France
| | - Alain Combes
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France.,Sorbonne Université, GRC 30, RESPIRE, Assistance Publique-Hôpitaux de Paris (APHP) Hôpital Pitié-Salpêtrière, Paris, France
| | - Jesus Alvarez-Garcia
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIb-SantPau, CIBERCV, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Matthieu Schmidt
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France.,Sorbonne Université, GRC 30, RESPIRE, Assistance Publique-Hôpitaux de Paris (APHP) Hôpital Pitié-Salpêtrière, Paris, France
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22
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Hékimian G, Paulo N, Waintraub X, Bréchot N, Schmidt M, Lebreton G, Pineton de Chambrun M, Muller G, Franchineau G, Bourcier S, Nieszkowska A, Masi P, Leprince P, Combes A, Gandjbakhch E, Luyt CE. Arrhythmia-induced cardiomyopathy: A potentially reversible cause of refractory cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation. Heart Rhythm 2021; 18:1106-1112. [PMID: 33722763 DOI: 10.1016/j.hrthm.2021.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/04/2021] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The most severe form of arrhythmia-induced cardiomyopathy in adults- refractory cardiogenic shock requiring mechanical circulatory support-has rarely been reported. OBJECTIVE The purpose of this study was to describe the management of critically ill patients admitted for acute, nonischemic, or worsening of previously known cardiac dysfunction and recent-onset supraventricular arrhythmia who developed refractory cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO). METHODS This study is a retrospective analysis of prospectively collected data. RESULTS Between 2004 and 2018, 35 patients received VA-ECMO for acute, nonischemic cardiogenic shock and recent supraventricular arrhythmia (77% atrial fibrillation [AF]). Cardiogenic shock was the first disease manifestation in 21 patients (60%). Characteristics at ECMO implantation [median (interquartile range)] were Sequential Organ Failure Assessment score 10 (7-13); inotrope score 29 (11-80); left ventricular ejection (LVEF) fraction 10% (10%-15%); and lactate level 8 (4-11) mmol/L. For 12 patients, amiodarone and/or electric cardioversion successfully reduced arrhythmia, improved LVEF, and enabled weaning off VA-ECMO; 11 had long-term survival without transplantation or long-term assist device. Eight patients experiencing arrhythmia-reduction failure underwent ablation procedures (7 atrioventricular node [AVN] with pacing, 1 atrial tachycardia) and were weaned off VA-ECMO; 7 survived. Of the remaining 15 patients without arrhythmia reduction or ablation, only the 6 bridged to heart transplantation or left ventricular (LV) assist device survived. CONCLUSION Arrhythmia-induced cardiomyopathy, mainly AF-related, is an underrecognized cause of refractory cardiogenic shock and should be considered in patients with nonischemic cardiogenic shock and recent-onset supraventricular arrhythmia. VA-ECMO support allowed safe arrhythmia reduction or rate control by AVN ablation while awaiting recovery, even among those with severe LV dilation.
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Affiliation(s)
- Guillaume Hékimian
- Service de Médecine Intensive Réanimation, Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; UPMC Université Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France.
| | - Nicolas Paulo
- Service de Médecine Intensive Réanimation, Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; UPMC Université Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Xavier Waintraub
- Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Nicolas Bréchot
- Service de Médecine Intensive Réanimation, Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; UPMC Université Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Matthieu Schmidt
- Service de Médecine Intensive Réanimation, Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; UPMC Université Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Guillaume Lebreton
- Department of Cardiac and Thoracic Surgery, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Marc Pineton de Chambrun
- Service de Médecine Intensive Réanimation, Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; UPMC Université Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | | | - Guillaume Franchineau
- Service de Médecine Intensive Réanimation, Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; UPMC Université Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Simon Bourcier
- Service de Médecine Intensive Réanimation, Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; UPMC Université Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Ania Nieszkowska
- Service de Médecine Intensive Réanimation, Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; UPMC Université Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Paul Masi
- Service de Médecine Intensive Réanimation, Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; UPMC Université Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Pascal Leprince
- Department of Cardiac and Thoracic Surgery, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Alain Combes
- Service de Médecine Intensive Réanimation, Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; UPMC Université Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Estelle Gandjbakhch
- Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Charles-Edouard Luyt
- Service de Médecine Intensive Réanimation, Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; UPMC Université Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
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23
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Tschöpe C, Spillmann F, Potapov E, Faragli A, Rapis K, Nelki V, Post H, Schmidt G, Alogna A. The "TIDE"-Algorithm for the Weaning of Patients With Cardiogenic Shock and Temporarily Mechanical Left Ventricular Support With Impella Devices. A Cardiovascular Physiology-Based Approach. Front Cardiovasc Med 2021; 8:563484. [PMID: 33681302 PMCID: PMC7933542 DOI: 10.3389/fcvm.2021.563484] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 01/20/2021] [Indexed: 01/14/2023] Open
Abstract
Objectives: Mechanical circulatory support (MCS) is often required to stabilize therapy-refractory cardiogenic shock patients. Left ventricular (LV) unloading by mechanical ventricular support (MVS) via percutaneous devices, such as with Impella® axial pumps, alone or in combination with extracorporeal life support (ECLS, ECMELLA approach), has emerged as a potential clinical breakthrough in the field. While the weaning from MCS is essentially based on the evaluation of circulatory stability of patients, weaning from MVS holds a higher complexity, being dependent on bi-ventricular function and its adaption to load. As a result of this, weaning from MVS is mostly performed in the absence of established algorithms. MVS via Impella is applied in several cardiogenic shock etiologies, such as acute myocardial infarction (support over days) or acute fulminant myocarditis (prolonged support over weeks, PROPELLA). The time point of weaning from Impella in these cohorts of patients remains unclear. We here propose a novel cardiovascular physiology-based weaning algorithm for MVS. Methods: The proposed algorithm is based on the experience gathered at our center undergoing an Impella weaning between 2017 and 2020. Before undertaking a weaning process, patients must had been ECMO-free, afebrile, and euvolemic, with hemodynamic stability guaranteed in the absence of any inotropic support. The algorithm consists of 4 steps according to the acronym TIDE: (i) Transthoracic echocardiography under full Impella-unloading; (ii) Impella rate reduction in single 8–24 h-steps according to patients hemodynamics (blood pressure, heart rate, and ScVO2), including a daily echocardiographic assessment at minimal flow (P2); (iii) Dobutamine stress-echocardiography; (iv) Right heart catheterization at rest and during Exercise-testing via handgrip. We here present clinical and hemodynamic data (including LV conductance data) from paradigmatic weaning protocols of awake patients admitted to our intensive care unit with cardiogenic shock. We discuss the clinical consequences of the TIDE algorithm, leading to either a bridge-to-recovery, or to a bridge-to-permanent LV assist device (LVAD) and/or transplantation. With this protocol we were able to wean 74.2% of the investigated patients successfully. 25.8% showed a permanent weaning failure and became LVAD candidates. Conclusions: The proposed novel cardiovascular physiology-based weaning algorithm is based on the characterization of the extent and sustainment of LV unloading reached during hospitalization in patients with cardiogenic shock undergoing MVS with Impella in our center. Prospective studies are needed to validate the algorithm.
