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Karahalios DS, Kadiu G, Farooqi A, Singh G, Aggarwal S. Effect of Atrial Septostomy on Left Ventricular Function in Pediatric Dilated Cardiomyopathy Requiring ECMO. Pediatr Cardiol 2024:10.1007/s00246-024-03615-5. [PMID: 39123074 DOI: 10.1007/s00246-024-03615-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 08/02/2024] [Indexed: 08/12/2024]
Abstract
Balloon atrial septostomy (BAS) reduces left ventricular (LV) hypertension during extracorporeal membrane oxygenation (ECMO). However, the acute effect of BAS on LV function as measured by echocardiography is unknown. This was a Retrospective analysis of clinical outcome, LV dimensions, and LV function in dilated cardiomyopathy patients 0-18 years old who underwent BAS on ECMO. In 13 patients with median (IQR) age of 2.3 (0.6-10.9) years, there were no differences in clinical markers of cardiac output at intervals between 12 h before and 6 days after BAS. In addition, BAS was associated with a low rate of periprocedural complications (0.0%), acute kidney injury (7.7%), and worsening radiographic pulmonary vascular congestion (30.7%). There was a significant worsening in LV end systolic diameter (LVIDs; 3.6 [2.9-4.8] cm vs 4.2 [3.2-5.6] cm vs 3.3 [2.6-4.6] cm, p = 0.025), LV end systolic posterior wall thickness (LVPWs; 0.7 [0.5-0.9] cm vs 0.6 [0.5-0.9] cm vs 0.8 [0.6-1.2] cm, p = 0.038), fractional shortening (FS; 17.6% [8.4-20.4%] vs 6.3% [2.0-9.9%] vs 13.2% [3.6-23.4%], p = 0.013), and ejection fraction (EF; 13.1% [8.7-18.9%] vs 5.3% [2.5-11.1%] vs 9.2% [6.0-16.3%], p = 0.039) following BAS that improved in approximately 1 week. There were no differences in LV global longitudinal strain following BAS. We conclude that BAS was associated with low procedural and clinical adverse event rates in our cohort. The worsening LVIDs, LVPWs, FS, and EF seen immediately after the procedure suggests that BAS causes altered loading conditions affecting LV function in pediatric patients with dilated cardiomyopathy requiring ECMO.
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Affiliation(s)
- Dean S Karahalios
- Department of Pediatrics, Division of Pediatric Cardiology, Northwestern University Ann and Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Chicago, IL, 60611, USA.
| | - Gilda Kadiu
- Department of Pediatrics, Division of Pediatric Cardiology, Central Michigan University Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI, 48201, USA
| | - Ahmad Farooqi
- Children's Research Institute, Central Michigan University Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI, 48201, USA
| | - Gautam Singh
- Department of Pediatrics, Division of Pediatric Cardiology, Central Michigan University Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI, 48201, USA
| | - Sanjeev Aggarwal
- Department of Pediatrics, Division of Pediatric Cardiology, Central Michigan University Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI, 48201, USA
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Shugh SB, Tume SC, Bansal N, Dykes JC, Esch JJ, Jeewa A, Law S, O'Connor M, Parent JJ, Said AS, Scholl FG, Shezad MF, Morray BH. Transcatheter Axial Pump Use in Pediatric Patients on Veno-Arterial Extracorporeal Membrane Oxygenation: An ACTION Collaborative Experience. ASAIO J 2024; 70:602-608. [PMID: 38949774 DOI: 10.1097/mat.0000000000002150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024] Open
Abstract
We report the largest pediatric multicenter experience with Impella pump use and peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. Utilizing the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) collaborative database, we conducted a retrospective, multicenter study of all patients with cardiogenic shock requiring VA-ECMO support with subsequent Impella implant between October 2014 and December 2021. The primary outcome was defined as death while on Impella support. Secondary outcomes were recovery, transplantation, and transition to durable ventricular assist device (VAD) at the time of Impella explantation. Adverse events were defined according to the ACTION registry criteria. Twenty subjects were supported with Impella; Impella 2.5 (n = 3), CP (n = 12), 5.0/5.5 (n = 5). The median Interquartile range (IQR) age, weight, and body surface area at implantation were 15.6 years (IQR = 13.9-17.2), 65.7 kg (IQR = 53.1-80.7), and 1.74 m2 (IQR = 1.58-1.98). Primary cardiac diagnoses were dilated cardiomyopathy/myocarditis in nine (45%), congenital heart disease in four (20%), graft failure/rejection in four (20%), and three (15%) others. Most common adverse events included hemolysis (50%) and bleeding (20%). There were two deaths (10%) in the cohort. Nine patients (45%) were explanted for recovery, eight (40%) were transitioned to a durable VAD, and one (5%) underwent heart transplantation. Impella percutaneous pump support should be considered in the older pediatric population supported with peripheral VA-ECMO, as a means of left heart decompression, and a strategy to come off ECMO to achieve endpoints of myocardial recovery, transition to a durable VAD, or transplantation.
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Affiliation(s)
- Svetlana B Shugh
- From The Division of Pediatric Cardiology, The Heart Institute, Joe DiMaggio Children's Hospital, Hollywood, Florida
| | - Sebastian C Tume
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Neha Bansal
- Division of Pediatric Cardiology, Mount Sinai Kravis Children's Hospital, New York, New York
| | - John C Dykes
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Jesse J Esch
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aamir Jeewa
- Division of Paediatric Cardiology, Hospital for Sick Children, Toronto, Canada
| | - Sabrina Law
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital of New York-Presbyterian, Columbia University, New York, New York
| | - Matthew O'Connor
- Division of Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - John J Parent
- Division of Pediatric Cardiology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ahmed S Said
- Division of Pediatric Critical Care, Washington University in St. Louis, St. Louis Children's Hospital, St. Louis, Missouri
| | - Frank G Scholl
- From The Division of Pediatric Cardiology, The Heart Institute, Joe DiMaggio Children's Hospital, Hollywood, Florida
| | - Muhammad F Shezad
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Brian H Morray
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
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Piperata A, Van den Eynde J, David CH, Akar AR, Watanabe M, Doulamis I, Piriou PG, Saricaoğlu MC, Ikenaga H, Gouttenegre T, Vourc'h M, Takahashi S, Ouattara A, Labrousse L, Frati G, Pernot M. ECMO Alone Versus ECPELLA in Patients Affected by Cardiogenic Shock: The Multicenter EVACS Study. ASAIO J 2024:00002480-990000000-00475. [PMID: 38701397 DOI: 10.1097/mat.0000000000002219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2024] Open
Abstract
The objective was to investigate the outcomes of concomitant venoarterial extracorporeal membrane oxygenation (ECMO) and left ventricular unloading with Impella (ECPELLA) compared with ECMO alone to treat patients affected by cardiogenic shock. Data from patients needing mechanical circulatory support from 4 international centers were analyzed. Of 438 patients included, ECMO alone and ECPELLA were adopted in 319 (72.8%) and 119 (27.2%) patients, respectively. Propensity score matching analysis identified 95 pairs. In the matched cohort, 30-day mortality rates in the ECMO and ECPELLA were 49.5% and 43.2% ( P = 0.467). The incidences of complications did not differ significantly between groups ( P = 0.877, P = 0.629, P = 1.000, respectively). After a median follow-up of 0.18 years (interquartile range 0.02-2.55), the use of ECPELLA was associated with similar mortality compared with ECMO alone (hazard ratio 0.81, 95% confidence interval 0.54-1.20, P = 0.285), with 1-year overall survival rates of 51.3% and 46.6%, for ECPELLA and ECMO alone, respectively. ECMO alone and ECPELLA are both effective strategies in patients needing mechanical circulatory support for cardiogenic shock, showing similar rates of early and mid-term survival.
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Affiliation(s)
- Antonio Piperata
- From the CHU Bordeaux, Department of Cardiovascular Anesthesia and Critical Care, Bordeaux, France
| | - Jef Van den Eynde
- Department of Cardiovascular Sciences, KU Leuven, Belgium
- Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, Baltimore, MD
| | - Charles-Henri David
- Department of Thoracic and Cardio-Vascular Surgery, Nantes Université, CHU Nantes, l'institut du thorax, Nantes, France
| | - Ahmet Ruchan Akar
- Department of Cardiovascular Surgery, Heart Center, Ankara University School of Medicine, Ankara, Turkey
| | - Masazumi Watanabe
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Ilias Doulamis
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Pierre-Guillaume Piriou
- Department of Thoracic and Cardio-Vascular Surgery, Nantes Université, CHU Nantes, l'institut du thorax, Nantes, France
| | - Mehmet Cahit Saricaoğlu
- Department of Cardiovascular Surgery, Heart Center, Ankara University School of Medicine, Ankara, Turkey
| | - Hiroki Ikenaga
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Thomas Gouttenegre
- From the CHU Bordeaux, Department of Cardiovascular Anesthesia and Critical Care, Bordeaux, France
| | - Mickael Vourc'h
- Department of Thoracic and Cardio-Vascular Surgery, Nantes Université, CHU Nantes, l'institut du thorax, Nantes, France
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Alexandre Ouattara
- From the CHU Bordeaux, Department of Cardiovascular Anesthesia and Critical Care, Bordeaux, France
- University of Bordeaux, INSERM, Biology of Cardiovascular Diseases, Pessac, France
| | - Louis Labrousse
- From the CHU Bordeaux, Department of Cardiovascular Anesthesia and Critical Care, Bordeaux, France
| | - Giacomo Frati
- Department of Medical Surgical Sciences and Biotechnology, Sapienza University of Rome, Latina, Italy
- IRCCS, Neuromed, Pozzilli, IS, Italy
| | - Mathieu Pernot
- From the CHU Bordeaux, Department of Cardiovascular Anesthesia and Critical Care, Bordeaux, France
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4
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Beurton A, Michot M, Hérion FX, Rienzo M, Oddos C, Couffinhal T, Imbault J, Ouattara A. Systemic Hemodynamics, Cardiac Mechanics, and Signaling Pathways Induced by Extracorporeal Membrane Oxygenation in a Cardiogenic Shock Model. ASAIO J 2024; 70:177-184. [PMID: 38261663 DOI: 10.1097/mat.0000000000002139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024] Open
Abstract
Peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used in patients suffering from refractory cardiogenic shock (CS). Although considered life-saving, peripheral VA-ECMO may also be responsible for intracardiac hemodynamic changes, including left ventricular overload and dysfunction. Venoarterial extracorporeal membrane oxygenation may also increase myocardial wall stress and stroke work, possibly affecting the cellular cardioprotective and apoptosis signaling pathways, and thus the infarct size. To test this hypothesis, we investigated the effects of increasing the peripheral VA-ECMO blood flow (25-100% of the baseline cardiac output) on systemic and cardiac hemodynamics in a closed-chest CS model. Upon completion of the experiment, the hearts were removed for assessment of infarct size, histology, apoptosis measurements, and phosphorylation statuses of p38 and protein Kinase B (Akt), and extracellular signal-regulated kinase mitogen-activated protein kinases (ERK-MAPK). Peripheral VA-ECMO restored systemic perfusion but induced a significant and blood flow-dependent increase in left ventricular preload and afterload. Venoarterial extracorporeal membrane oxygenation did not affect infarct size but significantly decreased p38-MAPK phosphorylation and cardiac myocyte apoptosis in the border zone.
