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Seeber F, Krenner N, Sames-Dolzer E, Tulzer A, Srivastava I, Kreuzer M, Mair R, Gierlinger G, Nawrozi MP, Mair R. Outcome after extracorporeal membrane oxygenation therapy in Norwood patients before the bidirectional Glenn operation. Eur J Cardiothorac Surg 2024; 65:ezae153. [PMID: 38603622 DOI: 10.1093/ejcts/ezae153] [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: 12/18/2023] [Revised: 02/26/2024] [Accepted: 04/09/2024] [Indexed: 04/13/2024] Open
Abstract
OBJECTIVES Patients after the Norwood procedure are prone to postoperative instability. Extracorporeal membrane oxygenation (ECMO) can help to overcome short-term organ failure. This retrospective single-centre study examines ECMO weaning, hospital discharge and long-term survival after ECMO therapy between Norwood and bidirectional Glenn palliation as well as risk factors for mortality. METHODS In our institution, over 450 Norwood procedures have been performed. Since the introduction of ECMO therapy, 306 Norwood operations took place between 2007 and 2022, involving ECMO in 59 cases before bidirectional Glenn. In 48.3% of cases, ECMO was initiated intraoperatively post-Norwood. Patient outcomes were tracked and mortality risk factors were analysed using uni- and multivariable testing. RESULTS ECMO therapy after Norwood (median duration: 5 days; range 0-17 days) saw 31.0% installed under CPR. Weaning was achieved in 46 children (78.0%), with 55.9% discharged home after a median of 45 (36-66) days. Late death occurred in 3 patients after 27, 234 and 1541 days. Currently, 30 children are in a median 4.8 year (3.4-7.7) follow-up. At the time of inquiry, 1 patient awaits bidirectional Glenn, 6 are at stage II palliation, Fontan was completed in 22 and 1 was lost to follow-up post-Norwood. Risk factor analysis revealed dialysis (P < 0.001), cerebral lesions (P = 0.026), longer ECMO duration (P = 0.002), cardiac indication and lower body weight (P = 0.038) as mortality-increasing factors. The 10-year mortality probability after ECMO therapy was 48.5% (95% CI 36.5-62.9%). CONCLUSIONS ECMO therapy in critically ill patients after the Norwood operation may significantly improve survival of a patient cohort otherwise forfeited and give the opportunity for successful future-stage operations.
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Affiliation(s)
- Fabian Seeber
- Department of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Krankenhausstraße 9, Linz 4020, Austria
- Medical Faculty, Johannes Kepler University, Krankenhausstraße 5, Linz 4020, Austria
| | - Niklas Krenner
- Department of Cardiothoracic and Vascular Surgery, Kepler University Hospital, Krankenhausstraße 9, Linz 4020, Austria
| | - Eva Sames-Dolzer
- Department of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Krankenhausstraße 9, Linz 4020, Austria
- Medical Faculty, Johannes Kepler University, Krankenhausstraße 5, Linz 4020, Austria
| | - Andreas Tulzer
- Medical Faculty, Johannes Kepler University, Krankenhausstraße 5, Linz 4020, Austria
- Department of Pediatric Cardiology, Kepler University Hospital, Krankenhausstraße 26-30, Linz 4020, Austria
| | - Ishita Srivastava
- Department of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Krankenhausstraße 9, Linz 4020, Austria
| | - Michaela Kreuzer
- Department of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Krankenhausstraße 9, Linz 4020, Austria
- Medical Faculty, Johannes Kepler University, Krankenhausstraße 5, Linz 4020, Austria
| | - Roland Mair
- Department of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Krankenhausstraße 9, Linz 4020, Austria
- Medical Faculty, Johannes Kepler University, Krankenhausstraße 5, Linz 4020, Austria
| | - Gregor Gierlinger
- Department of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Krankenhausstraße 9, Linz 4020, Austria
- Medical Faculty, Johannes Kepler University, Krankenhausstraße 5, Linz 4020, Austria
| | - Mohammad-Paimann Nawrozi
- Medical Faculty, Johannes Kepler University, Krankenhausstraße 5, Linz 4020, Austria
- Department of Cardiothoracic and Vascular Surgery, Kepler University Hospital, Krankenhausstraße 9, Linz 4020, Austria
| | - Rudolf Mair
- Department of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Krankenhausstraße 9, Linz 4020, Austria
- Medical Faculty, Johannes Kepler University, Krankenhausstraße 5, Linz 4020, Austria
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2
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Duarte CM, Lopes MI, Abecasis F. Transfusion policy in pediatric extracorporeal membrane oxygenation patients: Less could be more. Perfusion 2024; 39:96-105. [PMID: 35634987 DOI: 10.1177/02676591221105610] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To evaluate a restrictive transfusion policy of red blood cells (RBC) and platelets in pediatric patients submitted to extracorporeal membrane oxygenation (ECMO). METHODS Retrospective descriptive study of pediatric patients supported with ECMO, from January 2010 to December 2019. Hemoglobin, platelet, lactate and mixed venous oxygen saturation (SvO2) values of each patient while on ECMO, were collected. Transfusion efficiency and tissue oxygenation were statistically evaluated comparing pre-transfusion hemoglobin, lactate and SvO2 with post-transfusion values. Ranges of hemoglobin and platelets were established, and the number of transfusions registered. The bleeding complications and outcome were documented. RESULTS Of a total of 1016 hemoglobin values, the mean value before transfusion was 8.6 g/dl. Hemoglobin and SvO2 increased significantly post-transfusion. Red blood cell transfusion varied with hemoglobin values: when hemoglobin value was less than 7 g/dl, 89% (41/46) were transfused but just 23% (181/794) when greater or equal to 7 g/dl. In the presence of active bleeding, the frequency of RBC transfusion increased from 32% to 62%, with hemoglobin between 7 g/dl and 8 g/dl.The mean value for platelet transfusion was 32 x 109/L. Thirty-eight (43%) platelet values between 20 x 109/L and 30x109/L, and 31 (40%) between 30 x 109/L and 40 x 109/L led to platelet transfusion; between 40 x 109/L and 50 x 109/L, only 7 (9%) prompted platelet transfusion.Comparing the 2010-2015 to 2016-2019 periods there was a decrease in RBC and platelet transfusion threshold with similar survival (p = .528). Survival to discharge was 68%. CONCLUSIONS Using a restrictive RBC and platelet transfusion policy was safe and allowed a good outcome in this case series. The presence of active bleeding was an important decision factor when hemoglobin was above 7 g/dl and platelets were above 30 x 109/L.
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Affiliation(s)
- Catarina Marques Duarte
- Pediatric Department Lisbon Academic Medical Center, Hospital Santa Maria (CHULN), Lisbon, Portugal
| | - Maria Inȇs Lopes
- Lisbon Academic Medical Center, Hospital Santa Maria (CHULN), Lisbon, Portugal
| | - Francisco Abecasis
- Pediatric Intensive Care Unit, Pediatric Department, Lead of Pediatric Interhospital Transport System and Neonatal and Pediatric ECMO program, Hospital Santa Maria (CHULN), Portugal
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3
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Wang J, Wang S, Song Y, Huang M, Cao W, Liu S, Chen S, Li X, Liu M, He Y. Analysis of 24-hour Death Risk Factors in Circulatory Failure Patients Treated with Venoarterial Extracorporeal Membrane Oxygenation. Braz J Cardiovasc Surg 2023; 38:e20220398. [PMID: 37801399 PMCID: PMC10550103 DOI: 10.21470/1678-9741-2022-0398] [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: 04/01/2022] [Accepted: 12/27/2022] [Indexed: 10/08/2023] Open
Abstract
OBJECTIVE To explore the factors affecting short-term prognosis of circulatory failure patients undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO) treatment. METHODS A total of 136 patients undergoing VA-ECMO were enrolled in this study and subsequently divided into the death group (n=35) and the survival group (n=101) based on whether death occurred during hospitalisation. Extracorporeal membrane oxygenation (ECMO) running time, length of intensive care unit stay, length of hospital stay, costs, and ECMO complications were then compared between the two groups. RESULTS The average age of all patients undergoing ECMO was 47.64±16.78 years (53.2±16.20 years in the death group and 45.713±16.62 years in the survival group) (P=0.022). Patients in the survival group exhibited a clear downward trend in lactic acid value following ECMO treatment compared to those in the death group. Total hospitalisation stay was longer in the survival group (35 days) than in the death group (15.5 days) (P<0.001). In the analysis of ECMO complications, the incidence of neurological complications, renal failure, limb complications, and infection were higher in the death group than in the survival group (P<0.05 for all). Specifically, as a risk factor for patient survival and discharge, the occurrence of infection will lead to increased hospitalisation stays and costs (P<0.05 for both). CONCLUSION Complications such as kidney failure and infection are associated with in-hospital death, and ECMO-related complications should be actively prevented to improve the survival rate of VA-ECMO treatment.
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Affiliation(s)
- Jianwei Wang
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- Chinese People’s Liberation Army Medical School, Beijing, People’s
Republic of China
- Department of Critical Care Medicine, Puyang People’s Hospital,
Henan, People’s Republic of China
| | - Shengshu Wang
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
| | - Yang Song
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- Chinese People’s Liberation Army Medical School, Beijing, People’s
Republic of China
| | - MingJun Huang
- Department of Extracorporeal Support Center, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Wenzhe Cao
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- Chinese People’s Liberation Army Medical School, Beijing, People’s
Republic of China
| | - Shaohua Liu
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- Chinese People’s Liberation Army Medical School, Beijing, People’s
Republic of China
| | - Shimin Chen
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- Chinese People’s Liberation Army Medical School, Beijing, People’s
Republic of China
| | - Xuehang Li
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- Chinese People’s Liberation Army Medical School, Beijing, People’s
Republic of China
| | - Miao Liu
- Department of Statistics and Epidemiology, Graduate School, Chinese
People’s Liberation Army General Hospital, Beijing, People’s Republic of China
| | - Yao He
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- State Key Laboratory of Kidney Diseases, Beijing, People’s Republic
of China
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Deng B, Ying J, Mu D. Subtypes and Mechanistic Advances of Extracorporeal Membrane Oxygenation-Related Acute Brain Injury. Brain Sci 2023; 13:1165. [PMID: 37626521 PMCID: PMC10452596 DOI: 10.3390/brainsci13081165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a frequently used mechanical cardiopulmonary support for rescuing critically ill patients for whom conventional medical therapies have failed. However, ECMO is associated with several complications, such as acute kidney injury, hemorrhage, thromboembolism, and acute brain injury (ABI). Among these, ABI, particularly intracranial hemorrhage (ICH) and infarction, is recognized as the primary cause of mortality during ECMO support. Furthermore, survivors often suffer significant long-term morbidities, including neurocognitive impairments, motor disturbances, and behavioral problems. This review provides a comprehensive overview of the different subtypes of ECMO-related ABI and the updated advance mechanisms, which could be helpful for the early diagnosis and potential neuromonitoring of ECMO-related ABI.
