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Deshpande SR, Das B, Kumar A, Sinha P, Alsoufi B, Trivedi J. Impact of new allocation policy on waitlist and transplant outcomes of adult congenital heart patients supported with ECMO. Artif Organs 2024; 48:912-920. [PMID: 38483147 DOI: 10.1111/aor.14738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 02/01/2024] [Accepted: 02/22/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND The use of ECMO as a bridge to heart transplantation has been growing rapidly in all heart transplant recipients since the implementation of the new UNOS allocation policy; however, the impact on adult congenital heart disease (ACHD) patients is not known. METHODS We analyzed the UNOS data (2015-2021) for ACHD patients supported with extracorporeal membrane oxygenation (ECMO) during the waitlist, before and after October 2018, to assess the impact on the waitlist and posttransplant outcomes. We compared the characteristics and outcomes of ACHD patients with or without ECMO use during the waitlist and pre- and postpolicy changes. RESULTS A total of 23 821 patients underwent heart transplantation, and only 918 (4%) had ACHD. Out of all ACHD patients undergoing heart transplants, 6% of patients in the prepolicy era and 7.6% in the postpolicy era were on ECMO at the time of listing. Those on ECMO were younger and sicker compared to the rest of the ACHD cohort. Those on ECMO had similar profiles pre- and postpolicy change; however, there was a very significant decrease in the waitlist time [136 days (IQR 29-384) vs. 38 days (IQR 11-108), p = 0.01]. There was no difference in waitlist mortality; however, competing risk analyses showed a higher likelihood of transplantation (51% vs. 29%) and a lower likelihood of death or deterioration (31% vs. 42%) postpolicy change. Long-term outcomes posttransplant for those supported with ECMO compared to the non-ECMO cohort are similar for ACHD patients, although there was higher attrition in the first year for the ECMO cohort. CONCLUSION The new allocation policy has resulted in shorter waitlist times and a higher likelihood of transplantation for ACHD patients supported by ECMO. However, the appropriate use of ECMO and the underuse of durable circulatory support devices in this population need further exploration.
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Affiliation(s)
- Shriprasad R Deshpande
- Pediatric Cardiology Division, Children's National Hospital, George Washington University, Washington, DC, USA
| | - Bibhuti Das
- Pediatric Cardiology, Baylor College of Medicine-Temple, Temple, Texas, USA
| | - Akshay Kumar
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Pranava Sinha
- Department of Pediatric Cardiovascular Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, Norton Children's Hospital, University of Louisville, Louisville, Kentucky, USA
| | - Jaimin Trivedi
- Department of Cardiothoracic Surgery, University of Louisville, Louisville, Kentucky, USA
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Rali AS, Garry JD, Dieter RA, Schlendorf KH, Bacchetta MD, Zalawadiya SK, Mishra K, Trahanas J, Frischhertz BP, Lindenfeld J, Olson TL, Cedars AM, Anders MM, Tonna JE, Dolgner SJ, Alvis BD, Menachem JN. Extracorporeal Life Support for Cardiogenic Shock in Adult Congenital Heart Disease-An ELSO Registry Analysis. ASAIO J 2023; 69:984-992. [PMID: 37549669 DOI: 10.1097/mat.0000000000002026] [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: 08/09/2023] Open
Abstract
There are minimal data on the use of venoarterial extracorporeal membrane life support (VA-ECLS) in adult congenital heart disease (ACHD) patients presenting with cardiogenic shock (CS). This study sought to describe the population of ACHD patients with CS who received VA-ECLS in the Extracorporeal Life Support Organization (ELSO) Registry. This was a retrospective analysis of adult patients with diagnoses of ACHD and CS in ELSO from 2009-2021. Anatomic complexity was categorized using the American College of Cardiology/American Heart Association 2018 guidelines. We described patient characteristics, complications, and outcomes, as well as trends in mortality and VA-ECLS utilization. Of 528 patients who met inclusion criteria, there were 32 patients with high-complexity anatomy, 196 with moderate-complexity anatomy, and 300 with low-complexity anatomy. The median age was 59.6 years (interquartile range, 45.8-68.2). The number of VA-ECLS implants increased from five implants in 2010 to 81 implants in 2021. Overall mortality was 58.3% and decreased year-by-year (β= -2.03 [95% confidence interval, -3.36 to -0.70], p = 0.007). Six patients (1.1%) were bridged to heart transplantation and 21 (4.0%) to durable ventricular assist device. Complications included cardiac arrhythmia/tamponade (21.6%), surgical site bleeding (17.6%), cannula site bleeding (11.4%), limb ischemia (7.4%), and stroke (8.7%). Utilization of VA-ECLS for CS in ACHD patients has increased over time with a trend toward improvement in survival to discharge.