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Affiliation(s)
- Antoine Beurton
- From the CHU Bordeaux, Department of Cardiovascular Anesthesia and Critical Care, F-33000 Bordeaux, France
- Univ. Bordeaux, INSERM, Biology of cardiovascular diseases, U1034, F-33600 Pessac, France
| | - Maxime Michot
- Univ. Bordeaux, INSERM, Biology of cardiovascular diseases, U1034, F-33600 Pessac, France
| | - François-Xavier Hérion
- From the CHU Bordeaux, Department of Cardiovascular Anesthesia and Critical Care, F-33000 Bordeaux, France
- Univ. Bordeaux, INSERM, Biology of cardiovascular diseases, U1034, F-33600 Pessac, France
| | - Mario Rienzo
- Department of Anesthesia and Intensive Care, Private Hospital of Parly 2, Le Chesnay, France
| | - Claire Oddos
- From the CHU Bordeaux, Department of Cardiovascular Anesthesia and Critical Care, F-33000 Bordeaux, France
| | - Thierry Couffinhal
- Univ. Bordeaux, INSERM, Biology of cardiovascular diseases, U1034, F-33600 Pessac, France
| | - Julien Imbault
- From the CHU Bordeaux, Department of Cardiovascular Anesthesia and Critical Care, F-33000 Bordeaux, France
- Univ. Bordeaux, INSERM, Biology of cardiovascular diseases, U1034, F-33600 Pessac, France
| | - Alexandre Ouattara
- From the CHU Bordeaux, Department of Cardiovascular Anesthesia and Critical Care, F-33000 Bordeaux, France
- Univ. Bordeaux, INSERM, Biology of cardiovascular diseases, U1034, F-33600 Pessac, France
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Corujo Rodriguez A, Richter E, Ibekwe SO, Shah T, Faloye AO. Postcardiotomy Shock Syndrome: A Narrative Review of Perioperative Diagnosis and Management. J Cardiothorac Vasc Anesth 2023; 37:2621-2633. [PMID: 37806929 DOI: 10.1053/j.jvca.2023.09.011] [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: 06/14/2023] [Revised: 08/29/2023] [Accepted: 09/09/2023] [Indexed: 10/10/2023]
Abstract
Postcardiotomy shock (PCS) is generally described as the inability to separate from cardiopulmonary bypass due to ineffective cardiac output after cardiotomy, which is caused by a primary cardiac disorder, resulting in inadequate tissue perfusion. Postcardiotomy shock occurs in 0.5% to 1.5% of contemporary cardiac surgery cases, and is accompanied by an in-hospital mortality of approximately 67%. In the last 2 decades, the incidence of PCS has increased, likely due to the increased age and baseline morbidity of patients requiring cardiac surgery. In this narrative review, the authors discuss the epidemiology and pathophysiology of PCS, the rationale and evidence behind the initiation, continuation, escalation, and discontinuation of mechanical support devices in PCS, and the anesthetic implications.
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Affiliation(s)
| | - Ellen Richter
- Department of Anesthesiology, Emory University, Atlanta, GA
| | | | - Tina Shah
- Department of Anesthesiology, Emory University, Atlanta, GA
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Radwan M, Baghdadi K, Popov AF, Sandoval Boburg R, Risteski P, Schlensak C, Walter T, Berger R, Emrich F. Right Axillary Artery Cannulation for Veno-Arterial Extracorporeal Membrane Oxygenation in Postcardiotomy Patients: A Single-Center Experience. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2040. [PMID: 38004089 PMCID: PMC10673577 DOI: 10.3390/medicina59112040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/30/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023]
Abstract
Background and Objectives: To analyze the patient outcome and complication rate of axillary artery cannulation for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in patients who could not be weaned from cardiopulmonary bypass after cardiothoracic surgery. Materials and Methods: We analyzed the data of 179 patients who were supported with VA-ECMO with femoral-axillary access (FA VA-ECMO) after cardiothoracic surgery between January 2014 and January 2019 in our department. Patients requiring central aortic cannulation and patients with respiratory failure requiring veno-venous ECMO were excluded. Primary outcomes were in-hospital mortality and 1-year survival rate of patients who were weaned from VA-ECMO support. Secondary outcomes were cannulation-related complications at the axillary site, VA-ECMO-related complications, and systemic complications. Results: In our cohort, 60 (33.5%) patients were female. Mean age was 67.0 ± 10.9 years. Overall, 78 (43.5%) patients were operated upon electively, 37 (20.7%) patients underwent urgent surgery, and 64 (35.8%) patients underwent emergency surgical treatment. Sixty-seven patients (37.4%) were resuscitated preoperatively. The mean duration of VA-ECMO support was 8.4 ± 5.1 days. Weaning from VA-ECMO was successful in 87 (48.6%) patients; 62 (34.6%) patients survived the hospital stay. The 1-year survival rate was 74%. Subclavian bleeding occurred in 24 (13.4%) patients, femoral bleeding in 4 (2.2%) patients, ischemia of the upper limb in 11 (6.1%) patients, intracerebral bleeding in 9 (5%) patients, and stroke in 19 (10.6%) patients. Conclusions: In patients with acute LV dysfunction after cardiothoracic surgery who cannot be weaned from cardiopulmonary bypass, right axillary artery cannulation is a safe and reliable method for VA-ECMO support with an acceptable complication rate.
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Affiliation(s)
- Medhat Radwan
- Department of Thoracic and Cardiovascular Surgery, University Hospital of Tuebingen, 72076 Tuebingen, Germany; (M.R.); (R.S.B.); (C.S.)
| | - Karim Baghdadi
- Department of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University, 60590 Frankfurt am Main, Germany (T.W.); (F.E.)
| | - Aron Frederik Popov
- Division for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, 30625 Hannover, Germany;
| | - Rodrigo Sandoval Boburg
- Department of Thoracic and Cardiovascular Surgery, University Hospital of Tuebingen, 72076 Tuebingen, Germany; (M.R.); (R.S.B.); (C.S.)
| | - Petar Risteski
- Department of Cardiac Surgery, University Hospital Zuerich, 8091 Zuerich, Switzerland;
| | - Christian Schlensak
- Department of Thoracic and Cardiovascular Surgery, University Hospital of Tuebingen, 72076 Tuebingen, Germany; (M.R.); (R.S.B.); (C.S.)
| | - Thomas Walter
- Department of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University, 60590 Frankfurt am Main, Germany (T.W.); (F.E.)
| | - Rafal Berger
- Department of Thoracic and Cardiovascular Surgery, University Hospital of Tuebingen, 72076 Tuebingen, Germany; (M.R.); (R.S.B.); (C.S.)
| | - Fabian Emrich
- Department of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University, 60590 Frankfurt am Main, Germany (T.W.); (F.E.)
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Liu Y, Zeng M, Zhou Y, Qiu W, Zeng R, Zhou Y. Effect of intra-aortic balloon pump with veno-arterial extracorporeal membrane oxygenation in acute myocardial infarction with cardiogenic shock: A meta-analysis. Perfusion 2023:2676591231189941. [PMID: 37498618 DOI: 10.1177/02676591231189941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
BACKGROUND The effectiveness of a concomitant intra-aortic balloon pump (IABP) with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) intervention in acute myocardial infarction with cardiogenic shock (AMICS) patients is contested in the literature. This study sought to compare short-term mortality weaning rate from VA-ECMOin AMICS cases. METHODS We conducted a literature review and compared the primary and secondary endpoints in the following treatment groups of AMICS patients: (1) VA-ECMO plus IABP vs. IABP alone and (2) VA-ECMO plus IABP vs. VA-ECMO alone. The primary endpoint was in-hospital all-cause mortality; while 30-days mortality, weaning from VA-ECMO, and vascular complications comprised secondary endpoints. RESULTS VA-ECMO concomitant with IABP was administered to 3,580 (76.4%) patients, while IABP alone and VA-ECMO alone treatments accounted for 1.7% and 21.9% of the patients, respectively. We found that in-hospital mortality was significantly lower in patients treated with VA-ECMO plus IABP vs. VA-ECMO alone (odds ratio (OR) = 0.52; 95% Confidence Interval (CI) = 0.21-1.31; I-squared statistic (I2 = 30%) or IABP alone (OR = 0.20; 95% CI = 0.08-0.55; I2 = 0%). Additionally, 30-days mortality was significantly lower in patients treated with VA-ECMO plus IABP vs. VA-ECMO alone (OR = 0.31; 95% CI = 0.25-0.40; I2 = 0%) or IABP alone (OR = 0.24; 95% CI = 0.11-0.50; I2 = 0%). A significant difference was observed in weaning from VA-ECMO in patients treated with VA-ECMO plus IABP vs. VA-ECMO alone (OR = 1.91; 95% CI = 1.09-3.33; I2 = 0%). CONCLUSION In-hospital and 30-days mortality were significantly lower in AMICS patients treated with VA-ECMO plus IABP vs. VA-ECMO alone or IABP alone. VA-ECMO with concomitant IABP could increase the proportion of patients weaned from VA-ECMO, significantly reducing in-hospital mortality, without increasing complications.
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Affiliation(s)
- Yidan Liu
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Min Zeng
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yifang Zhou
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wenjie Qiu
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ruixiang Zeng
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Yuanshen Zhou
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
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8
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Klasen M, Smit M, Renes M, Damman K, Droogh JM. Cardiogenic shock due to probable SARS-CoV-2 myocarditis-a case report. Eur Heart J Case Rep 2023; 7:ytad232. [PMID: 37215518 PMCID: PMC10198703 DOI: 10.1093/ehjcr/ytad232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/22/2022] [Accepted: 04/28/2023] [Indexed: 05/24/2023]
Abstract
Background Since the start of the COVID-19 pandemic, many case reports have been presented describing different cardiac symptoms due to the SARS-CoV-2 infection. However, severe cardiac failure due to COVID-19 seems to be rare. Case summary A 30-year-old woman presented with COVID-19 and cardiogenic shock due to a lymphocytic myocarditis. Since she deteriorated under treatment with inotropes, she was referred to our centre, and veno-arterial extracorporeal life support was started. Subsequently, the aortic valve only opened sporadically, and spontaneous contrast appeared in the left ventricle (LV), pointing towards difficulties with unloading LV. Therefore, an Impella for venting the LV was implanted. After 6 days of mechanical circulatory support, her heart function recovered. All support could be weaned, and 2 months later, she had made a full recovery. Discussion We presented a patient with severe cardiogenic shock due to an acute virus-negative lymphocytic myocarditis associated with a SARS-CoV-2 infection. Since the precise aetiology of SARS-CoV-2-related myocarditis remains to be elucidated and no virus could be detected in the heart, a causal relationship remains speculative.
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Affiliation(s)
- Martiene Klasen
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Marije Smit
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Maurits Renes
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Kevin Damman
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Abstract
Mechanical circulatory support (MCS) devices provide temporary or intermediate- to long-term support for acute cardiopulmonary support. In the last 20 to 30 years, tremendous growth in MCS device usage has been seen. These devices offer support for isolated respiratory failure, isolated cardiac failure, or both. Initiation of MCS devices requires the input from multidisciplinary teams using patient factors and institutional resources to guide decision making, along with a planned "exit strategy" for bridge to decision, bridge to transplant, bridge to recovery, or as destination therapy. Important considerations for MCS use include patient selection, cannulation/insertion strategies, and complications of each device.
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Affiliation(s)
- Suzanne Bennett
- Department of Anesthesiology, University of Cincinnati College of Medicine, 2139 Albert Sabin Way, Cincinnati, OH 45267-0531, USA.
| | - Lauren Sutherland
- Columbia University Irving Medical Center, 622 W 168(th) Street, New York, NY 10032, USA
| | - Promise Ariyo
- Johns Hopkins University, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - Frank M O'Connell
- Anesthesiology, Atlanticare Regional Medical Center, 65 W Jimmie Leeds Road, Pomona, NJ 08240, USA
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Left Ventricular Unloading in Patients on Venoarterial Extracorporeal Membrane Oxygenation Therapy in Cardiogenic Shock: Prophylactic Versus Bail-Out Strategy. Life (Basel) 2023; 13:life13020582. [PMID: 36836939 PMCID: PMC9967184 DOI: 10.3390/life13020582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/30/2022] [Accepted: 02/17/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND The benefit of prophylactic left ventricular (LV) unloading during venoarterial extracorporeal membrane oxygenation (VA-ECMO) in selected patients at risk of developing LV distension remains unclear. METHODS We enrolled 136 patients treated with Impella pump decompression during VA-ECMO therapy for refractory cardiogenic shock. Patients were stratified by specific indication for LV unloading in the prophylactic vs. bail-out group. The bail-out unloading strategy was utilized to treat LV distension in VA-ECMO afterload-associated complications. The primary endpoint was all-cause 30-day mortality after VA-ECMO implantation. The secondary endpoint was successful myocardial recovery, transition to durable mechanical circulatory support (MCS), or heart transplantation. RESULTS After propensity score matching, prophylactic unloading was associated with a significantly lower 30-day mortality risk (risk ratio 0.38, 95% confidence interval 0.23-0.62, and p < 0.001) and a higher probability of myocardial recovery (risk ratio 2.9, 95% confidence interval 1.48-4.54, and p = 0.001) compared with the bail-out strategy. Heart transplantation or durable MCS did not differ significantly between groups. CONCLUSIONS Prophylactic unloading compared with the bail-out strategy may improve clinical outcomes in selected patients on VA-ECMO. Nevertheless, randomized trials are needed to validate these results.
