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Karahalios DS, Kadiu G, Farooqi A, Singh G, Aggarwal S. Effect of Atrial Septostomy on Left Ventricular Function in Pediatric Dilated Cardiomyopathy Requiring ECMO. Pediatr Cardiol 2024:10.1007/s00246-024-03615-5. [PMID: 39123074 DOI: 10.1007/s00246-024-03615-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 08/02/2024] [Indexed: 08/12/2024]
Abstract
Balloon atrial septostomy (BAS) reduces left ventricular (LV) hypertension during extracorporeal membrane oxygenation (ECMO). However, the acute effect of BAS on LV function as measured by echocardiography is unknown. This was a Retrospective analysis of clinical outcome, LV dimensions, and LV function in dilated cardiomyopathy patients 0-18 years old who underwent BAS on ECMO. In 13 patients with median (IQR) age of 2.3 (0.6-10.9) years, there were no differences in clinical markers of cardiac output at intervals between 12 h before and 6 days after BAS. In addition, BAS was associated with a low rate of periprocedural complications (0.0%), acute kidney injury (7.7%), and worsening radiographic pulmonary vascular congestion (30.7%). There was a significant worsening in LV end systolic diameter (LVIDs; 3.6 [2.9-4.8] cm vs 4.2 [3.2-5.6] cm vs 3.3 [2.6-4.6] cm, p = 0.025), LV end systolic posterior wall thickness (LVPWs; 0.7 [0.5-0.9] cm vs 0.6 [0.5-0.9] cm vs 0.8 [0.6-1.2] cm, p = 0.038), fractional shortening (FS; 17.6% [8.4-20.4%] vs 6.3% [2.0-9.9%] vs 13.2% [3.6-23.4%], p = 0.013), and ejection fraction (EF; 13.1% [8.7-18.9%] vs 5.3% [2.5-11.1%] vs 9.2% [6.0-16.3%], p = 0.039) following BAS that improved in approximately 1 week. There were no differences in LV global longitudinal strain following BAS. We conclude that BAS was associated with low procedural and clinical adverse event rates in our cohort. The worsening LVIDs, LVPWs, FS, and EF seen immediately after the procedure suggests that BAS causes altered loading conditions affecting LV function in pediatric patients with dilated cardiomyopathy requiring ECMO.
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Affiliation(s)
- Dean S Karahalios
- Department of Pediatrics, Division of Pediatric Cardiology, Northwestern University Ann and Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Chicago, IL, 60611, USA.
| | - Gilda Kadiu
- Department of Pediatrics, Division of Pediatric Cardiology, Central Michigan University Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI, 48201, USA
| | - Ahmad Farooqi
- Children's Research Institute, Central Michigan University Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI, 48201, USA
| | - Gautam Singh
- Department of Pediatrics, Division of Pediatric Cardiology, Central Michigan University Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI, 48201, USA
| | - Sanjeev Aggarwal
- Department of Pediatrics, Division of Pediatric Cardiology, Central Michigan University Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI, 48201, USA
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Zhang ZP, Guo PY, Ye QS, Zhang Y. Temporary mechanical circulatory support as a bridge to durable left ventricular assist device as destination therapy in fulminant giant cell myocarditis:A case report. Heliyon 2024; 10:e32324. [PMID: 38975127 PMCID: PMC11226815 DOI: 10.1016/j.heliyon.2024.e32324] [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: 11/04/2023] [Revised: 05/30/2024] [Accepted: 05/31/2024] [Indexed: 07/09/2024] Open
Abstract
Fulminant giant cell myocarditis is a fatal form of acute myocarditis leading to a rapid-onset clinical presentation with lethal arrhythmias, acute heart failure, or cardiogenic shock requiring mechanical circulatory support. We report the case of a 52-year-old female diagnosed with fulminant myocarditis requiring veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and intra-aortic balloon pump(IABP) support. Due to hemodynamic instability, she was transferred to our hospital by helicopter on day 4. On arrival at our hospital, she underwent percutaneous balloon atrial septostomy to decompress the left ventricle. Although the left ventricular distension and pulmonary edema improved after atrial septostomy, no signs of biventricular function recovery were identified on day 14. On day 23, V-A ECMO and IABP were switched to a durable left ventricular assist device(LVAD) system and a right ventricular assist device(RVAD) with ECMO (RVAD-ECMO) under median sternotomy. On day 37, RVAD-ECMO was eventually removed and rehabilitation was started with the remaining LVAD support as destination therapy. On day 78, the patient was finally discharged with LVAD support to follow-up as an outpatient. This case underscores the importance of a multidisciplinary approach and rigorous monitoring to optimize outcomes in the treatment of fulminant giant cell myocarditis.
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Affiliation(s)
- Zhi-Ping Zhang
- Wuhan Asia General Hospital, Affiliated to Wuhan University of Science and Technology, Wuhan, 430037, China
| | - Pen-Yu Guo
- Wuhan University of Science and Technology, Wuhan, 430065, China
| | - Qi-Shen Ye
- Wuhan University of Science and Technology, Wuhan, 430065, China
| | - Yong Zhang
- Wuhan Asia General Hospital, Affiliated to Wuhan University of Science and Technology, Wuhan, 430037, China
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3
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Delmas C, Ughetto A, Lebreton G, Roubille F. Venting strategies for extracorporeal membrane oxygenation patients: More questions than answers but a plea for more clinical trials on the topic! Eur J Heart Fail 2024; 26:1261-1264. [PMID: 37728031 DOI: 10.1002/ejhf.3038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 09/13/2023] [Indexed: 09/21/2023] Open
Affiliation(s)
- Clément Delmas
- Intensive Cardiac Care Unit, Cardiology Department, Toulouse University Hospital, Toulouse, France
- Recherche et Enseignement en Insuffisance Cardiaque Avancée, Assistance et Transplantation (REICATRA), Institut Saint Jacques, CHU de Toulouse, Toulouse, France
| | - Aurore Ughetto
- Anesthesia and Intensive Cardiac Care Unit, Montpellier University Hospital, Montpellier, France
| | - Guillaume Lebreton
- Cardiovascular Surgery Department, La Pitié University Hospital, Paris, France
| | - François Roubille
- Intensive Cardiac Care Unit, Cardiology Department, Montpellier University Hospital, Montpellier, France
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Lüsebrink E, Binzenhöfer L, Hering D, Villegas Sierra L, Schrage B, Scherer C, Speidl WS, Uribarri A, Sabate M, Noc M, Sandoval E, Erglis A, Pappalardo F, De Roeck F, Tavazzi G, Riera J, Roncon-Albuquerque R, Meder B, Luedike P, Rassaf T, Hausleiter J, Hagl C, Zimmer S, Westermann D, Combes A, Zeymer U, Massberg S, Schäfer A, Orban M, Thiele H. Scrutinizing the Role of Venoarterial Extracorporeal Membrane Oxygenation: Has Clinical Practice Outpaced the Evidence? Circulation 2024; 149:1033-1052. [PMID: 38527130 DOI: 10.1161/circulationaha.123.067087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for temporary mechanical circulatory support in various clinical scenarios has been increasing consistently, despite the lack of sufficient evidence regarding its benefit and safety from adequately powered randomized controlled trials. Although the ARREST trial (Advanced Reperfusion Strategies for Patients with Out-of-Hospital Cardiac Arrest and Refractory Ventricular Fibrillation) and a secondary analysis of the PRAGUE OHCA trial (Prague Out-of-Hospital Cardiac Arrest) provided some evidence in favor of VA-ECMO in the setting of out-of-hospital cardiac arrest, the INCEPTION trial (Early Initiation of Extracorporeal Life Support in Refractory Out-of-Hospital Cardiac Arrest) has not found a relevant improvement of short-term mortality with extracorporeal cardiopulmonary resuscitation. In addition, the results of the recently published ECLS-SHOCK trial (Extracorporeal Life Support in Cardiogenic Shock) and ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock) discourage the routine use of VA-ECMO in patients with infarct-related cardiogenic shock. Ongoing clinical trials (ANCHOR [Assessment of ECMO in Acute Myocardial Infarction Cardiogenic Shock, NCT04184635], REVERSE [Impella CP With VA ECMO for Cardiogenic Shock, NCT03431467], UNLOAD ECMO [Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO, NCT05577195], PIONEER [Hemodynamic Support With ECMO and IABP in Elective Complex High-risk PCI, NCT04045873]) may clarify the usefulness of VA-ECMO in specific patient subpopulations and the efficacy of combined mechanical circulatory support strategies. Pending further data to refine patient selection and management recommendations for VA-ECMO, it remains uncertain whether the present usage of this device improves outcomes.
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Affiliation(s)
- Enzo Lüsebrink
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Leonhard Binzenhöfer
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Daniel Hering
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Laura Villegas Sierra
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany and DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Germany (B.S.)
| | - Clemens Scherer
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Walter S Speidl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria (W.S.S.)
| | - Aitor Uribarri
- Cardiology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain. CIBER-CV (A.U.)
| | - Manel Sabate
- Interventional Cardiology Department, Hospital Clinic, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain (M.S.)
| | - Marko Noc
- Center for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia (M.N.)
| | - Elena Sandoval
- Department of Cardiovascular Surgery, Hospital Clínic, Barcelona, Spain (E.S.)
| | - Andrejs Erglis
- Latvian Centre of Cardiology, Paul Stradins Clinical University Hospital, Riga, Latvia (A.E.)
| | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy (F.P.)
| | - Frederic De Roeck
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium (F.D.R.)
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia Intensive Care, Fondazione IRCCS Policlinico San Matteo, Italy (G.T.)
| | - Jordi Riera
- Intensive Care Department, Vall d'Hebron University Hospital, and SODIR, Vall d'Hebron Research Institute, Barcelona, Spain (J.R.)
| | - Roberto Roncon-Albuquerque
- Department of Intensive Care Medicine, São João University Hospital Center, UnIC@RISE and Department of Surgery and Physiology, Faculty of Medicine of Porto, Portugal (R.R.-A.)
| | - Benjamin Meder
- Department of Cardiology, Angiology, and Pneumology, University Hospital Heidelberg, Germany (B.M.)
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen (P.L., T.R.)
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen (P.L., T.R.)
| | - Jörg Hausleiter
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Christian Hagl
- Department of Cardiac Surgery, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Germany (C.H.)
| | - Sebastian Zimmer
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, Germany (S.Z.)
| | - Dirk Westermann
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Germany (D.W.)
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France, and Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France (A.C.)
| | - Uwe Zeymer
- Klinikum der Stadt Ludwigshafen and Institut für Herzinfarktforschung, Ludwigshafen am Rhein, Germany (U.Z.)
| | - Steffen Massberg
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Andreas Schäfer
- Department of Cardiology and Angiology, Hannover Medical School, Germany (A.S.)
| | - Martin Orban
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Department of Internal Medicine/Cardiology and Leipzig Heart Science, Germany (H.T.)
