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Zhang A, Kurlansky P, Ning Y, Wang A, Kaku Y, Fried J, Takeda K. Outcomes following successful decannulation from extracorporeal life support for cardiogenic shock. J Thorac Cardiovasc Surg 2024; 167:1033-1046.e8. [PMID: 36180251 DOI: 10.1016/j.jtcvs.2022.08.007] [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: 02/03/2022] [Revised: 07/09/2022] [Accepted: 08/02/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Although extracorporeal life support (ECLS) has increasingly been used for the treatment of patients with cardiogenic shock (CS), the outcomes of those successfully weaned from support remain poorly defined. METHODS Of 510 venoarterial ECLS CS patients at our institution between January 2015 and December 2020, 249 were decannulated and survived for 30 days or until discharge (ie, successfully weaned). Factors associated with survival to discharge were assessed and 1-year survival was described. RESULTS Of 510 eligible CS ECLS patients, 249 (48.8%) were successfully decannulated, 227 (44.5%) died during/following ECLS, and 34 (6.7%) were bridged to heart transplantation or a ventricular assist device. Patients with a primary graft dysfunction etiology of CS had a greater chance of successful decannulation (odds ratio [OR], 3.088; 95% CI, 1.1-8.671; P = .0323), whereas patients with ECLS during cardiopulmonary resuscitation had a reduced chance of successful decannulation (OR, 0.354; 95% CI, 0.17-0.735; P = .0054). Of successfully decannulated patients, 218 (87.6%) survived to hospital discharge and 31 (12.4%) died in the hospital. Acute myocardial infarction etiology (OR, 4.751; 95% CI, 1.623-13.902; P = .0044), preexisting chronic kidney disease (OR, 3.422; 95% CI, 1.374-8.52; P = .0082), and initiation of continuous renal replacement therapies (OR, 3.188; 95% CI, 1.291-7.871; P = .012) were significantly associated with in-hospital mortality despite successful decannulation. One-year survival in successfully decannulated patients surviving to hospital discharge was 95.0% and comparable to 1-year survival in patients who received a heart transplant or ventricular assist device. CONCLUSIONS Successful decannulation can be achieved in a significant proportion of patients treated with ECLS for CS but does not guarantee survival to hospital discharge. However, 1-year survival of hospital survivors remains high and is comparable to patients bridged to transplant or a ventricular assist device.
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Affiliation(s)
- Ashley Zhang
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, NY
| | - Paul Kurlansky
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, NY; Department of Surgery, Center for Innovation and Outcomes Research, Columbia University Medical Center, New York, NY
| | - Yuming Ning
- Department of Surgery, Center for Innovation and Outcomes Research, Columbia University Medical Center, New York, NY
| | - Amy Wang
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, NY
| | - Yuji Kaku
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, NY
| | - Justin Fried
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Koji Takeda
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, NY.
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2
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Dardik G, Ning Y, Kurlansky P, Almodovar Cruz G, Vinogradsky A, Fried J, Topkara VK, Takeda K. Long-term outcomes of patients bridged to recovery with venoarterial extracorporeal life support. Perfusion 2023:2676591231206524. [PMID: 37861303 DOI: 10.1177/02676591231206524] [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: 10/21/2023]
Abstract
OBJECTIVE Our study examines the long-term outcomes of patients discharged from the hospital without heart replacement therapy (HRT) after recovery from cardiogenic shock using venoarterial extracorporeal life support (VA-ECLS). METHODS We retrospectively reviewed 615 cardiogenic shock patients who recovered from VA-ECLS at our institution between January 2015 and July 2021. Of those, 166 patients (27.0%) who recovered from VA-ECLS without HRT were included in this study. Baseline characteristics, discharge labs, vitals, electrocardiograms and echocardiograms were assessed. Patients were contacted to determine vital status. The primary outcome was post-discharge mortality. RESULTS Of 166 patients, 158 patients (95.2%) had post-discharge follow-up, with a median time of follow-up of 2 years (IQR: [1 year, 4 years]). At discharge, the median ejection fraction (EF) was 52.5% (IQR: [32.5, 57.5]). At discharge, 92 patients (56%) were prescribed β-blockers, 28 (17%) were prescribed an ACE inhibitor, ARB or ARNI, and 50 (30%) were prescribed loop diuretics. Kaplan-Meier analysis showed a 1-year survival rate of 85.6% (95% CI: [80.1%, 91.2%]) and a 5-year survival rate of 60.6% (95% CI: [49.9%, 71.3%]). A Cox regression model demonstrated that a history of congestive heart failure (CHF) was strongly predictive of increased mortality hazard (HR = 1.929; p = 0.036), while neither discharge EF nor etiology of VA-ECLS were associated with increased post-discharge mortality. CONCLUSIONS Patients discharged from the hospital after full myocardial recovery from VA-ECLS support without HRT should have close outpatient follow-up due to the risk of recurrent heart failure and increased mortality in these patients.