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Affiliation(s)
- Carsten Tschöpe
- Department of Cardiology, Charité-University Medicine Berlin, Campus Virchow Klinikum, Berlin, Germany.,Center for Regenerative Therapies (BCRT), Berlin Institute of Health (BIH), Charité-University Medicine Berlin, Campus Virchow Clinic, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Frank Spillmann
- Department of Cardiology, Charité-University Medicine Berlin, Campus Virchow Klinikum, Berlin, Germany.,Center for Regenerative Therapies (BCRT), Berlin Institute of Health (BIH), Charité-University Medicine Berlin, Campus Virchow Clinic, Berlin, Germany
| | - Evgenij Potapov
- Department of Heart Surgery, Deutsches Herzzentrum Berlin (DHZB), Berlin, Germany
| | - Alessandro Faragli
- Department of Cardiology, Charité-University Medicine Berlin, Campus Virchow Klinikum, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Department of Internal Medicine and Cardiology, Deutsches Herzzentrum Berlin (DHZB), Berlin, Germany
| | - Konstantinos Rapis
- Department of Cardiology, Charité-University Medicine Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Vivian Nelki
- Department of Cardiology, Charité-University Medicine Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Heiner Post
- Department of Cardiology, Charité-University Medicine Berlin, Campus Virchow Klinikum, Berlin, Germany.,Department of Cardiology, Contilia Heart and Vessel Centre, St. Marien-Hospital Mülheim, Mülheim, Germany
| | - Gunther Schmidt
- Department of Cardiology, Charité-University Medicine Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Alessio Alogna
- Department of Cardiology, Charité-University Medicine Berlin, Campus Virchow Klinikum, Berlin, Germany.,Center for Regenerative Therapies (BCRT), Berlin Institute of Health (BIH), Charité-University Medicine Berlin, Campus Virchow Clinic, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
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24
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Lim HS, Ranasinghe A, Quinn D, Chue C, Mascaro J. Outcomes of temporary mechanical circulatory support in cardiogenic shock due to end-stage heart failure. J Intensive Care Soc 2021; 23:170-176. [DOI: 10.1177/1751143720988706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background There are few reports of mechanical circulatory support (MCS) in patients with cardiogenic shock (CS) due to end-stage heart failure (ESHF). We evaluated our institutional MCS strategy and compared the outcomes of INTERMACS 1 and 2 patients with CS due to ESHF. Methods Retrospective analysis of prospectively collected data (November 2014 to July 2019) from a single centre. ESHF was defined by a diagnosis of HF prior to presentation with CS. Other causes of CS (eg: acute myocardial infarction) were excluded. We compared the clinical course, complications and 90-day survival of patients with CS due to ESHF in INTERMACS profile 1 and 2. Results We included 60 consecutive patients with CS due to ESHF Differences in baseline characteristics were consistent with the INTERMACS profiles. The duration of MCS was similar between INTERMACS 1 and 2 patients (14 (10–33) vs 15 (7–23) days, p = 0.439). There was no significant difference in the number of patients with complications that required intervention. Compared to INTERMACS 2, INTERMACS 1 patients had more organ dysfunction on support and significant lower 90-day survival (66% vs 34%, p = 0.016). Conclusion Our temporary MCS strategy, including earlier intervention in patients with CS due to ESHF at INTERMACS 2 was associated with less organ dysfunction and better 90-day survival compared to INTERMACS 1 patients.
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Affiliation(s)
- Hoong Sern Lim
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Aaron Ranasinghe
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - David Quinn
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Colin Chue
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jorge Mascaro
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Shiraishi Y, Kawana M, Nakata J, Sato N, Fukuda K, Kohsaka S. Time-sensitive approach in the management of acute heart failure. ESC Heart Fail 2020; 8:204-221. [PMID: 33295126 PMCID: PMC7835610 DOI: 10.1002/ehf2.13139] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/23/2020] [Accepted: 11/11/2020] [Indexed: 12/25/2022] Open
Abstract
Acute heart failure (AHF) has become a global public health burden largely because of the associated high morbidity, mortality, and cost. The treatment options for AHF have remained relatively unchanged over the past decades. Historically, clinical congestion alone has been considered the main target for treatment of acute decompensation in patients with AHF; however, this is an oversimplification of the complex pathophysiology. Within the similar clinical presentation of congestion, significant differences in pathophysiological mechanisms exist between the fluid accumulation and redistribution. Tissue hypoperfusion is another vital characteristic of AHF and should be promptly treated with appropriate interventions. In addition, recent clinical trials of novel therapeutic strategies have shown that heart failure management is ‘time sensitive’ and suggested that treatment selection based on individual aetiologies, triggers, and risk factor profiles could lead to better outcomes. In this review, we aim to describe the specifics of the ‘time‐sensitive’ approach by the clinical phenotypes, for example, pulmonary/systemic congestion and tissue hypoperfusion, wherein patients are classified based on pathophysiological conditions. This mechanistic classification, in parallel with the comprehensive risk assessment, has become a cornerstone in the management of patients with AHF and thus supports effective decision making by clinicians. We will also highlight how therapeutic modalities should be individualized according to each clinical phenotype.
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Affiliation(s)
- Yasuyuki Shiraishi
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Masataka Kawana
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | - Jun Nakata
- Division of Intensive and Cardiovascular Care Unit, Department of Cardiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Naoki Sato
- Department of Cardiovascular Medicine, Kawaguchi Cardiovascular and Respiratory Hospital, Saitama, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
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Shiraishi Y, Kohsaka S, Abe T, Nagai T, Goda A, Nishihata Y, Nagatomo Y, Saji M, Toyosaki Y, Takei M, Kitai T, Kohno T, Fukuda K, Matsue Y, Anzai T, Yoshikawa T. Derivation and Validation of Clinical Prediction Models for Rapid Risk Stratification for Time-Sensitive Management for Acute Heart Failure. J Clin Med 2020; 9:jcm9113394. [PMID: 33113911 PMCID: PMC7690673 DOI: 10.3390/jcm9113394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/14/2020] [Accepted: 10/20/2020] [Indexed: 02/07/2023] Open
Abstract
Early and rapid risk stratification of patients with acute heart failure (AHF) is crucial for appropriate patient triage and outcome improvements. We aimed to develop an easy-to-use, in-hospital mortality risk prediction tool based on data collected from AHF patients at their initial presentation. Consecutive patients’ data pertaining to 2006–2017 were extracted from the West Tokyo Heart Failure (WET-HF) and National Cerebral and Cardiovascular Center Acute Decompensated Heart Failure (NaDEF) registries (n = 4351). Risk model development involved stepwise logistic regression analysis and prospective validation using data pertaining to 2014–2015 in the Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure Syndrome (REALITY-AHF) (n = 1682). The final model included data describing six in-hospital mortality risk predictors, namely, age, systolic blood pressure, blood urea nitrogen, serum sodium, albumin, and natriuretic peptide (SOB-ASAP score), available at the time of initial triage. The model showed excellent discrimination (c-statistic = 0.82) and good agreement between predicted and observed mortality rates. The model enabled the stratification of the mortality rates across sixths (from 14.5% to <1%). When assigned a point for each associated factor, the integer score’s discrimination was similar (c-statistic = 0.82) with good calibration across the patients with various risk profiles. The models’ performance was retained in the independent validation dataset. Promptly determining in-hospital mortality risks is achievable in the first few hours of presentation; they correlate strongly with mortality among AHF patients, potentially facilitating clinical decision-making.
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Affiliation(s)
- Yasuyuki Shiraishi
- Department of Cardiology, Keio University School of Medicine, Tokyo 160-8582, Japan; (Y.S.); (K.F.)
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo 160-8582, Japan; (Y.S.); (K.F.)
- Correspondence: ; Tel.: +81-3-3353-1211; Fax: +81-3-5843-6167
| | - Takayuki Abe
- Biostatistics, Clinical and Translational Research Center, Keio University School of Medicine, Tokyo 160-8582, Japan;
- School of Data Science, Yokohama City University, Yokohama 236-0027, Japan
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka 565-8565, Japan; (T.N.); (T.A.)
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University, Sapporo 060-8638, Japan
| | - Ayumi Goda
- Department of Cardiovascular Medicine, Kyorin University School of Medicine, Tokyo 181-8611, Japan; (A.G.); (T.K.)
| | - Yosuke Nishihata
- Department of Cardiology, St. Luke’s International Hospital, Tokyo 104-8560, Japan;
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College Hospital, Tokorozawa 359-8513, Japan;
| | - Mike Saji
- Department of Cardiology, Sakakibara Heart Institute, Tokyo 183-0003, Japan; (M.S.); (T.Y.)
| | - Yuichi Toyosaki
- Department of Cardiology, Saitama Medical University International Medical Center, Saitama 350-1298, Japan;
| | - Makoto Takei
- Department of Cardiology, Tokyo Saiseikai Central Hospital, Tokyo 108-0073, Japan;
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe 650-0047, Japan;
| | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University School of Medicine, Tokyo 181-8611, Japan; (A.G.); (T.K.)
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo 160-8582, Japan; (Y.S.); (K.F.)
| | - Yuya Matsue
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo 113-8421, Japan;
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka 565-8565, Japan; (T.N.); (T.A.)
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University, Sapporo 060-8638, Japan
| | - Tsutomu Yoshikawa
- Department of Cardiology, Sakakibara Heart Institute, Tokyo 183-0003, Japan; (M.S.); (T.Y.)