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5
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Salah HM, Baratto C, Yaranov DM, Rommel KP, Achanta S, Caravita S, Reddy Vasanthu VK, Fudim M. Interatrial Shunt Devices. Heart Fail Clin 2024; 20:61-69. [PMID: 37953022 PMCID: PMC11232059 DOI: 10.1016/j.hfc.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Elevated left atrial pressure during exercise is a hallmark of heart failure (HF) and is associated with adverse left atrial remodeling and poor outcomes. To decompress the pressure-overloaded left atrium in patients with HF, several device-based approaches have been developed to create a permanent, pressure-dependent, left-to-right interatrial shunt. Such approaches are currently in various stages of investigations in both HF with reduced ejection fraction (EF) and HF with preserved EF. This review discusses the evolution of the concept of left atrial decompression and summarizes the current landscape of device-based approaches used for left atrial decompression.
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Affiliation(s)
- Husam M Salah
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Claudia Baratto
- Division of Cardiology, Dyspnea and Pulmonary Hypertension Clinic, Ospedale San Luca IRCCS Istituto Auxologico Italiano, Milano, Italy
| | - Dmitry M Yaranov
- Baptist Heart Institute, Baptist Memorial Hospital, Memphis, TN, USA
| | - Karl-Philipp Rommel
- Deptartment of Cardiology, Heart Center at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany; Cardiovacular Research Foundation, New York, NY, USA
| | | | - Sergio Caravita
- Division of Cardiology, Dyspnea and Pulmonary Hypertension Clinic, Ospedale San Luca IRCCS Istituto Auxologico Italiano, Milano, Italy; Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Province of Bergamo, Italy
| | | | - Marat Fudim
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
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Corujo Rodriguez A, Richter E, Ibekwe SO, Shah T, Faloye AO. Postcardiotomy Shock Syndrome: A Narrative Review of Perioperative Diagnosis and Management. J Cardiothorac Vasc Anesth 2023; 37:2621-2633. [PMID: 37806929 DOI: 10.1053/j.jvca.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/29/2023] [Accepted: 09/09/2023] [Indexed: 10/10/2023]
Abstract
Postcardiotomy shock (PCS) is generally described as the inability to separate from cardiopulmonary bypass due to ineffective cardiac output after cardiotomy, which is caused by a primary cardiac disorder, resulting in inadequate tissue perfusion. Postcardiotomy shock occurs in 0.5% to 1.5% of contemporary cardiac surgery cases, and is accompanied by an in-hospital mortality of approximately 67%. In the last 2 decades, the incidence of PCS has increased, likely due to the increased age and baseline morbidity of patients requiring cardiac surgery. In this narrative review, the authors discuss the epidemiology and pathophysiology of PCS, the rationale and evidence behind the initiation, continuation, escalation, and discontinuation of mechanical support devices in PCS, and the anesthetic implications.
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Affiliation(s)
| | - Ellen Richter
- Department of Anesthesiology, Emory University, Atlanta, GA
| | | | - Tina Shah
- Department of Anesthesiology, Emory University, Atlanta, GA
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Sperotto F, Polito A, Amigoni A, Maschietto N, Thiagarajan RR. Left Atrial Decompression in Pediatric Patients Supported With Extracorporeal Membrane Oxygenation for Failure to Wean From Cardiopulmonary Bypass: A Propensity-Weighted Analysis. J Am Heart Assoc 2022; 11:e023963. [PMID: 35535596 PMCID: PMC9851456 DOI: 10.1161/jaha.121.023963] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background Left atrial (LA) decompression on extracorporeal membrane oxygenation (ECMO) can reduce left ventricular distension, allowing myocardial rest and recovery, and protect from lung injury secondary to cardiogenic pulmonary edema. However, clinical benefits remain unknown. We sought to evaluate the association between LA decompression and in-hospital adverse outcome (mortality, transplant on ECMO, or conversion to ventricular assist device) in patients who failed to wean from cardiopulmonary bypass using a propensity score to adjust for baseline differences. Methods and Results Children (aged <18 years) with biventricular physiology supported with ECMO for failure to wean from cardiopulmonary bypass after cardiac surgery from 2000 through 2016, reported to the ELSO (Extracorporeal Life Support Organization) Registry, were included. Inverse probability of treatment weighted logistic regression was used to test the association between LA decompression and in-hospital adverse outcomes. Of the 2915 patients supported with venoarterial ECMO for failure to wean from cardiopulmonary bypass, 1508 had biventricular physiology and 279 (18%) underwent LA decompression (LA+). Genetic and congenital abnormalities (P=0.001) and pulmonary hypertension (P=0.010) were less frequent and baseline arrhythmias (P=0.022) were more frequent in LA+ patients. LA+ patients had longer pre-ECMO mechanical ventilation and CBP time (P<0.001), and used aortic cross-clamp (P=0.001) more frequently. Covariates were well balanced between the propensity-weighted cohorts. In-hospital adverse outcomes occurred in 47% of LA+ patients and 51% of the others. Weighted multivariate logistic regression showed LA decompression to be protective for in-hospital adverse outcomes (adjusted odds ratio, 0.775 [95% CI, 0.644-0.932]). Conclusions LA decompression independently decreased the risk of in-hospital adverse outcome in pediatric venoarterial ECMO patients who failed to wean from cardiopulmonary bypass, suggesting that these patients may benefit from LA decompression.
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Affiliation(s)
- Francesca Sperotto
- Department of Cardiology Boston Children's HospitalHarvard Medical School Boston MA.,Pediatric Intensive Care Unit Department of Women's and Children's Health University of Padova Italy
| | - Angelo Polito
- Pediatric Intensive Care Unit University Hospital of GenevaUniversity of Geneva Switzerland
| | - Angela Amigoni
- Pediatric Intensive Care Unit Department of Women's and Children's Health University of Padova Italy
| | - Nicola Maschietto
- Department of Cardiology Boston Children's HospitalHarvard Medical School Boston MA
| | - Ravi R Thiagarajan
- Department of Cardiology Boston Children's HospitalHarvard Medical School Boston MA
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Yan C. Is combined use of radiofrequency ablation and balloon dilation the future of interatrial communications? Expert Rev Cardiovasc Ther 2022; 20:895-903. [PMID: 36329641 DOI: 10.1080/14779072.2022.2144233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Personalized and stable interatrial communication is an important palliative therapy for patients with heart failure. However, this remains a technically challenging task. AREAS COVERED In the past decades, substantial advancements in atrial septostomy for the creation of controllable and durable interatrial communication have been made, and numerous novel devices and techniques are in various stages of development. In this review, we discuss the evolving indications for atrial septostomy, current approaches with or without device implantation, and indicators for optimal interatrial communication. The combined use of radiofrequency ablation and balloon dilation (CURB) is an individualized management approach based on underlying hemodynamics, which demonstrates unique advantages in creating a sufficient interatrial communication with satisfactory stability. The advantages and disadvantages of this implant-free procedure are analyzed and its clinical prospects are assessed. EXPERT OPINION With ready availability, high safety, and efficacy, CURB is a promising procedure for creating personalized and stable interatrial communication without device implantation. Further research is required to simplify the procedure, screen optimal reference parameters for personalized therapy, and evaluate the long-term outcome in a large population of patients.
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Affiliation(s)
- Chaowu Yan
- Department of Structural Heart Disease, Fuwai Hospital, 100037, Beijing, China
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Welker CC, Huang J, Boswell MR, Spencer PJ, Theoduloz MAV, Ramakrishna H. Left Ventricular Decompression in VA-ECMO: Analysis of Techniques and Outcomes. J Cardiothorac Vasc Anesth 2022; 36:4192-4197. [PMID: 35965232 DOI: 10.1053/j.jvca.2022.07.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 07/18/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Carson C Welker
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Jeffrey Huang
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Michael R Boswell
- Division of Cardiovascular Anesthesi, Mayo Clinic, Rochester, MN, United States
| | - Philip J Spencer
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States
| | | | - Harish Ramakrishna
- Division of Cardiovascular Anesthesia, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55901, United States.
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Delmas C, Vallee L, Bouisset F, Porterie J, Biendel C, Lairez O, Crognier L, Marcheix B, Conil JM, Maury P, Minville V. Use of Percutaneous Atrioseptotosmy for Left Heart Decompression During Veno-Arterial Extracorporeal Membrane Oxygenation Support: An Observational Study. J Am Heart Assoc 2022; 11:e024642. [PMID: 36000436 PMCID: PMC9496417 DOI: 10.1161/jaha.121.024642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Left ventricular overload is frequent under veno‐arterial extracorporeal membrane oxygenation, which is associated with a worsening of the prognosis of these patients. Several left heart decompression (LHD) techniques exist. However, there is no consensus on their timing and type. We aimed to describe characteristics and outcomes of patients undergoing LHD and to compare percutaneous atrioseptostomy (PA) to other LHD techniques. Methods and Results Retrospective analysis was conducted of consecutive and prospectively collected patients supported by veno‐arterial extracorporeal membrane oxygenation for refractory cardiac arrest or cardiogenic shock between January 2015 and April 2018, with a 90‐day follow‐up in our tertiary center. Patients were divided according to the presence of LHD, and then according to its type (PA versus others). Thirty‐nine percent (n=63) of our patients (n=163) required an LHD. Patients with LHD had lower left ventricular ejection fraction, more ischemic cardiomyopathy, and no drug intoxication‐associated cardiogenic shock. PA was frequently used for LHD (41% of first‐line and 57% of second‐line LHD). PA appears safe and fast to realize (6.3 [interquartile range, 5.8–10] minutes) under fluoroscopic and echocardiographic guidance, with no acute complications. PA was associated with fewer neurological complications (12% versus 38%, P=0.02), no need to insert a second LHD (0% versus 19%, P=0.04), and higher 90‐day survival compared with other techniques (42% versus 19%, log‐rank test P=0.02), despite more sepsis (96% versus 73%, P=0.02) and blood transfusions (13.5% versus 7%, P=0.01). Multivariate analysis confirms the association between PA and 90‐day survival (hazard ratio, 2.53 [1.18–5.45], P=0.019). Conclusions LHD was frequently used for patients supported with veno‐arterial extracorporeal membrane oxygenation, especially in cases of ischemic cardiomyopathy and low left ventricular ejection fraction. PA seems to be a safe and efficient LHD technique associated with greater mid‐term survival justifying the pursuit of research on this topic.