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Kashiura M, Kishihara Y, Ozawa H, Amagasa S, Yasuda H, Moriya T. Intra-aortic balloon pump use in out-of-hospital cardiac arrest patients who underwent extracorporeal cardiopulmonary resuscitation. Resuscitation 2023; 182:109660. [PMID: 36481238 DOI: 10.1016/j.resuscitation.2022.11.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 11/07/2022] [Accepted: 11/29/2022] [Indexed: 12/08/2022]
Abstract
AIM To investigate the effect of intra-aortic balloon pump (IABP) use after extracorporeal membrane oxygenation-assisted cardiopulmonary resuscitation (ECPR) on short-term neurological outcomes and survival in patients with out-of-hospital cardiac arrest (OHCA). METHODS We retrospectively analysed data collected between June 2014 and December 2019 from the Japanese OHCA registry. Adult patients (aged ≥18 years) who underwent ECPR were included. We divided the patients into those who received IABP and those who did not receive IABP. The primary outcome was the 30-day favourable neurological outcomes in survived patients. The secondary outcome was the 30-day survival. We performed propensity score matching (PSM) to adjust for confounding factors after multiple imputations of missing data. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated using logistic regression analysis after PSM to adjust for confounding factors after IABP initiation. RESULTS Among 2135 adult patients who underwent ECPR, 1173 received IABP. In 842 matched patients, IABP use was associated with survival (aOR, 1.98; 95% CI, 1.39-2.83; p < 0.001). However, IABP use was not significantly associated with the 30-day neurologically favourable outcome in 190 survived patients (aOR, 1.22; 95% CI, 0.79-1.89; p = 0.36). CONCLUSION The use of IABP in patients with OHCA who underwent ECPR was associated with 30-day survival. Among survived patients, there was no significant association between IABP use and 30-day neurological outcome. A further well-designed prospective study is needed.
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Affiliation(s)
- Masahiro Kashiura
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama City, Saitama 330-8503, Japan.
| | - Yuki Kishihara
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama City, Saitama 330-8503, Japan
| | - Hidechika Ozawa
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama City, Saitama 330-8503, Japan
| | - Shunsuke Amagasa
- Division of Emergency and Transport Services, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo 157-8535, Japan
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama City, Saitama 330-8503, Japan
| | - Takashi Moriya
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama City, Saitama 330-8503, Japan
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12
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Durak K, Rizk D, Emunds J, Vorwold F, Kalverkamp S, Steinseifer U, Strudthoff L, Spillner J, Hima F. Minimally Invasive Central Cannulation for Extracorporeal Life Support: The Uniportal and Subxiphoid Approach. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:528-537. [PMID: 36571269 PMCID: PMC9846569 DOI: 10.1177/15569845221137299] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Extracorporeal life support (ECLS) for circulatory and/or respiratory failure is improving. Currently, invasive sternotomies or rib-spreading thoracotomies are used for central cannulation of the heart and great vessels. Although peripheral cannulation of the extremities is often used, this approach may result in immobility and unintentional dislodgement. Less invasive methods for central cannulation are needed to achieve long-term ECLS. The objective of this study was to develop 2 different minimally invasive approaches for central thoracic cannulation. METHODS Porcine hearts were positioned in a plastic thoracic model. An endoscopic camera and multiple endoscopic instruments were used. Both access points, uniportal (lateral) and subxiphoidal, were simulatively investigated. A novel cannulation method using purse string sutures, a custom-made endoscopic puncture tool, guidewires, and dilator-assisted cannulas was developed. Simulations were tested in a closed circuit regarding leak tightness. RESULTS The uniportal approach allowed a cannulation of the aorta, inferior vena cava, right atrium, and main pulmonary artery. Cannulation of the right branches of the pulmonary artery and vein was also possible. From the subxiphoid approach, cannulation of the aorta, main pulmonary artery, and both atria were possible. Subsequent evaluation and leakage tests revealed no damage to the surrounding structures and tightly sealed cannulation sites. The uniportal approach was also successfully performed in a human cadaver to connect the aorta and right atrium with cannulas from the subxiphoidal space. CONCLUSIONS Both uniportal and subxiphoid central cannulation of potential sites for ECLS were feasible. This study encourages further investigation and potential clinical translation of minimally invasive central organ support.
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Affiliation(s)
- Koray Durak
- Department of Thoracic Surgery, RWTH
University Hospital Aachen, Germany,Koray Durak, BSc, Department of Thoracic
Surgery, RWTH University Hospital Aachen, Pauwelsstraße 30, Aachen, 52074,
Germany.
| | - Dana Rizk
- Department of Thoracic Surgery, RWTH
University Hospital Aachen, Germany
| | - Janina Emunds
- Department of Thoracic Surgery, RWTH
University Hospital Aachen, Germany
| | - Felix Vorwold
- Department of Thoracic Surgery, RWTH
University Hospital Aachen, Germany
| | | | - Ulrich Steinseifer
- Department of Cardiovascular
Engineering, Helmholtz-Institute for Biomedical Engineering, Aachen, Germany
| | - Lasse Strudthoff
- Department of Cardiovascular
Engineering, Helmholtz-Institute for Biomedical Engineering, Aachen, Germany
| | - Jan Spillner
- Department of Thoracic Surgery, RWTH
University Hospital Aachen, Germany
| | - Flutura Hima
- Department of Thoracic Surgery, RWTH
University Hospital Aachen, Germany
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13
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Sperotto F, Polito A, Amigoni A, Maschietto N, Thiagarajan RR. Left Atrial Decompression in Pediatric Patients Supported With Extracorporeal Membrane Oxygenation for Failure to Wean From Cardiopulmonary Bypass: A Propensity-Weighted Analysis. J Am Heart Assoc 2022; 11:e023963. [PMID: 35535596 PMCID: PMC9851456 DOI: 10.1161/jaha.121.023963] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background Left atrial (LA) decompression on extracorporeal membrane oxygenation (ECMO) can reduce left ventricular distension, allowing myocardial rest and recovery, and protect from lung injury secondary to cardiogenic pulmonary edema. However, clinical benefits remain unknown. We sought to evaluate the association between LA decompression and in-hospital adverse outcome (mortality, transplant on ECMO, or conversion to ventricular assist device) in patients who failed to wean from cardiopulmonary bypass using a propensity score to adjust for baseline differences. Methods and Results Children (aged <18 years) with biventricular physiology supported with ECMO for failure to wean from cardiopulmonary bypass after cardiac surgery from 2000 through 2016, reported to the ELSO (Extracorporeal Life Support Organization) Registry, were included. Inverse probability of treatment weighted logistic regression was used to test the association between LA decompression and in-hospital adverse outcomes. Of the 2915 patients supported with venoarterial ECMO for failure to wean from cardiopulmonary bypass, 1508 had biventricular physiology and 279 (18%) underwent LA decompression (LA+). Genetic and congenital abnormalities (P=0.001) and pulmonary hypertension (P=0.010) were less frequent and baseline arrhythmias (P=0.022) were more frequent in LA+ patients. LA+ patients had longer pre-ECMO mechanical ventilation and CBP time (P<0.001), and used aortic cross-clamp (P=0.001) more frequently. Covariates were well balanced between the propensity-weighted cohorts. In-hospital adverse outcomes occurred in 47% of LA+ patients and 51% of the others. Weighted multivariate logistic regression showed LA decompression to be protective for in-hospital adverse outcomes (adjusted odds ratio, 0.775 [95% CI, 0.644-0.932]). Conclusions LA decompression independently decreased the risk of in-hospital adverse outcome in pediatric venoarterial ECMO patients who failed to wean from cardiopulmonary bypass, suggesting that these patients may benefit from LA decompression.
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Affiliation(s)
- Francesca Sperotto
- Department of Cardiology Boston Children's HospitalHarvard Medical School Boston MA.,Pediatric Intensive Care Unit Department of Women's and Children's Health University of Padova Italy
| | - Angelo Polito
- Pediatric Intensive Care Unit University Hospital of GenevaUniversity of Geneva Switzerland
| | - Angela Amigoni
- Pediatric Intensive Care Unit Department of Women's and Children's Health University of Padova Italy
| | - Nicola Maschietto
- Department of Cardiology Boston Children's HospitalHarvard Medical School Boston MA
| | - Ravi R Thiagarajan
- Department of Cardiology Boston Children's HospitalHarvard Medical School Boston MA
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14
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Lim HS. Proportional pulmonary pulse pressure: A new index to assess response to veno-arterial extracorporeal membrane oxygenation. Perfusion 2022:2676591221140744. [PMID: 36422991 DOI: 10.1177/02676591221140744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND Based on theoretical physiology, the ratio of pulmonary artery pulse pressure to mean pulmonary pressure (PP-MPAP), termed proportional pulmonary pulse pressure, provides a measure of coupling between the right ventricle and the pulmonary circulation. This study tested the hypothesis that lower PP-MPAP ratio was associated with left ventricular (LV) distension in patients with cardiogenic shock who underwent extracorporeal life support (ECLS). METHODS This is a retrospective observational single-centre study of 22 patients with cardiogenic shock who underwent ECLS as the primary support modality without and with LV distension and Impella unloading. The relationship between post-support PP-MPAP and 12-hour lactate clearance was also assessed. RESULTS Of the 22 patients: 10 patients underwent additional Impella unloading due to LV distension (Group 1) and 12 patients on ECLS only without LV distension (Group 2). As predicted by the theoretical model, PP-MPAP on ECLS dropped in Group 1 (pre-Impella) from 0.473 ± 0.067 to 0.372 ± 0.087, p < 0.001; but increased in Group 2 patients without LV distension (0.518 ± 0.070 to 0.549 ± 0.072, p = 0.002). Impella support in Group 1 increased PP-MPAP (0.372 ± 0.087 to 0.615 ± 0.094, p < 0.001). On multiple regression analysis, post-support PP-MPAP was significantly associated with 12-hour lactate clearance. CONCLUSION Changes in PP-MPAP is associated hemodynamic response to ECLS and 12-hour lactate clearance. This simple parameter may guide therapeutic optimization in cardiogenic shock and ECLS.
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Affiliation(s)
- Hoong Sern Lim
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
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15
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Djordjevic I, Liakopoulos O, Elskamp M, Maier-Trauth J, Gerfer S, Mühlbauer T, Slottosch I, Kuhn E, Sabashnikov A, Rademann P, Maul A, Paunel-Görgülü A, Wahlers T, Deppe AC. Concomitant Intra-Aortic Balloon Pumping Significantly Reduces Left Ventricular Pressure during Central Veno-Arterial Extracorporeal Membrane Oxygenation-Results from a Large Animal Model. LIFE (BASEL, SWITZERLAND) 2022; 12:life12111859. [PMID: 36430994 PMCID: PMC9694613 DOI: 10.3390/life12111859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/10/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022]
Abstract
(1) Introduction: Simultaneous ECMO and IABP therapy is frequently used. Haemodynamic changes responsible for the success of the concomitant mechanical circulatory support system approach are rarely investigated. In a large-animal model, we analysed haemodynamic parameters before and during ECMO therapy, comparing central and peripheral ECMO circulation with and without simultaneous IABP support. (2) Methods: Thirty-three female pigs were divided into five groups: (1) SHAM, (2) (peripheral)ECMO(-)IABP, (3) (p)ECMO(+)IABP, (4) (central)ECMO(-)IABP, and (5) (c)ECMO(+)IABP. Pigs were cannulated in accordance with the group and supported with ECMO (±IABP) for 10 h. Systemic haemodynamics, cardiac index (CI), and coronary and carotid artery blood flow were determined before, directly after, and at five and ten hours on extracorporeal support. Systemic inflammation (IL-6; IL-10; TNFα; IFNγ), immune response (NETs; cf-DNA), and endothelial injury (ET-1) were also measured. (3) Results: IABP support during antegrade ECMO circulation led to a significant reduction of left ventricular pressure in comparison to retrograde flow in (p)ECMO(-)IABP and (p)ECMO(+)IABP. Blood flow in the left anterior coronary and carotid artery was not affected by extracorporeal circulation. (4) Conclusions: Concomitant central ECMO and IABP therapy leads to significant reduction of intracavitary cardiac pressure, reduces cardiac work, and might therefore contribute to improved recovery in ECMO patients.