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Combes A, Price S, Slutsky AS, Brodie D. Temporary circulatory support for cardiogenic shock. Lancet 2020; 396:199-212. [PMID: 32682486 DOI: 10.1016/s0140-6736(20)31047-3] [Citation(s) in RCA: 134] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/24/2020] [Accepted: 04/29/2020] [Indexed: 12/15/2022]
Abstract
Cardiogenic shock can occur due to acute ischaemic or non-ischaemic cardiac events, or from progression of long-standing underlying heart disease. When addressing the cause of underlying disease, the management of cardiogenic shock consists of vasopressors and inotropes; however, these agents can increase myocardial oxygen consumption, impair tissue perfusion, and are frequently ineffective. An alternative approach is to temporarily augment cardiac output using mechanical devices. The use of these devices-known as temporary circulatory support systems-has increased substantially in recent years, despite being expensive, resource intensive, associated with major complications, and lacking high-quality evidence to support their use. This Review summarises the physiological basis underlying the use of temporary circulatory support for cardiogenic shock, reviews the evidence informing indications and contraindications, addresses ethical considerations, and highlights the need for further research.
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Affiliation(s)
- Alain Combes
- Sorbonne Université, Institute of Cardiometabolism and Nutrition, Paris, France; Service de Médecine Intensive-Réanimation, Höpitaux Universitaires Pitié Salpêtrière, Assistance Publique-Höpitaux de Paris, Institut de Cardiologie, Paris, France.
| | - Susanna Price
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College, London, UK
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, NY, USA; Centre for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
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Guilherme E, Jacquet-Lagrèze M, Pozzi M, Achana F, Armoiry X, Fellahi JL. Can levosimendan reduce ECMO weaning failure in cardiogenic shock?: a cohort study with propensity score analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:442. [PMID: 32677985 PMCID: PMC7367381 DOI: 10.1186/s13054-020-03122-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 06/29/2020] [Indexed: 12/13/2022]
Abstract
Background Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been increasingly used over the last decade in patients with refractory cardiogenic shock. ECMO weaning can, however, be challenging and lead to circulatory failure and death. Recent data suggest a potential benefit of levosimendan for ECMO weaning. We sought to further investigate whether the use of levosimendan could decrease the rate of ECMO weaning failure in adult patients with refractory cardiogenic shock. Methods We performed an observational single-center cohort study. All patients undergoing VA-ECMO from January 2012 to December 2018 were eligible and divided into two groups: group levosimendan and group control (without levosimendan). The primary endpoint was VA-ECMO weaning failure defined as death during VA-ECMO treatment or within 24 h after VA-ECMO removal. Secondary outcomes were mortality at day 28 and at 6 months. The two groups were compared after propensity score matching. P < 0.05 was considered statistically significant. Results Two hundred patients were analyzed (levosimendan group: n = 53 and control group: n = 147). No significant difference was found between groups on baseline characteristics except for ECMO duration, which was longer in the levosimendan group (10.6 ± 4.8 vs. 6.5 ± 4.7 days, p < 0.001). Levosimendan administration started 6.6 ± 5.4 days on average following ECMO implantation. After matching of 48 levosimendan patients to 78 control patients, the duration of ECMO was similar in both groups. The rate of weaning failure was 29.1% and 35.4% in levosimendan and control groups, respectively (OR: 0.69, 95%CI: 0.25–1.88). No significant difference was found between groups for all secondary outcomes. Conclusion Levosimendan did not improve the rate of successful VA-ECMO weaning in patients with refractory cardiogenic shock. Trial registration ClinicalTrials.gov, NCT04323709.
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Affiliation(s)
- Enrique Guilherme
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service d'Anesthésie-Réanimation, Lyon, France
| | - Matthias Jacquet-Lagrèze
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service d'Anesthésie-Réanimation, Lyon, France. .,INSERM U1060, Laboratoire CarMeN, IHU OPeRa, Lyon, France.
| | - Matteo Pozzi
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service de Chirurgie Cardiaque, Lyon, France
| | - Felix Achana
- Nuffield Department of Primary care, Oxford University, Oxford, UK
| | - Xavier Armoiry
- Lyon School of Pharmacy (ISPB), Public Health department/UMR CNRS 5510 MATEIS, I2B Team, Lyon, France.,Division of Health Sciences, Warwick Medical School, Warwick university, Coventry, UK
| | - Jean-Luc Fellahi
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service d'Anesthésie-Réanimation, Lyon, France.,INSERM U1060, Laboratoire CarMeN, IHU OPeRa, Lyon, France
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Predictors of Survival for Patients with Acute Decompensated Heart Failure Requiring Extra-Corporeal Membrane Oxygenation Therapy. ASAIO J 2020; 65:781-787. [PMID: 30312208 DOI: 10.1097/mat.0000000000000898] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Chronic systolic heart failure (HF) with acute decompensation can result in cardiogenic shock (CS) requiring short-term mechanical circulatory support. We sought to identify predictors of survival for acute decompensated HF (ADHF) patients requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Patients >18 years old treated at our institution with VA-ECMO from 2009 to 2018 for ADHF with CS were studied. Demographic, hemodynamic, and echocardiographic data were collected. The primary outcome was survival to discharge. Fifty-two patients received VA-ECMO for ADHF with CS; 24 (46.2%) survived. Seventeen (32.7%) had suffered cardiac arrest, and 37 (71.2%) were mechanically ventilated. Mean lactate was 4.33 ± 3.45 mmol/L, and patients were receiving 2.7 ± 1.2 vasopressor/inotropic infusions at ECMO initiation; these did not differ significantly between survivors and nonsurvivors. Pre-ECMO cardiac index was 1.84 ± 0.56L/min/m and 1.94 ± 0.63L/min/m in survivors and nonsurvivors, respectively (p = 0.57). In multivariable analysis, only diabetes mellitus (DM; OR, 13.25; CI, 1.42-123.40; p = 0.02) and mineralocorticoid receptor antagonist use (OR, 0.12; CI, 0.02-0.78; p = 0.03) were independent predictors of mortality. Nineteen (79.2%) survivors required durable ventricular assist device. Among ADHF patients receiving VA-ECMO, DM is a powerful predictor of outcomes while markers of clinical acuity including hemodynamics, vasopressor/inotrope use, and lactate are not. The vast majority of survivors required durable left-ventricular assist devices.
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Prognosis Value of Early Veno Arterial PCO2 Difference in Patients Under Peripheral Veno Arterial Extracorporeal Membrane Oxygenation. Shock 2020; 54:744-750. [DOI: 10.1097/shk.0000000000001554] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Burgos LM, Seoane L, Furmento JF, Costabel JP, Diez M, Vrancic M, Aissaoui N, Benzadón MN, Navia D. Effects of levosimendan on weaning and survival in adult cardiogenic shock patients with veno-arterial extracorporeal membrane oxygenation: systematic review and meta-analysis. Perfusion 2020; 35:484-491. [DOI: 10.1177/0267659120918473] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Veno-arterial extracorporeal membrane oxygenation may be used to support patients with refractory cardiogenic shock. Many patients can be successfully weaned, the ability of some medications to facilitate weaning from veno-arterial extracorporeal membrane oxygenation were reported. To date, there are limited studies investigating the impact of levosimendan on veno-arterial extracorporeal membrane oxygenation weaning. The objective of this systematic review and meta-analysis was to assess the effects of levosimendan on successful weaning from veno-arterial extracorporeal membrane oxygenation and survival in adult patients with cardiogenic shock. Methods: We performed a systematic review and meta-analysis (PubMed, the Cochrane Library, and the International Clinical Trials Registry Platform published from the year 2000 onwards) investigating whether levosimendan offers advantages compared to standard therapy or placebo, in cardiogenic shock adult patients treated with veno-arterial extracorporeal membrane oxygenation. The primary outcome was veno-arterial extracorporeal membrane oxygenation successful weaning, whereas secondary outcome was all-cause mortality at the longest follow-up available. We pooled risk ratio and 95% confidence interval using fixed and random effects models according to the heterogeneity. Results: A total of five non-randomized clinical trials comprising 557 patients were included, 299 patients for levosimendan and 258 patients for control groups. The pooled prevalence of veno-arterial extracorporeal membrane oxygenation successful weaning was 61.4% (95% confidence interval 39.8-82.9%), and all-cause mortality was 36% (95% confidence interval 29.6-48.8%). There was a significant increase in veno-arterial extracorporeal membrane oxygenation successful weaning with levosimendan compared to the controls (risk ratio = 1.42 (95% confidence interval 1.12-1.8), p for effect = 0.004, I2 = 71%). A decrease risk of all-cause mortality in the levosimendan group was also observed, risk ratio = 0.62 (95% confidence interval 0.44-0.88), p for effect = 0.007, I2 = 36%. Conclusion: The use of levosimendan on adult patients with cardiogenic shock may facilitate the veno-arterial extracorporeal membrane oxygenation weaning and reduce all-cause mortality. Few articles of this topic are available, and prospective, randomized multi-center trials are warranted to conclude decisively on the benefits of levosimendan in this setting.