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Affiliation(s)
- Clément Delmas
- Intensive Cardiac Care Unit Cardiology Department Rangueil University Toulouse France.,Cardiology Department Rangueil University Hospital Toulouse France
| | - Luigi Vallee
- Department of Anesthesiology, Intensive Care Medicine, and Perioperative Medicine Rangueil University Hospital Toulouse France
| | | | - Jean Porterie
- Cardiovascular Surgery Department Rangueil University Hospital Toulouse France
| | - Caroline Biendel
- Intensive Cardiac Care Unit Cardiology Department Rangueil University Toulouse France.,Cardiology Department Rangueil University Hospital Toulouse France
| | - Olivier Lairez
- Cardiology Department Rangueil University Hospital Toulouse France
| | - Laure Crognier
- Department of Anesthesiology, Intensive Care Medicine, and Perioperative Medicine Rangueil University Hospital Toulouse France
| | - Bertrand Marcheix
- Cardiovascular Surgery Department Rangueil University Hospital Toulouse France
| | - Jean-Marie Conil
- Department of Anesthesiology, Intensive Care Medicine, and Perioperative Medicine Rangueil University Hospital Toulouse France
| | - Philippe Maury
- Cardiology Department Rangueil University Hospital Toulouse France
| | - Vincent Minville
- Department of Anesthesiology, Intensive Care Medicine, and Perioperative Medicine Rangueil University Hospital Toulouse France
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Lüsebrink E, Binzenhöfer L, Kellnar A, Müller C, Scherer C, Schrage B, Joskowiak D, Petzold T, Braun D, Brunner S, Peterss S, Hausleiter J, Zimmer S, Born F, Westermann D, Thiele H, Schäfer A, Hagl C, Massberg S, Orban M. Venting during venoarterial extracorporeal membrane oxygenation. Clin Res Cardiol 2022; 112:464-505. [PMID: 35986750 PMCID: PMC10050067 DOI: 10.1007/s00392-022-02069-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 07/12/2022] [Indexed: 11/03/2022]
Abstract
AbstractCardiogenic shock and cardiac arrest contribute pre-dominantly to mortality in acute cardiovascular care. Here, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has emerged as an established therapeutic option for patients suffering from these life-threatening entities. VA-ECMO provides temporary circulatory support until causative treatments are effective and enables recovery or serves as a bridging strategy to surgical ventricular assist devices, heart transplantation or decision-making. However, in-hospital mortality rate in this treatment population is still around 60%. In the recently published ARREST trial, VA-ECMO treatment lowered mortality rate in patients with ongoing cardiac arrest due to therapy refractory ventricular fibrillation compared to standard advanced cardiac life support in selected patients. Whether VA-ECMO can reduce mortality compared to standard of care in cardiogenic shock has to be evaluated in the ongoing prospective randomized studies EURO-SHOCK (NCT03813134) and ECLS-SHOCK (NCT03637205). As an innate drawback of VA-ECMO treatment, the retrograde aortic flow could lead to an elevation of left ventricular (LV) afterload, increase in LV filling pressure, mitral regurgitation, and elevated left atrial pressure. This may compromise myocardial function and recovery, pulmonary hemodynamics—possibly with concomitant pulmonary congestion and even lung failure—and contribute to poor outcomes in a relevant proportion of treated patients. To overcome these detrimental effects, a multitude of venting strategies are currently engaged for both preventive and emergent unloading. This review aims to provide a comprehensive and structured synopsis of existing venting modalities and their specific hemodynamic characteristics. We discuss in detail the available data on outcome categories and complication rates related to the respective venting option.
Graphical abstract
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Meani P, Lorusso R, Kowalewski M, Isgrò G, Cazzaniga A, Satriano A, Ascari A, Bernardinetti M, Cotza M, Marchese G, Ciotti E, Kandil H, Di Dedda U, Aloisio T, Varrica A, Giamberti A, Ranucci M. Influence of left ventricular unloading on pediatric post-cardiotomy veno-arterial extracorporeal life support outcomes. Front Cardiovasc Med 2022; 9:970334. [PMID: 36035925 PMCID: PMC9399613 DOI: 10.3389/fcvm.2022.970334] [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: 06/15/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe effectiveness of veno-arterial extracorporeal life support (V-A ECLS) in treating neonatal and pediatric patients with complex congenital heart disease (CHD) and requiring cardio-circulatory assistance is well-known. Nevertheless, the influence of left ventricle (LV) distension and its countermeasure, namely LV unloading, on survival and clinical outcomes in neonates and children treated with V-A ECLS needs still to be addressed. Therefore, the aim of this study was to determine the effects of LV unloading on in-hospital survival and complications in neonates and children treated with V-A ECLS.MethodsThe clinical outcomes of 90 pediatric patients with CHD under 16 years of age supported with V-A ECLS for post-cardiotomy cardiogenic shock (CS) were retrospectively reviewed in relationship with the presence or absence of an active LV unloading strategy.ResultsThe patient cohort included 90 patients (age 19.6 ± 31.54 months, 64.4% males), 42 of whom were vented with different techniques (38 with atrial septostomy (AS) or left atria cannula, two with cannula from LV apex, 1 with intra-aortic balloon pump (IABP), and one with pigtail across the aortic valve). The LV unloading strategy significantly increased the in-hospital survival (odds ratio [OR] = 2.74, 95% CI 1.06–7.08; p = 0.037). On the contrary, extracorporeal cardiopulmonary resuscitation decreased the related survival (OR = 0.32, 95% CI 1.09–0.96; p = 0.041). The most common complications were infections (28.8%), neurological injury (26%), and bleeding (25.6%). However, these did not differently occur in venting and no-venting groups.ConclusionIn pediatric patients with CHD supported with V-A ECLS for post-cardiotomy CS, the LV unloading strategy was associated with increased survival.
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Affiliation(s)
- Paolo Meani
- Cardio-Thoracic Surgery Department, ECLS Centrum, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, Netherlands
- *Correspondence: Paolo Meani
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, ECLS Centrum, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Mariusz Kowalewski
- Cardio-Thoracic Surgery Department, ECLS Centrum, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, Netherlands
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Giuseppe Isgrò
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Anna Cazzaniga
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Angela Satriano
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Alice Ascari
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Mattia Bernardinetti
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Mauro Cotza
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Giuseppe Marchese
- Department of Anesthesiology and Intensive Care, Ospedale Civile Legnano, Legnano, Italy
| | - Erika Ciotti
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Hassan Kandil
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Umberto Di Dedda
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Tommaso Aloisio
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Alessandro Varrica
- Department of Congenital Cardiac Surgery, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Alessandro Giamberti
- Department of Congenital Cardiac Surgery, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Marco Ranucci
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
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Jelenc M, Jelenc B, Novak R, Poglajen G. Left ventricular venting in veno-arterial extracorporeal membrane oxygenation: A computer simulation study. Int J Artif Organs 2022; 45:841-848. [PMID: 35903013 DOI: 10.1177/03913988221115444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is the fastest way to restore circulation in refractory cardiogenic shock, however it cannot unload the failing left ventricle. There is a lack of consensus regarding optimal approach to left ventricular venting in V-A ECMO patients with severely depressed or absent left ventricular function. METHODS A computer model was developed in Matlab Simulink R20016b (MathWorks, Inc., Natick, MA, USA) to analyze different venting options as well as atrial septostomy in the setting of cardiogenic shock and V-A ECMO. RESULTS The model has shown an inverse linear relationship between left atrial pressure and either vent, Impella or atrial septum defect flow rate. The minimum vent flow required to prevent pulmonary edema in complete loss of left ventricular function needed to be higher than the bronchial blood flow. Atrial septostomy restored normal pulmonary blood flow with low left atrial pressure but induced stasis in the left ventricle. Venting the pulmonary artery induced stasis in the entire pulmonary circulation as well as left atrium and left ventricle. Venting the left ventricle directly with a cannula or Impella device avoided blood stasis. CONCLUSION Our data suggest that reduction of left atrial pressure is linearly related to the vent, Impella or atrial septal defect flow rate. The preferred vent location is the left ventricle as it avoids stasis in the pulmonary circulation and cardiac chambers.
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Affiliation(s)
- Matija Jelenc
- Department of Cardiovascular Surgery, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Blaž Jelenc
- Faculty of Mathematics and Physics, University of Ljubljana, Ljubljana, Slovenia
| | - Robert Novak
- Department of Cardiovascular Surgery, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Gregor Poglajen
- Advanced Heart Failure and Transplantation Programme, Department of Cardiology, University Medical Center Ljubljana, Ljubljana, Slovenia
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Ak K, Arslanhan G, Tire Y, Tosun S, Kararmaz A, Hanta İ, Yıldızeli B. Transatrial balloon atrial septostomy to facilitate weaning off venoarterial ECMO after pulmonary endarterectomy. Int J Artif Organs 2022; 45:883-885. [PMID: 35815509 DOI: 10.1177/03913988221106216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Atrial septostomy has been the last resort in the management of patients with the right ventricular failure related to pulmonary hypertension before lung transplantation. In this paper, we present a simple and safe technique (transatrial approach) for balloon atrial septostomy in a patient who required central venoarterial extracorporeal membrane oxygenation after pulmonary endarterectomy.
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Affiliation(s)
- Koray Ak
- Department of Cardiovascular Surgery, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Gökhan Arslanhan
- Department of Cardiovascular Surgery, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Yakup Tire
- Department of Cardiovascular Surgery, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Sinan Tosun
- Department of Cardiovascular Surgery, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Alper Kararmaz
- Department of Anesthesiology and Reanimation, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - İsmail Hanta
- Department of Chest Diseases, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Bedrettin Yıldızeli
- Department of Thoracic Surgery, Marmara University Faculty of Medicine, Istanbul, Turkey
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Mlcek M, Meani P, Cotza M, Kowalewski M, Raffa GM, Kuriscak E, Popkova M, Pilato M, Arcadipane A, Ranucci M, Lorusso R, Belohlavek J. Atrial Septostomy for Left Ventricular Unloading During Extracorporeal Membrane Oxygenation for Cardiogenic Shock: Animal Model. JACC Cardiovasc Interv 2021; 14:2698-2707. [PMID: 34949394 DOI: 10.1016/j.jcin.2021.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/11/2021] [Accepted: 09/14/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The aim of this study was to quantify and understand the unloading effect of percutaneous balloon atrial septostomy (BAS) in acute cardiogenic shock (CS) treated with venoarterial (VA) extracorporeal membranous oxygenation (ECMO). BACKGROUND In CS treated with VA ECMO, increased left ventricular (LV) afterload is observed that commonly interferes with myocardial recovery or even promotes further LV deterioration. Several techniques for LV unloading exist, but the optimal strategy and the actual extent of such procedures have not been fully disclosed. METHODS In a porcine model (n = 11; weight 56 kg [53-58 kg]), CS was induced by coronary artery balloon occlusion (57 minutes [53-64 minutes]). Then, a step-up VA ECMO protocol (40-80 mL/kg/min) was run before and after percutaneous BAS was performed. LV pressure-volume loops and multiple hemoglobin saturation data were evaluated. The Wilcoxon rank sum test was used to assess individual variable differences. RESULTS Immediately after BAS while on VA ECMO support, LV work decreased significantly: pressure-volume area, end-diastolic pressure, and stroke volume to ∼78% and end-systolic pressure to ∼86%, while superior vena cava and tissue oximetry did not change. During elevating VA ECMO support (40-80 mL/kg/min) with BAS vs without BAS, we observed 1) significantly less mechanical work increase (122% vs 172%); 2) no end-diastolic volume increase (100% vs 111%); and 3) a considerable increase in end-systolic pressure (134% vs 144%). CONCLUSIONS In acute CS supported by VA ECMO, atrial septostomy is an effective LV unloading tool. LV pressure is a key component of LV work load, so whenever LV work reduction is a priority, arterial pressure should carefully be titrated low while maintaining organ perfusion.
