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Chang RW, Hsu MC, Lee TS, Chen YS, Wang CH. Selective brain perfusion improves the neurological outcomes after extracorporeal cardiopulmonary resuscitation in a rat model. Artif Organs 2024; 48:743-752. [PMID: 38391014 DOI: 10.1111/aor.14732] [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: 11/09/2023] [Revised: 02/08/2024] [Accepted: 02/12/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND The major concern in patients who have suffered from cardiac arrest (CA) and undergone successful extracorporeal cardiopulmonary resuscitation (E-CPR) is poor neurological outcomes. In this study, we aimed to introduce a rat model of selective brain perfusion (SBP) during E-CPR to improve the neurological outcome after CA. METHODS The rats underwent 7 min of untreated asphyxial CA and then were resuscitated with E-CPR for 30 min. The right external jugular vein and right femoral artery were separately cannulated to the E-CPR outflow and inflow. The right common carotid artery was cannulated from the proximal to the distal side for SBP. Subsequently, rats were removed from E-CPR, wounds were closed, and 90 min of intensive care were provided. Neurological deficit scores were tested after 4 h of recovery when the rats were mechanical ventilation-free. S100 calcium-binding protein B (S100B) and glial fibrillary acidic protein (GFAP) were detected through immunohistochemistry (IHC) of brain tissue. RESULTS The rats that received SBP while resuscitated by E-CPR showed markedly better neurological performances after 4-h recovery than those resuscitated by E-CPR only. The IHC staining of GFAP and S100B in the hippocampus was low in the rats receiving SBP during E-CPR, but only GFAP showed significant differences. CONCLUSIONS We successfully developed a novel and reproducible rat model of SBP while resuscitated by E-CPR to ameliorate the neurological performances after CA. This achievement might have opportunities for studying how to improve the neurological outcome in the clinical condition.
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Affiliation(s)
- Ru-Wen Chang
- Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Man-Chen Hsu
- Graduate Institute and Department of Physiology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tzong-Shyuan Lee
- Graduate Institute and Department of Physiology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yih-Sharng Chen
- Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Chih-Hsien Wang
- Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
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2
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Chalifoux N, Ko T, Slovis J, Spelde A, Kilbaugh T, Mavroudis CD. Cerebral Autoregulation: A Target for Improving Neurological Outcomes in Extracorporeal Life Support. Neurocrit Care 2024:10.1007/s12028-024-02002-5. [PMID: 38811513 DOI: 10.1007/s12028-024-02002-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/18/2024] [Indexed: 05/31/2024]
Abstract
Despite improvements in survival after illnesses requiring extracorporeal life support, cerebral injury continues to hinder successful outcomes. Cerebral autoregulation (CA) is an innate protective mechanism that maintains constant cerebral blood flow in the face of varying systemic blood pressure. However, it is impaired in certain disease states and, potentially, following initiation of extracorporeal circulatory support. In this review, we first discuss patient-related factors pertaining to venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) and their potential role in CA impairment. Next, we examine factors intrinsic to ECMO that may affect CA, such as cannulation, changes in pulsatility, the inflammatory and adaptive immune response, intracranial hemorrhage, and ischemic stroke, in addition to ECMO management factors, such as oxygenation, ventilation, flow rates, and blood pressure management. We highlight potential mechanisms that lead to disruption of CA in both pediatric and adult populations, the challenges of measuring CA in these patients, and potential associations with neurological outcome. Altogether, we discuss individualized CA monitoring as a potential target for improving neurological outcomes in extracorporeal life support.
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Affiliation(s)
- Nolan Chalifoux
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
- Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Tiffany Ko
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Julia Slovis
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Audrey Spelde
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Todd Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Constantine D Mavroudis
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
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3
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Dewilde M, Janssens B. Invisible Active Bleeding Due to the Watershed Phenomenon. J Belg Soc Radiol 2024; 108:56. [PMID: 38800107 PMCID: PMC11122696 DOI: 10.5334/jbsr.3604] [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: 04/06/2024] [Accepted: 05/10/2024] [Indexed: 05/29/2024] Open
Abstract
A case is presented of an 83-year-old female patient with a strong suspicion of active bleeding, but no diagnostic contrast blush could be seen on the original computed tomography (CT) scan. Teaching point: When performing CT angiography in veno-arterial extracorporeal membrane oxygenation (VA-ECMO), it is important to understand the altered haemodynamics, as flow-related artefacts such as the vascular watershed phenomenon can obscure bleeding.
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Inoue A, Ushioda R, Miyatani K, Shirakura K, Mochizuki N, Isa H, Setogawa Y, Narita M, Suzuki F, Hirofuji A, Okubo R, Kunioka S, Tsutsui M, Hiroyuki K. Fulminant respiratory failure due to severe pneumothorax after re-do coronary artery bypass grafting treated with veno-venous extracorporeal membrane oxygenation. J Surg Case Rep 2024; 2024:rjae360. [PMID: 38817783 PMCID: PMC11137602 DOI: 10.1093/jscr/rjae360] [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: 04/29/2024] [Accepted: 05/14/2024] [Indexed: 06/01/2024] Open
Abstract
This case report details the management of a 79-year-old man who developed massive postoperative pneumothorax following redo coronary artery bypass grafting due to severe lung adhesions. We successfully treated the patient using veno-venous extracorporeal membrane oxygenation without femoral cannulation, allowing for early rehabilitation initiation. Veno-venous extracorporeal membrane oxygenation is a reasonable option for cases of severe respiratory failure due to pneumothorax with lung destruction caused by re-sternotomy during re-do cardiac surgery.
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Affiliation(s)
- Akito Inoue
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Midorigaoka 1-1-1, Japan
| | - Ryohei Ushioda
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Midorigaoka 1-1-1, Japan
| | - Kazuki Miyatani
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Midorigaoka 1-1-1, Japan
| | - Kentaro Shirakura
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Midorigaoka 1-1-1, Japan
| | - Nobuhiro Mochizuki
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Midorigaoka 1-1-1, Japan
| | - Hideki Isa
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Midorigaoka 1-1-1, Japan
| | - Yuki Setogawa
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Midorigaoka 1-1-1, Japan
| | - Masahiko Narita
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Midorigaoka 1-1-1, Japan
| | - Fumitaka Suzuki
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Midorigaoka 1-1-1, Japan
| | - Aina Hirofuji
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Midorigaoka 1-1-1, Japan
| | - Ryo Okubo
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Midorigaoka 1-1-1, Japan
| | - Shingo Kunioka
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Midorigaoka 1-1-1, Japan
| | - Masahiro Tsutsui
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Midorigaoka 1-1-1, Japan
| | - Kamiya Hiroyuki
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Midorigaoka 1-1-1, Japan
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5
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Khamooshi M, Wickramarachchi A, Byrne T, Seman M, Fletcher DF, Burrell A, Gregory SD. Blood flow and emboli transport patterns during venoarterial extracorporeal membrane oxygenation: A computational fluid dynamics study. Comput Biol Med 2024; 172:108263. [PMID: 38489988 DOI: 10.1016/j.compbiomed.2024.108263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 02/15/2024] [Accepted: 03/06/2024] [Indexed: 03/17/2024]
Abstract
PROBLEM Despite advances in Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO), a significant mortality rate persists due to complications. The non-physiological blood flow dynamics of VA-ECMO may lead to neurological complications and organ ischemia. Continuous retrograde high-flow oxygenated blood enters through a return cannula placed in the femoral artery which opposes the pulsatile deoxygenated blood ejected by the left ventricle (LV), which impacts upper body oxygenation and subsequent hyperoxemia. The complications underscore the critical need to comprehend the impact of VA-ECMO support level and return cannula size, as mortality remains a significant concern. AIM The aim of this study is to predict and provide insights into the complications associated with VA-ECMO using computational fluid dynamics (CFD) simulations. These complications will be assessed by characterising blood flow and emboli transport patterns through a comprehensive analysis of the influence of VA-ECMO support levels and arterial return cannula sizes. METHODS Patient-specific 3D aortic and major branch models, derived from a male patient's CT scan during VA-ECMO undergoing respiratory dysfunction, were analyzed using CFD. The investigation employed species transport and discrete particle tracking models to study ECMO blood (oxygenated) mixing with LV blood (deoxygenated) and to trace emboli transport patterns from potential sources (circuit, LV, and aorta wall). Two cannula sizes (15 Fr and 19 Fr) were tested alongside varying ECMO pump flow rates (50%, 70%, and 90% of the total cardiac output). RESULTS Cannula size did not significantly affect oxygen transport. At 90% VA-ECMO support, all arteries distal to the aortic arch achieved 100% oxygen saturation. As support level decreased, oxygen transport to the upper body also decreased to a minimum saturation of 73%. Emboli transport varied substantially between emboli origin and VAECMO support level, with the highest risk of cerebral emboli coming from the LV with a 15 Fr cannula at 90% support. CONCLUSION Arterial return cannula sizing minimally impacted blood oxygen distribution; however, it did influence the distribution of emboli released from the circuit and aortic wall. Notably, it was the support level alone that significantly affected the mixing zone of VA-ECMO and cardiac blood, subsequently influencing the risk of embolization of the cardiogenic source and oxygenation levels across various arterial branches.
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Affiliation(s)
- Mehrdad Khamooshi
- Cardio-Respiratory Engineering and Technology Laboratory (CREATElab), Department of Mechanical and Aerospace Engineering, Monash University, Wellington Road, Clayton, 3800, Victoria, Australia.
| | - Avishka Wickramarachchi
- Cardio-Respiratory Engineering and Technology Laboratory (CREATElab), Department of Mechanical and Aerospace Engineering, Monash University, Wellington Road, Clayton, 3800, Victoria, Australia.
| | - Tim Byrne
- Intensive Care Unit, Alfred Hospital, 89 Commercial Road, Melbourne, 3004, Victoria, Australia.
| | - Michael Seman
- Cardio-Respiratory Engineering and Technology Laboratory (CREATElab), Department of Mechanical and Aerospace Engineering, Monash University, Wellington Road, Clayton, 3800, Victoria, Australia.
| | - David F Fletcher
- School of Chemical and Biomolecular Engineering, The University of Sydney, Darlington, 2006, New South Wales, Australia.
| | - Aidan Burrell
- Intensive Care Unit, Alfred Hospital, 89 Commercial Road, Melbourne, 3004, Victoria, Australia.
| | - Shaun D Gregory
- Cardio-Respiratory Engineering and Technology Laboratory (CREATElab), Department of Mechanical and Aerospace Engineering, Monash University, Wellington Road, Clayton, 3800, Victoria, Australia.