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Affiliation(s)
- Bixin Deng
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China;
| | - Junjie Ying
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu 610041, China;
| | - Dezhi Mu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China;
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu 610041, China;
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Danzer E, Massey SL, Flohr SJ, Mathew L, Hoffman C, Abramson A, Selenski P, Canning CE, Eppley E, Connelly JT, Herkert L, Rintoul NE, Adzick NS, Abend NS, Hedrick HL. Extracorporeal Membrane Oxygenation for Neonates With Congenital Diaphragmatic Hernia: Prevalence of Seizures and Outcomes. Pediatr Crit Care Med 2023; 24:e224-e235. [PMID: 37140337 PMCID: PMC10160669 DOI: 10.1097/pcc.0000000000003197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
OBJECTIVES We aimed to determine the prevalence of electrographic seizures and associated odds of adverse outcomes of electrographic seizures in neonates with congenital diaphragmatic hernia (CDH) receiving extracorporeal membrane oxygenation (ECMO). DESIGN Retrospective, descriptive case series. SETTING Neonatal ICU (NICU) in a quaternary care institution. PATIENTS All neonates with CDH receiving ECMO undergoing continuous electroencephalographic monitoring (CEEG) and follow-up between January 2012 and December 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS All eligible neonates with CDH receiving ECMO underwent CEEG (n = 75). Electrographic seizures occurred in 14 of 75 (19%): they were exclusively electrographic-only in nine of 14, both electrographic-only and electroclinical in three of 14, and electroclinical only in two of 14. Two neonates developed status epilepticus. We identified an association between presence of seizures, rather than not, and longer duration of initial session of CEEG monitoring (55.7 hr [48.2-87.3 hr] vs 48.0 hr [43.0-48.3 hr]; p = 0.001). We also found an association between presence of seizures, rather than not, and greater odds of use of a second CEEG monitoring (12/14 vs 21/61; odds ratio [OR], 11.43 [95% CI, 2.34-55.90; p = 0.0026). Most neonates with seizures (10/14), experienced their onset of seizures more than 96 hours after the start of ECMO. Overall, the presence of electrographic seizures, compared with not, was associated with lower odds of survival to NICU discharge (4/14 vs 49/61; OR 0.10 [95% CI 0.03 to 0.37], p = 0.0006). Also, the presence of seizures-rather than not-was associated with greater odds of a composite of death and all abnormal outcomes on follow-up (13/14 vs 26/61; OR, 17.5; 95% CI, 2.15-142.39; p = 0.0074). CONCLUSIONS Nearly one in five neonates with CDH receiving ECMO developed seizures during the ECMO course. Seizures were predominantly electrographic-only and when present were associated with great odds of adverse outcomes. The current study provides evidence to support standardized CEEG in this population.
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Affiliation(s)
- Enrico Danzer
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Shavonne L. Massey
- Department of Neurology and Pediatrics, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sabrina J. Flohr
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Leny Mathew
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Casey Hoffman
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Abigail Abramson
- Department of Neurology and Pediatrics, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paige Selenski
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Caroline E. Canning
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elizabeth Eppley
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - James T Connelly
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lisa Herkert
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Natalie E. Rintoul
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - N. Scott Adzick
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nicholas S. Abend
- Department of Neurology and Pediatrics, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Holly L. Hedrick
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Li Q, Wen C, Yang J, Zhou X, Zhu Y, Zheng J, Cheng G, Bai J, Xu T, Ji J, Jiang S, Zhang L, Zhang P. Zwitterionic Biomaterials. Chem Rev 2022; 122:17073-17154. [PMID: 36201481 DOI: 10.1021/acs.chemrev.2c00344] [Citation(s) in RCA: 122] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The term "zwitterionic polymers" refers to polymers that bear a pair of oppositely charged groups in their repeating units. When these oppositely charged groups are equally distributed at the molecular level, the molecules exhibit an overall neutral charge with a strong hydration effect via ionic solvation. The strong hydration effect constitutes the foundation of a series of exceptional properties of zwitterionic materials, including resistance to protein adsorption, lubrication at interfaces, promotion of protein stabilities, antifreezing in solutions, etc. As a result, zwitterionic materials have drawn great attention in biomedical and engineering applications in recent years. In this review, we give a comprehensive and panoramic overview of zwitterionic materials, covering the fundamentals of hydration and nonfouling behaviors, different types of zwitterionic surfaces and polymers, and their biomedical applications.
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Affiliation(s)
- Qingsi Li
- Department of Biochemical Engineering, Frontier Science Center for Synthetic Biology and Key Laboratory of Systems Bioengineering (MOE), School of Chemical Engineering and Technology, Tianjin University, Tianjin, 300350, China
| | - Chiyu Wen
- Department of Biochemical Engineering, Frontier Science Center for Synthetic Biology and Key Laboratory of Systems Bioengineering (MOE), School of Chemical Engineering and Technology, Tianjin University, Tianjin, 300350, China
| | - Jing Yang
- Department of Biochemical Engineering, Frontier Science Center for Synthetic Biology and Key Laboratory of Systems Bioengineering (MOE), School of Chemical Engineering and Technology, Tianjin University, Tianjin, 300350, China
| | - Xianchi Zhou
- MOE Key Laboratory of Macromolecule Synthesis and Functionalization, Department of Polymer Science and Engineering, Zhejiang University, Hangzhou, 310027, China
| | - Yingnan Zhu
- Institute of Drug Discovery and Development, School of Pharmaceutical Sciences, Center for Drug Safety Evaluation and Research, Zhengzhou University, Zhengzhou 450001, China
| | - Jie Zheng
- Department of Chemical, Biomolecular, and Corrosion Engineering, The University of Akron, Akron, Ohio 44325, United States
| | - Gang Cheng
- Department of Chemical Engineering, The University of Illinois at Chicago, Chicago, Illinois 60607, United States
| | - Jie Bai
- College of Chemical Engineering, Inner Mongolia University of Technology, Hohhot, Inner Mongolia 010051, China
| | - Tong Xu
- College of Chemical Engineering, Inner Mongolia University of Technology, Hohhot, Inner Mongolia 010051, China
| | - Jian Ji
- MOE Key Laboratory of Macromolecule Synthesis and Functionalization, Department of Polymer Science and Engineering, Zhejiang University, Hangzhou, 310027, China
| | - Shaoyi Jiang
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York 14853, United States
| | - Lei Zhang
- Department of Biochemical Engineering, Frontier Science Center for Synthetic Biology and Key Laboratory of Systems Bioengineering (MOE), School of Chemical Engineering and Technology, Tianjin University, Tianjin, 300350, China
| | - Peng Zhang
- MOE Key Laboratory of Macromolecule Synthesis and Functionalization, Department of Polymer Science and Engineering, Zhejiang University, Hangzhou, 310027, China
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Petrella F, Zorzino L, Frassoni S, Bagnardi V, Casiraghi M, Bardoni C, Mohamed S, Musso V, Simonini E, Rossi F, Alamanni F, Venturino M, Spaggiari L. Intraoperative Extra Corporeal Membrane Oxygenator for Lung Cancer Resections Does Not Impact Circulating Tumor Cells. Cancers (Basel) 2022; 14:cancers14205004. [PMID: 36291788 PMCID: PMC9599645 DOI: 10.3390/cancers14205004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/04/2022] [Accepted: 10/11/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary The diagnosis of active neoplastic disease was traditionally judged an absolute contraindication for extracorporeal membrane oxygenator (ECMO) because of long-term results uncertainty and co-existing acquired coagulation disorders often diagnosed in this group of patients. There is a growing body of evidence that circulating tumor cells (CTCs) can be detected in the blood of patients before the primary tumor is diagnosed and in the case of carcinoma recurrence; moreover, on some occasions, they persist in the blood of patients after radical resection of the primary tumor. The aim of this prospective, two-arm study is to compare the number of CTCs before and after surgery in patients undergoing lung cancer resection with and without intraoperative ECMO support. Intraoperative ECMO for lung cancer resections did not impact CTC variation after the procedure and did not impact postoperative complications, ICU stay, hospital total length of stay, and post operative C-reactive protein increase. Abstract Background: The diagnosis of active neoplastic disease was traditionally judged an absolute contraindication for extracorporeal membrane oxygenator (ECMO) because of the fear of tumor cells being scattered or seeded. The aim of this study is to compare the number of circulating tumor cells (CTCs) before and after surgery in patients receiving lung cancer resection with and without intraoperative ECMO support. Methods: This is a prospective, non-randomized, two-arms observational study comparing the number of CTCs before and after surgery in patients receiving lung cancer resection with and without intraoperative ECMO support. The ECMO arm includes patients suffering from lung cancer undergoing pulmonary resection with planned intraoperative ECMO support. The non-ECMO arm includes patients suffering from non-early-stage lung cancer undergoing pulmonary resection without planned intraoperative ECMO support. Results: Twenty patients entered the study, eight in the ECMO arm and twelve in the non-ECMO arm. We did not observe any significant difference between the ECMO and non-ECMO groups in terms of postoperative complications (p = 1.00), ICU stay (p = 0.30), hospital stay (p = 0.23), circulating tumor cells’ increase or decrease after surgery (p = 0.24), and postoperative C-reactive protein and C-reactive protein increase (p = 0.80). The procedures in the non-ECMO arm were significantly longer than those in the ECMO arm (p = 0.043). Conclusions: Intraoperative ECMO for lung cancer resections did not impact CTC increase or decrease after the procedure.