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Affiliation(s)
- Lucrecia María Burgos
- Heart Failure, Pulmonary Hypertension and Transplant Department, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Leonardo Seoane
- Critical Care Cardiology Department, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Juan Francisco Furmento
- Critical Care Cardiology Department, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Juan Pablo Costabel
- Critical Care Cardiology Department, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Mirta Diez
- Heart Failure, Pulmonary Hypertension and Transplant Department, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Mariano Vrancic
- Cardiac Surgery Department, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Nadia Aissaoui
- Penn State Heart and Vascular Institute (HVI), Critical Care Unit, Penn State Health Milton S. Hershey Medical Center (HMC), The Pennsylvania State University, Paris, France
| | - Mariano Noel Benzadón
- Critical Care Cardiology Department, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Daniel Navia
- Cardiac Surgery Department, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
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Extracorporeal Membrane Oxygenation Support Prior to Heart Transplantation: "Festina Lente" ("Make Haste Slowly"). Crit Care Med 2020; 48:e538-e539. [PMID: 32433090 DOI: 10.1097/ccm.0000000000004293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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33
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Ballout JA, Wazni OM, Tarakji KG, Saliba WI, Kanj M, Diab M, Bhargava M, Baranowski B, Dresing TJ, Callahan TD, Cantillon DJ, Rickard J, Martin DO, Varma N, Niebauer MJ, Chung MK, Tchou PJ, Lindsay BD, Hussein AA. Catheter Ablation in Patients With Cardiogenic Shock and Refractory Ventricular Tachycardia. Circ Arrhythm Electrophysiol 2020; 13:e007669. [PMID: 32281407 DOI: 10.1161/circep.119.007669] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is paucity of data regarding radiofrequency ablation for ventricular tachycardia (VT) in patients with cardiogenic shock and concomitant VT refractory to antiarrhythmic drugs on mechanical support. METHODS Patients undergoing VT ablation at our center were enrolled in a prospectively maintained registry and screened for the current study (2010-2017). RESULTS All 21 consecutive patients with cardiogenic shock and concomitant refractory ventricular arrhythmia undergoing bailout ablation due to inability to wean off mechanical support were included. Median age was 61 years, 86% were men, median left ventricular ejection fraction was 20%, 81% had ischemic cardiomyopathy, and PAINESD score was 18±5. The type of mechanical support in place before the procedure was intra-aortic balloon pump in 14 patients (67%), Impella CP in 2, extracorporeal membrane oxygenation in 2, extracorporeal membrane oxygenation and intra-aortic balloon pump in 2, and extracorporeal membrane oxygenation and Impella CP in 1. Endocardial voltage maps showed myocardial scar in 19 patients (90%). The clinical VTs were inducible in 13 patients (62%), whereas 6 patients had premature ventricular contraction-induced ventricular fibrillation/VT (29%), and VT could not be induced in 2 patients (9%). Activation mapping was possible in all 13 with inducible clinical VTs. Substrate modification was performed in 15 patients with scar (79%). After ablation and scar modification, the arrhythmia was noninducible in 19 patients (91%). Seventeen (81%) were eventually weaned off mechanical support successfully, but 6 (29%) died during the index admission from persistent cardiogenic shock. Patients who had ventricular arrhythmia and cardiogenic shock on presentation had a trend toward lower in-hospital mortality compared with those who presented with cardiogenic shock and later developed ventricular arrhythmia. CONCLUSIONS Bailout ablation for refractory ventricular arrhythmia in cardiogenic shock allowed successful weaning from mechanical support in a large proportion of patients. Mortality remains high, but the majority of patients were discharged home and survived beyond 1 year.
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Affiliation(s)
- Jad A Ballout
- Department of Internal Medicine (J.A.B.), Cleveland Clinic, OH
| | - Oussama M Wazni
- Cardiovascular Medicine (O.M.W., K.G.T., W.I.S., M.K., M.D., M.B., B.B., T.J.D., T.D.C., D.J.C., J.R., D.O.M., N.V., M.J.N., M.K.C., P.J.T., B.D.L., A.A.H.), Cleveland Clinic, OH
| | - Khaldoun G Tarakji
- Cardiovascular Medicine (O.M.W., K.G.T., W.I.S., M.K., M.D., M.B., B.B., T.J.D., T.D.C., D.J.C., J.R., D.O.M., N.V., M.J.N., M.K.C., P.J.T., B.D.L., A.A.H.), Cleveland Clinic, OH
| | - Walid I Saliba
- Cardiovascular Medicine (O.M.W., K.G.T., W.I.S., M.K., M.D., M.B., B.B., T.J.D., T.D.C., D.J.C., J.R., D.O.M., N.V., M.J.N., M.K.C., P.J.T., B.D.L., A.A.H.), Cleveland Clinic, OH
| | - Mohamed Kanj
- Cardiovascular Medicine (O.M.W., K.G.T., W.I.S., M.K., M.D., M.B., B.B., T.J.D., T.D.C., D.J.C., J.R., D.O.M., N.V., M.J.N., M.K.C., P.J.T., B.D.L., A.A.H.), Cleveland Clinic, OH
| | - Mohamed Diab
- Cardiovascular Medicine (O.M.W., K.G.T., W.I.S., M.K., M.D., M.B., B.B., T.J.D., T.D.C., D.J.C., J.R., D.O.M., N.V., M.J.N., M.K.C., P.J.T., B.D.L., A.A.H.), Cleveland Clinic, OH
| | - Mandeep Bhargava
- Cardiovascular Medicine (O.M.W., K.G.T., W.I.S., M.K., M.D., M.B., B.B., T.J.D., T.D.C., D.J.C., J.R., D.O.M., N.V., M.J.N., M.K.C., P.J.T., B.D.L., A.A.H.), Cleveland Clinic, OH
| | - Bryan Baranowski
- Cardiovascular Medicine (O.M.W., K.G.T., W.I.S., M.K., M.D., M.B., B.B., T.J.D., T.D.C., D.J.C., J.R., D.O.M., N.V., M.J.N., M.K.C., P.J.T., B.D.L., A.A.H.), Cleveland Clinic, OH
| | - Thomas J Dresing
- Cardiovascular Medicine (O.M.W., K.G.T., W.I.S., M.K., M.D., M.B., B.B., T.J.D., T.D.C., D.J.C., J.R., D.O.M., N.V., M.J.N., M.K.C., P.J.T., B.D.L., A.A.H.), Cleveland Clinic, OH
| | - Thomas D Callahan
- Cardiovascular Medicine (O.M.W., K.G.T., W.I.S., M.K., M.D., M.B., B.B., T.J.D., T.D.C., D.J.C., J.R., D.O.M., N.V., M.J.N., M.K.C., P.J.T., B.D.L., A.A.H.), Cleveland Clinic, OH
| | - Daniel J Cantillon
- Cardiovascular Medicine (O.M.W., K.G.T., W.I.S., M.K., M.D., M.B., B.B., T.J.D., T.D.C., D.J.C., J.R., D.O.M., N.V., M.J.N., M.K.C., P.J.T., B.D.L., A.A.H.), Cleveland Clinic, OH
| | - John Rickard
- Cardiovascular Medicine (O.M.W., K.G.T., W.I.S., M.K., M.D., M.B., B.B., T.J.D., T.D.C., D.J.C., J.R., D.O.M., N.V., M.J.N., M.K.C., P.J.T., B.D.L., A.A.H.), Cleveland Clinic, OH
| | - David O Martin
- Cardiovascular Medicine (O.M.W., K.G.T., W.I.S., M.K., M.D., M.B., B.B., T.J.D., T.D.C., D.J.C., J.R., D.O.M., N.V., M.J.N., M.K.C., P.J.T., B.D.L., A.A.H.), Cleveland Clinic, OH
| | - Niraj Varma
- Cardiovascular Medicine (O.M.W., K.G.T., W.I.S., M.K., M.D., M.B., B.B., T.J.D., T.D.C., D.J.C., J.R., D.O.M., N.V., M.J.N., M.K.C., P.J.T., B.D.L., A.A.H.), Cleveland Clinic, OH
| | - Mark J Niebauer
- Cardiovascular Medicine (O.M.W., K.G.T., W.I.S., M.K., M.D., M.B., B.B., T.J.D., T.D.C., D.J.C., J.R., D.O.M., N.V., M.J.N., M.K.C., P.J.T., B.D.L., A.A.H.), Cleveland Clinic, OH
| | - Mina K Chung
- Cardiovascular Medicine (O.M.W., K.G.T., W.I.S., M.K., M.D., M.B., B.B., T.J.D., T.D.C., D.J.C., J.R., D.O.M., N.V., M.J.N., M.K.C., P.J.T., B.D.L., A.A.H.), Cleveland Clinic, OH
| | - Patrick J Tchou
- Cardiovascular Medicine (O.M.W., K.G.T., W.I.S., M.K., M.D., M.B., B.B., T.J.D., T.D.C., D.J.C., J.R., D.O.M., N.V., M.J.N., M.K.C., P.J.T., B.D.L., A.A.H.), Cleveland Clinic, OH
| | - Bruce D Lindsay