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von Dossow V, Hulde N, Starke H, Schramm R. How Would We Treat Our Own Cystic Fibrosis With Lung Transplantation? J Cardiothorac Vasc Anesth 2024; 38:626-634. [PMID: 38030425 DOI: 10.1053/j.jvca.2023.10.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 10/18/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023]
Abstract
Lung transplantation is the only therapy for patients with end-stage lung disease. In advanced lung diseases such as cystic fibrosis (CF), life expectancy increases, and it is important to recognize extrapulmonary comorbidities. Cardiovascular involvement, including pulmonary hypertension, right-heart failure, and myocardial dysfunction, are manifest in the late stages of CF disease. Besides right-heart failure, left-heart dysfunction seems to be underestimated. Therefore, an optimal anesthesia and surgical management risk evaluation in this high-risk patient population is mandatory, especially concerning the perioperative use of mechanical circulatory support. The use of an index case of an older patient with the diagnosis of cystic fibrosis demonstrates the importance of early risk stratification and strategy planning in a multidisciplinary team approach to guarantee successful lung transplantation.
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Affiliation(s)
- Vera von Dossow
- Institute of Anesthesiology and Pain Therapy, Heart and Diabetes Center Bad Oeynhausen, University Clinic of Ruhr-University Bochum, Bochum, Germany
| | - Nikolai Hulde
- Institute of Anesthesiology and Pain Therapy, Heart and Diabetes Center Bad Oeynhausen, University Clinic of Ruhr-University Bochum, Bochum, Germany.
| | - Henning Starke
- Institute of Anesthesiology and Pain Therapy, Heart and Diabetes Center Bad Oeynhausen, University Clinic of Ruhr-University Bochum, Bochum, Germany
| | - Rene Schramm
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center Bad Oeynhausen, University Clinic of Ruhr-University Bochum, Bochum, Germany
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7
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Greer DM, Kirschen MP, Lewis A, Gronseth GS, Rae-Grant A, Ashwal S, Babu MA, Bauer DF, Billinghurst L, Corey A, Partap S, Rubin MA, Shutter L, Takahashi C, Tasker RC, Varelas PN, Wijdicks E, Bennett A, Wessels SR, Halperin JJ. Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline. Neurology 2023; 101:1112-1132. [PMID: 37821233 PMCID: PMC10791061 DOI: 10.1212/wnl.0000000000207740] [Citation(s) in RCA: 45] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/28/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The purpose of this guideline is to update the 2010 American Academy of Neurology (AAN) brain death/death by neurologic criteria (BD/DNC) guideline for adults and the 2011 American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care Medicine guideline for infants and children and to clarify the BD/DNC determination process by integrating guidance for adults and children into a single guideline. Updates in this guideline include guidance related to conducting the BD/DNC evaluation in the context of extracorporeal membrane oxygenation, targeted temperature management, and primary infratentorial injury. METHODS A panel of experts from multiple medical societies developed BD/DNC recommendations. Because of the lack of high-quality evidence on the subject, a novel, evidence-informed formal consensus process was used. This process relied on the panel experts' review and detailed knowledge of the literature surrounding BD/DNC to guide the development of preliminary recommendations. Recommendations were formulated and voted on, using a modified Delphi process, according to the 2017 AAN Clinical Practice Guideline Process Manual. MAJOR RECOMMENDATIONS Eighty-five recommendations were developed on the following: (1) general principles for the BD/DNC evaluation, (2) qualifications to perform BD/DNC evaluations, (3) prerequisites for BD/DNC determination, (4) components of the BD/DNC neurologic examination, (5) apnea testing as part of the BD/DNC evaluation, (6) ancillary testing as part of the BD/DNC evaluation, and (7) special considerations for BD/DNC determination.
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Affiliation(s)
- David M Greer
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Matthew P Kirschen
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Ariane Lewis
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Gary S Gronseth
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Alexander Rae-Grant
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Stephen Ashwal
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Maya A Babu
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - David F Bauer
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Lori Billinghurst
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Amanda Corey
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Sonia Partap
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Michael A Rubin
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Lori Shutter
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Courtney Takahashi
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Robert C Tasker
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Panayiotis Nicolaou Varelas
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Eelco Wijdicks
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Amy Bennett
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Scott R Wessels
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - John J Halperin
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
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Hoeper MM. Extracorporeal Life Support in Pulmonary Hypertension: Practical Aspects. Semin Respir Crit Care Med 2023; 44:771-776. [PMID: 37709284 DOI: 10.1055/s-0043-1772752] [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: 09/16/2023]
Abstract
Extracorporeal life support (ECLS), in particular veno-arterial extracorporeal membrane oxygenation, has emerged as a potentially life-saving treatment modality in patients presenting with pulmonary hypertension and right heart failure refractory to conventional treatment. Used mainly as a bridge to lung transplantation, ECLS is also being used occasionally as a bridge to recovery in patients with treatable causes of right heart failure. This review article describes indications, contraindications, techniques, and outcomes of the use of ECLS in patients with PH, focusing on practical aspects in the management of such patients.
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Affiliation(s)
- Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Member of the European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Hannover, Germany
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Wengenmayer T, Tigges E, Staudacher DL. Extracorporeal cardiopulmonary resuscitation in 2023. Intensive Care Med Exp 2023; 11:74. [PMID: 37902904 PMCID: PMC10616028 DOI: 10.1186/s40635-023-00558-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 10/20/2023] [Indexed: 11/01/2023] Open
Affiliation(s)
- Tobias Wengenmayer
- Interdisciplinary Medical Intensive Care, Faculty of Medicine and Medical Center-University of Freiburg, Hugstetterstrasse 55, 79106, Freiburg, Germany
| | - Eike Tigges
- Department of Cardiology and Critical Care, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Dawid L Staudacher
- Interdisciplinary Medical Intensive Care, Faculty of Medicine and Medical Center-University of Freiburg, Hugstetterstrasse 55, 79106, Freiburg, Germany.
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Supady A, Wengenmayer T. [Extracorporeal cardiopulmonary resuscitation-When the heart no longer functions]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:913-921. [PMID: 37713164 DOI: 10.1007/s00108-023-01587-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/18/2023] [Indexed: 09/16/2023]
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) is an option for restoring blood circulation in patients with refractory circulatory failure. While conventional resuscitation measures are being continued, venoarterial extracorporeal membrane oxygenation (VA ECMO) is established in patients with cardiac arrest. This bypass can compensate for the functions of the heart and lungs until recovery of organ function. The benefit of ECPR compared to conventional resuscitation appears to be evident, especially after a prolonged resuscitation period; however, in three prospective randomized controlled studies an advantage has not yet been conclusively proven for widespread use in clinical routine. ECPR systems are complex and resource-intensive and should therefore be limited to specialized centers where sufficient numbers of patients are treated to ensure a high level of expertise in the teams.
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Affiliation(s)
- A Supady
- Interdisziplinäre Medizinische Intensivtherapie (IMIT), Universitätsklinikum Freiburg, Medizinische Fakultät, Universität Freiburg, Hugstetter Straße 55, 79106, Freiburg, Deutschland.
| | - T Wengenmayer
- Interdisziplinäre Medizinische Intensivtherapie (IMIT), Universitätsklinikum Freiburg, Medizinische Fakultät, Universität Freiburg, Hugstetter Straße 55, 79106, Freiburg, Deutschland
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Malinowski D, Fournier Y, Horbach A, Frick M, Magliani M, Kalverkamp S, Hildinger M, Spillner J, Behbahani M, Hima F. Computational fluid dynamics analysis of endoluminal aortic perfusion. Perfusion 2023; 38:1222-1229. [PMID: 35549763 PMCID: PMC10466979 DOI: 10.1177/02676591221099809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION In peripheral percutaneous (VA) extracorporeal membrane oxygenation (ECMO) procedures the femoral arteries perfusion route has inherent disadvantages regarding poor upper body perfusion due to watershed. With the advent of new long flexible cannulas an advancement of the tip up to the ascending aorta has become feasible. To investigate the impact of such long endoluminal cannulas on upper body perfusion, a Computational Fluid Dynamics (CFD) study was performed considering different support levels and three cannula positions. METHODS An idealized literature-based- and a real patient proximal aortic geometry including an endoluminal cannula were constructed. The blood flow was considered continuous. Oxygen saturation was set to 80% for the blood coming from the heart and to 100% for the blood leaving the cannula. 50% and 90% venoarterial support levels from the total blood flow rate of 6 l/min were investigated for three different positions of the cannula in the aortic arch. RESULTS For both geometries, the placement of the cannula in the ascending aorta led to a superior oxygenation of all aortic blood vessels except for the left coronary artery. Cannula placements at the aortic arch and descending aorta could support supra-aortic arteries, but not the coronary arteries. All positions were able to support all branches with saturated blood at 90% flow volume. CONCLUSIONS In accordance with clinical observations CFD analysis reveals, that retrograde advancement of a long endoluminal cannula can considerably improve the oxygenation of the upper body and lead to oxygen saturation distributions similar to those of a central cannulation.