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Affiliation(s)
- Aniket S Rali
- From the Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonah D Garry
- From the Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Raymond A Dieter
- From the Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kelly H Schlendorf
- From the Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew D Bacchetta
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sandip K Zalawadiya
- From the Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kelly Mishra
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John Trahanas
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Benjamin P Frischhertz
- From the Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joann Lindenfeld
- From the Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Taylor L Olson
- Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia
| | - Ari M Cedars
- Division of Cardiovascular Medicine, The John Hopkins Hospital, Baltimore, Maryland
| | - Marc M Anders
- Division of Critical Care, Texas Children's Hospital, Houston, Texas
- Division of Critical Care, Baylor College of Medicine, Houston, Texas
| | - Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery and Department of Emergency Medicine, University of Utah Health, Salt Lake City, Utah
| | - Steven J Dolgner
- Division of Critical Care, Texas Children's Hospital, Houston, Texas
| | - Bret D Alvis
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan N Menachem
- From the Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
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Karsenty C, Touafchia A, Ladouceur M, Roubille F, Bonnefoy E, Bonello L, Leurent G, Levy B, Champion S, Lim P, Schneider F, Cariou A, Khachab H, Bourenne J, Seronde MF, Harbaoui B, Vanzetto G, Quentin C, Delabranche X, Combaret N, Morel O, Lattuca B, Leborgne L, Fillippi E, Gerbaud E, Brusq C, Bongard V, Lamblin N, Puymirat E, Delmas C. Cardiogenic shock in adults with congenital heart disease: Insights from the FRENSHOCK registry. Arch Cardiovasc Dis 2023; 116:390-396. [PMID: 37598062 DOI: 10.1016/j.acvd.2023.06.008] [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: 04/12/2023] [Revised: 06/13/2023] [Accepted: 06/19/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND Data on cardiogenic shock in adults with congenital heart disease (ACHD) are scarce. AIM We sought to describe cardiogenic shock in ACHD patients in a nationwide cardiogenic shock registry. METHODS From the multicentric FRENSHOCK registry (772 patients with cardiogenic shock from 49 French centres between April and October 2016), ACHD patients were compared with adults without congenital heart disease (non-ACHD). The primary outcome was defined by all-cause mortality, chronic ventricular assist device or heart transplantation at 1year. RESULTS Out of the 772 patients, seven (0.9%) were ACHD, who were younger (median age: 56 vs. 67years), had fewer cardiovascular risk factors, such as hypertension (14.3% vs. 47.5%) and diabetes (14.3% vs. 28.3%), and no previous ischaemic cardiopathy (0 vs. 61.5%). Right heart catheterization (57.1% vs. 15.4%), pacemakers (28.6% vs. 4.6%) and implantable cardioverter-defibrillators (28.6% vs. 4.8%) were indicated more frequently in the management of ACHD patients compared with non-ACHD patients, whereas temporary mechanical circulatory support (0 vs. 18.7%) and invasive mechanical ventilation (14.3% vs. 38.1%) were less likely to be used in ACHD patients. At 1year, the primary outcome occurred in 85.7% (95% confidence interval: 42.1-99.6) ACHD patients and 52.3% (95% confidence interval: 48.7-55.9) non-ACHD patients. Although 1-year mortality was not significantly different between ACHD patients (42.9%) and non-ACHD patients (45.4%), ventricular assist devices and heart transplantation tended to be more frequent in the ACHD group. CONCLUSIONS Cardiogenic shock in ACHD patients is rare, accounting for only 0.9% of an unselected cardiogenic shock population. Despite being younger and having fewer co-morbidities, the prognosis of ACHD patients with cardiogenic shock remains severe, and is similar to that of other patients.
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Affiliation(s)
- Clément Karsenty
- Paediatric and Adult Congenital Cardiology Unit, CHU de Toulouse, 31300 Toulouse, France; Institut Des Maladies Métaboliques et Cardiovasculaires (I2MC), Inserm U1048, 31432 Toulouse, France.
| | - Anthony Touafchia
- Intensive Cardiac Care Unit, Cardiology Department, Rangueil University Hospital, 31400 Toulouse, France
| | - Magalie Ladouceur
- Department of Cardiology, Hôpital Européen Georges-Pompidou, AP-HP, 75015 Paris, France; Université de Paris, 75006 Paris, France
| | - François Roubille
- PhyMedExp, Université de Montpellier, Inserm, CNRS, 34295 Montpellier, France; Cardiology Department, CHU de Montpellier, 34295 Montpellier, France
| | - Eric Bonnefoy
- Intensive Cardiac Care Unit, Lyon University Hospital, 69622 Bron, France
| | - Laurent Bonello
- Aix-Marseille University, 13385 Marseille, France; Intensive Care Unit, Department of Cardiology, Hôpital Nord, AP-HM, 13385 Marseille, France; Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), 13385 Marseille, France
| | - Guillaume Leurent
- Department of Cardiology, CHU de Rennes, 35000 Rennes, France; LTSI-UMR 1099, Inserm, University of Rennes 1, 35000 Rennes, France
| | - Bruno Levy
- Réanimation Médicale Brabois, CHRU Nancy, 54511 Vandœuvre-les Nancy, France
| | | | - Pascal Lim
- Université Paris-Est Créteil, Inserm, IMRB, 94010 Créteil, France; Service de Cardiologie, Hôpital Universitaire Henri-Mondor, AP-HP, 94010 Créteil, France
| | - Francis Schneider
- Médecine Intensive-Réanimation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 67200 Strasbourg, France
| | - Alain Cariou
- Medical Intensive Care Unit, Cochin Hospital, AP-HP, 75014 Paris, France; Medical School, Centre-Université de Paris, 75014 Paris, France
| | - Hadi Khachab
- Intensive Cardiac Care Unit, Department of Cardiology, CH d'Aix-en-Provence, 13616 Aix-en-Provence, France
| | - Jeremy Bourenne
- Service de Réanimation des Urgences, CHU de la Timone 2, Aix-Marseille Université, 13385 Marseille, France
| | | | - Brahim Harbaoui
- Cardiology Department, Hôpital Croix-Rousse and Hôpital Lyon Sud, Hospices Civils de Lyon, 69004 Lyon, France; University of Lyon, CREATIS UMR 5220, Inserm U1044, INSA-15, 69100 Lyon, France
| | - Gérald Vanzetto
- Department of Cardiology, Hôpital de Grenoble, 38700 La Tronche, France