- Cardiovascular Medicine (O.M.W., K.G.T., W.I.S., M.K., M.D., M.B., B.B., T.J.D., T.D.C., D.J.C., J.R., D.O.M., N.V., M.J.N., M.K.C., P.J.T., B.D.L., A.A.H.), Cleveland Clinic, OH
| | - Ayman A Hussein
- Cardiovascular Medicine (O.M.W., K.G.T., W.I.S., M.K., M.D., M.B., B.B., T.J.D., T.D.C., D.J.C., J.R., D.O.M., N.V., M.J.N., M.K.C., P.J.T., B.D.L., A.A.H.), Cleveland Clinic, OH
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34
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Coutance G, Jacob N, Demondion P, Nguyen LS, Bouglé A, Bréchot N, Varnous S, Leprince P, Combes A, Lebreton G. Favorable Outcomes of a Direct Heart Transplantation Strategy in Selected Patients on Extracorporeal Membrane Oxygenation Support. Crit Care Med 2020; 48:498-506. [PMID: 32205596 DOI: 10.1097/ccm.0000000000004182] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Heart transplantation in patients supported by venoarterial extracorporeal membrane oxygenation has been associated with poor prognosis. A specific protocol for extracorporeal membrane oxygenation management encompassing patient selection, implantation strategy, and preoperative and perioperative treatment is applied at our institution. Our aim was to compare posttransplant outcomes of patients supported or not by extracorporeal membrane oxygenation at the time of heart transplantation. DESIGN A large observational single-center retrospective study was conducted. The primary endpoint was overall survival after heart transplantation. Secondary endpoints included death-censored rejection-free survival and the frequency of extracorporeal membrane oxygenation-related complications. SETTING One heart transplantation and extracorporeal membrane oxygenation high-volume center. PATIENTS All consecutive patients over 18 years old with a first noncombined heart transplantation performed between 2012 and 2016 were included. INTERVENTIONS None (retrospective observational study). MEASUREMENTS AND MAIN RESULTS Among the 415 transplanted patients, 118 (28.4%) were on extracorporeal membrane oxygenation at the time of transplantation (peripheral, 94%; intrathoracic, 6%). Median time on extracorporeal membrane oxygenation before heart transplantation was 9 days (interquartile range, 5-15 d) and median follow-up post heart transplantation was 20.7 months. Posttransplant survival did not differ significantly between the two groups (1-yr survival = 85.5% and 80.7% in extracorporeal membrane oxygenation vs nonextracorporeal membrane oxygenation patients; hazard ratio, 0.69; 95% CI, 0.43-1.11; p = 0.12, respectively). Donor age, body mass index, creatinine clearance, and ischemic time were independently associated with overall mortality, but not extracorporeal membrane oxygenation at the time of heart transplantation. Rejection-free survival also did not significantly differ between groups (hazard ratio, 0.85; 95% CI, 0.60-1.23; p = 0.39). Local wound infection was the most frequent complication after extracorporeal membrane oxygenation (37% of patients). CONCLUSIONS With the implementation of a specific protocol, patients bridged to heart transplantation on extracorporeal membrane oxygenation had similar survival compared with those not supported by extracorporeal membrane oxygenation.
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Affiliation(s)
- Guillaume Coutance
- Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié-Salpêtrieère Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
- INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | | | - Pierre Demondion
- Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié-Salpêtrieère Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
- INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Lee S Nguyen
- Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié-Salpêtrieère Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
- INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Adrien Bouglé
- INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
- Department of Anesthesiology and Critical Care Medicine, Cardiology Institute, Pitié-Salpêtrière Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
| | - Nicolas Bréchot
- INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
- Department of Medical Intensive Care Unit, Cardiology Institute, Pitieé Salpeêtrieère Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
| | - Shaida Varnous
- Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié-Salpêtrieère Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
- INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Pascal Leprince
- Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié-Salpêtrieère Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
- INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Alain Combes
- INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
- Department of Medical Intensive Care Unit, Cardiology Institute, Pitieé Salpeêtrieère Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
| | - Guillaume Lebreton
- Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié-Salpêtrieère Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
- INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
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35
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Ellouze O, Abbad X, Constandache T, Missaoui A, Berthoud V, Daily T, Aho S, Bouchot O, Bouhemad B, Guinot PG. Risk Factors of Bleeding in Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation. Ann Thorac Surg 2020; 111:623-628. [PMID: 32171730 DOI: 10.1016/j.athoracsur.2020.02.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 12/10/2019] [Accepted: 02/04/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Venoarterial extracorporeal membrane oxygenation (VA ECMO) is increasingly being used for circulatory shock. Bleeding is a frequent complication and is associated with increased mortality. The purpose of our study was to identify factors associated with early major bleeding after VA ECMO initiation. METHODS We performed a retrospective observational study based on our database. In accordance with the Extracorporeal Life Support Organization definition, the population was divided in two groups: major bleeding events (group B) and no major bleeding events (group O). We collected data on all major bleeding events occurring during the first 48 hours after VA ECMO initiation. RESULTS Of the 243 patients analyzed, 111 patients (46%) had an early major bleeding event. Independent risk factors associated with early major bleeding events were postcardiotomy VA ECMO (odds ratio [OR] 1.98; 95% confidence interval [CI], 1.08 to 3.62; P = .02), body mass index (OR 0.91; 95% CI, 0.85 to 0.98; P = .01), hemoglobinemia (OR 0.8; 95% CI, 0.7 to 0.92; P = .002), fibrinogen (OR 0.67; 95% CI, 0.52 to 0.84; P = .001), and pH (OR 0.15; 95% CI, 0.02 to 1.04; P = .05). By using a receiver-operating characteristics curve analysis, hemoglobin level less than 9 g dL-1, fibrinogen level less than 2 g L-1, pH lower than 7.12, and body mass index below 25 kg/m2 were identified to predict early major bleeding events. Major bleeding events were independently associated with mortality (OR 2.54; CI 95%, 1.38 to 4.66; P = .01). CONCLUSIONS We found that postcardiotomy VA ECMO, hemoglobin levels less than 9 g dL-1, fibrinogen levels less than 2 g L-1, pH lower than 7.12, and body mass index below 25 kg/m2 were associated with a higher risk for early major bleeding events.
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Affiliation(s)
- Omar Ellouze
- Department of Cardio-Vascular Anesthesia and Intensive Care Medicine, François Mitterand University Hospital, Dijon, France.