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Affiliation(s)
- Gabriel Dardik
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Yuming Ning
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Paul Kurlansky
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | | | - Alice Vinogradsky
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Justin Fried
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Veli K Topkara
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Koji Takeda
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
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3
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Heart Lung Transplant 2023; 42:e1-e64. [PMID: 36805198 DOI: 10.1016/j.healun.2022.10.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 10/28/2022] [Indexed: 02/08/2023] Open
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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4
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Card Fail 2023; 29:304-374. [PMID: 36754750 DOI: 10.1016/j.cardfail.2022.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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5
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Reza J, Mila A, Ledzian B, Sun J, Silvestry S. Incremental cost-effectiveness of extracorporeal membranous oxygenation as a bridge to cardiac transplant or left ventricular assist device placement in patients with refractory cardiogenic shock. JTCVS OPEN 2022; 11:132-145. [PMID: 36172402 PMCID: PMC9510879 DOI: 10.1016/j.xjon.2022.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/26/2022] [Accepted: 06/27/2022] [Indexed: 11/18/2022]
Abstract
Objective Emerging literature has described using venoarterial extracorporeal membranous oxygenation (ECMO) as a bridge to transplant or left ventricular assist device (LVAD) placement. We sought to identify the incremental cost-effectiveness ratio (ICER) of ECMO used as a bridge to cardiac transplant or LVAD. Methods Patients with refractory cardiogenic shock who received venoarterial ECMO and were bridged to either cardiac transplant (n = 7) or a HeartMate 3 LVAD (n = 6) placement were included. Markov modeling was used, comparing ECMO bridging with non–ECMO-bridged patients. Cohorts entered the model alive and at every 1-year cycle, were exposed to risk of death, and ran forward for 20 years after transplant or LVAD. Results Patients bridged with ECMO to cardiac transplant were stratified as group 1 whereas those bridged with ECMO to LVAD were stratified as group 2. The average ECMO run was 3 days in group 1 versus 11 days in group 2. Among group 1 patients, the ICER was $246,629 but was paired with a longer life expectancy. The ICER of group 2 patients was –$107,088 and was not paired with a longer life expectancy. The average inpatient cost for group 1 was found to be $636,023 versus $769,471 for group 2 patients. The average inpatient costs for patients not bridged to ECMO who received cardiac transplant or LVAD was $538,928 and $325,242, respectively. Conclusions Using ECMO to bridge to transplant or LVAD placement is not cost effective. However, patients bridged to transplant are paired with longer life expectancy in contrast to patients bridged to LVAD.