| | | | - Xavier Delabranche
- Réanimation Chirurgicale Polyvalente, Pôle Anesthésie-Réanimation Chirurgicale-Médecine Péri-opératoire, Les Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil 1, 67091 Strasbourg, France
| | - Nicolas Combaret
- Department of Cardiology, CHU de Clermont-Ferrand, CNRS, Université Clermont Auvergne, 63000 Clermont-Ferrand, France
| | - Olivier Morel
- Pôle d'Activité Médico-Chirurgicale Cardiovasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France
| | - Benoit Lattuca
- Department of Cardiology, Nîmes University Hospital, Montpellier University, 30900 Nîmes, France
| | | | | | - Edouard Gerbaud
- Cardiology Intensive Care Unit and Interventional Cardiology, Hôpital Cardiologique du Haut-Lévêque, 33604 Pessac, France; Bordeaux Cardio-Thoracic Research Centre, U1045, Bordeaux University, Hôpital Xavier-Arnozan, 33600 Pessac, France
| | - Clara Brusq
- Unité de Soutien Méthodologique à la Recherche (USMR), Service d'Épidémiologie Clinique et Santé Publique, CHU de Toulouse, 31300 Toulouse, France
| | - Vanina Bongard
- Unité de Soutien Méthodologique à la Recherche (USMR), Service d'Épidémiologie Clinique et Santé Publique, CHU de Toulouse, 31300 Toulouse, France
| | - Nicolas Lamblin
- Urgences et Soins Intensifs de Cardiologie, CHU de Lille, Inserm U1167, University of Lille, 59000 Lille, France
| | - Etienne Puymirat
- Department of Cardiology, Hôpital Européen Georges-Pompidou, AP-HP, 75015 Paris, France; Université de Paris, 75006 Paris, France
| | - Clément Delmas
- Paediatric and Adult Congenital Cardiology Unit, CHU de Toulouse, 31300 Toulouse, France; Institut Des Maladies Métaboliques et Cardiovasculaires (I2MC), Inserm U1048, 31432 Toulouse, France; REICATRA, Institut Saint-Jacques, CHU de Toulouse, 31059 Toulouse, France
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Special Considerations in Critical Care of the Congenital Heart Disease Patient. Can J Cardiol 2023; 39:544-557. [PMID: 36682483 DOI: 10.1016/j.cjca.2023.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 01/21/2023] Open
Abstract
Outcomes of congenital heart disease have improved markedly over the past 20 years, with survival to adulthood now close to 90%. The mean age of admission to an intensive care unit (ICU) is 40 years. The incidence of hospital and critical care admissions have increased significantly as a consequence of this improved survival. Intensivists are now confronted with the management not only of complex adult congenital heart disease (ACHD) lesions from a cardiac perspective, but also of extracardiac organ consequences of years of abnormal circulation after surgical or palliative correction. Kidney and liver dysfunction and respiratory and hematologic abnormalities are very common in this population. ACHD patients can present to the ICU for a vast number of reasons, classified in this review as medical noncardiac, medical cardiac, and surgical. Community/hospital-acquired infections, cerebrovascular accidents, and respiratory failure, alongside arrhythmias and heart failure, are responsible for medical admissions. Surgical admissions include postoperative management after correction or palliation, but also medical optimisation and work-up for advanced therapies. ICU management of this large heterogeneous group requires a thorough understanding of the pathophysiology in order to apply conventional adult critical care modalities; left ventricular or right ventricular dysfunction, pulmonary hypertension, intracardiac, extracardiac, and palliative surgical shunts can be present and require additional consideration. This review focuses on the pathophysiology, long-term sequelae, and different treatment modalities to supply a framework for the ICU physician caring for these patients. Successful outcome, especially in complex lesions, depends on early involvement of specialised ACHD centres.
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Quantitative evaluation of hemodynamic parameters by echocardiography in patients with post-cardiotomy cardiac shock supported by extracorporeal membrane oxygenation. J Cardiothorac Surg 2023; 18:1. [PMID: 36600267 PMCID: PMC9811784 DOI: 10.1186/s13019-022-02074-4] [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: 04/02/2022] [Accepted: 12/09/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND When drugs fail to reverse post-cardiotomy cardiac shock (PCS), extracorporeal membrane oxygenation (ECMO) is considered the most effective adjuvant strategy. Transthoracic echocardiography is a useful imaging modality for monitoring of cardiac hemodynamics. The aim of this study was to investigate the value of echocardiography for monitoring the left and right heart hemodynamics in PCS patients before, during, and after weaning from ECMO. METHODS Fifty-two patients were divided into successful weaning group (group A, n = 23) and non-successful weaning group (group B, n = 29). Hemodynamic parameters measured by echocardiography were collected before, during, and after ECMO. The intra-group changes and inter-group differences were retrospectively analyzed. RESULTS In group A, the central venous pressure (CVP), proximal right ventricular outflow tract (RVOT), tricuspid annular plane systolic excursion (TAPSE), velocity of tricuspid valve (TVDV), and systolic velocity of tricuspid annulus ([Formula: see text]) during ECMO were significantly lower than those before ECMO. After ECMO, left ventricular ejection fraction (LVEF), systolic velocity of mitral annulus ([Formula: see text]), and velocity-time integral of LV outflow tract (LVOT-VTI) were higher than pre-ECMO levels, and CVP, LVEF, [Formula: see text], LVOT-VTI, RVOT, TAPSE, TVDV and [Formula: see text] were higher than those during ECMO (all P < 0.05). In group B, compared to pre-ECMO, subjects exhibited decreased CVP, RVOT, TAPSE, TVDV and [Formula: see text] during ECMO. TAPSE, TVDV, and [Formula: see text] were continuously lower after ECMO, while CVP and RVOT increased after ECMO (all P < 0.05). After ECMO, LVEF, [Formula: see text], LVOT-VTI, TAPSE, TVDV and [Formula: see text] in group A were higher than those in group B (all P < 0.05). Inter-group comparison showed the LVEF and RV Tei indices of group A were significantly different than those of group B before, during, and after ECMO. CONCLUSION Quantitative assessment of both LV and RV by echocardiography is important for ECMO weaning. Patients with better LVEF and lower RV Tei index may have a better chance of successful weaning from ECMO.