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Affiliation(s)
- Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
- Correspondence: ; Tel.: +49-(0)-221-478-30-835
| | - Oliver Liakopoulos
- Department of Cardiac Surgery, Kerckhoff-Clinic Bad Nauheim, Campus Kerckhoff, University of Giessen, 61231 Bad Nauheim, Germany
| | - Mara Elskamp
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Johanna Maier-Trauth
- Division of Thoracic and Cardiovascular Surgery, HELIOS Klinikum Siegburg, 53721 Siegburg, Germany
| | - Stephen Gerfer
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Thomas Mühlbauer
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Ingo Slottosch
- Department of Cardiothoracic Surgery, Otto-von-Guericke University Magdeburg, 39120 Magdeburg, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Pia Rademann
- Experimental Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, 51109 Cologne, Germany
| | - Alexandra Maul
- Experimental Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, 51109 Cologne, Germany
| | - Adnana Paunel-Görgülü
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Antje Christin Deppe
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
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16
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Percutaneous Left Ventricular Unloading in Cardiogenic Shock During Venoarterial Extracorporeal Membrane Oxygenation: A Radial Approach. CJC Open 2022; 5:86-89. [PMID: 36700180 PMCID: PMC9869361 DOI: 10.1016/j.cjco.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/02/2022] [Indexed: 11/09/2022] Open
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17
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González-Pizarro P, Álvarez Bartolomé A, García Fernández J. Peripheral VA-ECMO left ventricular dysfunction: A combined biventricular assistance two case-report. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:583-586. [PMID: 36241508 DOI: 10.1016/j.redare.2021.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 04/07/2021] [Indexed: 06/16/2023]
Abstract
We report 2 patients with cardiogenic shock that developed severe left ventricular dysfunction due to a non-opening aortic valve while on peripheral VA-ECMO (Veno-Arterial Extracorporeal Membrane Oxygenator). Patients were managed combining a LV (Left Ventricle) mechanical assist device, and central VA - ECMO to support the right ventricle, thus providing full circulatory and respiratory assistance. Patients were able to bridge to cardiac transplantation. We therefore recommend such combination in patients with severe LV dysfunction while on p-ECMO (peripheral ECMO) support.
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Affiliation(s)
- P González-Pizarro
- Servicio de Anestesiología, Cuidados Críticos y Dolor, Hospital Universitario La Paz, Madrid, Spain.
| | - A Álvarez Bartolomé
- Servicio de Anestesiología, Cuidados Críticos y Dolor, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - J García Fernández
- Servicio de Anestesiología, Cuidados Críticos y Dolor, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; Departamento de Cirugía, Facultad de Medicina, Universidad Autónoma, Madrid, Spain
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18
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Sommer P, Nunnally M. Mechanical circulatory support in the intensive care unit. Int Anesthesiol Clin 2022; 60:46-54. [PMID: 35993668 DOI: 10.1097/aia.0000000000000381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Philip Sommer
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Langone Health, New York, New York
| | - Mark Nunnally
- Departments of Anesthesiology, Perioperative Care and Pain Medicine, Medicine, Surgery, Neurology, NYU Langone Medical Center, New York, New York
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19
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Kim M, Seong SW, Song PS, Jeong JO, Yang JH, Gwon HC, Ko YG, Yu CW, Chun WJ, Jang WJ, Kim HJ, Bae JW, Kwon SU, Lee HJ, Lee WS, Park SD, Cho SS, Park JH. Inodilators May Improve the In-Hospital Mortality of Patients with Cardiogenic Shock Undergoing Veno-Arterial Extracorporeal Membrane Oxygenation. J Clin Med 2022; 11:jcm11174958. [PMID: 36078888 PMCID: PMC9456701 DOI: 10.3390/jcm11174958] [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: 07/11/2022] [Revised: 08/22/2022] [Accepted: 08/23/2022] [Indexed: 11/16/2022] Open
Abstract
Although inodilators (dobutamine and milrinone) are widely used empirically for cardiogenic shock (CS), the efficacy of inodilators for patients with CS undergoing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is controversial. We evaluated the effects of inodilators on clinical outcomes using the RESCUE (REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy of left ventricular assist device for Korean patients with cardiogenic shock; NCT02985008) registry. We selected and analyzed the clinical outcomes of 496 patients who underwent VA-ECMO and did or did not receive inodilators. Of the 496 patients, 257 (51.8%) died during hospitalization. We selected 191 matched pairs to adjust for baseline clinical characteristics after 1:1 propensity score matching (PSM). The univariate and multivariate analyses showed that the inodilator group had significantly lower in-hospital mortality than the no-inodilator group (unadjusted hazard ratio [HR], 0.768; 95% confidence interval [CI], 0.579–1.018; p = 0.066, adjusted HR, 0.702; 95% CI, 0.552–0.944; p = 0.019). For patients with CS undergoing VA-ECMO, inodilators may improve clinical outcomes.
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Affiliation(s)
- Mijoo Kim
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon 35015, Korea
| | - Seok-Woo Seong
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon 35015, Korea
| | - Pil Sang Song
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon 35015, Korea
| | - Jin-Ok Jeong
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon 35015, Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Young-Guk Ko
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Cheol Woong Yu
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul 02841, Korea
| | - Woo Jung Chun
- Department of Cardiology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon 51353, Korea
| | - Woo Jin Jang
- Department of Cardiology, Ewha Woman’s University Seoul Hospital, Ehwa Woman’s University School of Medicine, Seoul 07804, Korea
| | - Hyun-Joong Kim
- Division of Cardiology, Department of Medicine, Konkuk University Medical Center, Seoul 05030, Korea
| | - Jang-Whan Bae
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju 28644, Korea
| | - Sung Uk Kwon
- Division of Cardiology, Department of Internal Medicine, Ilsan Paik Hospital, University of Inje College of Medicine, Seoul 48108, Korea
| | - Hyun-Jong Lee
- Division of Cardiology, Department of Medicine, Sejong General Hospital, Bucheon 14754, Korea
| | - Wang Soo Lee
- Division of Cardiology, Department of Medicine, Chung-Ang University Hospital, Seoul 06973, Korea
| | - Sang-Don Park
- Division of Cardiology, Department of Medicine, Inha University Hospital, Incheon 22332, Korea
| | - Sung Soo Cho
- Division of Cardiovascular Medicine, Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan 31116, Korea
| | - Jae-Hyeong Park
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon 35015, Korea
- Correspondence: ; Tel.: +82-42-280-8237
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20
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Jelenc M, Jelenc B, Novak R, Poglajen G. Left ventricular venting in veno-arterial extracorporeal membrane oxygenation: A computer simulation study. Int J Artif Organs 2022; 45:841-848. [PMID: 35903013 DOI: 10.1177/03913988221115444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is the fastest way to restore circulation in refractory cardiogenic shock, however it cannot unload the failing left ventricle. There is a lack of consensus regarding optimal approach to left ventricular venting in V-A ECMO patients with severely depressed or absent left ventricular function. METHODS A computer model was developed in Matlab Simulink R20016b (MathWorks, Inc., Natick, MA, USA) to analyze different venting options as well as atrial septostomy in the setting of cardiogenic shock and V-A ECMO. RESULTS The model has shown an inverse linear relationship between left atrial pressure and either vent, Impella or atrial septum defect flow rate. The minimum vent flow required to prevent pulmonary edema in complete loss of left ventricular function needed to be higher than the bronchial blood flow. Atrial septostomy restored normal pulmonary blood flow with low left atrial pressure but induced stasis in the left ventricle. Venting the pulmonary artery induced stasis in the entire pulmonary circulation as well as left atrium and left ventricle. Venting the left ventricle directly with a cannula or Impella device avoided blood stasis. CONCLUSION Our data suggest that reduction of left atrial pressure is linearly related to the vent, Impella or atrial septal defect flow rate. The preferred vent location is the left ventricle as it avoids stasis in the pulmonary circulation and cardiac chambers.
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Affiliation(s)
- Matija Jelenc
- Department of Cardiovascular Surgery, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Blaž Jelenc
- Faculty of Mathematics and Physics, University of Ljubljana, Ljubljana, Slovenia
| | - Robert Novak
- Department of Cardiovascular Surgery, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Gregor Poglajen
- Advanced Heart Failure and Transplantation Programme, Department of Cardiology, University Medical Center Ljubljana, Ljubljana, Slovenia
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21
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Xu B, Li C, Cai T, Cui Y, Du Z, Fan Q, Guo D, Jiang C, Xing Z, Xin M, Wang P, Wang L, Yang F, Jia M, Wang H, Hou X. Intra‐aortic balloon pump impacts the regional haemodynamics of patients with cardiogenic shock treated with femoro‐femoral veno‐arterial extracorporeal membrane oxygenation. ESC Heart Fail 2022; 9:2610-2617. [PMID: 35644478 PMCID: PMC9288750 DOI: 10.1002/ehf2.13981] [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: 12/03/2021] [Revised: 04/14/2022] [Accepted: 05/06/2022] [Indexed: 11/13/2022] Open
Abstract
Aims To investigate the impact of intra‐aortic balloon pump (IABP) on the regional haemodynamics of patients with severe cardiogenic shock undergoing femoro‐femoral veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO). Methods and results From July 2017 to April 2018, a total of 39 adult patients with cardiogenic shock receiving both IABP and ECMO for circulatory support were enrolled consecutively in a university‐affiliated cardiac surgery intensive care unit. The blood flow rates (BFRs) of the bilateral femoral artery (IABP side: iFA, ECMO side: eFA) and carotid artery (left: LCA, right: RCA) and the velocity time integral (VTI) of aortic root were assessed by ultrasonography and compared when IABP was on and off. Seventeen of 39 (43.6%) patients survived to discharge, and 29 (74.4%) survived on ECMO. A total of 172 pairs of data (IABP on and off) were collected in this study, measured on the median of 2.0 (1.0, 4.5) days after patients received VA‐ECMO. The BFR on both sides of FA (iFA: 176.4 ± 104.5 vs. 152.2 ± 139.8 mL/min, P < 0.01; eFA: 299.3 ± 279.9 vs. 242.4 ± 258.8 mL/min, P < 0.01) and the aortic VTI (10.1 ± 4.4 vs. 8.5 ± 4.4 cm, P < 0.01) decreased significantly when turning the IABP off, while the BFR on both sides of CA remained unchanged (LCA: 555.7 ± 326.9 vs. 578.6 ± 328.0 mL/min, P = 0.27; RCA: 550.0 ± 331.1 vs. 533.0 ± 303.5 mL/min, P = 0.30). The LCA BFR dramatically increased after turning the IABP off (296.8 ± 129.7 vs. 401.4 ± 278.1 mL/min, P = 0.02) in patients with cardiac stunning (defined as pulse pressure ≤ 5 mmHg). However, there was no significant difference in LCA BFR between IABP‐On and IABD‐Off (359.6 ± 105.4 mL/min vs. 389.6 ± 139.3 mL/min, P = 0.31) in patients with cardiac stunning receiving a higher ECMO blood flow (> 3.5 L/min). Conclusions Concomitant IABP used in patients undergoing femoro‐femoral VA‐ECMO was associated with increased aortic VTI and BFR in bilateral FA. The change in CA BFR depended on cardiac function. A decreased LCA BFR was observed in patients with cardiac stunning when IABP was turned on, which might be compensated by a higher ECMO blood flow. Further study is needed to confirm the relationship between BFR and extremities and neurological complications.