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Affiliation(s)
- Mikulas Mlcek
- Department of Physiology, First Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Paolo Meani
- Department of Cardiovascular Anesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, Milan, Italy; Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Mauro Cotza
- Department of Cardiovascular Anesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Mariusz Kowalewski
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Giuseppe Maria Raffa
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands; Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
| | - Eduard Kuriscak
- Department of Physiology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Michaela Popkova
- Department of Physiology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Michele Pilato
- Intensive Care Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Mediterranean Institute for Transplantation and Advanced Specialized Therapies, Palermo, Italy
| | - Antonio Arcadipane
- Intensive Care Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Mediterranean Institute for Transplantation and Advanced Specialized Therapies, Palermo, Italy
| | - Marco Ranucci
- Department of Cardiovascular Anesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Roberto Lorusso
- Department of Cardiovascular Anesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, Milan, Italy; Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Jan Belohlavek
- Department of Physiology, First Faculty of Medicine, Charles University, Prague, Czech Republic; 2nd Department of Medicine, Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
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Rali AS, Hall EJ, Dieter R, Ranka S, Civitello A, Bacchetta MD, Shah AS, Schlendorf K, Lindenfeld J, Chatterjee S. Left Ventricular Unloading during Extracorporeal Life Support: Current Practice. J Card Fail 2021; 28:1326-1336. [PMID: 34936896 DOI: 10.1016/j.cardfail.2021.12.002] [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] [Received: 09/15/2021] [Revised: 11/24/2021] [Accepted: 12/06/2021] [Indexed: 11/29/2022]
Abstract
Veno-arterial extracorporeal life support (VA-ECLS) is a powerful tool that can provide complete cardiopulmonary support for patients with refractory cardiogenic shock. However, VA-ECLS increases left ventricular afterload resulting in greater myocardial oxygen demand, which can impair myocardial recovery and worsen pulmonary edema. These complications can be ameliorated by various LV venting strategies to unload the LV. Evidence suggests that LV venting improves outcomes in VA-ECLS, but there is a paucity of randomized trials to help guide optimal strategy and the timing of venting. In this review, we discuss the available evidence regarding LV venting in VA-ECLS, explain important hemodynamic principles involved, and propose a practical approach to LV venting in VA-ECLS.
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Key Words
- Atrial septal defect, BNP
- Brain natriuretic peptide, CS
- Cardiogenic shock, IABP
- Extracorporeal life support, left ventricular unloading, left ventricular venting, cardiogenic shock, Abbreviations, ASD
- Intra-aortic balloon pump, LA
- Left atrium, LV
- Left ventricle, LVAD
- Left ventricular assist device, MCS
- Mechanical circulatory support, PAC
- Percutaneous ventricular assist device, RV
- Pulmonary artery catheter, PCWP
- Pulmonary capillary wedge pressure, P-VAD
- Right ventricle, VA-ECLS
- Veno-arterial extracorporeal life support
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Affiliation(s)
- Aniket S Rali
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Eric J Hall
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Raymond Dieter
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sagar Ranka
- Department of Cardiovascular Diseases, University of Kansas Medical Center, Kansas City, Kansas
| | - Andrew Civitello
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Department of Cardiology, Texas Heart Institute, Houston, Texas
| | - Matthew D Bacchetta
- Division of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashish S Shah
- Division of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kelly Schlendorf
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - JoAnn Lindenfeld
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Subhasis Chatterjee
- Divisions of General and Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College Medicine, Houston, Texas; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
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Choudhury TA, Ofori-Amanfo G, Choi J, Eisenberg RE, Rycus P, Medar SS, Aydin SI. Left Heart Decompression on Veno-Arterial Extracorporeal Membrane Oxygenation in Children With Dilated Cardiomyopathy and Myocarditis: An Extracorporeal Life Support Organization Registry Review. Pediatr Crit Care Med 2021; 22:1026-1032. [PMID: 34054118 DOI: 10.1097/pcc.0000000000002775] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe the association between left heart decompression on veno-arterial extracorporeal membrane oxygenation and survival in patients with myocarditis and dilated cardiomyopathy. The secondary outcome is to study association of left heart decompression with survival in children with myocarditis compared with those with dilated cardiomyopathy. DESIGN Retrospective study of a multicenter registry database. SETTING Data reported to Extracorporeal Life Support Organization from international extracorporeal membrane oxygenation centers. PATIENTS Patients less than or equal to 18 years old with a diagnosis of myocarditis or dilated cardiomyopathy receiving extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 1,438 pediatric extracorporeal membrane oxygenation runs were identified. Thirty-seven percent of the patients had myocarditis (n = 532), whereas the rest had dilated cardiomyopathy. Survival to hospital discharge was 63%. Median extracorporeal membrane oxygenation duration was 148 hours with interquartile range (84-248 hr). Nineteen percent of patients (n = 274) had left heart decompression. Multivariable analysis revealed using left heart decompression (adjusted odds ratio, 1.42; 95% CI, 1.06-1.89; p = 0.02), e-cardiopulmonary resuscitation (adjusted odds ratio, 0.63; 95% CI, 0.51-0.79; p < 0.001), higher pH (adjusted odds ratio, 3.69; 95% CI, 1.80-7.53; p < 0.001), and diagnosis of myocarditis (adjusted odds ratio, 1.69; 95% CI, 1.35-2.08; p < 0.001) were associated with greater odds of survival. In the multivariable analysis for patients with dilated cardiomyopathy, left heart decompression failed to reveal a significant association with survival (20% among survivors vs 17% among nonsurvivors, 95% CI, -2.2% to 8.0%). Meanwhile in patients with myocarditis, the multivariable analysis failed to exclude the possibility that left heart decompression was associated with up to a three-fold greater odds of survival (adjusted odds ratio, 1.77; 95% CI, 0.99-.15). CONCLUSIONS Retrospective review of the Extracorporeal Life Support Organization registry revealed an association between left heart decompression and greater odds of survival in children with myocarditis and dilated cardiomyopathy on extracorporeal membrane oxygenation. When comparing patients with dilated cardiomyopathy against those with myocarditis, we could not exclude a three-fold greater odds of survival associated with the use of left heart decompression. This finding warrants further prospective evaluation.
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Affiliation(s)
- Tarif A Choudhury
- Divisions of Pediatric Critical Care Medicine and Pediatric Cardiology, Morgan Stanley Children's Hospital of New York, Columbia University Medical Center, New York, NY
| | - George Ofori-Amanfo
- Division of Critical Care Medicine, Kravis Children's Hospital, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jaeun Choi
- Division of Critical Care Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY
| | - Ruth E Eisenberg
- Division of Critical Care Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY
| | - Peter Rycus
- Extracorporeal Life Support Organization, Ann Arbor, MI
| | - Shivanand S Medar
- Division of Critical Care Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY
| | - Scott I Aydin
- Division of Critical Care Medicine, Kravis Children's Hospital, Icahn School of Medicine at Mount Sinai, New York, NY
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Cavayas YA, Noly PE, Singh G, Lamarche Y. Controversies in extracorporeal membrane oxygenation: Immediate versus watchful waiting for venoarterial extracorporeal membrane oxygenation venting. JTCVS OPEN 2021; 8:70-76. [PMID: 36004177 PMCID: PMC9390622 DOI: 10.1016/j.xjon.2021.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/15/2021] [Indexed: 11/30/2022]
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Piliero N, Bedague D, Fournel E, Saunier C, Bouvaist H. The Atrial Flow Regulator: A Novel Device for Left Ventricular Unloading in Patients Receiving Venoarterial Extracorporeal Membrane Oxygenation Support? Chest 2021; 160:e165-e167. [PMID: 34366037 DOI: 10.1016/j.chest.2021.03.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 03/12/2021] [Accepted: 03/13/2021] [Indexed: 10/20/2022] Open
Abstract
Severe pulmonary edema, secondary to left ventricular afterload increment, is a common problem occurring in patients receiving venoarterial extracorporeal membrane oxygenation. No consensus is currently available for its management, but several devices/procedures have been described, including an Impella device (Abiomed), balloon atrial septostomy, intraaortic balloon counterpulsation, or an additional venous cannula, as possible adjuncts. We report the feasibility and efficacy of the atrial flow regulator device (Occlutech) for left ventricular unloading in a 58-year-old patient receiving extracorporeal membrane oxygenation. However, the benefits of this device relative to simple balloon atrial septostomy need to be further investigated.
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Affiliation(s)
- Nicolas Piliero
- Service Hospitalier Universitaire de Cardiologie, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France.
| | - Damien Bedague
- Service Hospitalier Universitaire de Réanimation Cardiovasculaire et Thoracique, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Emmanuelle Fournel
- Service Hospitalier Universitaire de Réanimation Cardiovasculaire et Thoracique, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Carole Saunier
- Service Hospitalier Universitaire de Cardiologie, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Hélène Bouvaist
- Service Hospitalier Universitaire de Cardiologie, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
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Comparison of Circulatory Unloading Techniques for Venoarterial Extracorporeal Membrane Oxygenation. ASAIO J 2021; 67:623-631. [PMID: 33074863 DOI: 10.1097/mat.0000000000001268] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Left ventricular (LV) distention and pulmonary congestion are major complications inherent to venoarterial extracorporeal membrane oxygenation (ECMO). This study aimed to quantitatively compare the hemodynamic differences between common circulatory unloading methods for ECMO. Ten circulatory unloading techniques were evaluated on a mock circulatory loop simulating acute LV failure supported by ECMO. Simulated unloading techniques included: surgical and percutaneous pulmonary artery (PA) venting, surgical left atrial venting, surgical and percutaneous LV venting, atrial septal defect, partial support ventricular assist device, intraaortic balloon pump, and temporary VAD with inline oxygenator (tVAD). The most LV unloading occurred with the surgically placed LV vent and tVAD, which reduced LV end-diastolic volume from 295 to 167 ml and 82 ml, respectively. Meanwhile, the PA surgical vent was the most effective at reducing mean PA pressure from 21.0 to 10.6 mm Hg, and the tVAD was most effective at reducing left atrial pressure from 13.3 to 4.4 mm Hg. The major limitation of this study was the use of a mock circulatory loop, which simulated lower left atrial pressure than is typically seen clinically. This study identified clinically significant hemodynamic variability between the different circulatory unloading techniques evaluated. However, the applicability of these techniques will vary with different patient disease etiology. Further studies on ECMO unloading will help to quantify hemodynamic benefits and establish treatment guidelines.