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Saef J, Montgomery R, Cedars A, Tang WHW, Rossano JW, Maeda K, Kim YY, Vaikunth SS. Durable Mechanical Circulatory Support in Adult Congenital Heart Disease: Reviewing Clinical Considerations and Experience. J Clin Med 2022; 11:jcm11113200. [PMID: 35683587 PMCID: PMC9181100 DOI: 10.3390/jcm11113200] [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: 04/01/2022] [Revised: 05/25/2022] [Accepted: 06/01/2022] [Indexed: 12/10/2022] Open
Abstract
Adults with congenital heart disease (ACHD) patients are one of the fastest growing populations in cardiology, and heart failure (HF) is the most common cause of morbidity and mortality amongst them. The need for advanced HF therapies in ACHD patients stands to grow substantially. The anatomic considerations for placing durable mechanical circulatory support (MCS) devices in ACHD patients often require specialized approaches. Despite this, increasing evidence suggests that durable MCS can be implanted safely with favorable outcomes in ACHD patients. Expansion of MCS use in ACHD patients is imperative to improve their clinical outcomes. Knowledge of ACHD-specific anatomic and physiologic considerations is crucial to HF programs’ success as they work to provide care to this growing population.
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Affiliation(s)
- Joshua Saef
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (J.S.); (Y.Y.K.)
- Division of Cardiology, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA;
| | - Robert Montgomery
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA; (R.M.); (W.H.W.T.)
| | - Ari Cedars
- Division of Cardiology, Johns Hopkins Medicine, Baltimore, MD 21287, USA;
| | - Wai H. Wilson Tang
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA; (R.M.); (W.H.W.T.)
| | - Joseph W. Rossano
- Division of Cardiology, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA;
| | - Katsuhide Maeda
- Division of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA;
| | - Yuli Y. Kim
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (J.S.); (Y.Y.K.)
- Division of Cardiology, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA;
| | - Sumeet S. Vaikunth
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (J.S.); (Y.Y.K.)
- Division of Cardiology, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA;
- Correspondence: ; Tel.: +215-615-3388
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Kops SA, White SC, Klewer SE, Andrews JG, Seckeler MD. ECMO in adults with congenital heart disease - Analysis of a national discharge database. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Veno-Venous Extracorporeal Membrane Oxygenation to Treat Acute Respiratory Distress Syndrome in an Adult with Fontan Palliation. ASAIO J 2021; 67:e120-e123. [PMID: 33074864 DOI: 10.1097/mat.0000000000001293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
In patients with Fontan palliation, the systemic and pulmonary circulation is in series and supported by a single ventricle, resulting in fragile hemodynamics. Cardiac output is driven by low pressure nonpulsatile pulmonary flow and is highly dependent on pulmonary vascular resistance. An acute respiratory distress syndrome (ARDS) can rapidly alter this physiology and lead to severe cardiogenic shock. Herein, we describe the case of a 40 year old man with a classic modified Fontan procedure and bidirectional Glenn shunt who developed ARDS with cardiogenic shock following a resuscitated cardiac arrest with presumed aspiration pneumonia. In light of poorly tolerated positive end-expiratory pressure ventilation and underlying anatomical complexities, a multidisciplinary team was convened to optimize care. In part owing to the lack of femoral venous access, a veno-venous extracorporeal membrane oxygenation circuit was devised using bilateral internal jugular venous access. Under fluoroscopic guidance in a hybrid operating room, one cannula was placed in the inferior vena cava by means of the right internal jugular venous access, with the second cannula positioned in the right pulmonary artery through the left internal jugular vein. Oxygenation and hemodynamic status promptly improved, allowing the patient to recover from ARDS.
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Dolgner SJ, Keeshan BC, Burke CR, McMullan DM, Chan T. Outcomes of Adults with Congenital Heart Disease Supported with Extracorporeal Life Support After Cardiac Surgery. ASAIO J 2021; 66:1096-1104. [PMID: 33136596 DOI: 10.1097/mat.0000000000001141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Patients with adult congenital heart disease (ACHD) who undergo cardiac surgery may require extracorporeal life support (ECLS) for cardiopulmonary support, but outcomes after ECLS support have not been well described. This study aimed to identify risk factors for ECLS mortality in this population. We identified 368 ACHD patients who received ECLS after cardiac surgery between 1994 and 2016 in the Extracorporeal Life Support Organization (ELSO) database, a multicenter international registry of ECLS centers. Risk factors for mortality were assessed using multivariate logistic regression. Overall mortality was 61%. In a multivariate model using precannulation characteristics, Fontan physiology (odds ratio [OR]: 5.7; 95% CI: 1.6-20.0), weight over 100 kg (OR: 2.6; 95% CI: 1.3-5.4), female gender (OR: 1.6; 95% CI: 1.001-2.6), delayed ECLS cannulation (OR: 2.0; 95% CI: 1.2-3.2), and neuromuscular blockade (OR: 1.9; 95% CI: 1.1-3.3) were associated with increased mortality. Adding postcannulation characteristics to the model, renal complications (OR: 3.0; 95% CI: 1.7-5.2), neurologic complications (OR, 4.7; 95% CI: 1.5-15.2), and pulmonary hemorrhage (OR: 6.4; 95% CI: 1.3-33.2) were associated with increased mortality, whereas Fontan physiology was no longer associated, suggesting the association of Fontan physiology with mortality may be mediated by complications. Fontan physiology was also a risk factor for neurologic complications (OR: 8.2; 95% CI: 3.3-20.9). Given the rapid increase in ECLS use, understanding risk factors for ACHD patients receiving ECLS after cardiac surgery will aid clinicians in decision-making and preoperative planning.