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Affiliation(s)
- Bo Xu
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital Capital Medical University Beijing P.R. China
| | - Chenglong Li
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital Capital Medical University Beijing P.R. China
| | - Tong Cai
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital Capital Medical University Beijing P.R. China
| | - Yongchao Cui
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital Capital Medical University Beijing P.R. China
| | - Zhongtao Du
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital Capital Medical University Beijing P.R. China
| | - Qiushi Fan
- School of Public Health Capital Medical University Beijing P.R. China
| | - Dong Guo
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital Capital Medical University Beijing P.R. China
| | - Chunjing Jiang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital Capital Medical University Beijing P.R. China
| | - Zhichen Xing
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital Capital Medical University Beijing P.R. China
| | - Meng Xin
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital Capital Medical University Beijing P.R. China
| | - Pengcheng Wang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital Capital Medical University Beijing P.R. China
| | - Liangshan Wang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital Capital Medical University Beijing P.R. China
| | - Feng Yang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital Capital Medical University Beijing P.R. China
| | - Ming Jia
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital Capital Medical University Beijing P.R. China
| | - Hong Wang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital Capital Medical University Beijing P.R. China
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital Capital Medical University Beijing P.R. China
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22
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Heinsar S, Farah SM, Fraser JF. Add-on Therapies in VA-ECMO for Cardiogenic Shock: The Heart Recovers, Yet Other Organs Suffer. J Cardiothorac Vasc Anesth 2022; 36:2246. [DOI: 10.1053/j.jvca.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 02/28/2022] [Accepted: 03/04/2022] [Indexed: 11/11/2022]
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23
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Delmas C, Pernot M, Le Guyader A, Joret R, Roze S, Lebreton G. Budget Impact Analysis of Impella CP ® Utilization in the Management of Cardiogenic Shock in France: A Health Economic Analysis. Adv Ther 2022; 39:1293-1309. [PMID: 35067868 PMCID: PMC8918169 DOI: 10.1007/s12325-022-02040-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 01/05/2022] [Indexed: 11/16/2022]
Abstract
Introduction Early detection and treatment of cardiogenic shock (CS) is crucial to avoid irreparable multiorgan damage and mortality. Impella CP® is a novel temporary mechanical circulatory support (MCS) device associated with greater hemodynamic support and significantly fewer device-related complications compared with other MCS devices, e.g., intra-aortic balloon pumps (IABP) and venoarterial extracorporeal membrane oxygenation (VA-ECMO). The present study evaluated the budget impact of introducing Impella CP versus IABP and VA-ECMO in patients with CS following an acute myocardial infarction (MI) in France. Methods A budget impact model was developed to compare the cost of introducing Impella CP with continuing IABP and VA-ECMO treatment from a Mandatory Health Insurance (MHI) perspective in France over a 5-year time horizon, with 700 patients with refractory CS assumed to be eligible for treatment per year. Costs associated with Impella CP and device-related complications for all interventions were captured and clinical input data were based on published sources. Scenario analyses were performed around key parameters. Results Introducing Impella CP was associated with cumulative cost savings of EUR 2.7 million over 5 years, versus continuing current clinical practice with IABP and VA-ECMO. Cost savings were achieved in every year of the analysis and driven by the lower incidence of device-related complications with Impella CP, with estimated 5-year cost savings of EUR 22.4 million due to avoidance of complications. Total cost savings of more than EUR 250,000 were projected in the first year of the analysis, which increased as the market share of Impella CP was increased. Scenario analyses indicated that the findings of the analysis were robust. Conclusion Treatment with Impella CP in adult patients aged less than 75 years in a state of refractory CS following an MI was projected to lead to substantial cost savings from an MHI perspective in France, compared with continuing current clinical practice.
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24
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Possible Underestimation of Cerebral Hyperoxia in Patients With Left Ventricular Output Encountering With Extracorporeal Membrane Oxygenation Flow at the Aortic Arch. Crit Care Med 2022; 50:e98-e99. [PMID: 34914657 DOI: 10.1097/ccm.0000000000005249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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25
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Atrial Septostomy for Left Ventricular Unloading. JACC Cardiovasc Interv 2021; 14:2708-2710. [PMID: 34949395 DOI: 10.1016/j.jcin.2021.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 10/05/2021] [Accepted: 10/12/2021] [Indexed: 11/22/2022]
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26
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Rotar EP, Mehaffey JH. Commentary: Can we REVERSE the effects of venous-arterial extracorporeal membrane oxygenation in cardiogenic shock? JTCVS OPEN 2021; 8:403-404. [PMID: 36004097 PMCID: PMC9390361 DOI: 10.1016/j.xjon.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 09/02/2021] [Accepted: 09/03/2021] [Indexed: 11/27/2022]
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27
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Extracorporeal membrane oxygenation evolution: Left ventricular unloading strategies. JTCVS OPEN 2021; 8:85-89. [PMID: 36004150 PMCID: PMC9390686 DOI: 10.1016/j.xjon.2021.10.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/22/2021] [Indexed: 12/01/2022]
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28
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Elliott A, Dahyia G, Kalra R, Alexy T, Bartos J, Kosmopoulos M, Yannopoulos D. Extracorporeal Life Support for Cardiac Arrest and Cardiogenic Shock. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2021.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The rising incidence and recognition of cardiogenic shock has led to an increase in the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). As clinical experience with this therapy has increased, there has also been a rapid growth in the body of observational and randomized data describing the clinical and logistical considerations required to institute a VA-ECMO program with successful clinical outcomes. The aim of this review is to summarize this contemporary data in the context of four key themes that pertain to VA-ECMO programs: the principles of patient selection; basic hemodynamic and technical principles underlying VA-ECMO; contraindications to VA-ECMO therapy; and common complications and intensive care considerations that are encountered in the setting of VA-ECMO therapy.
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Affiliation(s)
- Andrea Elliott
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Garima Dahyia
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Rajat Kalra
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Tamas Alexy
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Jason Bartos
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Marinos Kosmopoulos
- Department of Medicine, Division of Cardiology, Center for Resuscitation Medicine, University of Minnesota, Minneapolis, MN
| | - Demetri Yannopoulos
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
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29
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Zhang P, Wei S, Zhai K, Huang J, Cheng X, Tao Z, Gao B, Liu D, Li Y. Efficacy of left ventricular unloading strategies during venoarterial extracorporeal membrane oxygenation in patients with cardiogenic shock: a protocol for a systematic review and Bayesian network meta-analysis. BMJ Open 2021; 11:e047046. [PMID: 34666998 PMCID: PMC8527161 DOI: 10.1136/bmjopen-2020-047046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been widely used for patients with refractory cardiogenic shock. A common side effect of this technic is the resultant increase in left ventricular (LV) afterload which could potentially aggravate myocardial ischaemia, delay ventricular recovery and increase the risk of pulmonary congestion. Several LV unloading strategies have been proposed and implemented to mitigate these complications. However, it is still indistinct that which one is the best choice for clinical application. This Bayesian network meta-analysis (NMA) aims to compare the efficacy of different LV unloading strategies during VA-ECMO. METHODS AND ANALYSIS PubMed, Embase, the Cochrane Library and the International Clinical Trials Registry Platform will be explored from their inception to 31 December 2020. Random controlled trials and cohort studies that compared different LV unloading strategies during VA-ECMO will be included in this study. The primary outcome will be in-hospital mortality. The secondary outcomes will include neurological complications, haemolysis, bleeding, limb ischaemia, renal failure, gastrointestinal complications, sepsis, duration of mechanical ventilation, length of intensive care unit and hospital stays. Pairwise and NMA will respectively be conducted using Stata (V.16, StataCorp) and Aggregate Data Drug Information System (V.1.16.5), and the cumulative probability will be used to rank the included LV unloading strategies. The risk of bias will be conducted using the Cochrane Collaboration's tool or Newcastle-Ottawa Quality Assessment Scale according to their study design. Subgroup analysis, sensitivity analysis and publication bias assessment will be performed. The Grading of Recommendations Assessment, Development and Evaluation will be conducted to explore the quality of evidence. ETHICS AND DISSEMINATION Either ethics approval or patient consent is not necessary, because this study will be based on literature. The results will be disseminated through peer-reviewed publications and conference presentations. PROSPERO REGISTRATION NUMBER CRD42020165093.
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Affiliation(s)
- Pengbin Zhang
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shilin Wei
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
- Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Kerong Zhai
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
- Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Jian Huang
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
- Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Xingdong Cheng
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
- Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Zhenze Tao
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
- Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Bingren Gao
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Debin Liu
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Yongnan Li
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
- Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou, Gansu, China
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30
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Heinsar S, Jung JS, Colombo SM, Rozencwajg S, Wildi K, Sato K, Ainola C, Wang X, Abbate G, Sato N, Dyer WB, Livingstone SA, Pimenta LP, Bartnikowski N, Bouquet MJP, Passmore M, Vidal B, Palmieri C, Reid JD, Haqqani HM, McGuire D, Wilson ES, Rätsep I, Lorusso R, Suen JY, Bassi GL, Fraser JF. An innovative ovine model of severe cardiopulmonary failure supported by veno-arterial extracorporeal membrane oxygenation. Sci Rep 2021; 11:20458. [PMID: 34650063 PMCID: PMC8516938 DOI: 10.1038/s41598-021-00087-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 09/29/2021] [Indexed: 01/17/2023] Open
Abstract
Refractory cardiogenic shock (CS) often requires veno-arterial extracorporeal membrane oxygenation (VA-ECMO) to sustain end-organ perfusion. Current animal models result in heterogenous cardiac injury and frequent episodes of refractory ventricular fibrillation. Thus, we aimed to develop an innovative, clinically relevant, and titratable model of severe cardiopulmonary failure. Six sheep (60 ± 6 kg) were anaesthetized and mechanically ventilated. VA-ECMO was commenced and CS was induced through intramyocardial injections of ethanol. Then, hypoxemic/hypercapnic pulmonary failure was achieved, through substantial decrease in ventilatory support. Echocardiography was used to compute left ventricular fractional area change (LVFAC) and cardiac Troponin I (cTnI) was quantified. After 5 h, the animals were euthanised and the heart was retrieved for histological evaluations. Ethanol (58 ± 23 mL) successfully induced CS in all animals. cTnI levels increased near 5000-fold. CS was confirmed by a drop in systolic blood pressure to 67 ± 14 mmHg, while lactate increased to 4.7 ± 0.9 mmol/L and LVFAC decreased to 16 ± 7%. Myocardial samples corroborated extensive cellular necrosis and inflammatory infiltrates. In conclusion, we present an innovative ovine model of severe cardiopulmonary failure in animals on VA-ECMO. This model could be essential to further characterize CS and develop future treatments.
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Affiliation(s)
- Silver Heinsar
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Intensive Care Unit, St Andrews War Memorial Hospital, Brisbane, QLD, Australia.,Department of Intensive Care, North Estonia Medical Centre, Tallinn, Estonia
| | - Jae-Seung Jung
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Department of Thoracic and Cardiovascular Surgery, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Sebastiano Maria Colombo
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Sacha Rozencwajg
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia.,Medical ICU, Pitié-Salpêtrière University Hospital, INSERM UMRS-1166, Sorbonne Université, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
| | - Karin Wildi
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Kei Sato
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Carmen Ainola
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Department of Intensive Care, North Estonia Medical Centre, Tallinn, Estonia
| | - Xiaomeng Wang
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia
| | - Gabriella Abbate
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia
| | - Noriko Sato
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia
| | - Wayne Bruce Dyer
- Research and Development, Australian Red Cross Lifeblood, Sydney, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Samantha Annie Livingstone
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Leticia Pretti Pimenta
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia
| | - Nicole Bartnikowski
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia.,Science and Engineering Faculty, Queensland University of Technology, Brisbane, QLD, Australia
| | - Mahe Jeannine Patricia Bouquet
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Margaret Passmore
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Bruno Vidal
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia
| | - Chiara Palmieri
- School of Veterinary Science, The University of Queensland, Gatton, Australia
| | - Janice D Reid
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Haris M Haqqani
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Daniel McGuire
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia
| | - Emily Susan Wilson
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Indrek Rätsep
- Department of Intensive Care, North Estonia Medical Centre, Tallinn, Estonia
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia. .,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia. .,Intensive Care Unit, St Andrews War Memorial Hospital, Brisbane, QLD, Australia. .,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain. .,Wesley Medical Research, Brisbane, QLD, Australia.