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Affiliation(s)
- Joseph Reza
- General Surgery Residency Program, AdventHealth Orlando, Orlando, Fla
- Address for reprints: Joseph Reza, MD, 3401 N. Broad St. C501. Philadelphia, PA 19140.
| | - Ashley Mila
- General Surgery Residency Program, AdventHealth Orlando, Orlando, Fla
| | - Bradford Ledzian
- AdventHealth Transplant Institute, Thoracic Transplant and Cardiovascular Surgery, AdventHealth Orlando, Orlando, Fla
| | - Jingwei Sun
- Center for Academic Research, AdventHealth Orlando, Orlando, Fla
| | - Scott Silvestry
- AdventHealth Transplant Institute, Thoracic Transplant and Cardiovascular Surgery, AdventHealth Orlando, Orlando, Fla
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Chang BY, Zhang Z, Feng K, Josephy N, Keller SP, Edelman ER. Hysteretic device characteristics indicate cardiac contractile state for guiding mechanical circulatory support device use. Intensive Care Med Exp 2021; 9:62. [PMID: 34928472 PMCID: PMC8688616 DOI: 10.1186/s40635-021-00426-3] [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: 07/01/2021] [Accepted: 12/10/2021] [Indexed: 11/10/2022] Open
Abstract
Background Acute heart failure and cardiogenic shock remain highly morbid conditions despite prompt medical therapy in critical care settings. Mechanical circulatory support (MCS) is a promising therapy for these patients, yet remains managed with open-loop control. Continuous measure of cardiac function would support and optimize MCS deployment and weaning. The nature of indwelling MCS provides a platform for attaining this information. This study investigates how hysteresis modeling derived from MCS device signals can be used to assess contractility changes to provide continuous indication of changing cardiac state. Load-dependent MCS devices vary their operation with cardiac state to yield a device–heart hysteretic interaction. Predicting and examining this hysteric relation provides insight into cardiac state and can be separated by cardiac cycle phases. Here, we demonstrate this by predicting hysteresis and using the systolic portion of the hysteresis loop to estimate changes in native contractility. This study quantified this measurement as the enclosed area of the systolic portion of the hysteresis loop and correlated it with other widely accepted contractility metrics in animal studies (n = 4) using acute interventions that alter inotropy, including a heart failure model. Clinical validation was performed in patients (n = 8) undergoing Impella support. Results Hysteresis is well estimated from device signals alone (r = 0.92, limits of agreement: − 0.18 to 0.18). Quantified systolic area was well correlated in animal studies with end-systolic pressure–volume relationship (r = 0.84), preload recruitable stroke work index (r = 0.77), and maximum slope of left ventricular pressure (dP/dtmax) (r = 0.95) across a range of inotropic conditions. Comparable results were seen in patients with dP/dtmax (r = 0.88). Diagnostic capability from ROC analysis yielded AUC measurements of 0.92 and 0.90 in animal and patients, respectively. Conclusions Mechanical circulatory support hysteretic behavior can be well modeled using device signals and used to estimate contractility changes. Contractility estimate is correlated with other accepted metrics, captures temporal trends that elucidate changing cardiac state, and is able to accurately indicate changes in inotropy. Inherently available during MCS deployment, this measure will guide titration and inform need for further intervention.