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Affiliation(s)
- Francesco Petrella
- Department of Thoracic Surgery, IRCCS European Institute of Oncology, 20141 Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
- Correspondence: or ; Tel.: +39-0257-489-362; Fax: +39-0294-379-218
| | - Laura Zorzino
- Division of Laboratory Medicine, IRCCS European Institute of Oncology, 20141 Milan, Italy
| | - Samuele Frassoni
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, 20126 Milan, Italy
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, 20126 Milan, Italy
| | - Monica Casiraghi
- Department of Thoracic Surgery, IRCCS European Institute of Oncology, 20141 Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Claudia Bardoni
- Department of Thoracic Surgery, IRCCS European Institute of Oncology, 20141 Milan, Italy
| | - Shehab Mohamed
- Department of Thoracic Surgery, IRCCS European Institute of Oncology, 20141 Milan, Italy
| | - Valeria Musso
- Department of Thoracic Surgery, IRCCS European Institute of Oncology, 20141 Milan, Italy
| | - Emanuele Simonini
- Department of Thoracic Surgery, IRCCS European Institute of Oncology, 20141 Milan, Italy
| | - Fabiana Rossi
- Department of Cardiovascular Surgery, IRCCS Centro Cardiologico Monzino, 20138 Milan, Italy
| | - Francesco Alamanni
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
- IRCCS Galeazzi Sant’Ambrogio, Cardiochirurgia Universitaria, 20157 Milan, Italy
| | - Marco Venturino
- Department of Anesthesiology, IRCCS European Institute of Oncology, 20141 Milan, Italy
| | - Lorenzo Spaggiari
- Department of Thoracic Surgery, IRCCS European Institute of Oncology, 20141 Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
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8
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Ono M, Yamaguchi O, Ohtani T, Kinugawa K, Saiki Y, Sawa Y, Shiose A, Tsutsui H, Fukushima N, Matsumiya G, Yanase M, Yamazaki K, Yamamoto K, Akiyama M, Imamura T, Iwasaki K, Endo M, Ohnishi Y, Okumura T, Kashiwa K, Kinoshita O, Kubota K, Seguchi O, Toda K, Nishioka H, Nishinaka T, Nishimura T, Hashimoto T, Hatano M, Higashi H, Higo T, Fujino T, Hori Y, Miyoshi T, Yamanaka M, Ohno T, Kimura T, Kyo S, Sakata Y, Nakatani T. JCS/JSCVS/JATS/JSVS 2021 Guideline on Implantable Left Ventricular Assist Device for Patients With Advanced Heart Failure. Circ J 2022; 86:1024-1058. [PMID: 35387921 DOI: 10.1253/circj.cj-21-0880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo
| | - Osamu Yamaguchi
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine
| | - Tomohito Ohtani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Koichiro Kinugawa
- Second Department of Internal Medicine, Faculty of Medicine, University of Toyama
| | - Yoshikatsu Saiki
- Department of Cardiovascular Surgery, Tohoku University Graduate School of Medicine
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Akira Shiose
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kyushu University
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University
| | - Norihide Fukushima
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Goro Matsumiya
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine
| | - Masanobu Yanase
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Kenji Yamazaki
- Advanced Medical Research Institute, Hokkaido Cardiovascular Hospital
| | - Kazuhiro Yamamoto
- Department of Cardiovascular Medicine and Endocrinology and Metabolism, Faculty of Medicine, Tottori University
| | - Masatoshi Akiyama
- Department of Cardiovascular Surgery, Tohoku University Graduate School of Medicine
| | - Teruhiko Imamura
- Second Department of Internal Medicine, Faculty of Medicine, University of Toyama
| | - Kiyotaka Iwasaki
- Cooperative Major in Advanced Biomedical Sciences, Graduate School of Advanced Science and Engineering, Waseda University
| | - Miyoko Endo
- Department of Nursing, The University of Tokyo Hospital
| | - Yoshihiko Ohnishi
- Department of Anesthesiology, National Cerebral and Cardiovascular Center
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Koichi Kashiwa
- Department of Medical Engineering, The University of Tokyo Hospital
| | - Osamu Kinoshita
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | - Kaori Kubota
- Department of Transplantation Medicine, Osaka University Graduate School of Medicine
| | - Osamu Seguchi
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Hiroshi Nishioka
- Department of Clinical Engineering, National Cerebral and Cardiovascular Center
| | - Tomohiro Nishinaka
- Department of Artificial Organs, National Cerebral and Cardiovascular Center
| | - Takashi Nishimura
- Department of Cardiovascular and Thoracic Surgery, Ehime University Hospital
| | - Toru Hashimoto
- Department of Cardiovascular Medicine, Kyushu University Hospital
| | - Masaru Hatano
- Department of Therapeutic Strategy for Heart Failure, Graduate School of Medicine, The University of Tokyo
| | - Haruhiko Higashi
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine
| | - Taiki Higo
- Department of Cardiovascular Medicine, Kyushu University Hospital
| | - Takeo Fujino
- Department of Cardiovascular Medicine, Kyushu University Hospital
| | - Yumiko Hori
- Department of Nursing and Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Toru Miyoshi
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine
| | | | - Takayuki Ohno
- Department of Cardiovascular Surgery, Mitsui Memorial Hospital
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine and Faculty of Medicine, Kyoto University
| | | | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
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9
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Huang W, Ye H, Cheng Z, Liao X, Wang L, Li B, Liang Y, Jiang H. Outcomes from the Use of Perioperative Extracorporeal Membrane Oxygenation in Patients Undergoing Thoracic Surgery: An 8-Year Single-Center Experience. Med Sci Monit 2021; 27:e931842. [PMID: 34725316 PMCID: PMC8570047 DOI: 10.12659/msm.931842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Extracorporeal membrane oxygenation (ECMO) plays an important role in thoracic surgery. This retrospective study from a single center aimed to evaluate patient outcomes from the use of perioperative ECMO in 22 patients undergoing thoracic surgery during an 8-year period. Material/Methods Data were collected retrospectively from 22 patients who received ECMO (veno-arterial and veno-venous ECMO) as perioperative treatment during general thoracic surgery from January 2012 to October 2020. Patients required ECMO due to perioperative cardiopulmonary resuscitation (CPR) (2 cases), perioperative pulmonary embolism (PE) (2 cases), lung transplant (4 cases), undergoing complicated thoracic surgery (5 cases), postoperative acute respiratory distress syndrome (ARDS) (6 cases), and thoracic trauma (3 cases). Results Veno-arterial ECMO was used for circulatory support in 13 cases and veno-venous ECMO was used for respiratory support in 9 cases. The average ECMO support time was 71.6±42.4 h. Twenty patients (90.9%) were successfully decannulated and 17 (77.2%) survived to discharge. Complications included severe hemorrhage (3/22 patients, 13.6%), sepsis (3/22, 13.6%), and destruction of blood cells (1/22, 4.5%). There were no significant differences in survival rates between patients receiving pre- or postoperative ECMO (P=0.135) or between veno-venous ECMO (V-V ECMO) and veno-arterial ECMO (V-A ECMO) (P=0.550). Conclusions The findings from this small retrospective study from a single center showed that perioperative ECMO improved cardiac and respiratory function in patients undergoing thoracic surgery. Optimal results require surgeons to have an understanding of the indications and ability to control the complications of ECMO.
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Affiliation(s)
- Weizhao Huang
- Department of Cardiothoracic Surgery, Zhongshan Hospital of Sun Yat-Sen University (Zhongshan People's Hospital), Zhongshan, Guangdong, China (mainland)
| | - Hongyu Ye
- Department of Cardiothoracic Surgery, Zhongshan Hospital of Sun Yat-Sen University (Zhongshan People's Hospital), Zhongshan, Guangdong, China (mainland)
| | - Zhou Cheng
- Department of Anesthesiology, Zhongshan Hospital of Sun Yat-Sen University (Zhongshan City People's Hospital), Zhongshan, Guangdong, China (mainland)
| | - Xiaozu Liao
- Department of Anesthesiology, Zhongshan Hospital of Sun Yat-Sen University (Zhongshan City People's Hospital), Zhongshan, Guangdong, China (mainland)
| | - Liqiang Wang
- Department of Anesthesiology, Zhongshan Hospital of Sun Yat-Sen University (Zhongshan City People's Hospital), Zhongshan, Guangdong, China (mainland)
| | - Binfei Li
- Department of Anesthesiology, Zhongshan Hospital of Sun Yat-Sen University (Zhongshan City People's Hospital), Zhongshan, Guangdong, China (mainland)
| | - Yi Liang
- Department of Cardiothoracic Surgery, Zhongshan Hospital of Sun Yat-Sen University (Zhongshan People's Hospital), Zhongshan, Guangdong, China (mainland)
| | - Haiming Jiang
- Department of Cardiothoracic Surgery, Zhongshan Hospital of Sun Yat-Sen University (Zhongshan People's Hospital), Zhongshan, Guangdong, China (mainland)
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10
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Boeken U, Assmann A, Beckmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan A, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Groesdonk H, Ferrari M, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel L, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Fischer S, Wiebe K, Hartog CS, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Kelm M, Ensminger S. S3 Guideline of Extracorporeal Circulation (ECLS/ECMO) for Cardiocirculatory Failure. Thorac Cardiovasc Surg 2021; 69:S121-S212. [PMID: 34655070 DOI: 10.1055/s-0041-1735490] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Udo Boeken
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Alexander Assmann
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Andreas Beckmann
- German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Karl Werdan
- Clinic for Internal Medicine III, University Hospital Halle (Saale), Martin-Luther University Halle-Wittenberg, Germany
| | - Guido Michels
- Department of Acute and Emergency Care, St Antonius Hospital Eschweiler, Eschweiler, Germany
| | - Oliver Miera
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Florian Schmidt
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Germany
| | - Stefan Klotz
- Department of Cardiac Surgery, Segeberger Kliniken, Bad Segeberg, Germany
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre, Berlin, German
| | - Kevin Pilarczyk
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Ardawan Rastan
- Department of Cardiac and Vascular Thoracic Surgery, Philipps-University Hospital Marburg, Marburg, Germany
| | - Marion Burckhardt
- Department of Health Sciences and Management; Baden-Wuerttemberg Cooperative State University (DHBW), Stuttgart, Germany
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies (AWMF), Universität Marburg, Marburg, Germany
| | - Ralf Muellenbach
- Department of Anaesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - York Zausig
- Department of Anesthesiology and Operative Intensive Care Medicine, Aschaffenburg-Alzenau Hospital, Aschaffenburg, Bavaria, Germany
| | - Nils Haake
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Heinrich Groesdonk
- Department of Intensive Care Medicine, Helios Clinic Erfurt, Erfurt, Germany
| | - Markus Ferrari
- HSK, Clinic of Internal Medicine I, Helios-Kliniken, Wiesbaden, Germany
| | - Michael Buerke
- Department of Cardiology, Angiology and Intensive Care Medicine, St. Marienkrankenhaus Siegen, Siegen, Germany
| | - Marcus Hennersdorf
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, SLK-Kliniken Heilbronn, Heilbronn, Germany
| | - Mark Rosenberg
- Klinikum Aschaffenburg-Alzenau, Medizinische Klinik 1, Aschaffenburg, Germany
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Harald Köditz
- Medical University Children's Hospital, Hannover, Germany
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St Antonius Hospital, Eschweiler, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Flemmer
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Munich, Germany
| | - Susanne Herber-Jonat
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Germany
| | - Lucas Wessel
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Dirk Buchwald
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | - Lars Krüger
- Division of Thoracic and Cardiovascular Surgery, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | - Andreas Fründ
- Department of Physiotherapy, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | | | - Stefan Fischer
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Karsten Wiebe
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Christiane S Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, and Klinik Bavaria, Kreischa
| | - Omer Dzemali
- Department of Cardiac Surgery, Triemli City hospital Zurich, Zurich, Switzerland
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Christian Schlensak
- Department of Cardio-Thoracic and Vascular Surgery, University of Tübingen, Tübingen, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig-Holstein, Lübeck, Germany
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11
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Erdem Ö, Kuiper JW, Houmes RJ, van Ommen CH, van Rosmalen J, Tibboel D, Wildschut ED. Coagulation complications after conversion from roller to centrifugal pump in neonatal and pediatric extracorporeal membrane oxygenation. J Pediatr Surg 2021; 56:1378-1385. [PMID: 33279215 DOI: 10.1016/j.jpedsurg.2020.11.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 11/01/2020] [Accepted: 11/11/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND/PURPOSE Coagulation complications are frequent, unwanted occurrences in extracorporeal membrane oxygenation (ECMO) treatment, possibly influenced by the pump in the ECMO-circuit. We hypothesized that fewer complications would occur with a smaller, heparin-coated ECMO system with a centrifugal pump (CP) than with one with a roller pump (RP) and that after conversion, complication rates would decrease over time. METHODS This single-center, retrospective chart study included all first neonatal and pediatric ECMO runs between 2009 and 2015. Differences between groups were assessed with Mann-Whitney U tests and Kruskal-Wallis tests. Determinants of complication rates were evaluated through Poisson regression models. The CP group was divided into three consecutive groups to assess whether complication rates decreased over time. RESULTS The RP group comprised 90 ECMO runs and the CP group 82. Hemorrhagic complication rates were significantly higher with the CP than with the RP, without serious therapeutic consequences, while thrombotic complications rates were unaffected. Intracranial hemorrhage rates and coagulation-related mortality rates were similar. Gained experience with the CP did not improve complication rates or survival over time. CONCLUSIONS Although the CP seems safe, it does not seem beneficial over the RP. Further research is warranted on how pump type affects coagulation, taking into account the severity and implications of coagulation complications. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Özge Erdem
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center - Sophia Children's Hospital, Dr. Molewaterplein 40, 3015GD, Rotterdam, the Netherlands
| | - Jan Willem Kuiper
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center - Sophia Children's Hospital, Dr. Molewaterplein 40, 3015GD, Rotterdam, the Netherlands.
| | - Robert Jan Houmes
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center - Sophia Children's Hospital, Dr. Molewaterplein 40, 3015GD, Rotterdam, the Netherlands
| | - Cornelia Heleen van Ommen
- Department of Pediatric Hematology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center - Sophia Children's Hospital, Dr. Molewaterplein 40, 3015GD, Rotterdam, the Netherlands
| | - Enno Diederik Wildschut
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center - Sophia Children's Hospital, Dr. Molewaterplein 40, 3015GD, Rotterdam, the Netherlands
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12
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Dipresa D, Kalozoumis P, Pflaum M, Peredo A, Wiegmann B, Haverich A, Korossis S. Hemodynamic Assessment of Hollow-Fiber Membrane Oxygenators Using Computational Fluid Dynamics in Heterogeneous Membrane Models. J Biomech Eng 2021; 143:051010. [PMID: 33462588 DOI: 10.1115/1.4049808] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Indexed: 07/25/2024]
Abstract
Extracorporeal membrane oxygenation (ECMO) has been used clinically for more than 40 years as a bridge to transplantation, with hollow-fiber membrane (HFM) oxygenators gaining in popularity due to their high gas transfer and low flow resistance. In spite of the technological advances in ECMO devices, the inevitable contact of the perfused blood with the polymer hollow-fiber gas-exchange membrane, and the subsequent thrombus formation, limits their clinical usage to only 2-4 weeks. In addition, the inhomogeneous flow in the device can further enhance thrombus formation and limit gas-transport efficiency. Endothelialization of the blood contacting surfaces of ECMO devices offers a potential solution to their inherent thrombogenicity. However, abnormal shear stresses and inhomogeneous blood flow might affect the function and activation status of the seeded endothelial cells (ECs). In this study, the blood flow through two HFM oxygenators, including the commercially available iLA® MiniLung Petite Novalung (Xenios AG, Germany) and an experimental one for the rat animal model, was modeled using computational fluid dynamics (CFD), with a view to assessing the magnitude and distribution of the wall shear stress (WSS) on the hollow fibers and flow fields in the oxygenators. This work demonstrated significant inhomogeneity in the flow dynamics of both oxygenators, with regions of high hollow-fiber WSS and regions of stagnant flow, implying a variable flow-induced stimulation on seeded ECs and possible EC activation and damage in a biohybrid oxygenator setting.