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Affiliation(s)
- Stephen J Dolgner
- From the Division of Cardiology, Department of Internal Medicine, University of Washington School of Medicine, Seattle, Washington
- The Heart Center, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Britton C Keeshan
- Pediatric Cardiology, Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | | | - David Michael McMullan
- Division of Pediatric Cardiac Surgery, Department of Surgery, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Titus Chan
- The Heart Center, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
- Division of Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
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Mariscalco G, Salsano A, Fiore A, Dalén M, Ruggieri VG, Saeed D, Jónsson K, Gatti G, Zipfel S, Dell'Aquila AM, Perrotti A, Loforte A, Livi U, Pol M, Spadaccio C, Pettinari M, Ragnarsson S, Alkhamees K, El-Dean Z, Bounader K, Biancari F, Dashey S, Yusuff H, Porter R, Sampson C, Harvey C, Settembre N, Fux T, Amr G, Lichtenberg A, Jeppsson A, Gabrielli M, Reichart D, Welp H, Chocron S, Fiorentino M, Lechiancole A, Netuka I, De Keyzer D, Strauven M, Pälve K. Peripheral versus central extracorporeal membrane oxygenation for postcardiotomy shock: Multicenter registry, systematic review, and meta-analysis. J Thorac Cardiovasc Surg 2020; 160:1207-1216.e44. [DOI: 10.1016/j.jtcvs.2019.10.078] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 10/04/2019] [Accepted: 10/04/2019] [Indexed: 12/13/2022]
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11
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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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12
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Abstract
PURPOSE Adults with congenital heart disease (ACHD) are a rapidly growing population with ever-increasing complexity, and intensive care unit (ICU) management is often necessary. This review summarizes common cardiovascular and non-cardiovascular complications in ACHD and provides a framework for ICU care. RECENT FINDINGS Heart failure is the leading cause of hospitalization and mortality in ACHD. Varied anatomy and repairs, as well as differing physiological complications, limit generalized application of management algorithms. Recent studies suggest that earlier mechanical support in advanced cases is feasible and potentially helpful. Cardiac arrhythmias are poorly tolerated and often require immediate attention. Other complications requiring intensive care include infections such as endocarditis and COVID-19, pulmonary hypertension, renal failure, hepatic dysfunction, coagulopathy, and stroke. Successful ICU care in ACHD requires a multi-disciplinary approach with careful consideration of anatomy, physiology, and associated comorbidities. Few studies have formally examined ICU management in ACHD and further research is necessary.
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Affiliation(s)
- Payton Kendsersky
- Department of Medicine, Duke University Medical Center, Durham, NC USA
| | - Richard A. Krasuski
- Division of Cardiology, Duke University Medical Center, DUMC 3010, Durham, NC 27710 USA
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13
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Haranal M, Luo S, Honjo O. Mechanical Circulatory Support for Patients With Adult Congenital Heart Disease. Circ J 2020; 84:533-541. [DOI: 10.1253/circj.cj-19-0821] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Maruti Haranal
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children
| | - Shuhua Luo
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children
| | - Osami Honjo
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children
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14
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Han F, McMullan M, Campbell WF. Tetralogy of Fallot: Pushing Through Despite Long Odds. JACC Case Rep 2019; 1:523-525. [PMID: 34316869 PMCID: PMC8288979 DOI: 10.1016/j.jaccas.2019.10.024] [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: 05/01/2019] [Revised: 10/01/2019] [Accepted: 10/24/2019] [Indexed: 11/22/2022]
Abstract
The natural history of tetralogy of Fallot depends on whether a transannular pulmonary valve patch or shunt surgery was necessary in infancy. This case illustrates the feasibility of cardiac rest on extracorporeal membranous oxygenation for a very ill adult with conduit endocarditis who received a right ventricle–to–pulmonary artery valveless conduit for later transcatheter pulmonary valve replacement. (Level of Difficulty: Advanced.)
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Affiliation(s)
- Frank Han
- Department of Cardiology, University of Mississippi, Jackson, Mississippi
| | - Michael McMullan
- Department of Cardiology, University of Mississippi, Jackson, Mississippi
| | - William F Campbell
- Department of Cardiology, University of Mississippi, Jackson, Mississippi
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15
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Al-Fares AA, Randhawa VK, Englesakis M, McDonald MA, Nagpal AD, Estep JD, Soltesz EG, Fan E. Optimal Strategy and Timing of Left Ventricular Venting During Veno-Arterial Extracorporeal Life Support for Adults in Cardiogenic Shock. Circ Heart Fail 2019; 12:e006486. [DOI: 10.1161/circheartfailure.119.006486] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background:
Veno-arterial extracorporeal life support (VA-ECLS) is widely used to treat refractory cardiogenic shock. However, increased left ventricular (LV) afterload in VA-ECLS can worsen pulmonary congestion and compromise myocardial recovery. Our objectives were to explore the efficacy, safety, and optimal timing of adjunctive LV venting strategies.
Methods:
A systematic search was performed on Medline, EMBASE, PubMed, CDSR, CCRCT, CINAHL, ClinicalTrials.Gov, and WHO ICTRP from inception until January 2019 for all relevant studies, including LV venting. Data were analyzed for mortality and weaning from VA-ECLS on the basis of timing of LV venting, along with adverse complications.