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Abstract
PURPOSE OF REVIEW Cardiogenic shock (CS) therapy involving catecholamines, inotropes, fluids and revascularization is often insufficient, and short-term mortality remains 50%. Different treatment algorithms and mechanical circulatory support devices (MCS) have been increasingly used in the treatment of CS. Coronavirus disease 2019 (COVID-19) pandemic is a major challenge faced by intensive care medicine providers inevitably influencing also CS management. RECENT FINDINGS There is a lack of prospective data as well as international consensus regarding CS classification, patient risk stratification, and MCS use. Veno-arterial extracorporeal membrane oxygenation is considered the first line MCS in refractory CS and Impella the MCS of choice for the left ventricle unloading. Several ongoing randomized trials will provide much-needed evidence for MCS use in the coming years. COVID-19 infection is associated with several cardiovascular disorders complicated by CS and more data regarding the prevalence and mortality of CS during COVID-19 infection are needed. SUMMARY This review summarizes current trends in the use of MCS in CS and discusses differences in CS management during the COVID-19 pandemic. Careful patient selection, early MCS initiation, and comprehensive intensive care by experienced team is key to successful outcome in patients with refractory CS.
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Affiliation(s)
- Daniel Rob
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
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Pozzi M, Grinberg D, Rioufol G. Percutaneous left ventricular unloading in veno-arterial extracorporeal membrane oxygenation. Eur Heart J 2021; 42:2397-2398. [PMID: 33393993 DOI: 10.1093/eurheartj/ehaa1071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Matteo Pozzi
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, 28 Avenue du Doyen Lépine, Lyon, 69500, France
| | - Daniel Grinberg
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, 28 Avenue du Doyen Lépine, Lyon, 69500, France
| | - Gilles Rioufol
- Department of Cardiology, "Louis Pradel" Cardiologic Hospital, 28 Avenue du Doyen Lépine, Lyon, 69500, France
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23
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Lüsebrink E, Massberg S, Orban M. The multiple options of left atrial and ventricular venting during veno-arterial extra-corporeal membrane oxygenation: practical considerations. Eur Heart J 2021; 42:2399-2400. [PMID: 33394031 DOI: 10.1093/eurheartj/ehaa1073] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Enzo Lüsebrink
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
| | - Steffen Massberg
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
| | - Martin Orban
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
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24
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Pham V, Schmidt M, Chastre T, Combes A, Waintraub X, Chommeloux J. [Refractory pulmonary edema under ECMO: Is there a place for Rashkind atrioseptotomy?]. Ann Cardiol Angeiol (Paris) 2021; 70:355-359. [PMID: 33958190 DOI: 10.1016/j.ancard.2021.04.007] [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: 09/22/2020] [Accepted: 04/05/2021] [Indexed: 10/21/2022]
Abstract
Hydrostatic pulmonary edema is a well-known complication of veinoarterial extracorporeal membrane oxygenation (VA-ECMO) caused by increased left ventricle afterload due to reverse blood flow in the aorta. Several techniques are commonly used for left ventricle venting such as intra-aortic balloon pump, Impella® (Abiomed, Danvers, MA), central surgical cannulation or Rahskind atrial septostomy. We reported two cases of hydrostatic pulmonary edema in patients under VA-ECMO for whom it was decided to perform Rashkind technique. The first is a late anterior myocardial infarction complicated with cardiac arrest and cardiogenic shock. Refractory hypoxemia due to hydrostatic pulmonary edema conducted us to perform atrial septostomy. The second case is a refractory cardiogenic shock due to left main stent thrombosis myocardial infarction. Procedural transesophageal echocardiography revealed a large left atrial thrombus extended to pulmonary veins preventing the procedure. These two cases illustrate the importance and gravity of pulmonary edema induced by VA-ECMO. The first shows that this technique is feasible, allows great left ventricle unloading and improves hypoxemia. The second underlines the interest of performing transesophageal echocardiography to look for pulmonary veins thrombosis that can take part in the elevation of hydrostatic pressure and forbid Rashkind manoeuver.
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Affiliation(s)
- V Pham
- Service de réanimation médicale, institut de cardiologie, groupe hospitalier Pitié-Salpêtrière, 75651 Paris cedex 13, France.
| | - M Schmidt
- Service de réanimation médicale, institut de cardiologie, groupe hospitalier Pitié-Salpêtrière, 75651 Paris cedex 13, France
| | - T Chastre
- Service de cardiologie, institut de cardiologie, groupe hospitalier Pitié-Salpêtrière, 75651 Paris cedex 13, France; Service de cardiologie, centre hospitalier Poissy-Saint-Germain-En-Laye, 78303 Poissy, France
| | - A Combes
- Service de réanimation médicale, institut de cardiologie, groupe hospitalier Pitié-Salpêtrière, 75651 Paris cedex 13, France
| | - X Waintraub
- Service de cardiologie, institut de cardiologie, groupe hospitalier Pitié-Salpêtrière, 75651 Paris cedex 13, France
| | - J Chommeloux
- Service de réanimation médicale, institut de cardiologie, groupe hospitalier Pitié-Salpêtrière, 75651 Paris cedex 13, France
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25
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Successful combination treatment with transcatheter balloon atrioseptostomy and bilateral pulmonary artery banding in a collapsed preterm neonate. Cardiol Young 2021; 31:867-869. [PMID: 33507139 DOI: 10.1017/s1047951120004977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
There has been an increase in the use of extracorporeal membrane oxygenation for severe neonatal cardiac failure. However, the frequency of complications is high, particularly in preterm and low-birth-weight neonates. Herein, we present combination treatment with transcatheter balloon atrioseptostomy and bilateral pulmonary artery banding in a collapsed preterm neonate. This strategy can be an alternative to circulatory support using extracorporeal membrane oxygenation.
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26
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Hasde Aİ, Sarıcaoğlu MC, Dikmen Yaman N, Baran Ç, Özçınar E, Çakıcı M, İnan MB, Akar AR. Comparison of left ventricular unloading strategies on venoarterial extracorporeal life support. Interact Cardiovasc Thorac Surg 2021; 32:467-475. [PMID: 33249443 PMCID: PMC8906780 DOI: 10.1093/icvts/ivaa284] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/16/2020] [Accepted: 09/20/2020] [Indexed: 01/22/2024] Open
Abstract
OBJECTIVES Our goal was to compare the haemodynamic effects of different mechanical left ventricular (LV) unloading strategies and clinical outcomes in patients with refractory cardiogenic shock supported with venoarterial extracorporeal membrane oxygenation (VA-ECMO). METHODS A total of 448 patients supported with VA-ECMO for refractory cardiogenic shock between 1 March 2015 and 31 January 2020 were included and analysed in a single-centre, retrospective case-control study. Fifty-three patients (11.8%) on VA-ECMO required LV unloading. Percutaneous balloon atrial septostomy (PBAS), intra-aortic balloon pump (IABP) and transapical LV vent (TALVV) strategies were compared with regards to the composite rate of death, procedure-related complications and neurological complications. The secondary outcomes were reduced pulmonary capillary wedge pressure, pulmonary artery pressure, central venous pressure, left atrial diameter and resolution of pulmonary oedema on a chest X-ray within 48 h. RESULTS No death related to the LV unloading procedure was detected. Reduction in pulmonary capillary wedge pressure was highest with the TALVV technique (17.2 ± 2.1 mmHg; P < 0.001) and was higher in the PBAS than in the IABP group; the difference was significant (9.6 ± 2.5 and 3.9 ± 1.3, respectively; P = 0.001). Reduction in central venous pressure with TALVV was highest with the other procedures (7.4 ± 1.1 mmHg; P < 0.001). However, procedure-related complications were significantly higher with TALVV compared to the PBAS and IABP groups (50% vs 17.6% and 10%, respectively; P = 0.015). We observed no significant differences in mortality or neurological complications between the groups. CONCLUSIONS Our results suggest that TALVV was the most effective method for LV unloading compared with PBAS and IABP for VA-ECMO support but was associated with complications. Efficient LV unloading may not improve survival.
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Affiliation(s)
- Ali İhsan Hasde
- Department of Cardiovascular Surgery, Heart Center, Ankara University School of Medicine, Ankara, Turkey
| | - Mehmet Cahit Sarıcaoğlu
- Department of Cardiovascular Surgery, Heart Center, Ankara University School of Medicine, Ankara, Turkey
| | - Nur Dikmen Yaman
- Department of Pediatric Cardiovascular Surgery, Sami Ulus Maternity and Children Research and Training Hospital, Ankara, Turkey
| | - Çağdaş Baran
- Department of Cardiovascular Surgery, Heart Center, Ankara University School of Medicine, Ankara, Turkey
| | - Evren Özçınar
- Department of Cardiovascular Surgery, Heart Center, Ankara University School of Medicine, Ankara, Turkey
| | - Mehmet Çakıcı
- Department of Cardiovascular Surgery, Heart Center, Ankara University School of Medicine, Ankara, Turkey
| | - Mustafa Bahadır İnan
- Department of Cardiovascular Surgery, Heart Center, Ankara University School of Medicine, Ankara, Turkey
| | - Ahmet Ruchan Akar
- Department of Cardiovascular Surgery, Heart Center, Ankara University School of Medicine, Ankara, Turkey
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27
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Das S, Gupta S, Das D, Dutta N. Basics of extra corporeal membrane oxygenation: a pediatric intensivist's perspective. Perfusion 2021; 37:439-455. [PMID: 33765881 DOI: 10.1177/02676591211005260] [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] [Indexed: 12/14/2022]
Abstract
Extra Corporeal membrane oxygenation (ECMO) is one of the most advanced forms of life support therapy in the Intensive Care Unit. It relies on the principle where an external artificial circuit carries venous blood from the patient to a gas exchange device (oxygenator) within which blood becomes enriched with oxygen and has carbon dioxide removed. The blood is then returned to the patient via a central vein or an artery. The goal of ECMO is to provide a physiologic milieu for recovery in refractory cardiac/respiratory failure. The technology is not a definitive treatment for a disease, but provides valuable time for the body to recover. In that way it can be compared to a bridge, where patients are initiated on ECMO as a bridge to recovery, bridge to decision making, bridge to transplant or bridge to diagnosis. The use of this modality in children is not backed by a lot of randomized controlled trials, but the use has increased dramatically in our country in last 10 years. This article is not intended to provide an in-depth overview of ECMO, but outlines the basic principles that a pediatric intensive care physician should know in order to manage a kid on ECMO support.