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Affiliation(s)
- Brian Y Chang
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA.,Program in Health Sciences and Technology, Harvard Medical School, Boston, MA, USA
| | - Zhengyang Zhang
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Kimberly Feng
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Noam Josephy
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA.,Abiomed, Danvers, MA, USA
| | - Steven P Keller
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA.,Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Elazer R Edelman
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA. .,Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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7
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Mørk SR, Frederiksen CA, Nielsen RR, Lichscheidt E, Christensen S, Greisen JR, Tang M, Vase H, Løgstrup BB, Mellemkjær S, Wiggers HS, Mølgaard H, Poulsen SH, Terkelsen CJ, Eiskjær H. A systematic approach to weaning from extracorporeal membrane oxygenation in patients with refractory cardiac failure. Acta Anaesthesiol Scand 2021; 65:936-943. [PMID: 33728635 DOI: 10.1111/aas.13814] [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] [Accepted: 02/22/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is commonly used to provide haemodynamic support for patients with severe cardiac failure. However, timing ECMO weaning remains challenging. We aimed to examine if an integrative weaning approach based on predefined haemodynamic, respiratory and echocardiographic criteria is associated with successful weaning. METHODS All patients weaned from ECMO between April 2017 and April 2019 at Aarhus University Hospital, Denmark, were consecutively enrolled. Predefined haemodynamic, respiratory and echocardiographic criteria were assessed before and during ECMO flow reduction. A weaning attempt was commenced in haemodynamic stable patients and patients remaining stable at minimal flow were weaned from ECMO. Comparisons were made between patients who met the criteria for weaning at first attempt and patients who did not meet these criteria. Patients completing a full weaning attempt with no further need for mechanical support within 24 h were defined as successfully weaned. RESULTS A total of 38 patients were included in the study, of whom 26 (68%) patients met the criteria for weaning. Among these patients, 25 (96%) could be successfully weaned. Successfully weaned patients were younger and had less need for inotropic support and ECMO duration was shorter. Fulfilling the weaning criteria was associated with successful weaning and both favourable 30-d survival and survival to discharge. CONCLUSION An integrative weaning approach based on haemodynamic, respiratory and echocardiographic criteria may strengthen the clinical decision process in predicting successful weaning in patients receiving ECMO for refractory cardiac failure.
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Affiliation(s)
| | | | - Roni R. Nielsen
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
| | - Emil Lichscheidt
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
| | - Steffen Christensen
- Department of Anaesthesiology and Intensive Care Aarhus University Hospital Aarhus Denmark
| | - Jacob R. Greisen
- Department of Anaesthesiology and Intensive Care Aarhus University Hospital Aarhus Denmark
| | - Mariann Tang
- Deparmtent of Cardiothoracic and Vascular Surgery Aarhus University Hospital Aarhus Denmark
| | - Henrik Vase
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
| | | | - Søren Mellemkjær
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
| | | | - Henning Mølgaard
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
| | - Steen H. Poulsen
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
| | | | - Hans Eiskjær
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
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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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Acute Cardiac Unloading and Recovery: Proceedings of the 5th Annual Acute Cardiac Unloading and REcovery (A-CURE) symposium held on 14 December 2020. Interv Cardiol 2021; 16:1-3. [PMID: 33986827 PMCID: PMC8108564 DOI: 10.15420/icr.2021.s2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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10
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ECMO in Cardiac Arrest: A Narrative Review of the Literature. J Clin Med 2021; 10:jcm10030534. [PMID: 33540537 PMCID: PMC7867121 DOI: 10.3390/jcm10030534] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/12/2021] [Accepted: 01/26/2021] [Indexed: 01/07/2023] Open
Abstract
Cardiac arrest (CA) is a frequent cause of death and a major public health issue. To date, conventional cardiopulmonary resuscitation (CPR) is the only efficient method of resuscitation available that positively impacts prognosis. Extracorporeal membrane oxygenation (ECMO) is a complex and costly technique that requires technical expertise. It is not considered standard of care in all hospitals and should be applied only in high-volume facilities. ECMO combined with CPR is known as ECPR (extracorporeal cardiopulmonary resuscitation) and permits hemodynamic and respiratory stabilization of patients with CA refractory to conventional CPR. This technique allows the parallel treatment of the underlying etiology of CA while maintaining organ perfusion. However, current evidence does not support the routine use of ECPR in all patients with refractory CA. Therefore, an appropriate selection of patients who may benefit from this procedure is key. Reducing the duration of low blood flow by means of performing high-quality CPR and promoting access to ECPR, may improve the survival rate of the patients presenting with refractory CA. Indeed, patients who benefit from ECPR seem to carry better neurological outcomes. The aim of this present narrative review is to present the most recent literature available on ECPR and to clarify its potential therapeutic role, as well as to provide an in-depth explanation of equipment and its set up, the patient selection process, and the patient management post-ECPR.