Results:
A total of 7995 patients were included from 62 observational studies, wherein 3458 patients had LV venting during VA-ECLS. LV venting significantly improved weaning from VA-ECLS (odds ratio, 0.62 [95% CI, 0.47–0.83];
P
=0.001) and reduced short-term (30 day; risk ratio [RR], 0.86 [95% CI, 0.77–0.96];
P
=0.008) but not in-hospital (RR, 0.92 [95% CI, 0.83–1.01]
P
=0.09) or long-term (6 months; RR, 0.96 [95% CI, 0.90–1.03];
P
=0.27) mortality. Early (<12 hours; RR, 0.86 [95% CI, 0.75–0.99];
P
=0.03) but not late (≥12 hours; RR, 0.99 [95% CI, 0.71–1.38];
P
=0.93) LV venting significantly reduced short-term mortality. Patients with LV venting spent more time on VA-ECLS (3.6 versus 2.8 days,
P
<0.001), and mechanical ventilation (7.1 versus 4.6 days,
P
=0.013). With the exception of hemolysis (RR, 2.18 [95% CI, 1.58–3.01];
P
<0.00001), overall adverse events did not differ.
Conclusions:
LV venting, especially if done early (<12 hours), appears to be associated with an increased success of weaning and reduced short-term mortality. Future studies are required to delineate the importance of any or early LV venting adjuncts on mortality and morbidity outcomes.
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Affiliation(s)
- Abdulrahman A. Al-Fares
- Interdepartmental Division of Critical Care Medicine (A.A.A.-F., E.F.), Toronto General Hospital, University of Toronto, ON, Canada
- Extracorporeal Life Support Program (A.A.A.-F., E.F.), Toronto General Hospital, University of Toronto, ON, Canada
- Al-Amiri Hospital, Ministry of Health, Kuwait (A.A.A.-F.)
| | - Varinder K. Randhawa
- Departments of Cardiovascular Medicine (V.K.R., J.D.E.), Kaufman Center for Heart Failure, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Marina Englesakis
- Library and Information Services (M.E.), Toronto General Hospital, University of Toronto, ON, Canada
| | - Michael A. McDonald
- Division of Cardiology, Peter Munk Cardiac Centre (M.A.M.), Toronto General Hospital, University of Toronto, ON, Canada
| | - A. Dave Nagpal
- Divisions of Cardiac Surgery and Critical Care, London Health Sciences Center, ON, Canada (A.D.N.)
| | - Jerry D. Estep
- Departments of Cardiovascular Medicine (V.K.R., J.D.E.), Kaufman Center for Heart Failure, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Edward G. Soltesz
- Thoracic and Cardiovascular Surgery (E.G.S.), Kaufman Center for Heart Failure, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine (A.A.A.-F., E.F.), Toronto General Hospital, University of Toronto, ON, Canada
- Extracorporeal Life Support Program (A.A.A.-F., E.F.), Toronto General Hospital, University of Toronto, ON, Canada
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16
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Dolgner SJ, Krieger EV, Wilkes J, Bratton SL, Thiagarajan RR, Barrett CS, Chan T. Predictors of extracorporeal membrane oxygenation support after surgery for adult congenital heart disease in children's hospitals. CONGENIT HEART DIS 2019; 14:559-570. [PMID: 30835967 DOI: 10.1111/chd.12758] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 12/31/2018] [Accepted: 01/22/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Adult congenital heart disease (ACHD) patients who undergo cardiac surgery are at risk for poor outcomes, including extracorporeal membrane oxygenation support (ECMO) and death. Prior studies have demonstrated risk factors for mortality, but have not fully examined risk factors for ECMO or death without ECMO (DWE). We sought to identify risk factors for ECMO and DWE in adults undergoing congenital heart surgery in tertiary care children's hospitals. DESIGN All adults (≥18 years) undergoing congenital heart surgery in the Pediatric Health Information System (PHIS) database between 2003 and 2014 were included. Patients were classified into three groups: ECMO-free survival, requiring ECMO, and DWE. Univariate analyses were performed, and multinomial logistic regression models were constructed examining ECMO and DWE as independent outcomes. SETTING Tertiary care children's hospitals. RESULTS A total of 4665 adult patients underwent ACHD surgery in 39 children's hospitals with 51 (1.1%) patients requiring ECMO and 64 (1.4%) patients experiencing DWE. Of the 51 ECMO patients, 34 (67%) died. Increasing patient age, surgical complexity, diagnosis of single ventricle heart disease, preoperative hospitalization, and the presence of noncardiac complex chronic conditions (CCC) were risk factors for both outcomes. Additionally, low and medium hospital ACHD surgical volume was associated with an increased risk of DWE in comparison with ECMO. CONCLUSIONS There are overlapping but separate risk factors for ECMO support and DWE among adults undergoing congenital heart surgery in pediatric hospitals.