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Affiliation(s)
- Shubhadeep Das
- Department of Pediatric Cardiac Intensive Care, NH Narayana Superspeciality Hospital, Howrah, West Bengal, India
| | - Sandip Gupta
- Department of Pediatric Intensive Care, Aster CMI Hospital, Bangalore, Karnataka, India
| | - Debasis Das
- Department of Cardiac Surgery, NH Narayana Superspeciality Hospital, Howrah, West Bengal, India
| | - Nilanjan Dutta
- Department of Cardiac Surgery, NH Narayana Superspeciality Hospital, Howrah, West Bengal, India
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28
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Ricarte Bratti JP, Cavayas YA, Noly PE, Serri K, Lamarche Y. Modalities of Left Ventricle Decompression during VA-ECMO Therapy. MEMBRANES 2021; 11:membranes11030209. [PMID: 33809568 PMCID: PMC8002319 DOI: 10.3390/membranes11030209] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/04/2021] [Accepted: 03/12/2021] [Indexed: 12/22/2022]
Abstract
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used to sustain circulatory and respiratory support in patients with severe cardiogenic shock or refractory cardiac arrest. Although VA-ECMO allows adequate perfusion of end-organs, it may have detrimental effects on myocardial recovery. Hemodynamic consequences on the left ventricle, such as the increase of afterload, end-diastolic pressure and volume, can lead to left ventricular (LV) distention, increase of myocardial oxygen consumption and delayed LV function recovery. LV distention occurs in almost 50% of patients supported with VA-ECMO and is associated with an increase in morbidity and mortality. Thus, recognizing, preventing and treating LV distention is key in the management of these patients. In this review, we aim to discuss the pathophysiology of LV distention and to describe the strategies to unload the LV in patients supported with VA-ECMO.
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Affiliation(s)
- Juan Pablo Ricarte Bratti
- Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC H1T 1C8, Canada; (J.P.R.B.); (Y.A.C.); (P.E.N.); (K.S.)
| | - Yiorgos Alexandros Cavayas
- Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC H1T 1C8, Canada; (J.P.R.B.); (Y.A.C.); (P.E.N.); (K.S.)
- Hôpital Sacré-Coeur de Montréal, 5400. Gouin Blvd. West, Montreal, QC H4J 1C5, Canada
| | - Pierre Emmanuel Noly
- Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC H1T 1C8, Canada; (J.P.R.B.); (Y.A.C.); (P.E.N.); (K.S.)
| | - Karim Serri
- Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC H1T 1C8, Canada; (J.P.R.B.); (Y.A.C.); (P.E.N.); (K.S.)
- Hôpital Sacré-Coeur de Montréal, 5400. Gouin Blvd. West, Montreal, QC H4J 1C5, Canada
| | - Yoan Lamarche
- Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC H1T 1C8, Canada; (J.P.R.B.); (Y.A.C.); (P.E.N.); (K.S.)
- Hôpital Sacré-Coeur de Montréal, 5400. Gouin Blvd. West, Montreal, QC H4J 1C5, Canada
- Correspondence: ; Tel.: +1-514-376-3330
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29
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Kloeckner M, Guihaire J, Hascoet S. Congestive pulmonary oedema during venoarterial extracorporeal membrane oxygenation support: a plea for balloon atrial septostomy. Eur Heart J 2021; 42:3103-3104. [PMID: 33675638 DOI: 10.1093/eurheartj/ehab118] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Martin Kloeckner
- Cardiology Department, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint-Joseph, 133 avenue de la Resistance, 92350 Plessis-Robinson, France
| | - Julien Guihaire
- Department of Adult Cardiac Surgery, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint-Joseph, 133 avenue de la Resistance, 92350 Plessis-Robinson, France.,UMR-S 999, Inserm, Paris-Saclay School of Medicine, Paris-Saclay University, Le Plessis Robinson, France
| | - Sebastien Hascoet
- UMR-S 999, Inserm, Paris-Saclay School of Medicine, Paris-Saclay University, Le Plessis Robinson, France.,Department of Congenital Heart Diseases, Centre Constitutif Malformations Cardiaques Congénitales Complexes M3C, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint-Joseph, 133 avenue de la Resistance, 92350 Plessis-Robinson, France
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30
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Donker DW, Sallisalmi M, Broomé M. Right-Left Ventricular Interaction in Left-Sided Heart Failure With and Without Venoarterial Extracorporeal Membrane Oxygenation Support-A Simulation Study. ASAIO J 2021; 67:297-305. [PMID: 33627604 PMCID: PMC7908866 DOI: 10.1097/mat.0000000000001242] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Left ventricular (LV) dilatation is commonly seen with LV failure and is often aggravated during venoarterial extracorporeal membrane oxygenation (VA ECMO). In this context, the intricate interaction between left and right heart function is considered to be of pivotal importance, yet mechanistically not well understood. We hypothesize that a preserved or enhanced right heart contractility causes increased LV loading both with and without VA ECMO. A closed-loop in-silico simulation model containing the cardiac chambers, the pericardium, septal interactions, and the pulmonary and systemic vascular systems with an option to connect a simulated VA ECMO circuit was developed. Right ventricular contractility was modified during simulation of severe LV failure with and without VA ECMO. Left atrial pressures increased from 14.0 to 23.8 mm Hg without VA ECMO and from 18.4 to 27.0 mm Hg under VA ECMO support when right heart contractility was increased between end-systolic elastance 0.1 and 1.0 mm Hg/ml. Left-sided end-diastolic volumes increased from 125 to 169 ml without VA ECMO and from 150 to 180 ml with VA ECMO. Simulations demonstrate that increased diastolic loading of the LV may be driven by increased right ventricular contractility and that left atrial pressures cannot be interpreted as a reflection of the degree of LV dysfunction and overload without considering right ventricular function. Our study illustrates that modelling and computer simulation are important tools to unravel complex cardiovascular mechanisms underlying the right-left heart interdependency both with and without mechanical circulatory support.
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Affiliation(s)
- Dirk W Donker
- From the Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marko Sallisalmi
- Anaesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- ECMO Department, Karolinska University Hospital, Stockholm, Sweden
| | - Michael Broomé
- Anaesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- ECMO Department, Karolinska University Hospital, Stockholm, Sweden
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31
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Amancherla K, Menachem JN, Shah AS, Lindenfeld J, O'leary J. Limited Balloon Atrial Septostomy for Left Ventricular Unloading in Peripheral Extracorporeal Membrane Oxygenation. J Card Fail 2021; 27:501-504. [PMID: 33358956 DOI: 10.1016/j.cardfail.2020.12.014] [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: 08/31/2020] [Revised: 11/22/2020] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND This study describes the authors' experience with a limited balloon atrial septostomy technique, using a median balloon size of 15 mm, as a left ventricular (LV) unloading strategy in venoarterial extracorporeal membrane oxygenation (VA-ECMO). There has been increasing use of VA-ECMO in cardiogenic shock. Although LV unloading strategies have been suggested to improve outcomes, it is unclear which strategy is optimal. METHODS AND RESULTS We performed a retrospective study of patients who underwent a limited balloon atrial septostomy for LV unloading in peripheral VA-ECMO at a single center. The goal of this study was to define the procedural outcomes and clinical characteristics of these patients. Of the 12 patients identified, none had complications related to the procedure. There was a significant decrease in the mean left atrial pressure and the majority of patients had radiologic improvement in pulmonary vascular congestion. Of the 12 patients, 58.3% survived to discharge. CONCLUSIONS Limited BAS is an elegant and safe method for unloading the LV in peripheral VA-ECMO.
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Affiliation(s)
| | | | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Jared O'leary
- Department of Medicine, Division of Cardiovascular Medicine.
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32
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Piccinelli E, Castro-Verdes MB, Fraisse A, Bautista-Rodriguez C. Implantation of an Atrial Flow Regulator in a Child on Venoarterial Extracorporeal Membrane Oxygenator as a Bridge to Heart Transplant: A Case Report. J Card Fail 2020; 27:364-367. [PMID: 33242607 DOI: 10.1016/j.cardfail.2020.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 10/21/2020] [Accepted: 11/16/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Balloon dilation and stenting of the atrial septum are techniques used to unload left heart cavities in acute or end-stage heart failure in children. However, they carry significant risks such as tamponade or device embolization. CASE PRESENTATION We report the first case of a child with an end-stage mitochondrial cardiomyopathy on a venoarterial extracorporeal membrane oxygenator as a bridge to heart transplant where an atrial flow regulator device has been implanted. CONCLUSIONS This case illustrates the feasibility and safety of atrial flow regulator implantation in this setting. This procedure allowed to wean inotropic support while awaiting heart transplantation.
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Affiliation(s)
- Enrico Piccinelli
- Paediatric Cardiology Services, Royal Brompton Hospital and Harefield NHS Foundation Trust, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Mireya Beatriz Castro-Verdes
- Paediatric Cardiology Services, Royal Brompton Hospital and Harefield NHS Foundation Trust, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Alain Fraisse
- Paediatric Cardiology Services, Royal Brompton Hospital and Harefield NHS Foundation Trust, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Carles Bautista-Rodriguez
- Paediatric Cardiology Services, Royal Brompton Hospital and Harefield NHS Foundation Trust, London, UK; National Heart and Lung Institute, Imperial College London, London, UK.
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33
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Emani S, Burkhoff D, Lilly SM. Interatrial shunt devices for the treatment of heart failure. Trends Cardiovasc Med 2020; 31:427-432. [DOI: 10.1016/j.tcm.2020.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/14/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
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34
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Yan S, Lou S, Zhao Y, Liu G, Ji B. Air in extracorporeal membrane oxygenation: can never be overemphasized. Perfusion 2020; 36:97-99. [PMID: 32423312 DOI: 10.1177/0267659120918471] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Air in extracorporeal membrane oxygenation circuit may lead to deleterious consequence. CASE REPORT Three cases of air in extracorporeal membrane oxygenation were presented. Air was introduced from right jugular venous sheath during percutaneous septal repair, pulmonary artery catheter during intensive care unit, and sewing holes on atrial wall during surgery respectively. Accidents in Case 2 and Case 3 were successfully managed, while Case 1 was suspected of cerebral air embolism through transseptal right-to-left shunt. DISCUSSION With extracorporeal membrane oxygenation being widely applied in more clinical settings, especially in catheterization lab, risks of air in extracorporeal membrane oxygenation increase. More attention should be paid to patients with communication between right and left heart system, especially in situations when venous accesses' exposure to air could not be avoided. CONCLUSION Air in the extracorporeal membrane oxygenation circuit should never be overemphasized, especially during special procedures.
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Affiliation(s)
- Shujie Yan
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Song Lou
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Zhao
- New Era Stroke Care and Research Institute, The PLA Rocket Force General Hospital, Beijing, China
| | - Gang Liu
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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35
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Guimaraes L, Del Val D, Bergeron S, O'Connor K, Bernier M, Rodés-Cabau J. Interatrial Shunting for Treating Acute and Chronic Left Heart Failure. Eur Cardiol 2020; 15:e18. [PMID: 32419849 PMCID: PMC7215499 DOI: 10.15420/ecr.2019.04] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 08/09/2019] [Indexed: 12/19/2022] Open
Abstract
The creation of an interatrial shunt has emerged as a new therapy to decompress the left atrium in patients with acute and chronic left heart failure (HF). Current data support the safety of this therapy, and promising preliminary efficacy results have been reported in patients who are refractory to optimal medical/device therapy. This article aims to provide an updated overview and clinical perspective on interatrial shunting for treating different HF conditions, and highlights the potential challenges and future directions of this therapy.