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Affiliation(s)
- Daniele Dipresa
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Hannover 30625, Germany; Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School, Hannover 30625, Germany
| | - Panagiotis Kalozoumis
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Hannover 30625, Germany; Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School, Hannover 30625, Germany
| | - Michael Pflaum
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Hannover 30625, Germany; Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School, Hannover 30625, Germany
| | - Ariana Peredo
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Hannover 30625, Germany; Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School, Hannover 30625, Germany
| | - Bettina Wiegmann
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Hannover 30625, Germany; Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School, Hannover 30625, Germany; German Centre for Lung Research (DZL), BREATH, Hannover Medical School, Hannover 30625, Germany
| | - Axel Haverich
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Hannover 30625, Germany; Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School, Hannover 30625, Germany; German Centre for Lung Research (DZL), BREATH, Hannover Medical School, Hannover 30625, Germany
| | - Sotirios Korossis
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Hannover 30625, Germany; Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School, Hannover 30625, Germany; German Centre for Lung Research (DZL), BREATH, Hannover Medical School, Hannover 30625, Germany; Cardiopulmonary Regenerative Engineering (CARE) Group, Centre for Biological Engineering (CBE), Wolfson School of Mechanical, Electrical and Manufacturing Engineering, Loughborough University, Loughborough LE11 3TU, UK
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13
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Bellomo TR, Jeakle MA, Meyerhoff ME, Bartlett RH, Major TC. The Effects of the Combined Argatroban/Nitric Oxide-Releasing Polymer on Platelet Microparticle-Induced Thrombogenicity in Coated Extracorporeal Circuits. ASAIO J 2021; 67:573-582. [PMID: 33902103 PMCID: PMC8083987 DOI: 10.1097/mat.0000000000001256] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Clotting, anticoagulation, platelet consumption, and poor platelet function are major factors in clinical extracorporeal circulation (ECC). We have shown that nitric oxide-releasing (NOReL) coatings prevent thrombosis in a rabbit model of ECC without systemic anticoagulation. Nitric oxide-releasing prevents platelet adhesion and activation, resulting in preserved platelet count and function. Previous work has shown that activated platelets form platelet-derived microparticles (PMPs). These experiments were designed to determine if PMPs can identify platelet function during ECC. The objective of this study is to investigate the effects of NOReL on platelet activation and PMP formation during ECC. Uncoated ECCs, including with and without systemic heparin, and NOReL-coated ECCs, including DBHD/N2O2 and argatroban (AG)/DBHD/N2O2-coated ECCs without systemic heparin, were tested in a 4-hour rabbit thrombogenicity model. Before and after ECC exposure, platelets were stimulated with collagen, and PMPs were measured using flow cytometry. The uncoated ECCs clotted within the first hour, while the NOReL-coated ECCs circulated for 4 hours. During pre-ECC blood exposure, platelets stimulated with collagen produced PMPs. With post-ECC exposure, platelets from uncoated circuits generated less PMPs than baseline (mean ± SDs: 23246 ± 3611 baseline vs. 1300 ± 523 uncoated post circuit, p = 0.018) when stimulated with collagen. However, platelets from the AG/DBHD/N2O2-coated ECCs generated a greater number of PMPs as baseline values (23246 ± 3611 baseline vs. 37040 ± 3263 AG/DBHD/N2O2 post 4 hours circuit, p = 0.023). Blood exposure during ECC results in platelet activation and clotting in uncoated ECCs. The remaining circulating platelets have lost function, as demonstrated by the low PMP formation in response to collagen. AG/DBHD/N2O2-coated ECCs prevented significant platelet activation and clotting, while DBHD/N2O2 trended towards prevention of platelet activation. In addition, function of the circulating platelets was preserved, as demonstrated by PMP formation in response to collagen. These results indicate that PMPs may be an important measure of platelet activation during ECC. Platelet-derived microparticles may provide a simplified way to measure platelet function during clinical ECC.
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Affiliation(s)
- Tiffany R Bellomo
- From the Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Mark A Jeakle
- From the Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Mark E Meyerhoff
- Department of Chemistry, University of Michigan, Ann Arbor, Michigan
| | - Robert H Bartlett
- From the Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Terry C Major
- From the Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan
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14
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Current Trends and Critical Care Considerations for the Management of Single Ventricle Neonates. CURRENT PEDIATRICS REPORTS 2020. [DOI: 10.1007/s40124-020-00227-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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15
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Abstract
Extracorporeal membrane oxygenation (ECMO) is a supportive therapy for patients with severe cardiovascular or respiratory failure refractory to conventional medical therapy. Improvements in ECMO technology, easy access to ECMO devices, and a greater understanding of care of ECMO patients have led to increased utilization of ECMO. The Extracorporeal Life Support Organization (ELSO) registry was established in 1984, to collect data on patients receiving ECMO support to help improve outcomes of these patients. The registry has grown to include over 400 contributing centers from 60 countries with data for more than 90,000 patients. Many investigators have used the ELSO registry to answer clinical questions on outcomes and care of this vulnerable patient population. This report provides a brief summary of 16 peer-reviewed articles that have advanced the knowledge and treatment of neonates, children, and adults supported with ECMO using data from the ELSO registry.
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16
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Chen Z, Zhang J, Li T, Tran D, Griffith BP, Wu ZJ. The impact of shear stress on device-induced platelet hemostatic dysfunction relevant to thrombosis and bleeding in mechanically assisted circulation. Artif Organs 2019; 44:E201-E213. [PMID: 31849074 DOI: 10.1111/aor.13609] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/18/2019] [Accepted: 11/20/2019] [Indexed: 12/21/2022]
Abstract
The aim of this study was to examine the impact of the nonphysiological shear stress (NPSS) on platelet hemostatic function relevant to thrombosis and bleeding in mechanically assisted circulation. Fresh human blood was circulated for four hours in in vitro circulatory flow loops with a CentriMag blood pump operated under a flow rate of 4.5 L/min against three pressure heads (70 mm Hg, 150 mm Hg, and 350 mm Hg) at 2100, 2800, and 4000 rpm, respectively. Hourly blood samples from the CentriMag pump-assisted circulation loops were collected and analyzed for glycoprotein (GP) IIb/IIIa activation and receptor shedding of GPVI and GPIbα on the platelet surface with flow cytometry. Adhesion of platelets to fibrinogen, collagen, and von Willebrand factor (VWF) of the collected blood samples was quantified with fluorescent microscopy. In parallel, mechanical shear stress fields within the CentriMag pump operated under the three conditions were assessed by computational fluid dynamics (CFD) analysis. The experimental results showed that levels of platelet GPIIb/IIIa activation and platelet receptor shedding (GPVI and GPIbα) in the blood increased with increasing the circulation time. The levels of platelet activation and loss of platelet receptors GPVI and GPIbα were consistently higher with higher pressure heads at each increasing hour in the CentriMag pump-assisted circulation. The platelet adhesion on fibrinogen increased with increasing the circulation time for all three CentriMag operating conditions and was correlated well with the level of platelet activation. In contrast, the platelet adhesion on collagen and VWF decreased with increasing the circulation time under all the three conditions and was correlated well with the loss of the receptors GPVI and GPIbα on the platelet surface, respectively. The CFD results showed that levels of shear stresses inside the CentriMag pump under all three operating conditions exceeded the maximum level of shear stress in the normal physiological circulation and were strongly dependent on the pump operating condition. The level of platelet activation and loss of key platelet adhesion receptors (GPVI and GPIbα) were correlated with the level of NPSS generated by the CentriMag pump, respectively. In summary, the level of NPSS associated with pump operating condition is a critical determinant of platelet dysfunction in mechanically assisted circulation.
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Affiliation(s)
- Zengsheng Chen
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jiafeng Zhang
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Tieluo Li
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Douglas Tran
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Bartley P Griffith
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Zhongjun J Wu
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland.,Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, Maryland
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17
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Sabashnikov A, Merkle J, Azizov F, Djordjevic I, Eghbalzadeh K, Tunggal I, Weber C, Weixler V, Rustenbach C, Zeriouh M, Kröner A, Wahlers T, Bennink G. Early and long-term outcomes comparing neonates, infants, and preadolescents requiring extracorporeal membrane oxygenation for heart failure. Perfusion 2019; 35:323-330. [PMID: 31608760 DOI: 10.1177/0267659119876800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Application of extracorporeal membrane oxygenation in pediatric patients with severe heart failure steadily increases. Differentiation of outcomes and survival of diverse pediatric groups is of interest for adequate therapy. METHODS Between January 2008 and December 2016, a total of 39 pediatric patients needed veno-arterial extracorporeal membrane oxygenation support in our department. Patients were retrospectively divided into three groups: neonates (<30 days), infants (>30 days/<1 year), and toddlers/preadolescents (>1 year). Early outcomes as well as mid- and long-term survival up to 7-year follow-up were analyzed. RESULTS Basic demographics significantly differed in terms of age, height, and weight among the groups in accordance with the intended group categorization (p < 0.05). Survival after 30 days of extracorporeal membrane oxygenation application was equally distributed among the groups, and 44% of all patients survived. In terms of survival to discharge, no significant differences were found among groups. In total, 28% of patients survived up to 7 years. Infants were significantly more likely to undergo elective surgery (p < 0.001) and were predominantly weaned off extracorporeal membrane oxygenation, whereas need for urgent surgery (p < 0.001) was significantly higher in neonate group in comparison to other groups. Multinominal logistic regression analysis revealed significantly higher odds for need for re-exposure in infant group in comparison to toddler/preadolescent group as well as for incidence of neurological impairment of toddler/preadolescent group in comparison to neonate group (odds ratio = 14.67, p = 0.009 and odds ratio = 34.67, p = 0.004, respectively). Kaplan-Meier survival estimation analysis revealed no significant differences in terms of mid- and long-term survival among the groups (Breslow p = 0.198 and log-rank p = 0.213, respectively). CONCLUSION Veno-arterial extracorporeal membrane oxygenation is a lifesaving therapeutic chance for pediatric patients in the setting of either failure to wean from cardiopulmonary bypass or failed resuscitation from cardiac arrest. A fair part of patients could be saved by using this technology. Survival rate among the groups was similar.