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Affiliation(s)
- Daniel Malinowski
- Institute for Bioengineering, Biomaterials Laboratory, University of Applied Sciences Aachen, Aachen, Germany
| | - Yvan Fournier
- Fluid Mechanics, Energy and Environment Dpt., EDF R&D, Chatou, France
| | - Andreas Horbach
- Institute for Bioengineering, Biomaterials Laboratory, University of Applied Sciences Aachen, Aachen, Germany
| | - Michael Frick
- Department of Cardiology, Angiology, and Intensive Care, University Hospital Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Mirko Magliani
- Division of Thoracic Surgery and Thoracic Organ Support, University Hospital Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Sebastian Kalverkamp
- Division of Thoracic Surgery and Thoracic Organ Support, University Hospital Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Martin Hildinger
- Division of Thoracic Surgery and Thoracic Organ Support, University Hospital Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Jan Spillner
- Division of Thoracic Surgery and Thoracic Organ Support, University Hospital Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Mehdi Behbahani
- Institute for Bioengineering, Biomaterials Laboratory, University of Applied Sciences Aachen, Aachen, Germany
| | - Flutura Hima
- Division of Thoracic Surgery and Thoracic Organ Support, University Hospital Medical Faculty, RWTH Aachen University, Aachen, Germany
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Gan J, Zou H, Yang F, Dai S, Jiang C, Xia J. Feasibility of watershed detection by point-of-care ultrasound in patients receiving bifemoral venoarterial extracorporeal membrane oxygenation: A prospective observational study. JTCVS Tech 2023; 20:111-115. [PMID: 37555048 PMCID: PMC10405304 DOI: 10.1016/j.xjtc.2023.06.001] [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: 03/06/2023] [Revised: 05/02/2023] [Accepted: 05/22/2023] [Indexed: 08/10/2023] Open
Affiliation(s)
- Jiaohong Gan
- Emergency Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Hao Zou
- Emergency Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Feihong Yang
- Emergency Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Shuai Dai
- Emergency Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Cheng Jiang
- Emergency Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jian Xia
- Emergency Center, Zhongnan Hospital of Wuhan University, Wuhan, China
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13
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Feiger B, Jensen CW, Bryner BS, Segars WP, Randles A. Modeling the effect of patient size on cerebral perfusion during veno-arterial extracorporeal membrane oxygenation. Perfusion 2023:2676591231187962. [PMID: 37395266 PMCID: PMC10786318 DOI: 10.1177/02676591231187962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
INTRODUCTION A well-known complication of veno-arterial extracorporeal membrane oxygenation (VA ECMO) is differential hypoxia, in which poorly-oxygenated blood ejected from the left ventricle mixes with and displaces well-oxygenated blood from the circuit, thereby causing cerebral hypoxia and ischemia. We sought to characterize the impact of patient size and anatomy on cerebral perfusion under a range of different VA ECMO flow conditions. METHODS We use one-dimensional (1D) flow simulations to investigate mixing zone location and cerebral perfusion across 10 different levels of VA ECMO support in eight semi-idealized patient geometries, for a total of 80 scenarios. Measured outcomes included mixing zone location and cerebral blood flow (CBF). RESULTS Depending on patient anatomy, we found that a VA ECMO support ranging between 67-97% of a patient's ideal cardiac output was needed to perfuse the brain. In some cases, VA ECMO flows exceeding 90% of the patient's ideal cardiac output are needed for adequate cerebral perfusion. CONCLUSIONS Individual patient anatomy markedly affects mixing zone location and cerebral perfusion in VA ECMO. Future fluid simulations of VA ECMO physiology should incorporate varied patient sizes and geometries in order to best provide insights toward reducing neurologic injury and improved outcomes in this patient population.
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Affiliation(s)
- Bradley Feiger
- Department of Bioengineering, School of Medicine, Duke University, Durham, NC, USA
| | - Christopher W Jensen
- Department of Bioengineering, School of Medicine, Duke University, Durham, NC, USA
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, NC, USA
| | - Benjamin S Bryner
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, NC, USA
| | - William P Segars
- Department of Radiology, School of Medicine, Duke Medicine, Chicago, IL, USA
| | - Amanda Randles
- Department of Bioengineering, School of Medicine, Duke University, Durham, NC, USA
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14
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Cho SM, Geocadin R, Whitman GJ. Extracorporeal CPR for Out-of-Hospital Cardiac Arrest. N Engl J Med 2023; 388:1915-1916. [PMID: 37195956 PMCID: PMC10564385 DOI: 10.1056/nejmc2302405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Affiliation(s)
- Sung-Min Cho
- Johns Hopkins University School of Medicine, Baltimore, MD
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15
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Heart Lung Transplant 2023; 42:e1-e64. [PMID: 36805198 DOI: 10.1016/j.healun.2022.10.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 10/28/2022] [Indexed: 02/08/2023] Open
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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16
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Wickramarachchi A, Burrell AJC, Stephens AF, Šeman M, Vatani A, Khamooshi M, Raman J, Bellomo R, Gregory SD. The effect of arterial cannula tip position on differential hypoxemia during venoarterial extracorporeal membrane oxygenation. Phys Eng Sci Med 2023; 46:119-129. [PMID: 36459331 DOI: 10.1007/s13246-022-01203-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 11/24/2022] [Indexed: 12/05/2022]
Abstract
Interaction between native ventricular output and venoarterial extracorporeal membrane oxygenation (VA ECMO) flow may hinder oxygenated blood flow to the aortic arch branches, resulting in differential hypoxemia. Typically, the arterial cannula tip is placed in the iliac artery or abdominal aorta. However, the hemodynamics of a more proximal arterial cannula tip have not been studied before. This study investigated the effect of arterial cannula tip position on VA ECMO blood flow to the upper extremities using computational fluid dynamics simulations. Four arterial cannula tip positions (P1. common iliac, P2. abdominal aorta, P3. descending aorta and P4. aortic arch) were compared with different degrees of cardiac dysfunction and VA ECMO support (50%, 80% and 90% support). P4 was able to supply oxygenated blood to the arch vessels at all support levels, while P1 to P3 only supplied the arch vessels during the highest level (90%) of VA ECMO support. Even during the highest level of support, P1 to P3 could only provide oxygenated VA-ECMO flow at 0.11 L/min to the brachiocephalic artery, compared with 0.5 L/min at P4. This study suggests that cerebral perfusion of VA ECMO flow can be increased by advancing the arterial cannula tip towards the aortic arch.
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Affiliation(s)
- Avishka Wickramarachchi
- Cardio-Respiratory Engineering and Technology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia.
- Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, Australia.
| | - Aidan J C Burrell
- Intensive Care Unit, Alfred Hospital, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Andrew F Stephens
- Cardio-Respiratory Engineering and Technology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia
- Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, Australia
| | - Michael Šeman
- Cardio-Respiratory Engineering and Technology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia
- School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia
- Department of Cardiology, Alfred Health, Melbourne, Australia
| | - Ashkan Vatani
- Cardio-Respiratory Engineering and Technology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia
- Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, Australia
| | - Mehrdad Khamooshi
- Cardio-Respiratory Engineering and Technology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia
- Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, Australia
| | - Jaishankar Raman
- Cardiothoracic Surgery, Austin & St Vincent's Hospitals, University of Melbourne, Melbourne, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Intensive Care Unit, Austin Hospital, Melbourne, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
| | - Shaun D Gregory
- Cardio-Respiratory Engineering and Technology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia
- Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, Australia
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17
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Card Fail 2023; 29:304-374. [PMID: 36754750 DOI: 10.1016/j.cardfail.2022.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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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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Székely M, Ruttkay T, Suhai FI, Bóna Á, Merkely B, Székely L. Minimally invasive apical cannulation and cannula design for short-term mechanical circulatory support devices. BMC Cardiovasc Disord 2022; 22:395. [PMID: 36058933 PMCID: PMC9441023 DOI: 10.1186/s12872-022-02826-z] [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: 05/06/2022] [Accepted: 08/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Refractory cardiogenic shock is still a major clinical challenge with high mortality rates, although several devices can be used to conquer this event. These devices have different advantages and disadvantages originating from their insertion or cannulation method, therefore many complications can occur during their use. The aim of our study was to develop and create prototypes of a novel minimal invasively insertable, transapical cannula for surgical ventricular assist devices, which uniquely incorporates the inflow and outflow routes for the blood of the patient in itself, therefore it enables the use for only one cannula for patients in cardiogenic shock. METHODS To define the available space for the planned cannula in the left ventricle and ascending aorta, we analyzed computed tomography scans of 24 heart failure patients, who were indicated to left ventricular assist device therapy. Parallel to these measurements, hydrodynamical calculations were performed to determine the sizes of the cannulas, which were necessary to provide effective cardiac output. RESULTS After the designing steps, we produced prototypes of double-lumened, tube-in-tube apically insertable devices for three different patient groups, which included a separated venous and an arterial part using 3D modelling and printing technology. All the created cannulas are able to provide 5 l/min circulatory support. CONCLUSION As a result of our research we created a sizing method based on the specific analysis of computed tomography pictures of end stage heart failure patients and a cannula concept, which can provide effective antegrade flow for patients in cardiogenic shock. We believe the improved version of our tool could have a significant therapeutic role in the future after further development based on animal and in vivo tests.
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Affiliation(s)
- Marcell Székely
- Laboratory for Applied and Clinical Anatomy, Department of Anatomy, Histology, and Embryology, Semmelweis University, 58 Tűzoltó Street, Budapest, 1094, Hungary.
| | - Tamás Ruttkay
- Laboratory for Applied and Clinical Anatomy, Department of Anatomy, Histology, and Embryology, Semmelweis University, 58 Tűzoltó Street, Budapest, 1094, Hungary
| | - Ferenc Imre Suhai
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Road, Budapest, 1122, Hungary
| | - Áron Bóna
- Soós Research and Development Center, University of Pannonia, 18 Zrínyi Miklós Street, Nagykanizsa, 8800, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Road, Budapest, 1122, Hungary
| | - László Székely
- Military Hospital Medical Centre, Cardiovascular and Thoracic Surgery Department, Hungarian Defense Forces, 44 Róbert Károly Boulevard, Budapest, 1134, Hungary
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20
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Starke H, von Dossow V, Karsten J. Intraoperative Circulatory Support in Lung Transplantation: Current Trend and Its Evidence. LIFE (BASEL, SWITZERLAND) 2022; 12:life12071005. [PMID: 35888094 PMCID: PMC9322250 DOI: 10.3390/life12071005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/02/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022]
Abstract
Lung transplantation has a high risk of haemodynamic complications in a highly vulnerable patient population. The effects on the cardiovascular system of the various underlying end-stage lung diseases also contribute to this risk. Following a literature review and based on our own experience, this review article summarises the current trends and their evidence for intraoperative circulatory support in lung transplantation. Identifiable and partly modifiable risk factors are mentioned and corresponding strategies for treatment are discussed. The approach of first identifying risk factors and then developing an adjusted strategy is presented as the ERSAS (early risk stratification and strategy) concept. Typical haemodynamic complications discussed here include right ventricular failure, diastolic dysfunction caused by left ventricular deconditioning, and reperfusion injury to the transplanted lung. Pre- and intra-operatively detectable risk factors for the occurrence of haemodynamic complications are rare, and the therapeutic strategies applied differ considerably between centres. However, all the mentioned risk factors and treatment strategies can be integrated into clinical treatment algorithms and can influence patient outcome in terms of both mortality and morbidity.