| | - Xavier Abbad
- Department of Cardio-Vascular Anesthesia and Intensive Care Medicine, François Mitterand University Hospital, Dijon, France
| | - Tiberiu Constandache
- Department of Cardio-Vascular Anesthesia and Intensive Care Medicine, François Mitterand University Hospital, Dijon, France
| | - Anis Missaoui
- Department of Cardio-Vascular Anesthesia and Intensive Care Medicine, François Mitterand University Hospital, Dijon, France
| | - Vivien Berthoud
- Department of Cardio-Vascular Anesthesia and Intensive Care Medicine, François Mitterand University Hospital, Dijon, France
| | - Theresa Daily
- Department of Cardio-Vascular Anesthesia and Intensive Care Medicine, François Mitterand University Hospital, Dijon, France
| | - Serge Aho
- Epidemiology and Infection Control Department, François Mitterand University Hospital, Dijon, France
| | - Olivier Bouchot
- Department of Cardio-Vascular and Thoracic Surgery, François Mitterand University Hospital, Dijon, France
| | - Belaid Bouhemad
- Department of Cardio-Vascular Anesthesia and Intensive Care Medicine, François Mitterand University Hospital, Dijon, France
| | - Pierre-Grégoire Guinot
- Department of Cardio-Vascular Anesthesia and Intensive Care Medicine, François Mitterand University Hospital, Dijon, France
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36
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Mortality Risk Factors for Cardiac Arrest Prior to Venoarterial Extracorporeal Membrane Oxygenation. Crit Care Med 2020; 48:e155. [PMID: 31939818 DOI: 10.1097/ccm.0000000000004028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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37
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Le Guennec L, Schmidt M, Clarençon F, Elhfnawy AM, Baronnet F, Kalamarides M, Lebreton G, Luyt CE. Mechanical thrombectomy in acute ischemic stroke patients under venoarterial extracorporeal membrane oxygenation. J Neurointerv Surg 2019; 12:486-488. [PMID: 31744852 DOI: 10.1136/neurintsurg-2019-015407] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/25/2019] [Accepted: 10/28/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in adult patients to treat refractory cardiogenic shock has increased in recent years, and ischemic stroke is the most frequent VA-ECMO-induced cerebrovascular complication. No adult case of mechanical thrombectomy (MT) has been reported. METHODS Retrospective observational study of hospital medical records of patients who received circulatory support with VA-ECMO with acute ischemic stroke treated with MT, from 2006 to 2018. RESULTS Two adult patients on VA-ECMO with acute ischemic stroke treated with MT were found. Both cases were successfully treated. CONCLUSION These cases illustrate the feasibility of performing MT in adult patients on ECMO.
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Affiliation(s)
- Loic Le Guennec
- Intensive Care, Pitié-Salpêtrière Hospital, Paris, France .,Sorbonne Université, Paris, France
| | - Matthieu Schmidt
- Intensive Care, Pitié-Salpêtrière Hospital, Paris, France.,Sorbonne Université, Paris, France
| | - Frédéric Clarençon
- Sorbonne Université, Paris, France.,Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Ahmed Mohamed Elhfnawy
- Sorbonne Université, Paris, France.,Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Flore Baronnet
- Sorbonne Université, Paris, France.,Vascular Neurology, Pitié-Salpêtrière Hospital, Paris, France
| | - Michel Kalamarides
- Sorbonne Université, Paris, France.,Neurosurgery, Pitié-Salpêtrière Hospital, Paris, France
| | - Guillaume Lebreton
- Sorbonne Université, Paris, France.,Cardiac Surgery, Pitié-Salpêtrière Hospital, Paris, France
| | - Charles-Edouard Luyt
- Intensive Care, Pitié-Salpêtrière Hospital, Paris, France.,Sorbonne Université, Paris, France
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38
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Al-Fares AA, Randhawa VK, Englesakis M, McDonald MA, Nagpal AD, Estep JD, Soltesz EG, Fan E. Optimal Strategy and Timing of Left Ventricular Venting During Veno-Arterial Extracorporeal Life Support for Adults in Cardiogenic Shock. Circ Heart Fail 2019; 12:e006486. [DOI: 10.1161/circheartfailure.119.006486] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background:
Veno-arterial extracorporeal life support (VA-ECLS) is widely used to treat refractory cardiogenic shock. However, increased left ventricular (LV) afterload in VA-ECLS can worsen pulmonary congestion and compromise myocardial recovery. Our objectives were to explore the efficacy, safety, and optimal timing of adjunctive LV venting strategies.
Methods:
A systematic search was performed on Medline, EMBASE, PubMed, CDSR, CCRCT, CINAHL, ClinicalTrials.Gov, and WHO ICTRP from inception until January 2019 for all relevant studies, including LV venting. Data were analyzed for mortality and weaning from VA-ECLS on the basis of timing of LV venting, along with adverse complications.
Results:
A total of 7995 patients were included from 62 observational studies, wherein 3458 patients had LV venting during VA-ECLS. LV venting significantly improved weaning from VA-ECLS (odds ratio, 0.62 [95% CI, 0.47–0.83];
P
=0.001) and reduced short-term (30 day; risk ratio [RR], 0.86 [95% CI, 0.77–0.96];
P
=0.008) but not in-hospital (RR, 0.92 [95% CI, 0.83–1.01]
P
=0.09) or long-term (6 months; RR, 0.96 [95% CI, 0.90–1.03];
P
=0.27) mortality. Early (<12 hours; RR, 0.86 [95% CI, 0.75–0.99];
P
=0.03) but not late (≥12 hours; RR, 0.99 [95% CI, 0.71–1.38];
P
=0.93) LV venting significantly reduced short-term mortality. Patients with LV venting spent more time on VA-ECLS (3.6 versus 2.8 days,
P
<0.001), and mechanical ventilation (7.1 versus 4.6 days,
P
=0.013). With the exception of hemolysis (RR, 2.18 [95% CI, 1.58–3.01];
P
<0.00001), overall adverse events did not differ.
Conclusions:
LV venting, especially if done early (<12 hours), appears to be associated with an increased success of weaning and reduced short-term mortality. Future studies are required to delineate the importance of any or early LV venting adjuncts on mortality and morbidity outcomes.
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Affiliation(s)
- Abdulrahman A. Al-Fares
- Interdepartmental Division of Critical Care Medicine (A.A.A.-F., E.F.), Toronto General Hospital, University of Toronto, ON, Canada
- Extracorporeal Life Support Program (A.A.A.-F., E.F.), Toronto General Hospital, University of Toronto, ON, Canada
- Al-Amiri Hospital, Ministry of Health, Kuwait (A.A.A.-F.)
| | - Varinder K. Randhawa
- Departments of Cardiovascular Medicine (V.K.R., J.D.E.), Kaufman Center for Heart Failure, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Marina Englesakis
- Library and Information Services (M.E.), Toronto General Hospital, University of Toronto, ON, Canada
| | - Michael A. McDonald
- Division of Cardiology, Peter Munk Cardiac Centre (M.A.M.), Toronto General Hospital, University of Toronto, ON, Canada
| | - A. Dave Nagpal
- Divisions of Cardiac Surgery and Critical Care, London Health Sciences Center, ON, Canada (A.D.N.)
| | - Jerry D. Estep
- Departments of Cardiovascular Medicine (V.K.R., J.D.E.), Kaufman Center for Heart Failure, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Edward G. Soltesz
- Thoracic and Cardiovascular Surgery (E.G.S.), Kaufman Center for Heart Failure, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine (A.A.A.-F., E.F.), Toronto General Hospital, University of Toronto, ON, Canada
- Extracorporeal Life Support Program (A.A.A.-F., E.F.), Toronto General Hospital, University of Toronto, ON, Canada
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Chaves RCDF, Rabello Filho R, Timenetsky KT, Moreira FT, Vilanova LCDS, Bravim BDA, Serpa Neto A, Corrêa TD. Extracorporeal membrane oxygenation: a literature review. Rev Bras Ter Intensiva 2019; 31:410-424. [PMID: 31618362 PMCID: PMC7005959 DOI: 10.5935/0103-507x.20190063] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 02/18/2019] [Indexed: 12/19/2022] Open
Abstract
Extracorporeal membrane oxygenation is a modality of extracorporeal life support that allows for temporary support in pulmonary and/or cardiac failure refractory to conventional therapy. Since the first descriptions of extracorporeal membrane oxygenation, significant improvements have occurred in the device and the management of patients and, consequently, in the outcomes of critically ill patients during extracorporeal membrane oxygenation. Many important studies about the use of extracorporeal membrane oxygenation in patients with acute respiratory distress syndrome refractory to conventional clinical support, under in-hospital cardiac arrest and with cardiogenic refractory shock have been published in recent years. The objective of this literature review is to present the theoretical and practical aspects of extracorporeal membrane oxygenation support for respiratory and/or cardiac functions in critically ill patients.