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Affiliation(s)
- Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Julia Merkle
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Farid Azizov
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Irawati Tunggal
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Carolyn Weber
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Viktoria Weixler
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Christian Rustenbach
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Mohamed Zeriouh
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Axel Kröner
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Gerardus Bennink
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
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Esiaba I, Mousselli I, M. Faison G, M. Angeles D, S. Boskovic D. Platelets in the Newborn. NEONATAL MEDICINE 2019. [DOI: 10.5772/intechopen.86715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Valencia E, Nasr VG. Updates in Pediatric Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2019; 34:1309-1323. [PMID: 31607521 DOI: 10.1053/j.jvca.2019.09.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 08/30/2019] [Accepted: 09/05/2019] [Indexed: 01/28/2023]
Abstract
Extracorporeal membrane oxygenation is an increasingly used mode of life support for patients with cardiac and/or respiratory failure refractory to conventional therapy. This review provides a synopsis of the evolution of extracorporeal life support in neonates, infants, and children and offers a framework for areas in need of research. Specific aspects addressed are the changing epidemiology; technologic advancements in extracorporeal membrane oxygenation circuitry; the current status and future direction of anticoagulation management; sedative and analgesic strategies; and outcomes, with special attention to the lessons learned from neonatal survivors.
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Affiliation(s)
- Eleonore Valencia
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA.
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Schmidt AE, Israel AK, Refaai MA. The Utility of Thromboelastography to Guide Blood Product Transfusion. Am J Clin Pathol 2019; 152:407-422. [PMID: 31263903 DOI: 10.1093/ajcp/aqz074] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To provide an overview of the clot viscoelastic testing technology and to describe its utility in guiding blood product transfusions. METHODS A case scenario will be discussed as well as interpretation of thromboelastography (TEG) tracings. In addition, literature examining the utility of viscoelastic testing in guiding patient management and blood product transfusions will be reviewed. RESULTS TEG/rotational thromboelastometry (ROTEM) is useful in evaluating clot kinetics in trauma and acutely bleeding patients. TEG/ROTEM parameters are reflective of values measured using standard coagulation assays; however, TEG/ROTEM parameters are more rapidly available and more costly. TEG and ROTEM are used in three main settings: cardiac surgery, liver transplantation, and trauma to assess global hemostasis and administration of blood products. CONCLUSIONS TEG/ROTEM can be helpful in guiding resuscitation and blood product transfusion. Several studies have demonstrated a reduction in transfusion of blood components with TEG/ROTEM; however, other studies have suggested that TEG/ROTEM is not clinically effective in guiding transfusion.
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Affiliation(s)
- Amy E Schmidt
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
| | - Anna Karolina Israel
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
| | - Majed A Refaai
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
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Merkle J, Azizov F, Sabashnikov A, Weixler V, Weber C, Djordjevic I, Eghbalzadeh K, Kröner A, Zeriouh M, Wahlers T, Bennink G. Pediatric patients requiring extracorporeal membrane oxygenation in heart failure: 30‐day outcomes; mid‐ and long‐term survival. A single center experience. Artif Organs 2019; 43:966-975. [DOI: 10.1111/aor.13501] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 05/10/2019] [Accepted: 05/16/2019] [Indexed: 01/04/2023]
Affiliation(s)
- Julia Merkle
- Department of Cardiothoracic Surgery University Hospital of Cologne Cologne Germany
| | - Farid Azizov
- Department of Cardiothoracic Surgery University Hospital of Cologne Cologne Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery University Hospital of Cologne Cologne Germany
| | - Viktoria Weixler
- Department of Cardiothoracic Surgery University Hospital of Cologne Cologne Germany
| | - Carolyn Weber
- Department of Cardiothoracic Surgery University Hospital of Cologne Cologne Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery University Hospital of Cologne Cologne Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery University Hospital of Cologne Cologne Germany
| | - Axel Kröner
- Department of Cardiothoracic Surgery University Hospital of Cologne Cologne Germany
| | - Mohamed Zeriouh
- Department of Cardiothoracic Surgery University Hospital of Cologne Cologne Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery University Hospital of Cologne Cologne Germany
| | - Gerardus Bennink
- Department of Cardiothoracic Surgery University Hospital of Cologne Cologne Germany
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Karsan RB, Powell AG, Nanjaiah P, Mehta D, Valtzoglou V. The top 100 manuscripts in emergency cardiac surgery. Potential role in cardiothoracic training. A bibliometric analysis. Ann Med Surg (Lond) 2019; 43:5-12. [PMID: 31193454 PMCID: PMC6531840 DOI: 10.1016/j.amsu.2019.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 04/29/2019] [Accepted: 05/09/2019] [Indexed: 12/15/2022] Open
Abstract
Background Emergency Cardiac Surgery (ECS) is a component of cardiothoracic training. Citations are considered to represent a papers influence. Bibliometric analyses allow us to identify the most influential work, and future research. We aim to highlight the key research themes within ECS and determine their potential impact on cardiothoracic training. Methods Thomas Reuters Web of Science was searched using terms [Emergency AND Card* AND Surg*]. Results were ranked by citation and reviewed by a panel of cardiac surgeons to identify the top 100 cited papers relevant to ECS. Papers were analysed by topic, journal and impact. Regression analysis was used to determine a link between impact factor and scientific impact. Results 3823 papers were identified. Median citations for the top 100 was 88. The paper with the highest impact was by Nashef et al. focusing on the use of EuroSCORE (2043 citations). The Annals of Thoracic Surgery published most papers (n = 18:1778 citations). The European Journal of Cardiothoracic Surgery coveted the most citations (n = 2649). The USA published most papers (n = 55).The most ubiquitous topics were; risk stratification, circulatory support and aortic surgery. A positive relationship between journal impact fact and the scientific impact of manuscripts in ECS (P = 0.043) was deduced. Conclusion This study is the first of its kind and identified the papers which are likely to the contribute most to training and understanding of ECS. A papers influence is partially determined by journal impact factor. Bibliometric analysis is a potent tool to identify surgical training needs.
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Affiliation(s)
- Rickesh B Karsan
- Department of Cardiothoracic Surgery, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
| | - Arfon Gmt Powell
- Division of Cancer and Genetics, Cardiff University, Heath Park, Cardiff, CF14 4XW, UK.,Department of Surgery, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
| | - Prakash Nanjaiah
- Department of Cardiothoracic Surgery, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
| | - Dheeraj Mehta
- Department of Cardiothoracic Surgery, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
| | - Vasileious Valtzoglou
- Department of Cardiothoracic Surgery, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
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Prognostic Risk Analyses for Postcardiotomy Extracorporeal Membrane Oxygenation in Children: A Review of Early and Intermediate Outcomes. Pediatr Cardiol 2019; 40:89-100. [PMID: 30132053 DOI: 10.1007/s00246-018-1964-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 08/12/2018] [Indexed: 10/28/2022]
Abstract
We evaluated the morbidity and mortality of children requiring postcardiotomy extracorporeal membrane oxygenation (ECMO) to determine independent factors affecting early and intermediate outcomes. Between January 2002 and December 2015, 79 instances of ECMO after cardiac surgery in 73 children were retrospectively reviewed. Follow-up was completed in December 2016. Predictive risk analyses were employed concerning weaning of ECMO, hospital discharge, and mortality after discharge. Age and weight were 14.9 ± 25.6 months and 7.0 ± 5.3 kg, respectively. Median support time was 8.3 ± 4.4 days. Sixty-seven (85%) were successfully weaned off ECMO and 48 (61%) survived to hospital discharge. Multi-variate logistic regression analysis identified the first day to obtain negative fluid balance after initiation of support (adjusted odds ratio = 0.42), high serum lactate levels (0.97), and high total bilirubin (0.84) during support as significant independent factors associated with successful separation from ECMO. The first day of negative fluid balance (0.65) after successful decannulation was an independent risk factor for survival to hospital discharge. After hospital discharge, actuarial 1-year, 5-year, and 10-year survival rates were 94%, 78%, and 78%, respectively. Low weight increased the risk of death after hospital discharge by a multi-variate Cox hazard model. High serum lactate, high serum bilirubin, and unable to obtain early negative fluid balance during support impacted mortality of decannulation. Obtaining a late negative fluid balance in post-ECMO were independent risk factors for death after successful weaning. Low weight affected intermediate outcomes.
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Shakoor A, Streltsova S, Brewer MP, Okochi S, Neunert CE, Cheung EW, Stylianos S, Duron V, Middlesworth W, Kadenhe-Chiweshe A. Continuous double volume exchange transfusion is a safe treatment for ECMO-induced hemolysis. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2018. [DOI: 10.1016/j.epsc.2018.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Abstract
The purpose of this report is to describe the international growth, outcomes, complications, and technology used in pediatric extracorporeal life support (ECLS) from 2009 to 2015 as reported by participating centers in the Extracorporeal Life Support Organization (ELSO). To date, there are 59,969 children who have received ECLS in the ELSO Registry; among those, 21,907 received ECLS since 2009 with an overall survival to hospital discharge rate of 61%. In 2009, 2,409 ECLS cases were performed at 157 centers. By 2015, that number grew to 2,992 cases in 227 centers, reflecting a 24% increase in patients and 55% growth in centers. ECLS delivered to neonates (0-28 days) for respiratory support was the largest subcategory of ECLS among children <18-years old. Overall, 48% of ECLS was delivered for respiratory support and 52% was for cardiac support or extracorporeal life support to support cardiopulmonary resuscitation (ECPR). During the study period, over half of children were supported on ECLS with centrifugal pumps (51%) and polymethylpentene oxygenators (52%). Adverse events including neurologic events were common during ECLS, a fact that underscores the opportunity and need to promote quality improvement work.
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Obstals F, Vorobii M, Riedel T, de los Santos Pereira A, Bruns M, Singh S, Rodriguez-Emmenegger C. Improving Hemocompatibility of Membranes for Extracorporeal Membrane Oxygenators by Grafting Nonthrombogenic Polymer Brushes. Macromol Biosci 2018; 18. [DOI: 10.1002/mabi.201700359] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/18/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Fabian Obstals
- DWI−Leibniz Institute for Interactive Materials and Institute of Technical and Macromolecular Chemistry; RWTH Aachen University; Forckenbeckstraße 50 52074 Aachen Germany
| | - Mariia Vorobii
- DWI−Leibniz Institute for Interactive Materials and Institute of Technical and Macromolecular Chemistry; RWTH Aachen University; Forckenbeckstraße 50 52074 Aachen Germany
| | - Tomáš Riedel
- Department of Chemistry and Physics of Surfaces and Biointerfaces; Institute of Macromolecular Chemistry; Academy of Sciences of the Czech Republic; v.v.i., Heyrovsky Square 2 162 06 Prague Czech Republic
| | - Andres de los Santos Pereira
- Department of Chemistry and Physics of Surfaces and Biointerfaces; Institute of Macromolecular Chemistry; Academy of Sciences of the Czech Republic; v.v.i., Heyrovsky Square 2 162 06 Prague Czech Republic
| | - Michael Bruns
- Institute for Applied Materials (IAM) and Karlsruhe Nano Micro Facility (KNMF); Karlsruhe Institute of Technology (KIT); Hermann-von-Helmholtz-Platz 1 76344 Eggenstein-Leopoldshafen Germany
| | - Smriti Singh
- DWI−Leibniz Institute for Interactive Materials and Institute of Technical and Macromolecular Chemistry; RWTH Aachen University; Forckenbeckstraße 50 52074 Aachen Germany
| | - Cesar Rodriguez-Emmenegger
- DWI−Leibniz Institute for Interactive Materials and Institute of Technical and Macromolecular Chemistry; RWTH Aachen University; Forckenbeckstraße 50 52074 Aachen Germany
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Ündar A. The Relative Citation Ratio: Measuring Impact of Publications From an International Conference With a New NIH Metric. Artif Organs 2017; 41:1085-1091. [DOI: 10.1111/aor.13079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 10/16/2017] [Indexed: 01/01/2023]
Affiliation(s)
- Akif Ündar
- Department of Pediatrics - H085. Penn State College of Medicine; Penn State Health Children's Hospital, 500 University Drive; Hershey PA 17033-0850 USA
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Thiagarajan RR, Barbaro RP, Rycus PT, Mcmullan DM, Conrad SA, Fortenberry JD, Paden ML. Extracorporeal Life Support Organization Registry International Report 2016. ASAIO J 2017; 63:60-67. [PMID: 27984321 DOI: 10.1097/mat.0000000000000475] [Citation(s) in RCA: 621] [Impact Index Per Article: 88.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Data on extracorporeal life support (ECLS) use and survival submitted to the Extracorporeal Life Support Organization's data registry from the inception of the registry in 1989 through July 1, 2016, are summarized in this report. The registry contained information on 78,397 ECLS patients with 58% survival to hospital discharge. Extracorporeal life support use and centers providing ECLS have increased worldwide. Extracorporeal life support use in the support of adults with respiratory and cardiac failure represented the largest growth in the recent time period. Extracorporeal life support indications are expanding, and it is increasingly being used to support cardiopulmonary resuscitation in children and adults. Adverse events during the course of ECLS are common and underscore the need for skilled ECLS management and appropriately trained ECLS personnel and teams.