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia. .,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia. .,Intensive Care Unit, St Andrews War Memorial Hospital, Brisbane, QLD, Australia. .,Wesley Medical Research, Brisbane, QLD, Australia.
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31
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Ye LF, Shu Q, Zhang C, Fan Y, Ying L, Yang L, Lin R. Surgical minimal invasive left atrial decompression during venoarterial extracorporeal membrane oxygenation for pediatric acute fulminant myocarditis. WORLD JOURNAL OF PEDIATRIC SURGERY 2021; 4:e000291. [DOI: 10.1136/wjps-2021-000291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2021] [Indexed: 11/04/2022] Open
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32
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Comparison of Circulatory Unloading Techniques for Venoarterial Extracorporeal Membrane Oxygenation. ASAIO J 2021; 67:623-631. [PMID: 33074863 DOI: 10.1097/mat.0000000000001268] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Left ventricular (LV) distention and pulmonary congestion are major complications inherent to venoarterial extracorporeal membrane oxygenation (ECMO). This study aimed to quantitatively compare the hemodynamic differences between common circulatory unloading methods for ECMO. Ten circulatory unloading techniques were evaluated on a mock circulatory loop simulating acute LV failure supported by ECMO. Simulated unloading techniques included: surgical and percutaneous pulmonary artery (PA) venting, surgical left atrial venting, surgical and percutaneous LV venting, atrial septal defect, partial support ventricular assist device, intraaortic balloon pump, and temporary VAD with inline oxygenator (tVAD). The most LV unloading occurred with the surgically placed LV vent and tVAD, which reduced LV end-diastolic volume from 295 to 167 ml and 82 ml, respectively. Meanwhile, the PA surgical vent was the most effective at reducing mean PA pressure from 21.0 to 10.6 mm Hg, and the tVAD was most effective at reducing left atrial pressure from 13.3 to 4.4 mm Hg. The major limitation of this study was the use of a mock circulatory loop, which simulated lower left atrial pressure than is typically seen clinically. This study identified clinically significant hemodynamic variability between the different circulatory unloading techniques evaluated. However, the applicability of these techniques will vary with different patient disease etiology. Further studies on ECMO unloading will help to quantify hemodynamic benefits and establish treatment guidelines.
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33
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González-Pizarro P, Álvarez Bartolomé A, García Fernández J. Peripheral VA-ECMO left ventricular dysfunction: A combined biventricular assistance two case-report. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 69:S0034-9356(21)00167-5. [PMID: 34187687 DOI: 10.1016/j.redar.2021.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 04/07/2021] [Indexed: 11/28/2022]
Abstract
We report 2patients with cardiogenic shock that developed severe left ventricular dysfunction due to a non-opening aortic valve while on peripheral VA-ECMO (Veno-Arterial Extracorporeal Membrane Oxygenator). Patients were managed combining a LV (Left Ventricle) mechanical assist device, and central VA - ECMO to support the right ventricle, thus providing full circulatory and respiratory assistance. Patients were able to bridge to cardiac transplantation. We therefore recommend such combination in patients with severe LV dysfunction while on p-ECMO (peripheral ECMO) support.
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Affiliation(s)
- P González-Pizarro
- Servicio de Anestesiología, Cuidados Críticos y Dolor. Hospital Universitario La Paz, Madrid, España.
| | - A Álvarez Bartolomé
- Servicio de Anestesiología, Cuidados Críticos y Dolor. Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | - J García Fernández
- Servicio de Anestesiología, Cuidados Críticos y Dolor. Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España; Departamento de Cirugía, Facultad de Medicina, Universidad Autónoma, Madrid, España
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34
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Mahesh B, Williams L, Punjabi PP, Katsaridis S. Novel strategy for improved outcomes of extra-corporeal membrane oxygenation as a treatment for refractory post cardiotomy cardiogenic shock in the current era: a refreshing new perspective. Perfusion 2021; 37:825-834. [PMID: 34112031 DOI: 10.1177/02676591211023304] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Post-cardiotomy cardiogenic shock is an infrequent but important cause of death following cardiac surgery. Extra-corporeal membrane oxygenation offers the opportunity for temporary cardiovascular support and myocardial rest, with a view to recovery. We examine our results with our recently-implemented management algorithm. METHODS We report our series of 15 consecutive patients out of 357 patients [4.2%] who required institution of veno-arterial extra-corporeal membrane oxygenation system support as treatment for Post-cardiotomy cardiogenic shock in the current era [January-2017 to January-2020]. RESULTS The mean age was 64.3 ± 11.6 years (range: 40-82 years); there were 13 males (86.7%). Duration of veno-arterial extra-corporeal membrane oxygenation support was 6.7 ± 1.9 days. Duration of stay on intensive care unit [ICU] was 18.9 ± 17.1 days. Duration of hospital-stay was 28.3 ± 20.8 days. Survival to discharge and at 2.2 ± 0.9 years was 67%. CONCLUSIONS We have shown clearly that veno-arterial extra-corporeal membrane oxygenation is an important rescue option for patients who develop refractory post-cardiotomy cardiogenic shock, with improved survival of 67% at 2.2 ± 0.9 years in those placed on post-cardiotomy veno-arterial extra corporeal membrane oxygenation support, which is superior to that reported hitherto in literature. We have sought to highlight the successes of post cardiotomy veno-arterial extra corporeal membrane oxygenation support, with improved results, based on careful patient selection, as well as diligent management of these critically-ill patients in the postoperative period, prior to establishment of irreversible end-organ dysfunction. Our strategy has also helped us rationalize and optimize the use of this expensive treatment modality.
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Affiliation(s)
- Balakrishnan Mahesh
- Division of Cardiothoracic Surgery and Transplantation, Harefield Hospital, London, UK
| | - Luke Williams
- Division of Cardiothoracic Surgery and Transplantation, Harefield Hospital, London, UK
| | - Prakash P Punjabi
- Division of Cardiothoracic Surgery, Hammersmith Hospital, London, UK
| | - Sotirios Katsaridis
- Division of Cardiothoracic Surgery and Transplantation, Harefield Hospital, London, UK
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35
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Lee SI, Lim YS, Park CH, Choi WS, Choi CH. Importance of pulse pressure after extracorporeal cardiopulmonary resuscitation. J Card Surg 2021; 36:2743-2750. [PMID: 33993537 DOI: 10.1111/jocs.15614] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 02/01/2021] [Accepted: 04/03/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Recent reports have revealed better clinical outcomes for extracorporeal cardiopulmonary resuscitation (ECPR) than conventional cardiopulmonary resuscitation (CPR). In this retrospective study, we attempted to identify predictors associated with successful weaning off extracorporeal membrane oxygenation (ECMO) support after ECPR. METHODS The demographic and clinical data of 30 ECPR patients aged over 18 years treated between August 2016 and January 2019 were analyzed. All clinical data were retrospectively collected. The primary endpoint was successful weaning off ECMO support after ECPR. Patients were divided into two groups based on successful or unsuccessful weaning off ECMO support (Weaned (n = 14) vs. Failed (n = 16)). RESULTS Univariate logistic regression analysis showed that age, CPR duration, ECMO complications, and loss of pulse pressure significantly predicted the results of weaning off ECMO support. However, multivariate logistic regression analysis showed that only CPR duration and loss of pulse pressure independently predicted unsuccessful weaning from ECMO support. CONCLUSION We conclude that long CPR duration and loss of pulse pressure after ECPR predict unsuccessful weaning from ECMO. However, unlike CPR duration, loss of pulse pressure during post-ECPR was related to subsequent management. In patients with reduced pulse pressure after ECPR, careful management is warranted because this reduction is closely associated with unsuccessful weaning off ECMO support after ECPR.
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Affiliation(s)
- Seok In Lee
- Department of Thoracic and Cardiovascular Surgery, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea
| | - Yong Su Lim
- Department of Emergency Medicine, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea
| | - Chul-Hyun Park
- Department of Thoracic and Cardiovascular Surgery, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea
| | - Woo Sung Choi
- Department of Emergency Medicine, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea
| | - Chang Hyu Choi
- Department of Thoracic and Cardiovascular Surgery, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea
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Left Ventricular Decompression by Transaortic Catheter Venting in Extracorporeal Membrane Oxygenation. ASAIO J 2021; 67:752-756. [PMID: 34170881 DOI: 10.1097/mat.0000000000001450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been widely applied to patients with cardiogenic shock. Left ventricle (LV) decompression is important when LV distension develops with pulmonary edema. The purpose of this study was to present the results of transaortic catheter venting (TACV) performed during VA-ECMO. We retrospectively reviewed the medical records of 18 patients who underwent both VA-ECMO and TACV between January 2017 and December 2019. Venoarterial extracorporeal membrane oxygenation was applied uneventfully. Lactate level and norepinephrine requirement for patients of weaning success were lower than those of patients of weaning failure after the application of TACV (p = 0.032 and p = 0.015, respectively). The successful weaning rate of ECMO was 77.8% (15/18) and survival rate was 50% (9/18). Transaortic catheter venting may be an easy, safe, and effective technique for LV decompression in patients with VA-ECMO for cardiogenic shock. Also, this technique may be helpful as an alternative or bridge method.
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Concomitant ECMO And IABP Support in Postcardiotomy Cardiogenic Shock Patients. Heart Lung Circ 2021; 30:1533-1539. [PMID: 33903028 DOI: 10.1016/j.hlc.2021.03.276] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/27/2021] [Accepted: 03/11/2021] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Simultaneous mechanical circulatory support (MCS) with intra-aortic balloon pump (IABP) to extracorporeal membrane oxygenation (ECMO) is common in postcardiotomy cardiogenic shock (PCS). This study aimed to analyse the effect of concomitant ECMO and IABP therapy on the short-term outcomes of patients with PCS. METHODS Between March 2006 and March 2017, 172 consecutive patients with central (c) or peripheral (p) veno-arterial ECMO therapy due to PCS were identified at the current institution and included in this retrospective analysis. Patients were divided into ECMO+IABP and ECMO alone groups. Further, the impact of ECMO flow direction was analysed for the groups. RESULTS A total of 129 patients received ECMO+IABP support and 43 patients were treated with ECMO alone. Median ECMO duration did not differ between the groups (68 [34; 95] hours ECMO+IABP vs 44 [20; 103] hours ECMO; p=0.151). However, a trend toward a higher weaning rate was evident in ECMO+IABP patients (75 [58%] ECMO+IABP vs 18 [42%] ECMO; p=0.078). Concomitant IABP support with either cECMO (73% [n=24] cECMO+IABP vs 50% [n=11] ECMO; p=0.098) or pECMO (57% [n=55] ECMO+IABP vs 33% [n=7] ECMO; p=0.056) was also associated with a trend toward a higher weaning rate off ECMO. In-hospital mortality did not differ between the groups. CONCLUSION This analysis found that, independent of ECMO type, additional IABP support might increase ECMO weaning; however, it did not influence survival in PCS patients. Larger studies are necessary to further analyse the impact of this concomitant MSC therapy on clinical outcomes.
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Bhaskar P, Davila S, Hoskote A, Thiagarajan R. Use of ECMO for Cardiogenic Shock in Pediatric Population. J Clin Med 2021; 10:jcm10081573. [PMID: 33917910 PMCID: PMC8068254 DOI: 10.3390/jcm10081573] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/18/2021] [Accepted: 03/03/2021] [Indexed: 01/11/2023] Open
Abstract
In children with severe advanced heart failure where medical management has failed, mechanical circulatory support in the form of veno-arterial extracorporeal membrane oxygenation (VA ECMO) or ventricular assist device represents life-sustaining therapy. This review provides an overview of VA ECMO used for cardiovascular support including medical and surgical heart disease. Indications, contraindications, and outcomes of VA ECMO in the pediatric population are discussed.VA ECMO provides biventricular and respiratory support and can be deployed in rapid fashion to rescue patient with failing physiology. There have been advances in conduct and technologic aspects of VA ECMO, but survival outcomes have not improved. Stringent selection and optimal timing of deployment are critical to improve mortality and morbidity of the patients supported with VA ECMO.