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Affiliation(s)
- Renato Carneiro de Freitas Chaves
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil.,Departamento de Anestesiologia, Irmandade da Santa Casa de Misericórdia de Santos - Santos (SP), Brasil
| | - Roberto Rabello Filho
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | | | - Fabio Tanzillo Moreira
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil.,Departamento de Medicina Intensiva, Hospital Municipal Dr. Moysés Deutsch - São Paulo (SP), Brasil
| | | | - Bruno de Arruda Bravim
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Ary Serpa Neto
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Thiago Domingos Corrêa
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil.,Departamento de Medicina Intensiva, Hospital Municipal Dr. Moysés Deutsch - São Paulo (SP), Brasil
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40
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Abstract
OBJECTIVES Cardiogenic shock is a highly morbid condition in which inadequate end-organ perfusion leads to death if untreated. Peripheral venoarterial extracorporeal membrane oxygenation is increasingly used to restore systemic perfusion despite limited understanding of how to optimally titrate support. This review provides insights into the physiologic basis of extracorporeal membrane oxygenation support and presents an approach to extracorporeal membrane oxygenation management in the cardiogenic shock patient. DATA SOURCES, STUDY SELECTION, AND DATA EXTRACTION Data were obtained from a PubMed search of the most recent medical literature identified from MeSH terms: extracorporeal membrane oxygenation, cardiogenic shock, percutaneous mechanical circulatory support, and heart failure. Articles included original articles, case reports, and review articles. DATA SYNTHESIS Current evidence detailing the use of extracorporeal membrane oxygenation to support patients in cardiogenic shock is limited to isolated case reports and single institution case series focused on patient outcomes but lacking in detailed approaches to extracorporeal membrane oxygenation management. Unlike medical therapy, in which dosages are either prescribed or carefully titrated to specific variables, extracorporeal membrane oxygenation is a mechanical support therapy requiring ongoing titration but without widely accepted variables to guide treatment. Similar to mechanical ventilation, extracorporeal membrane oxygenation can provide substantial benefit or induce significant harm. The widespread use and present lack of data to guide extracorporeal membrane oxygenation support demands that intensivists adopt a physiologically-based approach to management of the cardiogenic shock patient on extracorporeal membrane oxygenation. CONCLUSIONS Extracorporeal membrane oxygenation is a powerful mechanical circulatory support modality capable of rapidly restoring systemic perfusion yet lacking in defined approaches to management. Adopting a management approach based physiologic principles provides a basis for care.
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Affiliation(s)
- Steven P Keller
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA
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42
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Lim HS. Hemodynamic and Physiologic Approach to Cardiogenic Shock. J Am Coll Cardiol 2019; 74:592-593. [DOI: 10.1016/j.jacc.2019.04.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 04/05/2019] [Indexed: 10/26/2022]
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43
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Abstract
PURPOSE OF REVIEW Temporary circulatory support (TCS) with short-term mechanical circulatory support (MCS) devices is increasingly used as a salvage therapy for patients with refractory cardiogenic shock. This article provides an overview of current devices, their indications and management, and discusses results of recent case series and trials. RECENT FINDINGS Percutaneous active MCS devices (Impella, TandemHeart…) and venoarterial extracorporeal membrane oxygenation (VA-ECMO) are utilized as a bridge to 'decision' that includes weaning after cardiac function recovery, transplantation, long-term MCS and withdrawal in case of futility. VA-ECMO is considered the first-line TCS since it allows rapid improvement in oxygenation, is less expensive, and is also suitable for patients with biventricular failure. Combining Impella or intra-aortic balloon pump support with ECMO might decrease left ventricular pressure and improve outcomes. Sepsis-associated cardiomyopathy, massive pulmonary embolism, arrhythmic storm and Takotsubo-like cardiomyopathy are among emerging indications for TCS. SUMMARY TCS have become the cornerstone of the management of patients with cardiogenic shock, although the evidence supporting their efficacy is limited. VA-ECMO is considered the first-line option, with a growing number of accepted and emerging indications. Randomized clinical trials are now needed to determine the respective place of different MCS devices in cardiogenic shock treatment strategies.
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44
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The modern cardiovascular care unit: the cardiologist managing multiorgan dysfunction. Curr Opin Crit Care 2019; 24:300-308. [PMID: 29916835 DOI: 10.1097/mcc.0000000000000522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE OF REVIEW Despite many advances in the management of critically ill patients, cardiogenic shock remains a challenge because it is associated with high mortality. Even if there is no universally accepted definition of cardiogenic shock, end-perfusion organ dysfunction is an obligatory and major criterion of its definition.Organ dysfunction is an indicator that cardiogenic shock is already at an advanced stage and is undergoing a rapid self-aggravating evolution. The aim of the review is to highlight the importance to diagnose and to manage the organ dysfunction occurring in the cardiogenic shock patients by providing the best literature published this year. RECENT FINDINGS The first step is to diagnose the organ dysfunction and to assess their severity. Echo has an important and increasing place regarding the assessment of end-organ impairment whereas no new biomarker popped up. SUMMARY In this review, we aimed to highlight for intensivists and cardiologists managing cardiogenic shock, the recent advances in the care of end-organ dysfunctions associated with cardiogenic shock. The management of organ dysfunction is based on the improvement of the cardiac function by etiologic therapy, inotropes and assist devices but will often necessitate organ supports in hospitals with the right level of equipment and multidisciplinary expertise.
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45
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Confounders Affecting the Prognosis in Patients With Acute Decompensated Heart Failure Who Underwent Extracorporeal Membrane Oxygenation. Crit Care Med 2019; 45:e1309. [PMID: 29149013 DOI: 10.1097/ccm.0000000000002718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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46
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Ng WT, Ling L, Joynt GM, Chan KM. An audit of mortality by using ECMO specific scores and APACHE II scoring system in patients receiving extracorporeal membrane oxygenation in a tertiary intensive care unit in Hong Kong. J Thorac Dis 2019; 11:445-455. [PMID: 30962988 DOI: 10.21037/jtd.2018.12.121] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Outcomes of patients receiving extracorporeal membrane oxygenation (ECMO) therapies risk-adjusted by ECMO specific scores have rarely been reported. Our primary aim was to determine the risk adjusted outcome of these patients by the use of Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP), Survival After Veno-Arterial-ECMO (SAVE) and APACHE II scores. The differences in predicted mortality between these scoring systems were analyzed. Methods This is a single-center retrospective study reviewing 62 patients who received venous-venous ECMO (VV-ECMO) and venous-arterial ECMO (VA-ECMO) between 2009 and 2017 in a tertiary ICU. Demographic, clinical, laboratory, imaging data were analyzed. Primary outcome measures were the crude mortality and standardized mortality ratio (SMR), expressed as observed mortality divided by expected mortality predicted from RESP, SAVE and APACHE II scores, respectively. We also examined the difference in predicted mortality derived from RESP, SAVE, and APACHE II by using Bland Altman plots. Results Twenty and Forty-two patients received VV-ECMO (20 runs) and VA-ECMO (43 runs) respectively. For VV-ECMO, the mean RESP was 0.6 [standard deviation (SD) 4.86] with RESP-SMR of 1.16 [95% confidence interval (95% CI) =0.44-1.88]. For VA-ECMO, the mean SAVE score was -7.8 (SD 5.6), with SAVE-SMR of 0.69 (95% CI =0.39-0.98). In the Bland Altman plot for VA-ECMO, mean difference in predicted mortality between SAVE and APACHE II was 17.6% (95% CI: 7.6% to 27.6%, P<0.0001), with 95% limit of agreement of -30.2% to 65.5% and beta coefficient of -1.04. APACHE II predicted mortality for VA-ECMO was lower than that for SAVE until it crossed SAVE prediction at about 80% mortality. After this point, it becomes progressively higher than that for SAVE. Conclusions The mortality outcome of our patients on VV-ECMO and VA-ECMO compares favorably with predicted mortality based on RESP and SAVE, respectively. In our cohort of patients receiving VA-ECMO, APACHE II tends to underestimate mortality in lower risk patients, and overestimate the mortality in patients at high risk of death.
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Affiliation(s)
- Wai Tsan Ng
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Hong Kong, China
| | - Lowell Ling
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Hong Kong, China
| | - Gavin M Joynt
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Hong Kong, China
| | - Kai Man Chan
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Hong Kong, China
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47
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Wada K, Bunya N, Kakizaki R, Kasai T, Uemura S, Harada K, Narimatsu E. Successful use of veno-arterial extracorporeal membrane oxygenation for septic cardiomyopathy in a patient with pre-existing chronic heart failure. Acute Med Surg 2019; 6:301-304. [PMID: 31304033 PMCID: PMC6603327 DOI: 10.1002/ams2.407] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 02/15/2019] [Indexed: 11/24/2022] Open
Abstract
Background Indications for using veno‐arterial extracorporeal membrane oxygenation (V‐A ECMO) in sepsis cases remain unclear. Case Presentation A 66‐year‐old man with pre‐existing chronic heart failure developed severe pneumonia resulting in refractory septic shock. He was diagnosed with septic cardiomyopathy based on depressed left ventricular ejection fraction and a dilated left ventricle based on a transthoracic echocardiogram. We initiated V‐A ECMO on day 3 because the shock did not respond to conventional therapy. The patient's hemodynamics improved, and his infection was reduced. He recovered fully and was discharged on day 107 with his cardiac function restored to its baseline. Conclusion Septic cardiomyopathy is a form of reversible myocardial dysfunction. Veno‐arterial extracorporeal membrane oxygenation should be considered for septic cardiomyopathy with intractable circulatory failure. Pre‐existing chronic heart failure is not a contraindication for VA‐ECMO.