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Affiliation(s)
- Leonardo Guimaraes
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University Quebec City, Quebec, Canada
| | - David Del Val
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University Quebec City, Quebec, Canada
| | - Sebastien Bergeron
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University Quebec City, Quebec, Canada
| | - Kim O'Connor
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University Quebec City, Quebec, Canada
| | - Mathieu Bernier
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University Quebec City, Quebec, Canada
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36
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Meuwese CL, de Haan M, Zwetsloot PP, Braithwaite S, Ramjankhan F, van der Heijden J, Hermens J, Cremer O, Broomé M, Donker DW. The hemodynamic effect of different left ventricular unloading techniques during veno-arterial extracorporeal life support: a systematic review and meta-analysis. Perfusion 2020; 35:664-671. [DOI: 10.1177/0267659119897478] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Pulmonary edema and left ventricular thrombosis may arise during veno-arterial extracorporeal life support due to an increase in cardiac load. This mechanical stress can be reduced through different left ventricular unloading techniques. We set out to quantitatively summarize the hemodynamic effects of available methods in patients treated with veno-arterial extracorporeal life support. Methods: Literature was systematically searched for studies reporting left ventricular unloading during veno-arterial extracorporeal life support as reflected by changes in left atrial pressure, pulmonary capillary wedge pressure, diastolic pulmonary artery pressure, or left ventricular end-diastolic pressure. For studies including ⩾10 patients per group, changes in these parameters were pooled using (1) standardized mean differences and (2) ratio of means. Assessment of potential bias was performed for all studies. Results: Eight studies met the inclusion criteria. Reported techniques included use of intra-aortic balloon pump (n = 1), micro-axial blood pump (Impella®, n = 2), left ventricular venting (n = 1), and atrial septostomy (n = 4). Overall, left ventricular unloading was associated with a statistically significant reduction in preload parameters (standardized mean differences = −1.05 (95% confidence interval = −1.24 to −0.86) and ratio of means = 0.60 (0.47 to 0.76)). Effect sizes were strongest for micro-axial blood pump and atrial septostomy (standardized mean differences = −1.11 (−1.55 to −0.68) and −1.22 (−1.47 to −0.96), and ratio of means = 0.58 (0.39 to 0.86) and 0.54 (0.36 to 0.83), respectively). Conclusion: Left ventricular unloading was associated with a significant reduction in left ventricular preload parameters in the setting of veno-arterial extracorporeal life support. This effect may be most pronounced for micro-axial blood pump and atrial septostomy.
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Affiliation(s)
- Christiaan Lucas Meuwese
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marloes de Haan
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter-Paul Zwetsloot
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sue Braithwaite
- Department of Cardio-Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Faiz Ramjankhan
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joris van der Heijden
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeannine Hermens
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Olaf Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michael Broomé
- ECMO Department, Karolinska University Hospital, Stockholm, Sweden
- Division of Anesthesia and Intensive Care, Department of Physiology and Pharmacology, Karolinska University Hospital, Stockholm, Sweden
| | - Dirk Wilhelm Donker
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
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37
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Desai SR, Hwang NC. Strategies for Left Ventricular Decompression During Venoarterial Extracorporeal Membrane Oxygenation - A Narrative Review. J Cardiothorac Vasc Anesth 2020; 34:208-218. [DOI: 10.1053/j.jvca.2019.08.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 07/26/2019] [Accepted: 08/17/2019] [Indexed: 01/21/2023]
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Phoophiboon V, Jaimchariyatam N, Srimahachota S, Sirinawin C. Successful multimodality management of severe pulmonary arterial hypertension during pregnancy with VA-ECMO and atrial septostomy using stent. BMJ Case Rep 2019; 12:12/12/e231916. [PMID: 31796462 DOI: 10.1136/bcr-2019-231916] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 30-year-old Thai woman (gravida 1, para 0) at 33 weeks gestation was referred to our hospital due to acute right ventricular failure. Pulmonary vasodilators were gradually administered before delivery. On the verge of sudden postpartum cardiac circulation collapse, she was resuscitated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Abdominal compartment syndrome was developed in the early period of the mechanical support. Knowledge of pathophysiology about pulmonary arterial hypertension during pregnancy was applied. Atrial septostomy was the effective procedure for discontinuing mechanical support (VA-ECMO) corresponding to the suitable timing for maximal effect of pulmonary vasodilators. The patient and her child were safe and discharged in 2 months after the admission.
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Affiliation(s)
- Vorakamol Phoophiboon
- Division of Pulmonology and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Nattapong Jaimchariyatam
- Division of Pulmonology and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Suphot Srimahachota
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University Faculty of Medicine, Bangkok, Thailand
| | - Chayatat Sirinawin
- Division of Cardiothoracic Surgery, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Kim S, Kim JS, Shin JS, Shin HJ. How small is enough for the left heart decompression cannula during extracorporeal membrane oxygenation? Acute Crit Care 2019; 34:263-268. [PMID: 31795624 PMCID: PMC6895469 DOI: 10.4266/acc.2019.00577] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 11/04/2019] [Indexed: 11/30/2022] Open
Abstract
Background Left ventricular (LV) distension is a recognizable problem accompanied by subsequent complications during venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, no gold standard for LV decompression has been established, and no minimal flow requirement has been designated. Thus, we evaluated the efficacy of the 8-Fr Mullins sheath for left heart decompression during VA-ECMO in adult patients. Methods Left heart decompression was performed when severe pulmonary edema was detected on chest radiography or when no generation of pulse pressure followed severe LV dysfunction in patients receiving VA-ECMO. We punctured the interatrial septum and inserted an 8-Fr Mullins sheath into the left atrium via the femoral vein. The sheath was connected to the venous catheter used for ECMO. The catheter was maintained during VA-ECMO. Results The left heart decompression procedure was performed in seven of 35 patients who received VA-ECMO between February 2017 and June 2018. Three patients had acute myocardial infarction; three, fulminant myocarditis; and one, dilated cardiomyopathy. Four patients showed noticeable improvement of pulmonary edema within 3 days, and three patients with a pulse pressure of <10 mm Hg showed an increase in pulse pressure of >20 mm Hg within 24 hours from the left heart decompression procedure. All seven patients were successfully weaned from VA-ECMO. No complications related to the left heart decompression procedure occurred. Conclusions An 8-Fr sheath may be a possible option for left heart decompression in adult patients with LV distension under VA-ECMO who are expecting recovery of LV function.
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Affiliation(s)
- Sua Kim
- Department of Critical Care Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea.,Division of Cardiology, Department of Internal Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Jin Seok Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Jae Seung Shin
- Department of Thoracic and Cardiovascular Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Hong Ju Shin
- Department of Thoracic and Cardiovascular Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
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40
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Singh G, Hudson D, Shaw A. Medical Optimization and Liberation of Adult Patients From VA-ECMO. Can J Cardiol 2019; 36:280-290. [PMID: 32036869 DOI: 10.1016/j.cjca.2019.10.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 10/31/2019] [Accepted: 10/31/2019] [Indexed: 12/30/2022] Open
Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) can be an efficacious cardiopulmonary support for adults as rescue from refractory cardiogenic shock. It is best employed as a bridging strategy to recovery or alternative support rather than sustained, long-term mechanical circulatory support. The purpose of this paper is to discuss strategies to optimize patient management on VA-ECMO and approaches to promote successful separation from support. Rapid medical optimization will assist in reducing the time on VA-ECMO, thereby improving the likelihood of patient salvage. Suitably trained physicians and personnel, guided by structured protocols, can promote excellence in team care and provision of consistent management. Focusing on anticoagulation, careful neurologic monitoring, prevention of leg ischemia, awareness of differential hypoxemia, optimizing mechanical ventilation, identifying and timely intervention for left-ventricular distension (LVD), along with a strategic weaning algorithm, can prevent significant morbidity and mortality. LVD physiology, diagnosis, and risk factors are reviewed. Indications for LV decompression, along with medical and mechanical management options, are elucidated.
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Affiliation(s)
- Gurmeet Singh
- Critical Care Medicine, Edmonton, Alberta, Canada; Cardiac Surgery, Edmonton, Alberta, Canada; Adult ECMO Program, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada; University of Alberta, Edmonton, Alberta, Canada.
| | - Darren Hudson
- Critical Care Medicine, Edmonton, Alberta, Canada; University of Alberta, Edmonton, Alberta, Canada
| | - Andrew Shaw
- Department of Anesthesiology and Pain Medicine, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada; University of Alberta, Edmonton, Alberta, Canada
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41
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Left Atrial Decompression on Venoarterial Extracorporeal Membrane Oxygenation: Getting to the Heart of the Matter. Pediatr Crit Care Med 2019; 20:780-781. [PMID: 31397811 DOI: 10.1097/pcc.0000000000001956] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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42
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Relationship Between Time to Left Atrial Decompression and Outcomes in Patients Receiving Venoarterial Extracorporeal Membrane Oxygenation Support: A Multicenter Pediatric Interventional Cardiology Early-Career Society Study. Pediatr Crit Care Med 2019; 20:728-736. [PMID: 30985609 DOI: 10.1097/pcc.0000000000001936] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess the variation in timing of left atrial decompression and its association with clinical outcomes in pediatric patients supported with venoarterial extracorporeal membrane oxygenation across a multicenter cohort. DESIGN Multicenter retrospective study. SETTING Eleven pediatric hospitals within the United States. PATIENTS Patients less than 18 years on venoarterial extracorporeal membrane oxygenation who underwent left atrial decompression from 2004 to 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 137 patients (median age, 4.7 yr) were included. Cardiomyopathy was the most common diagnosis (47%). Cardiac arrest (39%) and low cardiac output (50%) were the most common extracorporeal membrane oxygenation indications. Median time to left atrial decompression was 6.2 hours (interquartile range, 3.8-17.2 hr) with the optimal cut-point of greater than or equal to 18 hours for late decompression determined by receiver operating characteristic curve. In univariate analysis, late decompression was associated with longer extracorporeal membrane oxygenation duration (median 8.5 vs 5 d; p = 0.02). In multivariable analysis taking into account clinical confounder and center effects, late decompression remained significantly associated with prolonged extracorporeal membrane oxygenation duration (adjusted odds ratio, 4.4; p = 0.002). Late decompression was also associated with longer duration of mechanical ventilation (adjusted odds ratio, 4.8; p = 0.002). Timing of decompression was not associated with in-hospital survival (p = 0.36) or overall survival (p = 0.42) with median follow-up of 3.2 years. CONCLUSIONS In this multicenter study of pediatric patients receiving venoarterial extracorporeal membrane oxygenation, late left atrial decompression (≥ 18 hr) was associated with longer duration of extracorporeal membrane oxygenation support and mechanical ventilation. Although no survival benefit was demonstrated, the known morbidities associated with prolonged extracorporeal membrane oxygenation use may justify a recommendation for early left atrial decompression.