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Affiliation(s)
- Priya Bhaskar
- Division of Pediatric Critical Care, UT Southwestern Medical Center, Children’s Medical Center, Dallas, TX 75235, USA; (P.B.); (S.D.)
| | - Samuel Davila
- Division of Pediatric Critical Care, UT Southwestern Medical Center, Children’s Medical Center, Dallas, TX 75235, USA; (P.B.); (S.D.)
| | - Aparna Hoskote
- Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK;
| | - Ravi Thiagarajan
- Department of Cardiology, Division of Cardiovascular Critical Care, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Correspondence:
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Hasde Aİ, Sarıcaoğlu MC, Dikmen Yaman N, Baran Ç, Özçınar E, Çakıcı M, İnan MB, Akar AR. Comparison of left ventricular unloading strategies on venoarterial extracorporeal life support. Interact Cardiovasc Thorac Surg 2021; 32:467-475. [PMID: 33249443 PMCID: PMC8906780 DOI: 10.1093/icvts/ivaa284] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/16/2020] [Accepted: 09/20/2020] [Indexed: 01/22/2024] Open
Abstract
OBJECTIVES Our goal was to compare the haemodynamic effects of different mechanical left ventricular (LV) unloading strategies and clinical outcomes in patients with refractory cardiogenic shock supported with venoarterial extracorporeal membrane oxygenation (VA-ECMO). METHODS A total of 448 patients supported with VA-ECMO for refractory cardiogenic shock between 1 March 2015 and 31 January 2020 were included and analysed in a single-centre, retrospective case-control study. Fifty-three patients (11.8%) on VA-ECMO required LV unloading. Percutaneous balloon atrial septostomy (PBAS), intra-aortic balloon pump (IABP) and transapical LV vent (TALVV) strategies were compared with regards to the composite rate of death, procedure-related complications and neurological complications. The secondary outcomes were reduced pulmonary capillary wedge pressure, pulmonary artery pressure, central venous pressure, left atrial diameter and resolution of pulmonary oedema on a chest X-ray within 48 h. RESULTS No death related to the LV unloading procedure was detected. Reduction in pulmonary capillary wedge pressure was highest with the TALVV technique (17.2 ± 2.1 mmHg; P < 0.001) and was higher in the PBAS than in the IABP group; the difference was significant (9.6 ± 2.5 and 3.9 ± 1.3, respectively; P = 0.001). Reduction in central venous pressure with TALVV was highest with the other procedures (7.4 ± 1.1 mmHg; P < 0.001). However, procedure-related complications were significantly higher with TALVV compared to the PBAS and IABP groups (50% vs 17.6% and 10%, respectively; P = 0.015). We observed no significant differences in mortality or neurological complications between the groups. CONCLUSIONS Our results suggest that TALVV was the most effective method for LV unloading compared with PBAS and IABP for VA-ECMO support but was associated with complications. Efficient LV unloading may not improve survival.
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Affiliation(s)
- Ali İhsan Hasde
- Department of Cardiovascular Surgery, Heart Center, Ankara University School of Medicine, Ankara, Turkey
| | - Mehmet Cahit Sarıcaoğlu
- Department of Cardiovascular Surgery, Heart Center, Ankara University School of Medicine, Ankara, Turkey
| | - Nur Dikmen Yaman
- Department of Pediatric Cardiovascular Surgery, Sami Ulus Maternity and Children Research and Training Hospital, Ankara, Turkey
| | - Çağdaş Baran
- Department of Cardiovascular Surgery, Heart Center, Ankara University School of Medicine, Ankara, Turkey
| | - Evren Özçınar
- Department of Cardiovascular Surgery, Heart Center, Ankara University School of Medicine, Ankara, Turkey
| | - Mehmet Çakıcı
- Department of Cardiovascular Surgery, Heart Center, Ankara University School of Medicine, Ankara, Turkey
| | - Mustafa Bahadır İnan
- Department of Cardiovascular Surgery, Heart Center, Ankara University School of Medicine, Ankara, Turkey
| | - Ahmet Ruchan Akar
- Department of Cardiovascular Surgery, Heart Center, Ankara University School of Medicine, Ankara, Turkey
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Ricarte Bratti JP, Cavayas YA, Noly PE, Serri K, Lamarche Y. Modalities of Left Ventricle Decompression during VA-ECMO Therapy. MEMBRANES 2021; 11:membranes11030209. [PMID: 33809568 PMCID: PMC8002319 DOI: 10.3390/membranes11030209] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/04/2021] [Accepted: 03/12/2021] [Indexed: 12/22/2022]
Abstract
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used to sustain circulatory and respiratory support in patients with severe cardiogenic shock or refractory cardiac arrest. Although VA-ECMO allows adequate perfusion of end-organs, it may have detrimental effects on myocardial recovery. Hemodynamic consequences on the left ventricle, such as the increase of afterload, end-diastolic pressure and volume, can lead to left ventricular (LV) distention, increase of myocardial oxygen consumption and delayed LV function recovery. LV distention occurs in almost 50% of patients supported with VA-ECMO and is associated with an increase in morbidity and mortality. Thus, recognizing, preventing and treating LV distention is key in the management of these patients. In this review, we aim to discuss the pathophysiology of LV distention and to describe the strategies to unload the LV in patients supported with VA-ECMO.
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Affiliation(s)
- Juan Pablo Ricarte Bratti
- Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC H1T 1C8, Canada; (J.P.R.B.); (Y.A.C.); (P.E.N.); (K.S.)
| | - Yiorgos Alexandros Cavayas
- Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC H1T 1C8, Canada; (J.P.R.B.); (Y.A.C.); (P.E.N.); (K.S.)
- Hôpital Sacré-Coeur de Montréal, 5400. Gouin Blvd. West, Montreal, QC H4J 1C5, Canada
| | - Pierre Emmanuel Noly
- Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC H1T 1C8, Canada; (J.P.R.B.); (Y.A.C.); (P.E.N.); (K.S.)
| | - Karim Serri
- Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC H1T 1C8, Canada; (J.P.R.B.); (Y.A.C.); (P.E.N.); (K.S.)
- Hôpital Sacré-Coeur de Montréal, 5400. Gouin Blvd. West, Montreal, QC H4J 1C5, Canada
| | - Yoan Lamarche
- Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC H1T 1C8, Canada; (J.P.R.B.); (Y.A.C.); (P.E.N.); (K.S.)
- Hôpital Sacré-Coeur de Montréal, 5400. Gouin Blvd. West, Montreal, QC H4J 1C5, Canada
- Correspondence: ; Tel.: +1-514-376-3330
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Donker DW, Sallisalmi M, Broomé M. Right-Left Ventricular Interaction in Left-Sided Heart Failure With and Without Venoarterial Extracorporeal Membrane Oxygenation Support-A Simulation Study. ASAIO J 2021; 67:297-305. [PMID: 33627604 PMCID: PMC7908866 DOI: 10.1097/mat.0000000000001242] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Left ventricular (LV) dilatation is commonly seen with LV failure and is often aggravated during venoarterial extracorporeal membrane oxygenation (VA ECMO). In this context, the intricate interaction between left and right heart function is considered to be of pivotal importance, yet mechanistically not well understood. We hypothesize that a preserved or enhanced right heart contractility causes increased LV loading both with and without VA ECMO. A closed-loop in-silico simulation model containing the cardiac chambers, the pericardium, septal interactions, and the pulmonary and systemic vascular systems with an option to connect a simulated VA ECMO circuit was developed. Right ventricular contractility was modified during simulation of severe LV failure with and without VA ECMO. Left atrial pressures increased from 14.0 to 23.8 mm Hg without VA ECMO and from 18.4 to 27.0 mm Hg under VA ECMO support when right heart contractility was increased between end-systolic elastance 0.1 and 1.0 mm Hg/ml. Left-sided end-diastolic volumes increased from 125 to 169 ml without VA ECMO and from 150 to 180 ml with VA ECMO. Simulations demonstrate that increased diastolic loading of the LV may be driven by increased right ventricular contractility and that left atrial pressures cannot be interpreted as a reflection of the degree of LV dysfunction and overload without considering right ventricular function. Our study illustrates that modelling and computer simulation are important tools to unravel complex cardiovascular mechanisms underlying the right-left heart interdependency both with and without mechanical circulatory support.
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Affiliation(s)
- Dirk W Donker
- From the Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marko Sallisalmi
- Anaesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- ECMO Department, Karolinska University Hospital, Stockholm, Sweden
| | - Michael Broomé
- Anaesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- ECMO Department, Karolinska University Hospital, Stockholm, Sweden
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ECMO in Cardiac Arrest: A Narrative Review of the Literature. J Clin Med 2021; 10:jcm10030534. [PMID: 33540537 PMCID: PMC7867121 DOI: 10.3390/jcm10030534] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/12/2021] [Accepted: 01/26/2021] [Indexed: 01/07/2023] Open
Abstract
Cardiac arrest (CA) is a frequent cause of death and a major public health issue. To date, conventional cardiopulmonary resuscitation (CPR) is the only efficient method of resuscitation available that positively impacts prognosis. Extracorporeal membrane oxygenation (ECMO) is a complex and costly technique that requires technical expertise. It is not considered standard of care in all hospitals and should be applied only in high-volume facilities. ECMO combined with CPR is known as ECPR (extracorporeal cardiopulmonary resuscitation) and permits hemodynamic and respiratory stabilization of patients with CA refractory to conventional CPR. This technique allows the parallel treatment of the underlying etiology of CA while maintaining organ perfusion. However, current evidence does not support the routine use of ECPR in all patients with refractory CA. Therefore, an appropriate selection of patients who may benefit from this procedure is key. Reducing the duration of low blood flow by means of performing high-quality CPR and promoting access to ECPR, may improve the survival rate of the patients presenting with refractory CA. Indeed, patients who benefit from ECPR seem to carry better neurological outcomes. The aim of this present narrative review is to present the most recent literature available on ECPR and to clarify its potential therapeutic role, as well as to provide an in-depth explanation of equipment and its set up, the patient selection process, and the patient management post-ECPR.
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Kim AR, Park H, Lee SE, Ahn JM, Park DW, Lee SW, Kim JJ, Park SJ, Hong JA, Kang PJ, Jung SH, Kim MS. Outcomes of left ventricular unloading with a transseptal cannula during extracorporeal membrane oxygenation in adults. Artif Organs 2020; 45:390-398. [PMID: 33001468 DOI: 10.1111/aor.13838] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/16/2020] [Accepted: 09/24/2020] [Indexed: 12/20/2022]
Abstract
We evaluated the benefit of left ventricular (LV) unloading using a percutaneous transseptal left atrial (LA) drain catheter via femoral vein incorporated into the ECMO venous circuit. This single-center retrospective observational study analyzed clinical outcomes of the LA venting group (N = 62) who underwent percutaneous transseptal LA drain placement comparing with the conventionally treated control group (N = 62) with an arterial pulse pressure below 10 mm Hg for at least 24 hours from December 2012 to August 2018. The ECMO weaning rate (61.3% vs. 38.7%, P = .012) and cardiac transplantation rate (29.0% vs. 11.3%, P = .014) were higher in the LA venting group than in the control group. Inhospital mortality was not significantly different (56.5% vs. 69.4%, P = .191). Pulmonary congestion mostly improved after LA decompression (61.3%, P = .003). A serum lactate level at 24 hours after LA venting of more than 2.2 mmol/L was associated with poor outcomes. LA venting via transseptal cannula reduced pulmonary venous congestion and achieved higher rates of successful ECMO weaning and cardiac transplantation. Placement of a transseptal venous drain cannula should be considered in patients with uncontrolled pulmonary edema secondary to severe LV loading undergoing VA-ECMO.