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Affiliation(s)
- Kenshiro Wada
- Department of Emergency Medicine Sapporo Medical University Hokkaido Japan
| | - Naofumi Bunya
- Department of Emergency Medicine Sapporo Medical University Hokkaido Japan
| | - Ryuichiro Kakizaki
- Department of Emergency Medicine Sapporo Medical University Hokkaido Japan
| | - Takehiko Kasai
- Emergency Department Hakodate Municipal Hospital Hokkaido Japan
| | - Shuji Uemura
- Department of Emergency Medicine Sapporo Medical University Hokkaido Japan
| | - Keisuke Harada
- Department of Emergency Medicine Sapporo Medical University Hokkaido Japan
| | - Eichi Narimatsu
- Department of Emergency Medicine Sapporo Medical University Hokkaido Japan
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Ortuno S, Delmas C, Diehl JL, Bailleul C, Lancelot A, Naili M, Cholley B, Pirracchio R, Aissaoui N. Weaning from veno-arterial extra-corporeal membrane oxygenation: which strategy to use? Ann Cardiothorac Surg 2019; 8:E1-E8. [PMID: 30854330 DOI: 10.21037/acs.2018.08.05] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Refractory cardiogenic shock patients may be rescued by veno-arterial extracorporeal membrane oxygenation (VA ECMO). After a few days of mechanical assistance, the device can sometimes be successfully removed if the patient has partially or fully recovered from the condition that required the use of ECMO. The percentage of patients with refractory cardiogenic shock who are successfully weaned from ECMO varies from 31% to 76%. Weaning does not mean survival, because 20% to 65% of patients weaned from VA ECMO support do not survive to hospital discharge. The high death rate after successful weaning shows that many questions remain unresolved in this field. In this review, we will discuss the various factors influencing survival and a successful weaning from VA ECMO, in addition to weaning approaches proposed in the literature. Based on this information, we will propose a strategy to optimize the weaning process.
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Affiliation(s)
- Sofia Ortuno
- Department of Intensive Care Cnit, Hôpital Européen Georges Pompidou (HEGP) Assistance Publique-Hôpitaux de Paris (APHP) and Université Paris Descartes, Paris, France
| | - Clément Delmas
- Intensive Cardiac Care Unit, Rangueil University, Toulouse, France
| | - Jean-Luc Diehl
- Department of Intensive Care Cnit, Hôpital Européen Georges Pompidou (HEGP) Assistance Publique-Hôpitaux de Paris (APHP) and Université Paris Descartes, Paris, France
| | - Clotilde Bailleul
- Department of Intensive Care Cnit, Hôpital Européen Georges Pompidou (HEGP) Assistance Publique-Hôpitaux de Paris (APHP) and Université Paris Descartes, Paris, France
| | - Aymeric Lancelot
- Department of Intensive Care Cnit, Hôpital Européen Georges Pompidou (HEGP) Assistance Publique-Hôpitaux de Paris (APHP) and Université Paris Descartes, Paris, France
| | - Mahassen Naili
- Department of Cardiology, Hôpital Européen Georges Pompidou, APHP, Paris, France
| | - Bernard Cholley
- Department of Anesthesiology and Intensive Care, Paris, Hôpital Européen Georges Pompidou, APHP, Université Paris-Descartes, Paris, France
| | - Romain Pirracchio
- Department of Anesthesiology and Intensive Care, Paris, Hôpital Européen Georges Pompidou, APHP, Université Paris-Descartes, Paris, France
| | - Nadia Aissaoui
- Department of Intensive Care Cnit, Hôpital Européen Georges Pompidou (HEGP) Assistance Publique-Hôpitaux de Paris (APHP) and Université Paris Descartes, Paris, France.,Paris-Cardiovascular-Research-Center, INSERM U970, Paris, France
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49
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Le Guennec L, Cholet C, Huang F, Schmidt M, Bréchot N, Hékimian G, Besset S, Lebreton G, Nieszkowska A, Leprince P, Combes A, Luyt CE. Ischemic and hemorrhagic brain injury during venoarterial-extracorporeal membrane oxygenation. Ann Intensive Care 2018; 8:129. [PMID: 30570687 PMCID: PMC6301905 DOI: 10.1186/s13613-018-0475-6] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 12/15/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Structural neurological complications (ischemic stroke and intracranial bleeding) and their risk factors in patients receiving venoarterial-extracorporeal membrane oxygenation (VA-ECMO) are poorly described. Our objective was to describe frequencies, outcomes and risk factors for neurological complications (ischemic stroke and intracranial bleeding) in patients receiving VA-ECMO. METHODS Retrospective observational study conducted, from 2006 to 2014, in a tertiary referral center on patients who developed a neurological complication(s) on VA-ECMO. RESULTS Among 878 VA-ECMO-treated patients, 65 (7.4%) developed an ECMO-related brain injury: 42 (5.3%) ischemic strokes and 20 (2.8%) intracranial bleeding, occurring after a median [25th;75th percentile] of 11 [6;18] and 5 [2;9] days of support, respectively. Intracranial bleeding but not ischemic stroke was associated with higher mortality. Multivariable analysis retained only platelet level > 350 giga/L as being associated with ischemic stroke. Female sex, central VA-ECMO and platelets < 100 giga/L at ECMO start were independently associated with intracranial bleeding with respective odds ratios [95% CI] of 2.9 [1.1-7.5], 3.8 [1.1-10.2] and 3.7 [1.4-9.7]. In a nested case-control study, rapid CO2-level change from before-to-after ECMO start also seemed to be associated with intracranial bleeding. CONCLUSIONS Neurological events are frequent in VA-ECMO-treated patients. Ischemic stroke is the most frequent, occurs after 1 week on ECMO support, has no specific risk factor and is not associated with higher mortality. Intracranial bleeding occurs earlier and is associated with female sex, central VA-ECMO, low platelet count and rapid CO2 change at ECMO start, and high mortality. LEVEL OF EVIDENCE This study provides Class IV evidence that central VA-ECMO, low platelet count and rapid CO2 change at ECMO start are associated with intracranial bleeding and high mortality.
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Affiliation(s)
- Loïc Le Guennec
- Service de Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47, boulevard de l'Hôpital, 75013, Paris, France.
| | - Clémentine Cholet
- Service de Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47, boulevard de l'Hôpital, 75013, Paris, France
| | - Florent Huang
- Service de Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47, boulevard de l'Hôpital, 75013, Paris, France
| | - Matthieu Schmidt
- Service de Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47, boulevard de l'Hôpital, 75013, Paris, France.,UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Universités, UPMC Université Paris 06, INSERM, Paris, France
| | - Nicolas Bréchot
- Service de Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47, boulevard de l'Hôpital, 75013, Paris, France.,UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Universités, UPMC Université Paris 06, INSERM, Paris, France
| | - Guillaume Hékimian
- Service de Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47, boulevard de l'Hôpital, 75013, Paris, France
| | - Sébastien Besset
- Service de Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47, boulevard de l'Hôpital, 75013, Paris, France
| | - Guillaume Lebreton
- UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Universités, UPMC Université Paris 06, INSERM, Paris, France.,Service de Chirurgie Thoracique et Cardiovasculaire, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Ania Nieszkowska
- Service de Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47, boulevard de l'Hôpital, 75013, Paris, France
| | - Pascal Leprince
- UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Universités, UPMC Université Paris 06, INSERM, Paris, France.,Service de Chirurgie Thoracique et Cardiovasculaire, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alain Combes
- Service de Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47, boulevard de l'Hôpital, 75013, Paris, France.,UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Universités, UPMC Université Paris 06, INSERM, Paris, France
| | - Charles-Edouard Luyt
- Service de Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47, boulevard de l'Hôpital, 75013, Paris, France.,UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Universités, UPMC Université Paris 06, INSERM, Paris, France
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50
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Predictors of mid-term outcomes in patients undergoing implantation of a ventricular assist device directly after extracorporeal life support. Eur J Cardiothorac Surg 2018; 55:773-779. [DOI: 10.1093/ejcts/ezy351] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/23/2018] [Accepted: 09/13/2018] [Indexed: 01/07/2023] Open
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