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Affiliation(s)
- Henning Starke
- Institute of Anaesthesiology, Heart and Diabetes Centre NRW, Bad Oeynhausen, Ruhr University Bochum, 44801 Bochum, Germany;
| | - Vera von Dossow
- Institute of Anaesthesiology, Heart and Diabetes Centre NRW, Bad Oeynhausen, Ruhr University Bochum, 44801 Bochum, Germany;
- Correspondence: ; Tel.: +49-(0)-5731-97-1128; Fax: +49-(0)-5731-97-2196
| | - Jan Karsten
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, 30625 Hannover, Germany;
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21
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Levy Y, Starck J, Mary AL, Soreze Y, Jean S, Kreitmann B, Léger PL, Rambaud J. Hidden Harlequin syndrome in neonatal and pediatric VA-ECMO. Crit Care 2022; 26:146. [PMID: 35596209 PMCID: PMC9121566 DOI: 10.1186/s13054-022-04017-w] [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: 03/18/2022] [Accepted: 05/05/2022] [Indexed: 11/26/2022] Open
Affiliation(s)
- Yael Levy
- Pediatric and Neonatal Intensive Care Unit, Armand-Trousseau Hospital, APHP, 26 avenue du Dr Arnold Netter, 75012, Paris, France. .,Sorbonne University, Paris, France. .,INSERM, IMRB, Univ Paris Est Créteil, 94010, Créteil, France.
| | - Julie Starck
- Pediatric and Neonatal Intensive Care Unit, Armand-Trousseau Hospital, APHP, 26 avenue du Dr Arnold Netter, 75012, Paris, France
| | - Anne-Lise Mary
- Pediatric and Neonatal Intensive Care Unit, Armand-Trousseau Hospital, APHP, 26 avenue du Dr Arnold Netter, 75012, Paris, France
| | - Yohan Soreze
- Pediatric and Neonatal Intensive Care Unit, Armand-Trousseau Hospital, APHP, 26 avenue du Dr Arnold Netter, 75012, Paris, France
| | - Sandrine Jean
- Pediatric and Neonatal Intensive Care Unit, Armand-Trousseau Hospital, APHP, 26 avenue du Dr Arnold Netter, 75012, Paris, France
| | | | - Pierre-Louis Léger
- Pediatric and Neonatal Intensive Care Unit, Armand-Trousseau Hospital, APHP, 26 avenue du Dr Arnold Netter, 75012, Paris, France.,Sorbonne University, Paris, France.,INSERM, IMRB, Univ Paris Est Créteil, 94010, Créteil, France
| | - Jerome Rambaud
- Pediatric and Neonatal Intensive Care Unit, Armand-Trousseau Hospital, APHP, 26 avenue du Dr Arnold Netter, 75012, Paris, France.,Sorbonne University, Paris, France.,INSERM, IMRB, Univ Paris Est Créteil, 94010, Créteil, France
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22
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Du G, Zhang J, Liu J, Fan L. Case Report: Two Cases of Watershed Phenomenon in Mechanical Circulatory Support Devices: Computed Tomography Angiography Imaging and Literature Review. Front Cardiovasc Med 2022; 9:893355. [PMID: 35647037 PMCID: PMC9136032 DOI: 10.3389/fcvm.2022.893355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/26/2022] [Indexed: 11/13/2022] Open
Abstract
Mechanical circulatory support (MCS) has become a processing technique used in end-stage heart failure (ESHF) because it can significantly improve survival and quality of life in patients with ESHF as either a transitional support therapy or a permanent replacement therapy before heart transplant. However, various potential complications associated with MCS need to be considered, especially aortic root thrombus formation. It’s critical to have an appropriate diagnosis of aortic root thrombus and “watershed” because the prognosis and treatment are different. Both “watershed” and aortic root thrombus formation can be characterized by computed tomography angiography. The CT manifestations of two patients who had MCS device implantation in our hospital (one with intra-aortic balloon pumps + extracorporeal membrane oxygenators, the other with left ventricular assist devices) were reported, and a literature review that recognized of “watershed” phenomenon in the aortic root was conducted.
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23
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Impact of the inspiratory oxygen fraction on the cardiac output during jugulo-femoral venoarterial extracorporeal membrane oxygenation in the rat. BMC Cardiovasc Disord 2022; 22:174. [PMID: 35428203 PMCID: PMC9013166 DOI: 10.1186/s12872-022-02613-w] [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: 03/30/2021] [Accepted: 04/01/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Venoarterial extracorporeal membrane oxygenation (V-A ECMO) with femoral access has gained wide acceptance in the treatment of critically ill patients. Since the patient´s cardiac output (CO) can compete with the retrograde aortic ECMO-flow, the aim of this study was to examine the impact of the inspiratory oxygen fraction on the cardiac function during V-A ECMO therapy.
Methods
Eighteen male Lewis rats (350–400 g) received V-A ECMO therapy. The inspiratory oxygen fraction on the ventilator was randomly set to 0.5 (group A), 0.21 (group B), or 0 in order to simulate apnea (group C), respectively. Each group consisted of six animals. Arterial blood pressure, central venous saturation (ScvO2), CO, stroke volume, left ventricular ejection fraction (LVEF), end diastolic volume, and pressure were measured. Cardiac injury was determined by analyzing the amount of lactate dehydrogenase (LDH).
Results
During anoxic ventilation the systolic, mean and diastolic arterial pressure, CO, stroke volume, LVEF and ScvO2 were significantly impaired compared to group A and B. The course of LDH values revealed no significant differences between the groups.
Conclusion
Anoxic ventilation during V-A ECMO with femoral cannulation leads to cardiogenic shock in rats. Therefore, awake V-A ECMO patients might be at risk for hypoxia-induced complications.
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24
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Cai T, Li C, Xu B, Wang L, Du Z, Hao X, Guo D, Xing Z, Jiang C, Xin M, Wang P, Fan Q, Wang H, Hou X. Drainage From Superior Vena Cava Improves Upper Body Oxygenation in Patients on Femoral Veno-Arterial Extracorporeal Membrane Oxygenation. Front Cardiovasc Med 2022; 8:807663. [PMID: 35242819 PMCID: PMC8886363 DOI: 10.3389/fcvm.2021.807663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/27/2021] [Indexed: 01/20/2023] Open
Abstract
Objective To investigate the feasibility of drainage from the superior vena cava (SVC) to improve upper body oxygenation in patients with cardiogenic shock undergoing femoral veno-arterial extracorporeal membrane oxygenation (VA ECMO). Methods Seventeen adult patients receiving peripheral femoral VA ECMO for circulatory support were enrolled. The femoral drainage cannula was shifted three times (from the inferior vena cava (IVC) level to the SVC level and then the IVC level again), all under ultrasound guidance, at an interval of 15 minutes. The blood gas levels of the right radial artery (RA) and SVC and cerebral oxygen saturation (ScO2) were measured and compared. Results Fifteen patients (88.2%) were successfully weaned from ECMO, and 12 patients (70.6%) survived to discharge. The oxygen saturation (SO2) and oxygen partial pressure (PO2) of the RA (97.0 ± 3.5% to 98.3 ± 1.5%, P < 0.05, SO2; 127.4 ± 58.2 mmHg to 153.1 ± 67.8 mmHg, P < 0.05, PO2) and SVC (69.5 ± 9.0% to 75.7 ± 8.5%, P < 0.05, SO2; 38.5 ± 5.6 mmHg to 43.6 ± 6.4 mmHg, P < 0.05, PO2) were increased; ScO2 was also increased on both sides (left: 50.6 ± 8.6% to 55.0 ± 9.0%, P < 0.05; right: 48.7 ± 9.2% to 52.3 ± 9.8%, P < 0.05) when the femoral drainage cannula was shifted from the IVC level to the SVC level. When the femoral drainage cannula was shifted from SVC level to the IVC level again, the SO2 and PO2 of RA (98.3 ± 1.5% to 96.9 ± 3.2%, P <0.05, SO2; 153.1 ± 67.8 mmHg to 125.8 ± 63.3 mmHg, P <0.05, PO2) and SVC (75.7 ± 38.5% to 70.4 ± 7.6%, P <0.05, SO2; 43.6 ± 6.4 mmHg to 38.9 ± 4.5 mmHg, P <0.05, PO2) were decreased; ScO2 was also reduced on both sides (left: 55.0 ± 9.0% to 50.7 ± 8.2%, P < 0.05; right: 52.3 ± 9.8% to 48.7 ± 9.3%, P <0.05). Conclusion Drainage from the SVC by shifting the cannula upward could improve upper body oxygenation in patients with cardiogenic shock undergoing femoral VA ECMO. This cannulation strategy provides an alternative solution for differential hypoxia.
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Affiliation(s)
- Tong Cai
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Chenglong Li
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Bo Xu
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Liangshan Wang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhongtao Du
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xing Hao
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dong Guo
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhichen Xing
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Chunjing Jiang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Meng Xin
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Pengcheng Wang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Qiushi Fan
- School of Public Health, Capital Medical University, Beijing, China
| | - Hong Wang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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25
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Abstract
OVERVIEW The use of extracorporeal membrane oxygenation (ECMO) is becoming commonplace worldwide in ICUs for the care of patients with respiratory and/or cardiac failure. Understanding the use of ECMO and the management of these complex patients will be vital to current and future clinicians as ECMO use continues to grow.