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Ryan M, Briceno N, Perera D. Mechanical Circulatory Support in the Cardiac Catheterization Laboratory for Cardiogenic Shock. Korean Circ J 2019; 49:197-213. [PMID: 30808071 PMCID: PMC6393319 DOI: 10.4070/kcj.2018.0443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 12/23/2018] [Indexed: 01/06/2023] Open
Abstract
Despite the development of acute revascularisation, the mortality rate for cardiogenic shock remains around 50%. Mechanical circulatory support devices have long held promise in improving outcomes in shock, but high-quality evidence of benefit has not been forthcoming. In this article we review the currently available devices for treating shock, their physiological effects and the evidence base for their use in practice. We subsequently look ahead within this developing field, including new devices and novel indications for established technology.
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Affiliation(s)
- Matt Ryan
- School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Natalia Briceno
- School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Divaka Perera
- School of Cardiovascular Medicine and Sciences, King's College London, London, UK.
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Choi MS, Sung K, Cho YH. Clinical Pearls of Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock. Korean Circ J 2019; 49:657-677. [PMID: 31364329 PMCID: PMC6675698 DOI: 10.4070/kcj.2019.0188] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 06/24/2019] [Indexed: 12/26/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a technique that uses a pump to drain blood from a body, circulate blood through a membrane lung, and return the oxygenated blood back into the body. Venoarterial (VA) ECMO is a simplified version of the heart-lung machine that assists native pulmonary and/or cardiac function. VA ECMO is composed of a drainage cannula in the venous system and a return cannula in the arterial system. Because VA ECMO can increase tissue perfusion by increasing the arterial blood flow, it is used to treat medically refractory cardiogenic shock or cardiac arrest. VA ECMO has a distinct physiology that is referred to as differential flows. It can cause several complications such as left ventricular distension with pulmonary edema, distal limb ischemia, bleeding, and thromboembolism. Physicians who are using this technology should be knowledgeable on the prevention and management of these complications. We review the basic physiology of VA ECMO, the mechanism of complications, and the simple management of VA ECMO.
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Affiliation(s)
- Min Suk Choi
- Department of Thoracic and Cardiovascular Surgery, Dongguk University Ilsan Hospital, Dongguk University School of Medicine, Goyang, Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Rodés-Cabau J, Bernier M, Amat-Santos IJ, Ben Gal T, Nombela-Franco L, García Del Blanco B, Kerner A, Bergeron S, Del Trigo M, Pibarot P, Shkurovich S, Eigler N, Abraham WT. Interatrial Shunting for Heart Failure: Early and Late Results From the First-in-Human Experience With the V-Wave System. JACC Cardiovasc Interv 2018; 11:2300-2310. [PMID: 30391390 DOI: 10.1016/j.jcin.2018.07.001] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 06/25/2018] [Accepted: 07/03/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This was a first-in-human study to assess the feasibility, safety, and exploratory efficacy of interatrial shunting for treating high-risk heart failure (HF) in patients with reduced and preserved ejection fraction. METHODS A single-arm open-label study of patients with New York Heart Association functional class III or IV HF on optimal therapy was performed at 6 centers. The V-Wave shunt, an hourglass-shaped implant containing a 1-way bioprosthetic valve, was implanted by transseptal catheterization. Clinical, functional, echocardiographic, and hemodynamic evaluations were performed at baseline, 3 and 12 months, and annually (clinical follow-up) thereafter (median follow-up 28 months; interquartile range: 21 to 31 months). RESULTS A total of 38 patients were enrolled (30 with HF with reduced ejection fraction and 8 with HF with preserved ejection fraction; mean age 66 ± 9 years; 97% and 3% in New York Heart Association functional classes III and IV, respectively), and the shunt device was successfully implanted in all cases without periprocedural mortality. The rate of major device- or procedure-related complications during the first 12 months was 2.6% (periprocedural cardiac tamponade in 1 patient). At 3- and 12-month follow-up, there were improvements in New York Heart Association functional class (classes I and II in 78% and 60% of patients, respectively), quality of life (improvements ≥5 points in 74% and 73% of patients, respectively), and 6-min walk distance (mean increases of 41 ± 63 m and 28 ± 83 m, respectively) (p < 0.02 for all, data available for 36 patients), without changes in objective measures of left- or right-sided function. All shunts were patent at 3 months, but 5 of 36 (14%) had occluded, and another 13 of 36 (36%) were stenotic at the valve by 12 months. Patients with widely patent shunts had lower long-term rates of death, left ventricular assist device placement or heart transplantation (p = 0.001), and HF hospitalization (p = 0.008), along with a reduction of pulmonary capillary wedge pressure (from 23.3 ± 5.4 mm Hg at baseline to 18.0 ± 4.0 mm Hg at 12 months; p = 0.011). CONCLUSIONS Interatrial shunting with the V-Wave system was feasible and safe in patients with HF with reduced and preserved ejection fraction. Improvements in clinical and functional status were observed early and at 12 months despite attenuation of shunt patency in one-half of the patients. Patients with preserved shunt patency tended to maintain clinical benefit during longer term follow-up. Device modification that improves the durability of patency is likely worthwhile before confirmation of these findings in a randomized trial.
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Affiliation(s)
| | - Mathieu Bernier
- Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
| | | | | | - Luis Nombela-Franco
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | | | | | | | - Maria Del Trigo
- Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
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Bautista-Rodriguez C, Sanchez-de-Toledo J, Da Cruz EM. The Role of Echocardiography in Neonates and Pediatric Patients on Extracorporeal Membrane Oxygenation. Front Pediatr 2018; 6:297. [PMID: 30416991 PMCID: PMC6212474 DOI: 10.3389/fped.2018.00297] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 09/21/2018] [Indexed: 11/13/2022] Open
Abstract
Indications for extracorporeal membrane oxygenation (ECMO) and extracorporeal cardiopulmonary resuscitation (ECPR) are expanding, and echocardiography is a tool of utmost importance to assess safety, effectiveness and readiness for circuit initiation and separation. Echocardiography is key to anticipating complications and improving outcomes. Understanding the patient's as well as the ECMO circuit's anatomy and physiology is crucial prior to any ECMO echocardiographic evaluation. It is also vital to acknowledge that the utility of echocardiography in ECMO patients is not limited to the evaluation of cardiac function, and that clinical decisions should not be made exclusively upon echocardiographic findings. Though echocardiography has specific indications and applications, it also has limitations, characterized as: prior to and during cannulation, throughout the ECMO run, upon separation and after separation from the circuit. The use of specific and consistent echocardiographic protocols for patients on ECMO is recommended.
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Affiliation(s)
- Carles Bautista-Rodriguez
- Pediatric Cardiology Department, Hospital Sant Joan de Deu Barcelona, Universitat de Barcelona, Barcelona, Spain
- Department of Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Joan Sanchez-de-Toledo
- Pediatric Cardiology Department, Hospital Sant Joan de Deu Barcelona, Universitat de Barcelona, Barcelona, Spain
- Division of Cardiac Intensive Care, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Eduardo M. Da Cruz
- Department of Pediatrics, Heart Institute, Children's Hospital Colorado, School of Medicine, University of Colorado Denver, Aurora, CO, United States
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47
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Donker DW, Brodie D, Henriques JPS, Broomé M. Left ventricular unloading during veno-arterial ECMO: a review of percutaneous and surgical unloading interventions. Perfusion 2018; 34:98-105. [PMID: 30112975 PMCID: PMC6378398 DOI: 10.1177/0267659118794112] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Short-term mechanical support by veno-arterial extracorporeal membrane oxygenation (VA ECMO) is more and more applied in patients with severe cardiogenic shock. A major shortcoming of VA ECMO is its variable, but inherent increase of left ventricular (LV) mechanical load, which may aggravate pulmonary edema and hamper cardiac recovery. In order to mitigate these negative sequelae of VA ECMO, different adjunct LV unloading interventions have gained a broad interest in recent years. Here, we review the whole spectrum of percutaneous and surgical techniques combined with VA ECMO reported to date.
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Affiliation(s)
- Dirk W Donker
- 1 Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Daniel Brodie
- 2 Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA
| | - José P S Henriques
- 3 Department of Cardiology, Academic Medical Center, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Michael Broomé
- 4 ECMO Department, Karolinska University Hospital, Stockholm, Sweden.,5 Anaesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden.,6 School of Technology and Health, Royal Institute of Technology, Stockholm, Sweden
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48
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Vrints CJ. Cardiogenic shock: the next frontier in acute cardiovascular care! EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 7:3-6. [PMID: 29412021 DOI: 10.1177/2048872618760183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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49
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Mechanical circulatory support in patients with cardiogenic shock in intensive care units: A position paper of the "Unité de Soins Intensifs de Cardiologie" group of the French Society of Cardiology, endorsed by the "Groupe Athérome et Cardiologie Interventionnelle" of the French Society of Cardiology. Arch Cardiovasc Dis 2018; 111:601-612. [PMID: 29903693 DOI: 10.1016/j.acvd.2018.03.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 03/11/2018] [Accepted: 03/12/2018] [Indexed: 12/17/2022]
Abstract
Cardiogenic shock (CS) is a major challenge in contemporary cardiology. Despite a better understanding of the pathophysiology of CS, its management has only improved slightly. The prevalence of CS has remained stable over the past decade, but its outcome has seen few improvements, with the 1-month mortality rate still in the range of 40-60%. Inotropes and vasopressors are the first-line therapies for CS, but they are associated with significant hazards, and have well-known deleterious effects. Furthermore, a significant number of patients develop refractory CS with haemodynamic instability, causing critical organ hypoperfusion and/or pulmonary congestion, despite increasing doses of catecholamines. A major change has resulted from the recent advent and availability of potent mechanical circulatory support (MCS) devices. These devices, which ensure sustained blood flow, provide a great and long-awaited opportunity to improve the prognosis of CS. Several efficient MCS devices are now available, including left ventricle-to-aorta circulatory support devices and full pulmonary and circulatory support with venoarterial extracorporeal membrane oxygenation. However, evidence to support their indications, the timing of implantation and the selection of patients and devices is scarce. Because these devices are gaining momentum and are becoming readily available, the "Unité de Soins Intensifs de Cardiologie" group of the French Society of Cardiology aims to propose practical algorithms for the use of these devices, to help intensive care unit and cardiac care unit physicians in this complex area, where evidence is limited.
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50
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Riahi M, Baruteau AE. Left ventricular distention under venoarterial extracorporeal membrane oxygenation support: when should we consider percutaneous left heart decompression? J Thorac Dis 2017; 9:4919-4921. [PMID: 29312692 DOI: 10.21037/jtd.2017.11.97] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Mounir Riahi
- Department of Cardiology, St Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Alban-Elouen Baruteau
- Department of Congenital Cardiology, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,M3C CHU de Nantes, Fédération des Cardiopathies Congénitales, Nantes, France.,IHU LIRYC, Electrophysiology and Heart Modeling Institute, Bordeaux, France
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