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Affiliation(s)
- Stephen J Dolgner
- Division of Cardiology, Seattle Children's Hospital, Seattle, Washington.,Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington.,Division of Cardiology, Department of Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Eric V Krieger
- Division of Cardiology, Seattle Children's Hospital, Seattle, Washington.,Division of Cardiology, Department of Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Jacob Wilkes
- Pediatric Clinical Program, Intermountain Healthcare, Salt Lake City, Utah
| | - Susan L Bratton
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Ravi R Thiagarajan
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.,Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Cindy S Barrett
- Division of Pediatric Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Titus Chan
- Division of Cardiology, Seattle Children's Hospital, Seattle, Washington.,Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington.,Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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17
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Pozzi M, Alvau F, Armoiry X, Grinberg D, Hugon-Vallet E, Koffel C, Portran P, Scollo G, Fellahi JL, Obadia JF. Outcomes after extracorporeal life support for postcardiotomy cardiogenic shock. J Card Surg 2019; 34:74-81. [DOI: 10.1111/jocs.13985] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Matteo Pozzi
- Department of Cardiac Surgery; “Louis Pradel” Cardiologic Hospital; “Claude Bernard” University; Lyon France
| | - Francesca Alvau
- Department of Cardiac Surgery; “Louis Pradel” Cardiologic Hospital; “Claude Bernard” University; Lyon France
| | - Xavier Armoiry
- University of Lyon, School of Pharmacy (ISPB)/UMR CNRS 5510 MATEIS/Lyon University Hospitals, “Edouard Herriot” Hospital; Pharmacy Department; Lyon France
| | - Daniel Grinberg
- Department of Cardiac Surgery; “Louis Pradel” Cardiologic Hospital; “Claude Bernard” University; Lyon France
| | - Elisabeth Hugon-Vallet
- Department of Cardiology, “Louis Pradel” Cardiologic Hospital; “Claude Bernard” University; Lyon France
| | - Catherine Koffel
- Department of Anesthesia and ICU, “Louis Pradel” Cardiologic Hospital; “Claude Bernard” University; Lyon France
| | - Philippe Portran
- Department of Anesthesia and ICU, “Louis Pradel” Cardiologic Hospital; “Claude Bernard” University; Lyon France
| | - Giovanni Scollo
- Department of Anesthesia and ICU, “Louis Pradel” Cardiologic Hospital; “Claude Bernard” University; Lyon France
| | - Jean Luc Fellahi
- Department of Anesthesia and ICU, “Louis Pradel” Cardiologic Hospital; “Claude Bernard” University; Lyon France
| | - Jean Francois Obadia
- Department of Cardiac Surgery; “Louis Pradel” Cardiologic Hospital; “Claude Bernard” University; Lyon France
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18
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Chen K, Hou J, Tang H, Hu S. Concurrent Implantation of Intra-Aortic Balloon Pump and Extracorporeal Membrane Oxygenation Improved Survival of Patients With Postcardiotomy Cardiogenic Shock. Artif Organs 2018; 43:142-149. [PMID: 30346032 PMCID: PMC6587979 DOI: 10.1111/aor.13317] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 06/08/2018] [Accepted: 06/15/2018] [Indexed: 12/12/2022]
Abstract
The aim of this study is to report the combined application of extracorporeal membrane oxygenation (ECMO) with intra‐aortic balloon pumping (IABP) in postcardiotomy cardiac shock (PCS). A total of 60 consecutive patients who received both ECMO and IABP (concomitantly 24 hours) for PCS from February 2006 to March 2017 at Fuwai Hospital were included in our study. Clinical characteristics of the patients were collected retrospectively and compared between survivors and non‐survivors. Logistic regression analysis was used as predictors for survival to discharge. The study cohort had a mean age of 51.4±12.7 years with 75% males. ECMO was implanted intra‐operatively in 38 (63%) patients and post‐operatively in 22 (37%) patients. ECMO was implanted concurrently with IABP in 38 (63%) patients. Heart transplantation (38%) and coronary artery bypass graft (33%) were the main surgical procedures. ECMO was weaned successfully in 48% patients, and the rate of survival to discharge was 43%. Survivors showed less bedside ECMO implantation (12% vs. 41%, P=0.012) and more concurrent implantation of ECMO with IABP (81% vs. 50%, P=0.014). Concurrent implantation of IABP with ECMO (OR=0.177, P=0.015, 95% CI: 0.044‐0.718) was an independent predictor of survival to discharge. As for complications, the rate of renal failure (59% vs. 15%, P=0.001) and multiple organ dysfunction syndrome (29% vs. 0, P=0.003) was higher in patients who failed to survive to discharge. Patients who had heart transplantation had a better long‐term survival than others (P=0.0358). In summary, concurrent implantation of ECMO with IABP provides better short‐term outcome for PCS and combined application of ECMO with IABP for PCS after heart transplantation had a favorable long‐term outcome.
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Affiliation(s)
- Kai Chen
- 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
| | - Jianfeng Hou
- 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
| | - Hanwei Tang
- 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
| | - Shengshou Hu
- 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
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19
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Abstract
High-value CCC is rapidly evolving to meet the demands of increased patient acuity and to incorporate advances in technology. The high-performing CCC system and culture should aim to learn quickly and continuously improve. CCC demands a proactive, interactive, precise, an expert team, and continuity.
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20
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Khorsandi M, Dougherty S, Bouamra O, Pai V, Curry P, Tsui S, Clark S, Westaby S, Al-Attar N, Zamvar V. Extra-corporeal membrane oxygenation for refractory cardiogenic shock after adult cardiac surgery: a systematic review and meta-analysis. J Cardiothorac Surg 2017; 12:55. [PMID: 28716039 PMCID: PMC5512816 DOI: 10.1186/s13019-017-0618-0] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 07/10/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Postcardiotomy cardiogenic shock (PCCS) refractory to inotropic support and intra-aortic balloon pump (IABP) occurs rarely but is almost universally fatal without mechanical circulatory support. In this systematic review and meta-analysis we looked at the evidence behind the use of veno-arterial extra-corporeal membrane oxygenation (VA ECMO) in refractory PCCS from a patient survival rate and determinants of outcome viewpoint. METHODS A systematic review was performed in January 2017 using PubMed (with no defined time period) using the keywords "postcardiotomy", "cardiogenic shock", "extracorporeal membrane oxygenation" and "cardiac surgery". We excluded papers pertaining to ECMO following paediatric cardiac surgery, medical causes of cardiogenic shock, as well as case reports, review articles, expert opinions, and letters to the editor. Once the studies were collated, a meta-analysis was performed on the proportion of survivors in those papers that met the inclusion criteria. Meta-regression was performed for the most commonly reported adverse prognostic indicators (API). RESULTS We identified 24 studies and a cumulative pool of 1926 patients from 1992 to 2016. We tabulated the demographic data, including the strengths and weaknesses for each of the studies, outcomes of VA ECMO for refractory PCCS, complications, and APIs. All the studies were retrospective cohort studies. Meta-analysis of the moderately heterogeneous data (95% CI 0.29 to 0.34, p < 0.01, I 2 = 60%) revealed overall survival rate to hospital discharge of 30.8%. Some of the commonly reported APIs were advanced age (>70 years, 95% CI -0.057 to 0.001, P = 0.058), and long ECMO support (95% CI -0.068 to 0.166, P = 0.412). Postoperative renal failure, high EuroSCORE (>20%), diabetes mellitus, obesity, rising lactate whilst on ECMO, gastrointestinal complications had also been reported. CONCLUSION Haemodynamic support with VA ECMO provides a survival benefit with reasonable intermediate and long-term outcomes. Many studies had reported advanced age, renal failure and prolonged VA ECMO support as the most likely APIs for VA ECMO in PCCS. EuroSCORE can be utilized to anticipate the need for prophylactic perioperative VA ECMO in the high-risk category. APIs can be used to aid decision-making regarding both the institution and weaning of ECMO for refractory PCCS.