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26
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Edinger F, Schmitt C, Koch C, McIntosh JM, Janciauskiene S, Markmann M, Sander M, Padberg W, Grau V. Application of alpha1-antitrypsin in a rat model of veno-arterial extracorporeal membrane oxygenation. Sci Rep 2021; 11:15849. [PMID: 34349162 PMCID: PMC8339069 DOI: 10.1038/s41598-021-95119-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 07/19/2021] [Indexed: 11/08/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving intervention for patients suffering from respiratory or cardiac failure. The ECMO-associated morbidity and mortality depends to a large extent on the underlying disease and is often related to systemic inflammation, consecutive immune paralysis and sepsis. Here we tested the hypothesis that human α1-antitrypsin (SERPINA1) due to its anti-protease and anti-inflammatory functions may attenuate ECMO-induced inflammation. We specifically aimed to test whether intravenous treatment with α1-antitrypsin reduces the release of cytokines in response to 2 h of experimental ECMO. Adult rats were intravenously infused with α1-antitrypsin immediately before starting veno-arterial ECMO. We measured selected pro- and anti-inflammatory cytokines and found, that systemic levels of tumor necrosis factor-α, interleukin-6 and interleukin-10 increase during experimental ECMO. As tachycardia and hypertension developed in response to α1-antitrypsin, a single additional bolus of fentanyl and midazolam was given. Treatment with α1-antitrypsin and higher sedative doses reduced all cytokine levels investigated. We suggest that α1-antitrypsin might have the potential to protect against both ECMO-induced systemic inflammation and immune paralysis. More studies are needed to corroborate our findings, to clarify the mechanisms by which α1-antitrypsin inhibits cytokine release in vivo and to explore the potential application of α1-antitrypsin in clinical ECMO.
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Affiliation(s)
- Fabian Edinger
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Justus-Liebig University of Giessen, Giessen, Germany.
| | - Christoph Schmitt
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Justus-Liebig University of Giessen, Giessen, Germany
| | - Christian Koch
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Justus-Liebig University of Giessen, Giessen, Germany
| | - J Michael McIntosh
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT, USA
- Department of Biology, University of Utah, Salt Lake City, UT, USA
- Department of Psychiatry, University of Utah, Salt Lake City, UT, USA
| | - Sabina Janciauskiene
- Department of Respiratory Medicine, Hannover Medical School, German Centre for Lung Research (DZL), Hannover, Germany
| | - Melanie Markmann
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Justus-Liebig University of Giessen, Giessen, Germany
| | - Michael Sander
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Justus-Liebig University of Giessen, Giessen, Germany
| | - Winfried Padberg
- Laboratory of Experimental Surgery, Department of General and Thoracic Surgery, German Centre for Lung Research (DZL), Justus-Liebig-University of Giessen, Giessen, Germany
| | - Veronika Grau
- Laboratory of Experimental Surgery, Department of General and Thoracic Surgery, German Centre for Lung Research (DZL), Justus-Liebig-University of Giessen, Giessen, Germany
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Douraghi-Zadeh D, Logaraj A, Lazoura O, Downey K, Gill S, Finney SJ, Padley S. Extracorporeal membrane oxygenation (ECMO): Radiographic appearances, complications and imaging artefacts for radiologists. J Med Imaging Radiat Oncol 2021; 65:888-895. [PMID: 34219399 DOI: 10.1111/1754-9485.13280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/15/2021] [Indexed: 11/26/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a form of cardiopulmonary support primarily used in cardiothoracic and intensive care unit (ICU) settings. The purpose of this review is to familiarise radiologists with the imaging features of ECMO devices, their associated complications and appropriate imaging protocols for contrast-enhanced CT imaging of ECMO patients. This paper will provide a brief introduction to ECMO and the imaging modalities utilised in ECMO patients, followed by a description of the types of ECMO available and cannula positioning. Indications and contraindications for ECMO will be outlined followed by a description of the complications associated with ECMO, which radiologists should recognise. Finally, the imaging protocol and interpretation of contrast-enhanced CT imaging in ECMO patients will be discussed. In the current clinical climate with millions of COVID-19 cases around the world and tens of thousands of critically ill patients, many requiring cardiopulmonary support in intensive care units, the use of ECMO in adults has increased, and thus so has the volume of imaging. Radiologists need to be familiar with the types of ECMO available, the correct positioning of the catheters depending on the type of ECMO being utilised, and the associated complications and imaging artefacts.
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Affiliation(s)
| | - Anthony Logaraj
- Department of Radiology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Olga Lazoura
- Department of Radiology, Royal Free London NHS Trust, London, UK
| | | | - Simon Gill
- Department of Radiology, Frimley Health NHS Trust, Surrey, UK
| | - Simon J Finney
- Department of Intensive Care, Barts Health NHS Trust, London, UK
| | - Simon Padley
- Department of Radiology, Royal Brompton & Harefield NHS Trust, London, UK
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He Y, Yao P, Xu P, Zhou T, Zhou Y, Cao Y. Should "Cardiopulmonary Resuscitation-Associated Lung Edema" be Diagnosed More Cautiously? Am J Respir Crit Care Med 2021; 204:740-741. [PMID: 34181867 PMCID: PMC8521694 DOI: 10.1164/rccm.202104-0960le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Yarong He
- West China Hospital of Medicine, 34753, Emergency Department, Chengdu, China.,Sichuan University, 12530, Disaster Medical Center, Chengdu, China
| | - Peng Yao
- Sichuan University West China Hospital, 34753, Emergency Medicine, Chengdu, China
| | - Ping Xu
- Sichuan University West China Hospital, 34753, Emergency Medicine, Chengdu, China
| | - Tingyuan Zhou
- Sichuan University West China Hospital, 34753, Emergency Medicine, Chengdu, China
| | - Yaxiong Zhou
- Sichuan University West China Hospital, 34753, Emergency Medicine, Chengdu, China
| | - Yu Cao
- Sichuan University West China Hospital, 34753, Department of Emergency Medicine, Chengdu, China;
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Hansen HC, Wertheimer D, Soeffker G, Els T. [Irreversible loss of brain function : Requirements and Clinical diagnosis]. Med Klin Intensivmed Notfmed 2021; 116:459-471. [PMID: 34009402 DOI: 10.1007/s00063-021-00824-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/12/2021] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
Abstract
Brain death (irreversible loss of brain function), according to German regulations, is investigated exclusively by qualified specialists in a strictly hierarchical three-step pattern and a four-eyes principle. In step 1 all necessary prerequisites are to be checked and the pathophysiology of brain damage has to be classified. Step 2 comprises the clinical investigation of reactivity to external stimuli and the upper, middle and lower brain stem reflexes including apnea testing. Step 3 exclusively checks for irreversibility of this condition. The latter is achieved by appropriate technical investigations or by repeated clinical examinations within context-specified intervals (range 12-72 h). However, exclusion of contributing primarily infratentorial pathologies is necessary to avoid limitations of the clinical findings. In this paper, both the initiation of brain death diagnostics and the approved clinical tests regarding to their execution, their alternatives and limits are presented and special situations like conditions with extracorporeal membrane oxygenation (ECMO) are also examined.
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Affiliation(s)
- H-C Hansen
- Klinik für Neurologie, Friedrich-Ebert-Krankenhaus GmbH Neumünster, Universität Hamburg, 24534, Neumünster, Deutschland.
| | - D Wertheimer
- Neurologische Abteilung, Schön Klinik Hamburg Eilbek, Dehnhaide 120, 22081, Hamburg, Deutschland
| | - G Soeffker
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - T Els
- Klinik für Neurologie und klinische Neurophysiologie, GFO-Kliniken Rhein-Berg, Betriebsstätte Marien-Krankenhaus, Dr.-Robert-Koch-Straße 18, 51465, Bergisch Gladbach, Deutschland
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Lashin H, Shepherd S, Smith A. Contrast-Enhanced Echocardiography Application in Patients Supported by Extracorporeal Membrane Oxygenation (ECMO): A Narrative Review. J Cardiothorac Vasc Anesth 2021; 36:2080-2089. [PMID: 34074555 DOI: 10.1053/j.jvca.2021.04.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/25/2021] [Accepted: 04/20/2021] [Indexed: 11/11/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a lifesaving intervention increasingly used to support patients with severe respiratory and cardiac dysfunction. Echocardiography is an important tool, aiding implantation and monitoring during ECMO therapy, but often its use is limited by poor acoustic windows. This limitation may be overcome by the use of echocardiography contrast agents to improve diagnostic yield and reduce the need for other imaging modalities that may require patient transfer, involve ionizing radiation and, occasionally, nephrotoxic radio-opaque contrast medium. In this article the authors review the literature addressing the use of contrast-enhanced echocardiography (CEE) in ECMO-supported patients. The authors discuss the role of CEE in guiding implantation of ECMO, cardiac assessment and diagnosis of complications during ECMO therapy, as well as the safety of ultrasound-enhancing agents in this cohort of patients.
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Affiliation(s)
- Hazem Lashin
- Adult Critical Care Unit, Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London, England, United Kingdom; William Harvey Research Institute, Barts, and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, England, United Kingdom.
| | - Stephen Shepherd
- Adult Critical Care Unit, Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London, England, United Kingdom; William Harvey Research Institute, Barts, and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, England, United Kingdom
| | - Andrew Smith
- Adult Critical Care Unit, Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London, England, United Kingdom; William Harvey Research Institute, Barts, and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, England, United Kingdom
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Central Versus Peripheral Arterial Cannulation for Veno-Arterial Extracorporeal Membrane Oxygenation in Post-Cardiotomy Patients. ASAIO J 2021; 67:67-73. [PMID: 33346992 DOI: 10.1097/mat.0000000000001202] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Different arterial cannulation strategies are feasible for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in postcardiotomy shock. We aimed to analyze potential benefits and safety of different arterial cannulation strategies. We identified 158 patients with postcardiotomy cardiogenic shock requiring VA-ECMO between 01/10 and 01/19. Eighty-eight patients were cannulated via axillary or femoral artery (group P), and 70 centrally via the ascending aorta directly or through an 8 mm vascular graft anastomosed to the ascending aorta (group C). Demographics and operative parameters were similar. Change of cannulation site for Harlequin's syndrome or hyperperfusion of an extremity occurred in 13 patients in group P but never in group C (p = 0.001). Surgical revision of cannulation site was also encountered more often in group P than C. The need for left ventricular (LV) unloading was similar between groups, whereas surgical venting was more often implemented in group C (11.4% vs. 2.3, p = 0.023). Stroke rates, renal failure, and peripheral ischemia were similar. Weaning rate from ECMO (52.9% vs. 52.3%, p = NS) was similar. The 30 day mortality was higher in group P (60% vs. 76.1%, p = 0.029). Central cannulation for VA-ECMO provides antegrade flow without Harlequin's syndrome, changes of arterial cannula site, and better 30 day survival. Complication rates regarding need for reexploration and transfusion requirements were similar.