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Affiliation(s)
- Ravi R Thiagarajan
- From the *Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; †Department of Pediatrics, C.S. Mott Children's Hospital, Ann Arbor, Michigan; ‡Extracorporeal Life Support Organization, Ann Arbor, Michigan; §Department of Cardiac Surgery, Seattle Children's Hospital, Seattle, Washington; ¶Departments of Medicine, Pediatrics and Emergency Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana; and ‖Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia
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Pediatric Heart Failure: A Practical Guide to Diagnosis and Management. Pediatr Neonatol 2017; 58:303-312. [PMID: 28279666 DOI: 10.1016/j.pedneo.2017.01.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 01/04/2017] [Accepted: 01/09/2017] [Indexed: 12/27/2022] Open
Abstract
Pediatric heart failure represents an important cause of morbidity and mortality in childhood. Currently, there are well-established guidelines for the management of heart failure in the adult population, but an equivalent consensus in children is lacking. In the clinical setting, ensuring an accurate diagnosis and defining etiology is essential to optimal treatment. Diuretics and angiotensin-converting enzyme inhibition are the first-line therapies, whereas beta-blockers and devices for electric therapy are less used in children than in adults. In the end-stage disease, heart transplantation is the best choice of treatment, while a left ventricular assist device can be used as a bridge to transplantation (due to the difficulties in finding organ donors), recovery (in the case of myocarditis), or destination therapy (for patients with systemic disease).
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Daniel JM, Bernard PA, Skinner SC, Bhandary P, Ruzic A, Bacon MK, Ballard HO. Hollow Fiber Oxygenator Composition Has a Significant Impact on Failure Rates in Neonates on Extracorporeal Membrane Oxygenation: A Retrospective Analysis. J Pediatr Intensive Care 2017; 7:7-13. [PMID: 31073461 DOI: 10.1055/s-0037-1599150] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 01/22/2017] [Indexed: 10/20/2022] Open
Abstract
In extracorporeal life support (ECLS), there are two main types of oxygenators in clinical use for neonates: polymethylpentene (PMP) hollow fiber and polypropylene (PP) hollow fiber. A retrospective study was performed on neonates ( n = 44) who had undergone ECLS for noncardiac indications from 2009 to 2015. Between the two groups (PMP n = 21, PP n = 23), the PP oxygenators failed 91% of the time, whereas the PMP oxygenators failed 43% of the time ( p < 0.05). Analysis suggests PMP oxygenators are less prone to failure than PP oxygenators, and they require fewer number of oxygenator changes during a neonatal ECLS.
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Affiliation(s)
- John M Daniel
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, Kentucky, United States
| | - Philip A Bernard
- Division of Pediatric Critical Care, Department of Pediatrics, University of Kentucky, Lexington, Kentucky, United States
| | - Sean C Skinner
- Division of Pediatric Surgery, Department of Surgery, University of Kentucky, Lexington, Kentucky, United States
| | - Prasad Bhandary
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, Kentucky, United States
| | - Ana Ruzic
- Division of Pediatric Surgery, Department of Surgery, University of Kentucky, Lexington, Kentucky, United States
| | - Matthew K Bacon
- Division of Pediatric Critical Care, Department of Pediatrics, University of Kentucky, Lexington, Kentucky, United States
| | - Hubert O Ballard
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, Kentucky, United States
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Abstract
OBJECTIVE We aimed to determine the prevalence and risk factors for electrographic seizures in neonates and children requiring extracorporeal membrane oxygenation support. DESIGN Prospective quality improvement project. SETTING Quaternary care pediatric institution. PATIENTS Consistent with American Clinical Neurophysiology Society electroencephalographic monitoring recommendations, neonates and children requiring extracorporeal membrane oxygenation support underwent clinically indicated electroencephalographic monitoring. INTERVENTIONS We performed a 2-year quality improvement study from July 2013 to June 2015 evaluating electrographic seizure prevalence and risk factors. MAIN RESULTS Ninety-nine of 112 patients (88%) requiring extracorporeal membrane oxygenation support underwent electroencephalographic monitoring. Electrographic seizures occurred in 18 patients (18%), of whom 11 patients (61%) had electrographic status epilepticus and 15 patients (83%) had exclusively electrographic-only seizures. Electrographic seizures were more common in patients with low cardiac output syndrome (p = 0.03). Patients with electrographic seizures were more likely to die prior to discharge (72% vs 30%; p = 0.01) and have unfavorable outcomes (54% vs 17%; p = 0.004) than those without electrographic seizures. CONCLUSIONS Electrographic seizures occurred in 18% of neonates and children requiring extracorporeal membrane oxygenation support, often constituted electrographic status epilepticus, and were often electrographic-only thereby requiring electroencephalographic monitoring for identification. Low cardiac output syndrome was associated with an increased risk for electrographic seizures. Electrographic seizures were associated with higher mortality and unfavorable outcomes. Further investigation is needed to determine whether electrographic seizures identification and management improves outcomes.
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Kattan J, González Á, Castillo A, Caneo LF. Neonatal and pediatric extracorporeal membrane oxygenation in developing Latin American countries. J Pediatr (Rio J) 2017; 93:120-129. [PMID: 28034729 DOI: 10.1016/j.jped.2016.10.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 10/11/2016] [Accepted: 10/11/2016] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To review the principles of neonatal-pediatric extracorporeal membrane oxygenation therapy, prognosis, and its establishment in limited resource-limited countries in Latino America. SOURCES The PubMed database was explored from 1985 up to the present, selecting from highly-indexed and leading Latin American journals, and Extracorporeal Life Support Organization reports. SUMMARY OF THE FINDINGS Extracorporeal membrane oxygenation provides "time" for pulmonary and cardiac rest and for recovery. It is used in the neonatal-pediatric field as a rescue therapy for more than 1300 patients with respiratory failure and around 1000 patients with cardiac diseases per year. The best results in short- and long-term survival are among patients with isolated respiratory diseases, currently established as a standard therapy in referral centers for high-risk patients. The first neonatal/pediatric extracorporeal membrane oxygenation Program in Latin America was established in Chile in 2003, which was also the first program in Latin America to affiliate with the Extracorporeal Life Support Organization. New extracorporeal membrane oxygenation programs have been developed in recent years in referral centers in Argentina, Colombia, Brazil, Mexico, Perú, Costa Rica, and Chile, which are currently funding the Latin American Extracorporeal Life Support Organization chapter. CONCLUSIONS The best results in short- and long-term survival are in patients with isolated respiratory diseases. Today extracorporeal membrane oxygenation therapy is a standard therapy in some Latin American referral centers. It is hoped that these new extracorporeal membrane oxygenation centers will have a positive impact on the survival of newborns and children with respiratory or cardiac failure, and that they will be available for an increasing number of patients from this region in the near future.
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Affiliation(s)
- Javier Kattan
- Pontificia Universidad Católica de Chile, Escuela de Medicina, Departamento de Neonatología, Santiago, Chile.
| | - Álvaro González
- Pontificia Universidad Católica de Chile, Escuela de Medicina, Departamento de Neonatología, Santiago, Chile
| | - Andrés Castillo
- Pontificia Universidad Católica de Chile, Escuela de Medicina, Unidad de Cuidados Intensivos Pediátricos, Santiago, Chile
| | - Luiz Fernando Caneo
- Universidade de São Paulo (USP), Faculdade de Medicina, Cirurgia Cardiovascular Pediátrica, São Paulo, SP, Brazil
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Neonatal and pediatric extracorporeal membrane oxygenation in developing Latin American countries. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2017. [DOI: 10.1016/j.jpedp.2017.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Sánchez Pérez R, Rey-Lois J, Polo-López L, González-Rocafort Á, Builes-Cardona LM, Uceda-Galiano A, Labrandero-de Lera C, Marín-Huarte N, Sanabria-Carretero P, Verdú-Sánchez C, Menéndez-Suso JJ, Villar-Sánchez-Real MA, Segura-Escobar J, Aroca Peinado Á. ¿Es necesario disponer de ECMO para reparar cardiopatías congénitas de complejidad elevada? Nuestra experiencia en los últimos 6 años. CIRUGIA CARDIOVASCULAR 2017. [DOI: 10.1016/j.circv.2016.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Katz S, Landau Y, Pode-Shakked B, Pessach IM, Rubinshtein M, Anikster Y, Salem Y, Paret G. Cardiac failure in very long chain acyl-CoA dehydrogenase deficiency requiring extracorporeal membrane oxygenation (ECMO) treatment: A case report and review of the literature. Mol Genet Metab Rep 2016; 10:5-7. [PMID: 27995075 PMCID: PMC5154967 DOI: 10.1016/j.ymgmr.2016.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 11/30/2016] [Accepted: 11/30/2016] [Indexed: 11/01/2022] Open
Abstract
Fatty acid oxidation (FAO) defects often present with multi-system involvement, including several life-threatening cardiac manifestations, such as cardiomyopathy, pericardial effusion and arrhythmias. We report herein a fatal case of cardiac dysfunction and rapid-onset tamponade following an acute illness in a neonate with molecularly proven very long chain acyl-CoA dehydrogenase (VLCAD) deficiency (harboring the known del799_802 mutation), requiring 15 days of extracorporeal membrane oxygenation (ECMO) treatment. As data regarding the use of ECMO in FAO defects in general, and VLCAD in particular, are scarce, we review the literature and discuss insights from in vitro models and several successful reported cases.