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Affiliation(s)
- Ah-Ram Kim
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hanbit Park
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Eun Lee
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Min Ahn
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duk-Woo Park
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Whan Lee
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Joong Kim
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jung Park
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Ae Hong
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Pil-Je Kang
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min-Seok Kim
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Madjarov JM, Katz MG, Fazal S, Madzharov S. Mechanical circulatory support with extracorporeal membrane oxygenation and Impella 5.5 in patients with a postinfarction VSD: Combined or separate assist strategy? J Card Surg 2020; 36:781. [PMID: 33225456 DOI: 10.1111/jocs.15204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Jeko M Madjarov
- Department of Cardio-Vascular Surgery, Atrium Sanger Heart and Vascular Institute, Charlotte, North Carolina, USA
| | - Michael G Katz
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shahood Fazal
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Svetozar Madzharov
- Department of Cardio-Vascular Surgery, Atrium Sanger Heart and Vascular Institute, Charlotte, North Carolina, USA
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Orozco-Hernandez EJ, Ahmed MI, Von Meering G, Mcelwee SK, Prejean SP, Gongora E, Hoopes CW. Femoral venoarterial extracorporeal membrane oxygenation using a novel biatrial cannula for venous drainage and left ventricular venting. J Card Surg 2020; 35:3631-3633. [PMID: 33001516 DOI: 10.1111/jocs.15087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/29/2020] [Accepted: 09/21/2020] [Indexed: 12/01/2022]
Abstract
Extracorporeal life support (ECLS) is an expanding technology for patients in cardiogenic shock. The majority of patients requiring ECLS can be managed with percutaneous venoarterial (VA) femoral cannulation. Despite sufficient extracorporeal circulatory support, a unclear number of patients develop left ventricular distension which can result in increased wall tension and stress as well as worsening pulmonary edema. Indications to vent the left ventricle can be controversial. When venting is indicated, a number of additional procedures may be considered including inotropic support, intra-aortic balloon pump, impella, balloon atrial septostomy, or placement of a transseptal cannula. We present a unique case of a femoral VA extracorporeal membrane oxygenation as a bridge to transplant with left-sided venting using a Bio-Medicus NextGen cannula (Medtronic) with a transseptal approach.
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Affiliation(s)
- Erik J Orozco-Hernandez
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Mustafa I Ahmed
- Section of Interventional Cardiology, Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Greg Von Meering
- Section of Interventional Cardiology, Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Samuel K Mcelwee
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Shane P Prejean
- Section of Interventional Cardiology, Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Enrique Gongora
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Charles W Hoopes
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Li Y, Yan S, Gao S, Liu M, Lou S, Liu G, Ji B, Gao B. Effect of an intra-aortic balloon pump with venoarterial extracorporeal membrane oxygenation on mortality of patients with cardiogenic shock: a systematic review and meta-analysis†. Eur J Cardiothorac Surg 2020; 55:395-404. [PMID: 30252028 DOI: 10.1093/ejcts/ezy304] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 07/26/2018] [Accepted: 07/31/2018] [Indexed: 12/29/2022] Open
Abstract
An intra-aortic balloon pump (IABP) concomitant with venoarterial extracorporeal membrane oxygenation (VA-ECMO) is frequently used to support patients with refractory cardiogenic shock (CS). Because of the lack of evidence of the adjunctive benefit, the goal of the study was to compare the effect of VA-ECMO plus IABP with that of VA-ECMO alone. Systematic searches were conducted to identify studies using PubMed, Embase, the Cochrane Library and the International Clinical Trials Registry Platform. Studies reporting on patients with adult CS treated with VA-ECMO plus IABP or VA-ECMO alone were identified and included. The primary outcome was in-hospital death. The secondary outcomes included neurological, gastrointestinal and limb-related complications. The study protocol was registered at PROSPERO (CRD42017069259). A total of 29 studies comprising 4576 patients were included. The pooled in-hospital deaths of patients on VA-ECMO were 1441/2285 (63.1%) compared with 1339/2291 (58.4%) for patients with adjunctive IABP. VA-ECMO plus IABP was associated with decreased in-hospital deaths [risk ratio (RR) 0.90; 95% confidence interval (CI) 0.85-0.95; P < 0.0001]. Moreover, IABP was related to decreased in-hospital deaths of patients with extracorporeal cardiopulmonary resuscitation, postcardiotomy CS and ischaemic heart disease (RR 0.78; 95% CI 0.64-0.95; P = 0.01; RR 0.91; 95% CI: 0.85-0.98; P = 0.008; RR 0.83; 95% CI 0.73-0.96, P = 0.009). Neurological, gastrointestinal and limb-related complications did not differ significantly between patients on ECMO with and without concurrent IABP. VA-ECMO plus IABP was associated with decreased in-hospital deaths in patients with CS.
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Affiliation(s)
- Yongnan Li
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China.,Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Shujie Yan
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Sizhe Gao
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Mingyue Liu
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Song Lou
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Gang Liu
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Bingren Gao
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
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Zangrillo A, Morselli F, Lombardi G, Yavorovskiy A, Likhvantsev V, Beretta L, Monaco F, Landoni G. Procedural sedation and analgesia for percutaneous high-tech cardiac procedures. Minerva Cardiol Angiol 2020; 69:358-369. [PMID: 32989964 DOI: 10.23736/s2724-5683.20.05211-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The interest in percutaneous high-tech cardiac procedures has increased in recent years together with its safety and efficacy. In fragile patients, procedural sedation and analgesia are used to perform most of the procedures. General anesthesia remains the technique of choice during the team learning curve and might be required in selected patients or in emergent situations. Despite the high costs of percutaneous high-tech cardiac procedures, the decrease in length of hospital stays, rate of intensive care admission and complications, balance the increase in devices costs. In fragile patients who undergo percutaneous high tech cardiac procedures, the primary role of the anesthesiologist is to prevent the need for postprocedural intensive care unit and complications rate. Starting from the experience of a large university third level hospital we identified the eight most commonly performed contemporary percutaneous high tech cardiac procedures (ventricular tachycardia and atrial fibrillation ablation, protected percutaneous coronary intervention, transcatheter aortic valve implantation, MitraClip® (Abbott Laboratories; Abbott Park, IL, USA), percutaneous patent foramen ovale closure, left atrial appendage closure, and dysfunctional lead extraction), discuss the role of procedural sedation and analgesia in this setting, and explore future perspectives.
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Affiliation(s)
- Alberto Zangrillo
- IRCCS San Raffaele Scientific Institute, Milan, Italy.,IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | | | | | - Andrey Yavorovskiy
- Department of Anesthesiology and Intensive Care, First Moscow State Medical University, Moscow, Russia
| | | | - Luigi Beretta
- IRCCS San Raffaele Scientific Institute, Milan, Italy.,IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Giovanni Landoni
- IRCCS San Raffaele Scientific Institute, Milan, Italy - .,IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
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The Validity of SOFA Score to Predict Mortality in Adult Patients with Cardiogenic Shock on Venoarterial Extracorporeal Membrane Oxygenation. Crit Care Res Pract 2020; 2020:3129864. [PMID: 32963830 PMCID: PMC7495164 DOI: 10.1155/2020/3129864] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 08/19/2020] [Indexed: 01/31/2023] Open
Abstract
Background Venoarterial ECMO is increasingly used in resuscitation of adult patients with cardiogenic shock with variable mortality reports worldwide. Our objectives were to study the variables associated with hospital mortality in adult patients supported with VA-ECMO and to determine the validity of repeated assessments of those patients by the Sequential Organ Failure Assessment (SOFA) score for prediction of hospital mortality. We retrospectively studied adult patients admitted to the cardiac surgical critical care unit with cardiogenic shock supported with VA-ECMO from January 2015 to August 2019 in our tertiary care hospital. Results One hundred and six patients supported with VA-ECMO were included in our study with in-hospital mortality of 56.6%. The mean age of studied patients was 40.2 ± 14.4 years, and the patients were mostly males (69.8%) with a mean BMI of 26.5 ± 7 without statistically significant differences between survivors and nonsurvivors. Presence of CKD, chronic atrial fibrillation, and cardiac surgeries was significantly more frequent in the nonsurvivors group. The nonsurvivors had more frequent AKI (p < 0.001), more haemodialysis use (p < 0.001), more gastrointestinal bleeding (p = 0.039), more ICH (p = 0.006), and fewer ICU days (p = 0.002) compared to the survivors group. The mean peak blood lactate level was 11 ± 3 vs 16.7 ± 3.3, p < 0.001, and the mean lactate level after 24 hours of ECMO initiation was 2.2 ± 0.9 vs 7.9 ± 5.7, p < 0.001, in the survivors and nonsurvivors, respectively. Initial SOFA score ≥13 measured upon ICU admission had a 85% sensitivity and 73.9% specificity for predicting hospital mortality [AUROC = 0.862, 95% CI: 0.791–0.932; p < 0.001] with 81% PPV, 79.1% NPV, and 80.2% accuracy while SOFA score ≥13 at day 3 had 100% sensitivity and 91.3% specificity for predicting mortality with 93.8% PPV, 100% NPV, and 96.2% accuracy [AUROC = 0.995, 95% CI: 0.986–1; p < 0.001]. The ∆1 SOFA (3-1) ≥2 had 95% sensitivity and 93.5% specificity for predicting hospital mortality [AUROC = 0.958, 95% CI: 0.913–1; p < 0.001] with 95% PPV, 93.5% NPV, and 94.3% accuracy. SOFA score ≥15 at day 5 had 98% sensitivity and 100% specificity for predicting mortality with 99% accuracy [AUROC = 0.994, 95% CI: 0.982–1; p < 0.001]. The ∆2 SOFA (5-1) ≥2 had 90% sensitivity and 97.8% specificity for predicting hospital mortality [AUROC = 0.958, 95% CI: 0.909–1; p < 0.001] with 97.8% PPV, 90% NPV, and 94.8% accuracy. Multivariable regression analysis revealed that increasing ∆1 SOFA score (OR = 2.506, 95% CI: 1.681–3.735, p < 0.001) and increasing blood lactate level (OR = 1.388, 95% CI: 1.015–1.898, p = 0.04) were significantly associated with hospital mortality after VA-ECMO support for adults with cardiogenic shock. Conclusion The use of VA-ECMO in adult patients with cardiogenic shock is still associated with high mortality. Serial evaluation of those patients with SOFA score during the first few days of ECMO support is a good predictor of hospital mortality. Increase in SOFA score after 48 hours and hyperlactataemia are significantly associated with increased hospital mortality.
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Usefulness of contrast computed tomography for diagnosing left ventricular thrombus before impella insertion. J Cardiol Cases 2020; 22:291-293. [PMID: 33304424 DOI: 10.1016/j.jccase.2020.07.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/23/2020] [Accepted: 07/14/2020] [Indexed: 11/20/2022] Open
Abstract
The Impella (Abiomed, Danvers, MA, USA) is a novel percutaneous heart pump device for left ventricular (LV) assistance; however, LV thrombus is a notable contraindication for this device. Contrast computed tomography assessment is useful for detecting LV thrombus and preventing thromboembolism in patients recommended for Impella use. <Learning objective: The Impella (Abiomed, Danvers, MA, USA) is a heart pump device which aspirates blood from a left ventricular (LV) cavity and ejects it into an ascending aorta. Therefore, LV thrombus should be explored before the Impella insertion to prevent systemic embolism. Generally, echocardiography is the first choice to detect LV thrombus. Given limited diagnostic sensitivity for detecting LV thrombus in echocardiography, contrast computed tomography might be a useful strategy for the patient targeting Impella insertion.>.
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50
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Krishnamoorthy V, Babu S, Koshy T, Devarakonda BV, Palaniswamy N, Dharan BS. Left Ventricular Thrombus Formation During Cardiopulmonary Bypass Diagnosed by Intraoperative Transesophageal Echocardiography in a Case of Anomalous Left Coronary Artery From the Pulmonary Artery. J Cardiothorac Vasc Anesth 2020; 35:2751-2755. [PMID: 32798167 DOI: 10.1053/j.jvca.2020.07.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Vasanth Krishnamoorthy
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Saravana Babu
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India.
| | - Thomas Koshy
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Bhargava V Devarakonda
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Nithiyanandhan Palaniswamy
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Baiju S Dharan
- Department of Cardiothoracic and Vascular surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
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