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The Effect of Additional Stepwise Venous Inflow on Differential Hypoxia of Veno-Arterial Extracorporeal Membrane Oxygenation. ASAIO J 2021; 66:803-808. [PMID: 31425264 PMCID: PMC7316147 DOI: 10.1097/mat.0000000000001052] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Use of femoral-femoral veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) for cardiopulmonary support during lung transplantation can be inadequate for efficient distribution of oxygenated blood into the coronary circulation. We hypothesized that creating a left-to-right shunt flow using veno-arterio-venous (VAV) ECMO would alleviate the differential hypoxia. Total 10 patients undergoing lung transplantation were enrolled in this study. An additional inflow cannula was inserted into the right internal jugular (RIJ) vein for VAV ECMO. During left one-lung ventilation using a 1.0 inspired oxygen fraction (FiO2), the left-to-right shunt flow was incrementally increased from 0 to 500, 1,000, and 1,500 ml/min. The arterial oxygen partial pressure (PaO2) and oxygen saturation (SaO2) were measured at the proximal ascending aorta and right radial artery. The ascending aorta gas analysis revealed that six patients had a PaO2/FiO2 ratio less than 200 mm Hg at a 0 ml/min shunt flow. The PaO2 (SaO2) values were 48.5 ± 14.8 mm Hg (80.9 ± 11.6%) at the ascending aorta and 77.8 ± 69.7 mm Hg (83.3 ± 13.2%) at the right radial artery. As the left-to-right shunt flow rate increased over 1,000 ml/min, the PaO2 and SaO2 values for the ascending aorta and right radial artery significantly increased. In conclusion, femoral-femoral VA ECMO can produce suboptimal coronary oxygenation in patients unable to tolerate one-lung ventilation. A left-to-right shunt using VAV ECMO can alleviate the differential hypoxia.
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Hoyler MM, Flynn B, Iannacone EM, Jones MM, Ivascu NS. Clinical Management of Venoarterial Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2020; 34:2776-2792. [DOI: 10.1053/j.jvca.2019.12.047] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 12/04/2019] [Accepted: 12/29/2019] [Indexed: 12/13/2022]
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Implantationstechniken für temporäre ECLS-Systeme. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2020. [DOI: 10.1007/s00398-020-00384-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Taran S, Steel A, Healey A, Fan E, Singh JM. Organ donation in patients on extracorporeal membrane oxygenation: considerations for determination of death and withdrawal of life support. Can J Anaesth 2020; 67:1035-1043. [PMID: 32440908 DOI: 10.1007/s12630-020-01714-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/23/2020] [Accepted: 05/12/2020] [Indexed: 02/07/2023] Open
Abstract
The use of extracorporeal membrane oxygenation (ECMO) is increasing globally, although mortality in this setting remains high. Patients on ECMO may be potential organ donors in the context of withdrawal of life-sustaining measures (WLSM) or neurologic determination of death (NDD). Nevertheless, there are currently no Canadian standards to guide clinicians on NDD or WLSM for the purposes of organ donation in this patient population. Apnea testing remains fundamental to determining NDD and is an area where ECMO may alter routine procedures. In this review, we outline protocols for the performance of apnea testing and WLSM for patients supported with ECMO, highlighting important technical and physiologic considerations that may affect the determination of death. In addition, we review important considerations for NDD in ECMO, including management of potential confounders, strategies for controlling oxygen and carbon dioxide levels during apnea testing, and the appropriate use of ancillary tests to support NDD. In the context of ECMO support, there is limited evidence to guide NDD and WLSM for the purposes of organ donation. Drawing upon extensive clinical experience, we provide protocols for these processes and review other important considerations in an effort to maximize donor potential in this growing patient population.
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Affiliation(s)
- Shaurya Taran
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
- Interdepartmental Division of Critical Care, Li Ka Shing Knowledge Institute, University of Toronto, 204 Victoria Street, 4th Floor, Room 411, Toronto, ON, M5B 1T8, Canada.
| | - Andrew Steel
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anaesthesiology, University Health Network, Toronto, ON, Canada
- Trillium Gift of Life Network, Toronto, ON, Canada
| | - Andrew Healey
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Trillium Gift of Life Network, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network, Toronto, ON, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Jeffrey M Singh
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network, Toronto, ON, Canada
- Trillium Gift of Life Network, Toronto, ON, Canada
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Development and Validation of a Life-Sized Mock Circulatory Loop of the Human Circulation for Fluid-Mechanical Studies. ASAIO J 2020; 65:788-797. [PMID: 30281544 DOI: 10.1097/mat.0000000000000880] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Mock circulatory loops (MCLs) are usually developed for assessment of ventricular assist devices and consist of abstracted anatomical structures represented by connecting tubing pipes and controllable actuators which could mimic oscillating flow processes. However, with increasing use of short-term peripheral mechanical support (extracorporeal life support [ECLS]) and the upcoming evidence of even counteracting flow processes between the failing native circulation and ECLS, MCLs incorporating the peripheral vascular system and preserved anatomical structures are becoming more important for systematic assessment of these processes. For reproducible and standardized fluid-mechanical studies using magnetic resonance imaging, Doppler ultrasound, and computational fluid dynamics measurements, we developed a MCL of the human circulation. Silicon-based life-sized dummies of the human aorta and vena cava (vascular module) were driven by paracorporeal pneumatic assist devices. The vascular module is placed in a housing with all arterial branches merging into peripheral resistance and compliances modules, and blood-mimicking fluid returns to the heart module through the venous dummy. Compliance and resistance chambers provide for an adequate simulation of the capillary system. Extracorporeal life support cannulation can be performed in the femoral and subclavian arteries and in the femoral and jugular veins. After adjusting vessel diameters using variable Hoffmann clamps, physiologic flow rates were achieved in the supraaortic branches, the renal and mesenteric arteries, and the limb arteries with physiologic blood pressure and cardiac output (4 L/min). This MCL provides a virtually physiologic platform beyond conventional abstracted MCLs for simulation of flow interactions between the human circulation and external circulation generated by ECLS.
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Gehron J, Schuster M, Rindler F, Bongert M, Böning A, Krombach G, Fiebich M, Grieshaber P. Watershed phenomena during extracorporeal life support and their clinical impact: a systematic in vitro investigation. ESC Heart Fail 2020; 7:1850-1861. [PMID: 32530129 PMCID: PMC7373893 DOI: 10.1002/ehf2.12751] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/13/2020] [Accepted: 04/20/2020] [Indexed: 11/27/2022] Open
Abstract
Aims Extracorporeal life support (ECLS) during acute cardiac failure restores haemodynamic stability and provides life‐saving cardiopulmonary support. Unfortunately, all common cannulation strategies and remaining pulmonary blood flow increase left‐ventricular afterload and may favour pulmonary congestion. The resulting disturbed pulmonary gas exchange and a residual left‐ventricular action can contribute to an inhomogeneous distribution of oxygenated blood into end organs. These complex flow interactions between native and artificial circulation cannot be investigated at the bedside: only an in vitro simulation can reveal the underlying activities. Using an in vitro mock circulation loop, we systematically investigated the impact of heart failure, extracorporeal support, and cannulation routes on the formation of flow phenomena and flow distribution in the arterial tree. Methods and results The mock circulation loop consisted of two flexible life‐sized vascular models (aorta and vena cava) driven by two paracorporeal assist devices, resistance elements, and compliance reservoirs to mimic the circulatory system. Several large‐bore antegrade and retrograde access ports allowed connection to an ECLS system for extracorporeal support. With four degrees of extracorporeal support—that for cardiac failure, early recovery, late recovery, and weaning—we investigated aortic blood flow velocity, blood flow, and mixing zones using colour‐coded Doppler ultrasound in the aorta and its corresponding branches. Full retrograde extracorporeal support (3–4 L/min) perfused major portions of the aorta but did not reach the supra‐aortic branches and ascending aorta, resulting in an area in the thoracic aorta demonstrating nearly stagnant blood flow velocities during cardiogenic shock and early recovery (0 ± 4 cm/s; −10 ± 15 cm/s, respectively) confined by two watersheds at the aortic isthmus and renal artery origin. Even increased ECLS flow was unable to shift the watershed towards the aortic arch. Antegrade support resulted in homogeneous flow distribution during all stages of cardiac failure but created a markedly negative flow vector in the ascending aorta during cardiogenic shock and early recovery with increased afterload. Conclusions Our systematic fluid‐mechanical analysis confirms the clinical assumption that despite restoring haemodynamic stability, extracorporeal support generates an inhomogeneous distribution of oxygenated blood with an inadequate supply to end organs and increased left‐ventricular afterload with absent ventricular unloading. End‐organ supply may be monitored by near‐infrared spectroscopy, but an obviously non‐controllable watershed emphasizes the need for additional measures: pre‐pulmonary oxygenation with a veno‐arterial‐venous ECLS configuration can allow a transpulmonary passage of oxygenated blood, providing improved end‐organ supply.