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Affiliation(s)
- Sharon Katz
- Department of Pediatrics B, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yuval Landau
- Metabolic Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ben Pode-Shakked
- Metabolic Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel; The Dr. Pinchas Borenstein Talpiot Medical Leadership Program, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Itai M Pessach
- The Dr. Pinchas Borenstein Talpiot Medical Leadership Program, Sheba Medical Center, Tel-Hashomer, Israel; Department of Pediatric Intensive Care, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Marina Rubinshtein
- Department of Pediatric Intensive Care, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
| | - Yair Anikster
- Metabolic Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yishay Salem
- Pediatric Cardiology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gideon Paret
- Department of Pediatric Intensive Care, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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The Incidence of Acute Kidney Injury and Its Effect on Neonatal and Pediatric Extracorporeal Membrane Oxygenation Outcomes: A Multicenter Report From the Kidney Intervention During Extracorporeal Membrane Oxygenation Study Group. Pediatr Crit Care Med 2016; 17:1157-1169. [PMID: 27755398 PMCID: PMC5138084 DOI: 10.1097/pcc.0000000000000970] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In a population of neonatal and pediatric patients on extracorporeal membrane oxygenation; to describe the prevalence and timing of acute kidney injury utilizing a consensus acute kidney injury definition and investigate the association of acute kidney injury with outcomes (length of extracorporeal membrane oxygenation and mortality). DESIGN Multicenter retrospective observational cohort study. SETTING Six pediatric extracorporeal membrane oxygenation centers. PATIENTS Pediatric patients (age, < 18 yr) on extracorporeal membrane oxygenation at six centers during a period of January 1, 2007, to December 31, 2011. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Complete data were analyzed for 832 patients on extracorporeal membrane oxygenation. Sixty percent of patients had acute kidney injury utilizing the serum creatinine Kidney Disease Improving Global Outcomes criteria (AKI) and 74% had acute kidney injury using the full Kidney Disease Improving Global Outcomes criteria including renal support therapy (AKI). Of those who developed acute kidney injury, it was present at extracorporeal membrane oxygenation initiation in a majority of cases (52% AKI and 65% AKI) and present by 48 hours of extracorporeal membrane oxygenation support in 86% (AKI) and 93% (AKI). When adjusted for patient age, center of support, mode of support, patient complications and preextracorporeal membrane oxygenation pH, the presence of acute kidney injury by either criteria was associated with a significantly longer duration of extracorporeal membrane oxygenation support (AKI, 152 vs 110 hr; AKI, 153 vs 99 hr) and increased adjusted odds of mortality at hospital discharge (AKI: odds ratio, 1.77; 1.22-2.55 and AKI: odds ratio, 2.50; 1.61-3.90). With the addition of renal support therapy to the model, acute kidney injury was associated with a longer duration of extracorporeal membrane oxygenation support (AKI, 149 vs 121 hr) and increased risk of mortality at hospital discharge (AKI: odds ratio, 1.52; 1.04-2.21). CONCLUSION Acute kidney injury is present in 60-74% of neonatal-pediatric patients supported on extracorporeal membrane oxygenation and is present by 48 hours of extracorporeal membrane oxygenation support in 86-93% of cases. Acute kidney injury has a significant association with increased duration of extracorporeal membrane oxygenation support and increased adjusted odds of mortality at hospital discharge.
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Antithrombin Concentrate Use in Pediatric Extracorporeal Membrane Oxygenation: A Multicenter Cohort Study. Pediatr Crit Care Med 2016; 17:1170-1178. [PMID: 27662567 DOI: 10.1097/pcc.0000000000000955] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe antithrombin concentrate use and to compare thrombotic and hemorrhagic outcomes throughout the hospital stay in pediatric subjects who received extracorporeal membrane oxygenation in a Pediatric Health Information System-participating children's hospital. DESIGN Retrospective, multi-center, cohort study. SETTING Forty-three free-standing children's hospitals participating in Pediatric Health Information System. SUBJECTS Children older than or equal to 18 years of age who underwent extracorporeal membrane oxygenation between 2003 and 2012. INTERVENTIONS Subjects were classified as receiving antithrombin if they received at least one dose of antithrombin while on extracorporeal membrane oxygenation. MEASUREMENTS AND MAIN RESULTS International Classification of Diseases, Ninth Revision, Clinical Modification codes codes were used to identify hemorrhagic and thrombotic complications during their hospitalization. Pediatric Health Information System data were analyzed to determine hospital-length of stay and in-hospital mortality. A total of 1,931 of 8,601 eligible subjects (21.5%) received at least one dose of antithrombin during their extracorporeal membrane oxygenation course. Antithrombin use during extracorporeal membrane oxygenation increased from 2.4% to 51.9% (p < 0.001) over the 10-year study period. Subjects who received antithrombin while on extracorporeal membrane oxygenation were younger (p = 0.02), had more chronic conditions (p < 0.001), and longer hospital stays (p < 0.001). On multivariate analysis, antithrombin use was associated with thrombotic events (odds ratio, 1.55; 95% CI, 1.36-1.77; p < 0.001), hemorrhagic events (odds ratio, 1.27; 95% CI, 1.14-1.42; p < 0.001), and longer hospital length of stays (slope coefficient, 1.05 d; 95% CI, 1.04-1.06; p < 0.001). No difference was observed in mortality (odds ratio, 0.99; 95% CI, 0.89-1.11; p = 0.90). CONCLUSIONS In this multicenter retrospective cohort study, subjects who received antithrombin during extracorporeal membrane oxygenation had a higher number of thrombotic and hemorrhagic events throughout the hospitalization and longer length of stays without an associated difference in mortality. While limitations exist with this analysis and results should be interpreted with caution, the fact remains that over half of pediatric patients on extracorporeal membrane oxygenation are currently receiving antithrombin without clear benefit, with extra cost, and potential harms, there needs to be strong consideration for a clinical trial.
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Venkatesh K, Nair PS, Hoechter DJ, Buscher H. Current Limitations of the Assessment of Haemostasis in Adult Extracorporeal Membrane Oxygenation Patients and the Role of Point-of-Care Testing. Anaesth Intensive Care 2016; 44:669-680. [DOI: 10.1177/0310057x1604400601] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Haemostatic perturbations are commonly seen in extracorporeal membrane oxygenation (ECMO) patients and remain a clinical challenge, contributing significantly to morbidity and mortality. The approach to anticoagulation monitoring and the management of bleeding varies considerably across ECMO centres. Routine laboratory tests have their limitations in terms of turnaround time and specificity of information provided. Newer point-of-care testing (POCT) for coagulation may overcome these issues, as it provides information about the entire coagulation pathway from clot initiation to lysis. It is also possible to obtain qualitative information on platelet function from these tests. Furthermore, the ability to incorporate these results into a goal-directed algorithm to manage bleeding with targeted transfusion strategies appears particularly attractive and cost effective. Further studies are required to evaluate the utility of POCT to optimise bleeding and anticoagulation management in these complex patients.
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Affiliation(s)
- K. Venkatesh
- Prince of Wales Hospital, Conjoint Associate Lecturer, University of New South Wales, Sydney, New South Wales
| | - P. S. Nair
- Intensive Care Unit, St Vincent's Hospital, Conjoint Senior Lecturer, University of New South Wales, Sydney, New South Wales
| | - D. J. Hoechter
- Department of Anaesthesiology, University of Munich (LMU), Munich, Germany
| | - H. Buscher
- Intensive Care Unit, St Vincent's Hospital, Conjoint Senior Lecturer, University of New South Wales, Sydney, New South Wales
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Factors Associated With Mortality in Neonates Requiring Extracorporeal Membrane Oxygenation for Cardiac Indications: Analysis of the Extracorporeal Life Support Organization Registry Data. Pediatr Crit Care Med 2016; 17:860-70. [PMID: 27355824 DOI: 10.1097/pcc.0000000000000842] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Survival among neonates supported with extracorporeal membrane oxygenation for cardiac indications is 39%. Previous single-center studies have identified factors associated with mortality, but a comprehensive multivariate analysis is not available for this population. Understanding factors associated with mortality may help design treatment strategies, determine optimal timing for cannulation, and inform patient selection. This study identifies factors associated with mortality in neonates supported with extracorporeal membrane oxygenation for cardiac indications. DESIGN Retrospective cohort study. SETTING Two hundred and thirty U.S. and international centers reporting extracorporeal membrane oxygenation data to the Extracorporeal Life Support Organization. SUBJECTS Four thousand and four seventy one neonates with congenital and acquired cardiac disease supported with extracorporeal membrane oxygenation for cardiac indications during 2001-2011. INTERVENTIONS None. MEASUREMENTS AND RESULTS The primary outcome measure was mortality prior to hospital discharge. Overall hospital mortality was 59%. Demographic and preextracorporeal membrane oxygenation factors associated with mortality were evaluated in a multivariable model. Factors associated with death prior to hospital discharge included lower body weight, earlier era, single ventricle physiology, lower preextracorporeal membrane oxygenation arterial pH, and longer time from intubation to extracorporeal membrane oxygenation cannulation. Lower pH was associated with increased mortality regardless of cardiac diagnosis and surgical complexity. The majority of survivors separated from extracorporeal membrane oxygenation less than 8 days after extracorporeal membrane oxygenation deployment. CONCLUSIONS Mortality for neonates supported with extracorporeal membrane oxygenation for cardiac indications is high. Severity of preextracorporeal membrane oxygenation acidosis was independently associated with increased risk of mortality. Earlier initiation of extracorporeal membrane oxygenation may reduce the degree and duration of acidosis and may improve survival. Further studies are needed to determine optimal timing of cannulation in this population.
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Lim JY, Kim JB, Choo SJ, Chung CH, Lee JW, Jung SH. Anticoagulation During Extracorporeal Membrane Oxygenation; Nafamostat Mesilate Versus Heparin. Ann Thorac Surg 2016; 102:534-9. [DOI: 10.1016/j.athoracsur.2016.01.044] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 01/05/2016] [Accepted: 01/11/2016] [Indexed: 10/21/2022]
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Flores S, Rhodes Proctor Short S, Basu RK. Acute kidney injury in pediatric heart transplantation and extracorporeal cardiac support therapies. PROGRESS IN PEDIATRIC CARDIOLOGY 2016. [DOI: 10.1016/j.ppedcard.2015.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Alkhatib B, Wolfe L, Naidu SS. Hemodynamic Support Devices for Complex Percutaneous Coronary Intervention. Interv Cardiol Clin 2016; 5:187-200. [PMID: 28582203 DOI: 10.1016/j.iccl.2015.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
High-risk percutaneous coronary intervention (PCI) encompasses a growing portion of total PCIs performed and typically includes patients with high-risk clinical and anatomic characteristics. Such patients may represent not only a high-risk group for complications but also a group who may derive the most benefit from complete revascularization. Several hemodynamic support devices are available. Trial data, consensus documents, and guidelines currently recommend high-risk PCI aided by hemodynamic support devices, and this article discusses the patient populations who would benefit from such an approach, the available devices and strategies, and expected outcomes.
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Affiliation(s)
- Basil Alkhatib
- Division of Cardiology, Winthrop University Hospital, 120 Mineola Boulevard, Suite 500, Mineola NY 11501, USA
| | - Laura Wolfe
- Division of Cardiology, Winthrop University Hospital, 120 Mineola Boulevard, Suite 500, Mineola NY 11501, USA
| | - Srihari S Naidu
- Cardiac Catheterization Laboratory, Division of Cardiology, Winthrop University Hospital, 120 Mineola Boulevard, Suite 500, Mineola, NY 11501, USA.
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Rihal CS, Naidu SS, Givertz MM, Szeto WY, Burke JA, Kapur NK, Kern M, Garratt KN, Goldstein JA, Dimas V, Tu T. 2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care (Endorsed by the American Heart Association, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; Affirmation of Value by the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d'intervention). J Card Fail 2016; 21:499-518. [PMID: 26036425 DOI: 10.1016/j.cardfail.2015.03.002] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Although historically the intra-aortic balloon pump has been the only mechanical circulatory support device available to clinicians, a number of new devices have become commercially available and have entered clinical practice. These include axial flow pumps, such as Impella(®); left atrial to femoral artery bypass pumps, specifically the TandemHeart; and new devices for institution of extracorporeal membrane oxygenation. These devices differ significantly in their hemodynamic effects, insertion, monitoring, and clinical applicability. This document reviews the physiologic impact on the circulation of these devices and their use in specific clinical situations. These situations include patients undergoing high-risk percutaneous coronary intervention, those presenting with cardiogenic shock, and acute decompensated heart failure. Specialized uses for right-sided support and in pediatric populations are discussed and the clinical utility of mechanical circulatory support devices is reviewed, as are the American College of Cardiology/American Heart Association clinical practice guidelines.