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Affiliation(s)
- Maziar Khorsandi
- Department of Cardiac Surgery and Transplantation, Golden Jubilee National Hospital, Glasgow, UK.
| | | | - Omar Bouamra
- Medical Statistics, Trauma, Audit & Research Network, University of Manchester, Salford Royal NHS foundation trust, Manchester, UK
| | - Vasudev Pai
- Department of Cardiovascular and Thoracic Surgery, Kasturba Medical College, Manipal University, Manipal, India
| | - Philip Curry
- Department of Cardiac Surgery and Transplantation, Golden Jubilee National Hospital, Glasgow, UK
| | - Steven Tsui
- Department of Cardiac Surgery and Transplantation, Papworth hospital, Cambridge, UK
| | - Stephen Clark
- Department of Cardiac surgery and Transplantation, Freeman hospital, Newcastle, UK
| | - Stephen Westaby
- Department of Cardiac Surgery, Oxford Heart Center, John Radcliffe Hospital, Oxford, UK
| | - Nawwar Al-Attar
- Department of Cardiac Surgery and Transplantation, Golden Jubilee National Hospital, Glasgow, UK
| | - Vipin Zamvar
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
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21
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Aiello S, Loomba RS, Kriz C, Buelow M, Aggarwal S, Arora RR. The Need for Extracorporeal Membrane Oxygenation in Adults Undergoing Congenital Heart Surgery: Impact and Trends of Utilization. Indian J Crit Care Med 2017; 21:547-551. [PMID: 28970652 PMCID: PMC5613604 DOI: 10.4103/ijccm.ijccm_169_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Introduction: Adults with congenital heart disease (ACHD) represent a population with unique health-care needs. Many patients require cardiac surgery, with some requiring postoperative extracorporeal membrane oxygenation (ECMO). This study aimed to identify the risk factors for the need of postoperative ECMO and characterize the impact of ECMO on admission characteristics. Methods: Data from the 2005–2012 iterations of the Nationwide Inpatient Sample were used. ACHD admissions over 18 years with a documented cardiac surgery were included. Univariate analysis was conducted to compare the characteristics between those requiring ECMO and those who did not. Regression analysis was done to identify the independent risk factors associated with ECMO and to determine the impact of ECMO on length, cost, and mortality of the admission. Results: A total of 186,829 admissions were included. Of these, 446 (0.2%) admissions required ECMO. Those with acute kidney injury, double-outlet right ventricle, or total anomalous pulmonary venous connection were more likely to require ECMO. ECMO was also significantly more utilized in patients undergoing septal defect repair, complete repair of tetralogy of Fallot, atrial switch, and heart transplant. The use of ECMO significantly increased length, cost, and mortality of stay. Overall mortality was 62.6% in the ECMO group. Conclusion: ECMO is only needed in a small proportion of postoperative ACHD patients. The use of ECMO significantly increases cost, length of stay and mortality in these patients. Improved identification of postoperative ACHD patients who are more likely to survive ECMO may facilitate improved survival and decreased resource utilization.
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Affiliation(s)
- Salvatore Aiello
- Division of Cardiology, Chicago Medical School, North Chicago, IL, USA
| | - Rohit S Loomba
- Division of Cardiology, Children's Hospital of Wisconsin/Medical College of Wisconsin, Milwaukee, WI, USA
| | - Connor Kriz
- Division of Cardiology, Chicago Medical School, North Chicago, IL, USA
| | - Matthew Buelow
- Division of Cardiology, Children's Hospital of Wisconsin/Medical College of Wisconsin, Milwaukee, WI, USA
| | - Saurabh Aggarwal
- Division of Cardiology, Creighton University School of Medicine, Omaha, NE, USA
| | - Rohit R Arora
- Division of Cardiology, Chicago Medical School, North Chicago, IL, USA
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22
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Clift P, Celermajer D. Managing adult Fontan patients: where do we stand? Eur Respir Rev 2016; 25:438-450. [PMID: 27903666 PMCID: PMC9487559 DOI: 10.1183/16000617.0091-2016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/13/2016] [Indexed: 01/10/2023] Open
Abstract
The Fontan operation is performed as a palliative procedure to improve survival in infants born with a functionally univentricular circulation. The success of the operation is demonstrated by a growing adult Fontan population that exists with this unique physiology. Late follow-up has demonstrated expected and unexpected sequelae, and has shown multisystem effects of this circulation. This review discusses the challenges of managing the late complications in terms of understanding this unique physiology and the innovative therapeutic interventions that are being investigated. The challenge remains to maintain quality of life for adult survivors, as well as extending life expectancy. Innovative solutions are required to meet the challenges of the Fontan circulation faced in adult lifehttp://ow.ly/XTSm305oH8b
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