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Affiliation(s)
- Johannes Gehron
- Department of Adult and Pediatric Cardiovascular Surgery, University Hospital Giessen, Rudolf-Buchheim-Str. 7, 35392, Giessen, Germany
| | - Maximilian Schuster
- Department of Adult and Pediatric Cardiovascular Surgery, University Hospital Giessen, Rudolf-Buchheim-Str. 7, 35392, Giessen, Germany
| | - Florian Rindler
- Department of Adult and Pediatric Cardiovascular Surgery, University Hospital Giessen, Rudolf-Buchheim-Str. 7, 35392, Giessen, Germany
| | - Markus Bongert
- Research Center for Biomedical Technology (BMT), University of Applied Sciences and Arts, Dortmund, Germany
| | - Andreas Böning
- Department of Adult and Pediatric Cardiovascular Surgery, University Hospital Giessen, Rudolf-Buchheim-Str. 7, 35392, Giessen, Germany
| | - Gabriele Krombach
- Department of Diagnostic and Interventional Radiology, University Hospital Giessen, Giessen, Germany
| | - Martin Fiebich
- Division of Life Science Engineering, University of Applied Sciences, Giessen, Germany
| | - Philippe Grieshaber
- Department of Adult and Pediatric Cardiovascular Surgery, University Hospital Giessen, Rudolf-Buchheim-Str. 7, 35392, Giessen, Germany
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Nix C, Ishikawa K, Meyns B, Yasuda S, Adriaenssens T, Barth S, Zayat R, Leprince P, Lebreton G. Comparison of Hemodynamic Support by Impella vs. Peripheral Extra-Corporeal Membrane Oxygenation: A Porcine Model of Acute Myocardial Infarction. Front Cardiovasc Med 2020; 7:99. [PMID: 32587862 PMCID: PMC7299088 DOI: 10.3389/fcvm.2020.00099] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 05/11/2020] [Indexed: 01/25/2023] Open
Abstract
Objectives: Several mechanical circulatory assist devices are used to treat critically ill patients requiring hemodynamic support during post-myocardial infarction or cardiogenic shock. However, little guidance is available to choose an appropriate device to match a particular patient's needs. An increased understanding of hemodynamic effects of the pump systems and their impact on myocardial pre-/afterload might help to better understand their behavior in different clinical settings. Methods: This was an open-labeled, randomized acute animal experiment. A model of acute univentricular myocardial injury by temporary balloon occlusion was used. The experiment was carried out in 10 juveniles female Piétrain pigs. The animals were randomized to mechanical hemodynamic support either by peripheral veno-arterial (VA-)ECMO or Impella CP. Results: While both devices were able to provide flows above 3 L/min and maintain sufficient end-organ perfusion, support by Impella resulted in a significantly more pronounced immediate effect on myocardial unloading: At the onset of device support, the remaining native cardiac output was reduced by 23.5 ± 15.3% ECMO vs. 66.2 ± 36.2% (Impella, p = 0.021). Native stroke volume was significantly decreased by Impella support compared to ECMO, indicating less mechanical work being conducted by the Impella-supported hearts despite similar total assisted cardiac output. Conclusions: Peripheral VA-ECMO and the transaortic Impella pump resulted in contrasting hemodynamic fingerprints. Both devices provided sufficient hemodynamic support and reduce left ventricular end-diastolic pressure in the acute setting. Treatment with the Impella device resulted in a more effective volume unloading of the left ventricle. A significant reduction in myocardial oxygen consumption equivalent was achieved by both devices: The Impella device resulted in a left-shift of the pressure-volume loop and a decreased pressure-volume-area (PVA), while VA-ECMO increased PVA but decreased heart rate. These data highlight the importance of specifically targeting heart rate in the management of AMI patients on hemodynamic support.
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Affiliation(s)
- Christoph Nix
- Department of Anesthesiology, RWTH Aachen University Hospital, Aachen, Germany.,Abiomed Europe GmbH, Aachen, Germany
| | - Kiyotake Ishikawa
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospital UZ Leuven, Leuven, Belgium
| | - Shota Yasuda
- Department of Cardiac Surgery, University Hospital UZ Leuven, Leuven, Belgium
| | - Tom Adriaenssens
- Department of Cardiology, University Hospital UZ Leuven, Leuven, Belgium
| | | | - Rashad Zayat
- Department of Thoracic and Cardiovascular Surgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Pascal Leprince
- Department of Thoracic and Cardiovascular Surgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Guillaume Lebreton
- Department of Cardiac Surgery, Hôpital Universitaire Pitié-Salpêtrière, Paris, France
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Mogaldea A, Rojas SV, Ius F, Kaufeld T, Sommer W, Avsar M, Bara C, Haverich A, Warnecke G, Kuehn C. Upper-body cannulation for midterm mechanical circulatory support: A novel bridging strategy to cardiac retransplantation. Int J Artif Organs 2020; 43:391398820915476. [PMID: 32323596 DOI: 10.1177/0391398820915476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Heart retransplantation remains a controversial issue, due to the overall shortage of donor organs. Many patients put on the waiting list for retransplantation, decompensate rapidly, and do not survive. The use of veno-arterial extracorporeal life support remains an option in such emergency situations as bridge-to-recovery or bridge-to-transplantation therapy. In peripheral femoral configuration, veno-arterial extracorporeal life support improves the patient's condition by relieving low-cardiac output but immobilizes him or her for an uncertain period of time. The upper-body cannulation is an alternative approach, which allows to maintain the patient awake and mobile. We present two cases of midterm circulatory support as a bridge to heart retransplantation, using upper-body cannulation veno-arterial extracorporeal life support. Two male patients, presenting with progressive cardiac decompensation due to severe graft rejection, were placed on upper-body veno-arterial extracorporeal life support. The stabilization of hemodynamics and improvement of end-organ perfusion could be achieved after extracorporeal life support initiation. After 48 and 40 days, respectively, on extracorporeal life support with active physical therapy and no major adverse events, both patients received a cardiac retransplantation and were eventually discharged home. The presented cases are the first reported where a successful cardiac retransplant was performed following prolonged upper-body extracorporeal life support.
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Affiliation(s)
- Alexandru Mogaldea
- Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School (MHH), Hannover, Germany
| | - Sebastian V Rojas
- Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School (MHH), Hannover, Germany
| | - Fabio Ius
- Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School (MHH), Hannover, Germany
| | - Tim Kaufeld
- Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School (MHH), Hannover, Germany
| | - Wiebke Sommer
- Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School (MHH), Hannover, Germany
| | - Murat Avsar
- Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School (MHH), Hannover, Germany
| | - Christoph Bara
- Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School (MHH), Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School (MHH), Hannover, Germany
| | - Gregor Warnecke
- Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School (MHH), Hannover, Germany
| | - Christian Kuehn
- Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School (MHH), Hannover, Germany
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Buchtele N, Staudinger T, Schwameis M, Schörgenhofer C, Herkner H, Hermann A. Feasibility and safety of watershed detection by contrast-enhanced ultrasound in patients receiving peripheral venoarterial extracorporeal membrane oxygenation: a prospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:126. [PMID: 32241290 PMCID: PMC7118965 DOI: 10.1186/s13054-020-02849-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/23/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Nina Buchtele
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria
| | - Thomas Staudinger
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | | | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Alexander Hermann
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria
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Wollborn J, Steiger C, Doostkam S, Schallner N, Schroeter N, Kari FA, Meinel L, Buerkle H, Schick MA, Goebel U. Carbon Monoxide Exerts Functional Neuroprotection After Cardiac Arrest Using Extracorporeal Resuscitation in Pigs. Crit Care Med 2020; 48:e299-e307. [PMID: 32205620 DOI: 10.1097/ccm.0000000000004242] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Neurologic damage following cardiac arrest remains a major burden for modern resuscitation medicine. Cardiopulmonary resuscitation with extracorporeal circulatory support holds the potential to reduce morbidity and mortality. Furthermore, the endogenous gasotransmitter carbon monoxide attracts attention in reducing cerebral injury. We hypothesize that extracorporeal resuscitation with additional carbon monoxide application reduces neurologic damage. DESIGN Randomized, controlled animal study. SETTING University research laboratory. SUBJECTS Landrace-hybrid pigs. INTERVENTIONS In a porcine model, carbon monoxide was added using a novel extracorporeal releasing system after resuscitation from cardiac arrest. MEASUREMENTS AND MAIN RESULTS As markers of cerebral function, neuromonitoring modalities (somatosensory-evoked potentials, cerebral oximetry, and transcranial Doppler ultrasound) were used. Histopathologic damage and molecular markers (caspase-3 activity and heme oxygenase-1 expression) were analyzed. Cerebral oximetry showed fast rise in regional oxygen saturation after carbon monoxide treatment at 0.5 hours compared with extracorporeal resuscitation alone (regional cerebral oxygen saturation, 73% ± 3% vs 52% ± 8%; p < 0.05). Median nerve somatosensory-evoked potentials showed improved activity upon carbon monoxide treatment, whereas post-cardiac arrest cerebral perfusion differences were diminished. Histopathologic damage scores were reduced compared with customary resuscitation strategies (hippocampus: sham, 0.4 ± 0.2; cardiopulmonary resuscitation, 1.7 ± 0.4; extracorporeal cardiopulmonary resuscitation, 2.3 ± 0.2; extracorporeal cardiopulmonary resuscitation with carbon monoxide application [CO-E-CPR], 0.9 ± 0.3; p < 0.05). Furthermore, ionized calcium-binding adaptor molecule 1 staining revealed reduced damage patterns upon carbon monoxide treatment. Caspase-3 activity (cardiopulmonary resuscitation, 426 ± 169 pg/mL; extracorporeal cardiopulmonary resuscitation, 240 ± 61 pg/mL; CO-E-CPR, 89 ± 26 pg/mL; p < 0.05) and heme oxygenase-1 (sham, 1 ± 0.1; cardiopulmonary resuscitation, 2.5 ± 0.4; extracorporeal cardiopulmonary resuscitation, 2.4 ± 0.2; CO-E-CPR, 1.4 ± 0.2; p < 0.05) expression were reduced after carbon monoxide exposure. CONCLUSIONS Carbon monoxide application during extracorporeal resuscitation reduces injury patterns in neuromonitoring and decreases histopathologic cerebral damage by reducing apoptosis. This may lay the basis for further clinical translation of this highly salutary substance.