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Affiliation(s)
- Charanjit S Rihal
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
| | - Srihari S Naidu
- Division of Cardiology, Winthrop University Hospital, Mineola, New York
| | - Michael M Givertz
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Wilson Y Szeto
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James A Burke
- Division of Cardiology, Lehigh Valley Heart Specialists, Allentown, Pennsylvania
| | - Navin K Kapur
- Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Morton Kern
- Division of Cardiology, UCI Medical Center, Orange, California
| | - Kirk N Garratt
- Department of Cardiac and Vascular Services, Heart and Vascular Institute of New York, Lenox Hill Hospital, New York, New York
| | - James A Goldstein
- Division of Cardiology, Beaumont Heart Center Clinic, Royal Oak, Michigan
| | - Vivian Dimas
- Pediatric Cardiology, UT Southwestern, Dallas, Texas
| | - Thomas Tu
- Louisville Cardiology Group, Interventional Cardiology, Louisville, Kentucky
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Thrombosis in Centrifugal Pumps: Location and Composition in Clinical and in Vitro Circuits. Int J Artif Organs 2016; 39:200-4. [DOI: 10.5301/ijao.5000498] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2016] [Indexed: 11/20/2022]
Abstract
Purpose Extracorporeal membrane oxygenation (ECMO) is a form of cardiopulmonary mechanical life support for critically ill patients. ECMO is burdened by both thrombotic and hemorrhagic complications. Recently there has been a clinical shift from roller pumps to centrifugal pumps. In this study, we report on bulk thrombus formation within pumps recovered from clinical use. We then replicate this thrombus formation in vitro. Methods Clinical pediatric ECMO circuits driven with the Sorin Revolution were collected from 16 patients. The location and extent of thrombus formation in the pumps were recorded. Pump heads were also tested in a laboratory circulatory loop. The location, extent, and appearance of the thrombi were recorded. Thrombi were examined histologically using Carstairs' stain. Results Gross thrombus was observed in all pump heads at the stainless steel bearing at the inlet. In 19% of the pumps larger thrombi grew into the head over the cone and along the vanes. The thrombi were adherent and cohesive upon extraction. The thrombus formation was strikingly similar between the clinical pump heads and in vitro pump heads. Histology of both clinical and experimental samples exhibited a platelet-rich thrombus. Conclusions Our studies have revealed platelet-rich thrombus in clinical and in vitro circuits. The location and composition of the thrombi suggest that the exposed metal shaft was initially covered by contact activated coagulation followed by large-scale growth by rapid platelet accumulation from high shear rates at the inlet. The in vitro system may be used to further identify the mechanisms for pump thrombus and test new designs.
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Abstract
The domain of pediatric ventricular assist device (VAD) has recently gained considerable attention. Despite the fact that, historically, the practice of pediatric mechanical circulatory support (MCS) has lagged behind that of adult patients, this gap between the two groups is narrowing. Currently, the Berlin EXCOR VAD is the only pediatric-specific durable VAD approved by the U.S Food and Drug Administration (FDA). The prospective Berlin Heart trial demonstrated a successful outcome, either bridge to transplantation (BTT), or in rare instances, bridge to recovery, in approximately 90% of children. Also noted during the trial was, however, a high incidence of adverse events such as embolic stroke, bleeding and infection. This has incentivized some pediatric centers to utilize adult implantable continuous-flow devices, for instance the HeartMate II and HeartWare HVAD, in children. As a result of this paradigm shift, the outlook of pediatric VAD support has dramatically changed: Treatment options previously unavailable to children, including outpatient management and even destination therapy, have now been becoming a reality. The sustained demand for continued device miniaturization and technological refinements is anticipated to extend the range of options available to children-HeartMate 3 and HeartWare MVAD are two examples of next generation VADs with potential pediatric application, both of which are presently undergoing clinical trials. A pediatric-specific continuous-flow device is also on the horizon: the redesigned Infant Jarvik VAD (Jarvik 2015) is undergoing pre-clinical testing, with a randomized clinical trial anticipated to follow thereafter. The era of pediatric VADs has begun. In this article, we discuss several important aspects of contemporary VAD therapy, with a particular focus on challenges unique to the pediatric population.
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Affiliation(s)
- Iki Adachi
- 1 Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA ; 2 Division of Pediatric Cardiothoracic Surgery, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Sarah Burki
- 1 Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA ; 2 Division of Pediatric Cardiothoracic Surgery, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Farhan Zafar
- 1 Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA ; 2 Division of Pediatric Cardiothoracic Surgery, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - David Luis Simon Morales
- 1 Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA ; 2 Division of Pediatric Cardiothoracic Surgery, Cincinnati Children's Hospital, Cincinnati, OH, USA
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Im D, Shi W, Driscoll B. Pediatric Acute Respiratory Distress Syndrome: Fibrosis versus Repair. Front Pediatr 2016; 4:28. [PMID: 27066462 PMCID: PMC4811965 DOI: 10.3389/fped.2016.00028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 03/15/2016] [Indexed: 01/11/2023] Open
Abstract
Clinical and basic experimental approaches to pediatric acute lung injury (ALI), including acute respiratory distress syndrome (ARDS), have historically focused on acute care and management of the patient. Additional efforts have focused on the etiology of pediatric ALI and ARDS, clinically defined as diffuse, bilateral diseases of the lung that compromise function leading to severe hypoxemia within 7 days of defined insult. Insults can include ancillary events related to prematurity, can follow trauma and/or transfusion, or can present as sequelae of pulmonary infections and cardiovascular disease and/or injury. Pediatric ALI/ARDS remains one of the leading causes of infant and childhood morbidity and mortality, particularly in the developing world. Though incidence is relatively low, ranging from 2.9 to 9.5 cases/100,000 patients/year, mortality remains high, approaching 35% in some studies. However, this is a significant decrease from the historical mortality rate of over 50%. Several decades of advances in acute management and treatment, as well as better understanding of approaches to ventilation, oxygenation, and surfactant regulation have contributed to improvements in patient recovery. As such, there is a burgeoning interest in the long-term impact of pediatric ALI/ARDS. Chronic pulmonary deficiencies in survivors appear to be caused by inappropriate injury repair, with fibrosis and predisposition to emphysema arising as irreversible secondary events that can severely compromise pulmonary development and function, as well as the overall health of the patient. In this chapter, the long-term effectiveness of current treatments will be examined, as will the potential efficacy of novel, acute, and long-term therapies that support repair and delay or even impede the onset of secondary events, including fibrosis.
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Affiliation(s)
- Daniel Im
- Pediatric Critical Care Medicine, Department of Pediatrics, The Saban Research Institute, Children's Hospital Los Angeles, University of Southern California , Los Angeles, CA , USA
| | - Wei Shi
- Developmental Biology and Regenerative Medicine Program, Department of Surgery, The Saban Research Institute, Children's Hospital Los Angeles, University of Southern California , Los Angeles, CA , USA
| | - Barbara Driscoll
- Developmental Biology and Regenerative Medicine Program, Department of Surgery, The Saban Research Institute, Children's Hospital Los Angeles, University of Southern California , Los Angeles, CA , USA
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Epidemiology of Stroke in Pediatric Cardiac Surgical Patients Supported With Extracorporeal Membrane Oxygenation. Ann Thorac Surg 2015; 100:1751-7. [PMID: 26298170 DOI: 10.1016/j.athoracsur.2015.06.020] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 05/01/2015] [Accepted: 06/08/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Stroke is a common complication of extracorporeal membrane oxygenation (ECMO), and pediatric cardiac surgical patients may be at higher risk. Epidemiology and risk factors for stroke in these patients are not well characterized. METHODS We analyzed pediatric (<18 years) cardiac ECMO cases in the Extracorporeal Life Support Organization Registry from 2002 to 2013. Cardiac surgical patients were identified, and procedures were stratified according to The Society of Thoracic Surgeons morbidity categories. The primary outcome was any stroke (hemorrhagic or infarction) identified by neuroimaging. Risk factors were identified through multivariable logistic regression. RESULTS We analyzed 3,517 cardiac surgical patients; 81% with cyanotic disease, and 57% in high-risk categories from The Society of Thoracic Surgeons (categories 4 and 5). Overall, 12% experienced stroke while receiving ECMO, and those with stroke had greater in-hospital mortality (72% versus 51%; p < 0.0001). In multivariable analysis, neonatal status (adjusted odds ratio, 1.8; 95% confidence interval, 1.3 to 2.4), lower weight-for-age z score (adjusted odds ratio, 1.1 for each 1-point decrease; 95% confidence interval, 1.04 to 1.25), and longer ECMO duration (upper quartile [≥ 167 hours] adjusted odds ratio, 1.4; 95% confidence interval, 1.1 to 1.8) were independently associated with increased stroke risk, whereas cyanotic disease, The Society of Thoracic Surgeons category, and bypass time were not. CONCLUSIONS This multicenter analysis demonstrates that pediatric cardiac surgical patients on ECMO are at high risk of stroke; younger or underweight patients and those with longer ECMO duration are at greatest risk, independent of procedural complexity. Future study is necessary to determine how anticoagulation or other clinical practices can be modified to reduce stroke incidence.
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Platelet-derived microparticles generated by neonatal extracorporeal membrane oxygenation systems. ASAIO J 2015; 61:37-42. [PMID: 25303795 DOI: 10.1097/mat.0000000000000164] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Current anticoagulation strategies do not eliminate thromboembolic stroke or limb loss during neonatal extracorporeal membrane oxygenation (ECMO), a form of cardiopulmonary bypass (CPB). In adults, CPB surgery generates prothrombotic platelet-derived microparticles (PMPs), submicron membrane vesicles released from activated platelets. However, information on PMP generation in neonatal ECMO systems is lacking. The objective of this study was to compare PMP generation in five different neonatal ECMO systems, using a simulated circuit with swine blood at 300 ml/min for 4 hours. Systems were composed of both newer components (centrifugal pump and hollow-fiber oxygenator) and traditional components (roller-head pump and silicone membrane oxygenator). Free plasma hemoglobin levels were measured as an indicator of hemolysis and flow cytometry-measured PMP. Hemolysis generated in all ECMO systems was similar to that observed in noncirculated static blood (p = 0.48). There was no difference in net PMP levels between different oxygenators with a given pump. In contrast, net PMP generation in ECMO systems with a centrifugal pump was at least 2.5 times greater than in roller-head pump systems. This was significant when using either a hollow-fiber (p < 0.005) or a silicone membrane (p < 0.05) oxygenator. Future studies are needed to define the relationship between pump-generated PMP and thrombosis.
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Wang S, Krawiec C, Patel S, Kunselman AR, Song J, Lei F, Baer LD, Ündar A. Laboratory Evaluation of Hemolysis and Systemic Inflammatory Response in Neonatal Nonpulsatile and Pulsatile Extracorporeal Life Support Systems. Artif Organs 2015; 39:774-81. [DOI: 10.1111/aor.12466] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Shigang Wang
- Penn State Hershey Pediatric Cardiovascular Research Center; Department of Pediatrics; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Penn State Milton S. Hershey Medical Center; Hershey PA USA
| | - Conrad Krawiec
- Penn State Hershey Pediatric Cardiovascular Research Center; Department of Pediatrics; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Penn State Milton S. Hershey Medical Center; Hershey PA USA
- Pediatric Critical Care Unit; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Penn State Milton S. Hershey Medical Center; Hershey PA USA
| | - Sunil Patel
- Penn State Hershey Pediatric Cardiovascular Research Center; Department of Pediatrics; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Penn State Milton S. Hershey Medical Center; Hershey PA USA
- Pediatric Cardiology; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Penn State Milton S. Hershey Medical Center; Hershey PA USA
| | - Allen R. Kunselman
- Department of Public Health Sciences; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Penn State Milton S. Hershey Medical Center; Hershey PA USA
| | - Jianxun Song
- Department of Microbiology & Immunology; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Penn State Milton S. Hershey Medical Center; Hershey PA USA
| | - Fengyang Lei
- Department of Microbiology & Immunology; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Penn State Milton S. Hershey Medical Center; Hershey PA USA
| | - Larry D. Baer
- Heart and Vascular Institute; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Penn State Milton S. Hershey Medical Center; Hershey PA USA
| | - Akif Ündar
- Penn State Hershey Pediatric Cardiovascular Research Center; Department of Pediatrics; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Penn State Milton S. Hershey Medical Center; Hershey PA USA
- Surgery and Bioengineering; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Penn State Milton S. Hershey Medical Center; Hershey PA USA
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