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Affiliation(s)
- Jakob Wollborn
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Steiger
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA
- Institute for Pharmacy and Food Chemistry, University of Wuerzburg, Wuerzburg, Germany
| | - Soroush Doostkam
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Neuropathology, Medical Center - University of Freiburg, Freiburg, Germany
| | - Nils Schallner
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Nils Schroeter
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Neurology, Medical Center - University of Freiburg, Freiburg, Germany
| | - Fabian A Kari
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Freiburg, Germany
| | - Lorenz Meinel
- Institute for Pharmacy and Food Chemistry, University of Wuerzburg, Wuerzburg, Germany
| | - Hartmut Buerkle
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin A Schick
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrich Goebel
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
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A Protocol that Mandates Postoxygenator and Arterial Blood Gases to Confirm Brain Death on Venoarterial Extracorporeal Membrane Oxygenation. ASAIO J 2020; 66:e23-e28. [DOI: 10.1097/mat.0000000000001086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Burrell AJC, Bennett V, Serra AL, Pellegrino VA, Romero L, Fan E, Brodie D, Cooper DJ, Kaye DM, Fraser JF, Hodgson CL. Venoarterial extracorporeal membrane oxygenation: A systematic review of selection criteria, outcome measures and definitions of complications. J Crit Care 2019; 53:32-37. [PMID: 31181462 DOI: 10.1016/j.jcrc.2019.05.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 04/28/2019] [Accepted: 05/22/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to systematically investigate the reporting of selection criteria and outcome measures, and to examine definitions of complications used in venoarterial extracorporeal membrane oxygenation studies (V-A ECMO). MATERIALS AND METHODS Medline, EMBASE and the Cochrane central register were searched for V-A ECMO studies from January 2005 to July 2017. Studies with ≤99 patients or without patient centered outcomes were excluded. Two reviewers independently assessed search results and undertook data extraction. RESULTS Forty-six studies met the inclusion criteria, and all were retrospective, observational studies. Inconsistent reporting of selection criteria, ECMO management and outcome measures was common. In-hospital mortality was the most common primary outcome (41% of studies), followed by 30-day mortality (11%). Bleeding was the most frequent complication reported, most commonly defined as "bleeding requiring transfusion" (median ≥ 2 Units/day). Significant variation in reporting and definitions was also evident for vascular, neurological renal and infectious complications. CONCLUSION This systematic review provides clinicians with the most commonly reported selection criteria, outcome measures and complications used in ECMO practice. However non-standardized definitions and inconsistent reporting limits their ability to inform practice. New consensus driven definitions of complications and patient centred outcomes are urgently needed.
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Affiliation(s)
- Aidan J C Burrell
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care, The Alfred Hospital, Melbourne, Australia.
| | - Victoria Bennett
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Alexis L Serra
- Division of Pulmonary, Allergy, and Critical Care, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, USA.
| | - Vincent A Pellegrino
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care, The Alfred Hospital, Melbourne, Australia.
| | - Lorena Romero
- The Ian Potter Library, The Alfred Hospital, Melbourne, Australia.
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Departments of Medicine and Physiology, Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, USA.
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care, The Alfred Hospital, Melbourne, Australia.
| | - David M Kaye
- Baker IDI Heart and Diabetes Research Institute, Melbourne, Australia.
| | - John F Fraser
- Critical Care Research Group Adult Intensive Care Service, The Prince Charles Hospital and University of Queensland, Brisbane, Australia
| | - Carol L Hodgson
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care, The Alfred Hospital, Melbourne, Australia.
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Confirmation of brain death on VA-ECMO should mandate simultaneous distal arterial and post-oxygenator blood gas sampling. Intensive Care Med 2019; 45:1165-1166. [DOI: 10.1007/s00134-019-05637-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2019] [Indexed: 11/26/2022]
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45
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Alexis-Ruiz A, Ghadimi K, Raiten J, Mackay E, Laudanski K, Cannon J, Ramakrishna H, Evans A, Augoustides JG, Vallabhajosyula P, Milewski R, McDonald M, Patel P, Vernick W, Gutsche J. Hypoxia and Complications of Oxygenation in Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2019; 33:1375-1381. [DOI: 10.1053/j.jvca.2018.05.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Indexed: 11/11/2022]
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Hoeper MM, Benza RL, Corris P, de Perrot M, Fadel E, Keogh AM, Kühn C, Savale L, Klepetko W. Intensive care, right ventricular support and lung transplantation in patients with pulmonary hypertension. Eur Respir J 2019; 53:13993003.01906-2018. [PMID: 30545979 PMCID: PMC6351385 DOI: 10.1183/13993003.01906-2018] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 10/09/2018] [Indexed: 12/30/2022]
Abstract
Intensive care of patients with pulmonary hypertension (PH) and right-sided heart failure includes treatment of factors causing or contributing to heart failure, careful fluid management, and strategies to reduce ventricular afterload and improve cardiac function. Extracorporeal membrane oxygenation (ECMO) should be considered in distinct situations, especially in candidates for lung transplantation (bridge to transplant) or, occasionally, in patients with a reversible cause of right-sided heart failure (bridge to recovery). ECMO should not be used in patients with end-stage disease without a realistic chance for recovery or for transplantation. For patients with refractory disease, lung transplantation remains an important treatment option. Patients should be referred to a transplant centre when they remain in an intermediate- or high-risk category despite receiving optimised pulmonary arterial hypertension therapy. Meticulous peri-operative management including the intra-operative and post-operative use of ECMO effectively prevents graft failure. In experienced centres, the 1-year survival rates after lung transplantation for PH now exceed 90%.
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Affiliation(s)
- Marius M Hoeper
- Dept of Respiratory Medicine, Hannover Medical School and Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Raymond L Benza
- The Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Paul Corris
- Institute of Cellular Medicine, Newcastle University and Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Elie Fadel
- Dept of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie Lannelongue and Université Paris-Sud, Paris, France
| | - Anne M Keogh
- Heart Transplant Unit, St Vincent's Public Hospital, Darlinghurst, Australia.,University of New South Wales, Sydney, Australia
| | - Christian Kühn
- Dept of Cardiothoracic, Vascular and Transplantation Surgery, Hannover Medical School and Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Laurent Savale
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de Pneumologie, Département Hospitalo-Universitaire (DHU) Thorax Innovation (TORINO), Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Walter Klepetko
- Dept of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
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Camboni D, Philip A, Schmid C, Loforte A. Double, triple and quadruple cannulation for veno-arterial extracorporeal membrane oxygenation support: is there a limit? Ann Cardiothorac Surg 2019; 8:151-159. [PMID: 30854325 DOI: 10.21037/acs.2019.01.03] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Each cannulation strategy for venoarterial extracorporeal membrane oxygenation (VA ECMO) has distinct benefits and drawbacks. In this article, various cannulation strategies including their indications are discussed. The gold standard for cannulation involves peripheral, percutaneous double cannulation utilizing the patient's femoral vein and artery. In emergency situations under mechanical resuscitation, a simple and fast cannulation technique is crucial to reestablish circulation. This is usually performed percutaneously utilizing the femoral approach. However, in cases of anticipated long-term support, such as while awaiting cardiac transplantation, more sophisticated cannulation techniques (e.g., internal jugular vein to left axillary artery, left axillary artery for neuroprotection) are necessary to facilitate mobilization and physical conditioning on VA ECMO. More complicated are cases involving combined respiratory and cardiac failure requiring dual organ support or triple cannulation with an additional venous return cannula resulting in a veno-arterio-venous (VAV) configuration. Cases with left ventricular stasis with need for unloading are also highly demanding. Unloading the left ventricle (LV) can be performed in numerous ways, described elsewhere in this issue. However, one particular mode of unloading the LV is described as a stepwise and cost saving bridge to a durable paracorporeal left ventricular assist device in patients with an uncertain prognosis, which involves implantation of Berlin Heart® EXCOR cannulas with temporary right heart support as an example of quadruple cannulation.
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Affiliation(s)
- Daniele Camboni
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Alois Philip
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Antonio Loforte
- Department of Cardiovascular Surgery and Transplantation, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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Rao P, Khalpey Z, Smith R, Burkhoff D, Kociol RD. Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock and Cardiac Arrest. Circ Heart Fail 2018; 11:e004905. [DOI: 10.1161/circheartfailure.118.004905] [Citation(s) in RCA: 184] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Prashant Rao
- Sarver Heart Center, University of Arizona, Tucson (P.R.)
| | - Zain Khalpey
- Division of Cardiothoracic Surgery, Department of Surgery, University of Arizona, Tucson (Z.K.)
| | - Richard Smith
- Artificial Heart and Perfusion Programs, Banner University Medical Center, Tucson, AZ (R.S.)
| | - Daniel Burkhoff
- Cardiovascular Research Foundation, Columbia University Medical Center, New York, NY (D.B.)
| | - Robb D. Kociol
- Advanced Heart Failure and Mechanical Circulatory Support Program, University of Massachusetts Memorial Medical Center, Worcester (R.D.K.)
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Pillai AK, Bhatti Z, Bosserman AJ, Mathew MC, Vaidehi K, Kalva SP. Management of vascular complications of extra-corporeal membrane oxygenation. Cardiovasc Diagn Ther 2018; 8:372-377. [PMID: 30057883 DOI: 10.21037/cdt.2018.01.11] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Extra-corporeal membrane oxygenation (ECMO) is a well-established treatment for cardiopulmonary failure. Based on the requirement for cardiac and or respiratory support different configurations of ECMO circuits are utilized. Vascular complication of ECMO constitutes the most important determinant of treatment outcomes. The complications are primarily related to limb ischemia, vascular injury, hemorrhage, and infection. Endovascular and surgical treatment options are the cornerstone for managing vascular complications of ECMO.
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Affiliation(s)
- Anil K Pillai
- Health Science Center, University of Texas, Houston, USA
| | - Zagum Bhatti
- Health Science Center, University of Texas, Houston, USA
| | | | - Manoj C Mathew
- Health Science Center, University of Texas, Houston, USA
| | - Kaza Vaidehi
- Southwestern Medical Center, University of Texas, Houston, USA
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Abstract
Differential hypoxia and the arterial mixing zone are two important factors in managing peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO). With the aim of improving perfusion to the aortic arch branches and coronaries, we describe our approach for VA-ECMO cannulation: bicaval drainage through the femoral vein and proximal retrograde ECMO flow using a multi-stage venous cannula inserted in the femoral artery and the tip placed at the proximal descending thoracic aorta. We report the use of this VA-ECMO approach on a 15-year-old female with combined cardiorespiratory failure and on a 12-year-old male with acute cardiac failure.
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