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Sertic F, Bermudez C, Rame JE. Venoarterial Extracorporeal Membrane Oxygenation as a Bridge to Recovery or Bridge to Heart Replacement Therapy in Refractory Cardiogenic Shock. Curr Heart Fail Rep 2020; 17:341-349. [DOI: 10.1007/s11897-020-00495-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 01/16/2023]
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Combes A, Price S, Slutsky AS, Brodie D. Temporary circulatory support for cardiogenic shock. Lancet 2020; 396:199-212. [PMID: 32682486 DOI: 10.1016/s0140-6736(20)31047-3] [Citation(s) in RCA: 126] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/24/2020] [Accepted: 04/29/2020] [Indexed: 12/15/2022]
Abstract
Cardiogenic shock can occur due to acute ischaemic or non-ischaemic cardiac events, or from progression of long-standing underlying heart disease. When addressing the cause of underlying disease, the management of cardiogenic shock consists of vasopressors and inotropes; however, these agents can increase myocardial oxygen consumption, impair tissue perfusion, and are frequently ineffective. An alternative approach is to temporarily augment cardiac output using mechanical devices. The use of these devices-known as temporary circulatory support systems-has increased substantially in recent years, despite being expensive, resource intensive, associated with major complications, and lacking high-quality evidence to support their use. This Review summarises the physiological basis underlying the use of temporary circulatory support for cardiogenic shock, reviews the evidence informing indications and contraindications, addresses ethical considerations, and highlights the need for further research.
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Affiliation(s)
- Alain Combes
- Sorbonne Université, Institute of Cardiometabolism and Nutrition, Paris, France; Service de Médecine Intensive-Réanimation, Höpitaux Universitaires Pitié Salpêtrière, Assistance Publique-Höpitaux de Paris, Institut de Cardiologie, Paris, France.
| | - Susanna Price
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College, London, UK
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, NY, USA; Centre for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
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13
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Predictors of Survival for Patients with Acute Decompensated Heart Failure Requiring Extra-Corporeal Membrane Oxygenation Therapy. ASAIO J 2020; 65:781-787. [PMID: 30312208 DOI: 10.1097/mat.0000000000000898] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Chronic systolic heart failure (HF) with acute decompensation can result in cardiogenic shock (CS) requiring short-term mechanical circulatory support. We sought to identify predictors of survival for acute decompensated HF (ADHF) patients requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Patients >18 years old treated at our institution with VA-ECMO from 2009 to 2018 for ADHF with CS were studied. Demographic, hemodynamic, and echocardiographic data were collected. The primary outcome was survival to discharge. Fifty-two patients received VA-ECMO for ADHF with CS; 24 (46.2%) survived. Seventeen (32.7%) had suffered cardiac arrest, and 37 (71.2%) were mechanically ventilated. Mean lactate was 4.33 ± 3.45 mmol/L, and patients were receiving 2.7 ± 1.2 vasopressor/inotropic infusions at ECMO initiation; these did not differ significantly between survivors and nonsurvivors. Pre-ECMO cardiac index was 1.84 ± 0.56L/min/m and 1.94 ± 0.63L/min/m in survivors and nonsurvivors, respectively (p = 0.57). In multivariable analysis, only diabetes mellitus (DM; OR, 13.25; CI, 1.42-123.40; p = 0.02) and mineralocorticoid receptor antagonist use (OR, 0.12; CI, 0.02-0.78; p = 0.03) were independent predictors of mortality. Nineteen (79.2%) survivors required durable ventricular assist device. Among ADHF patients receiving VA-ECMO, DM is a powerful predictor of outcomes while markers of clinical acuity including hemodynamics, vasopressor/inotrope use, and lactate are not. The vast majority of survivors required durable left-ventricular assist devices.
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Fried JA, Masoumi A, Takeda K, Brodie D. How I approach weaning from venoarterial ECMO. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:307. [PMID: 32513218 PMCID: PMC7278069 DOI: 10.1186/s13054-020-03010-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 05/20/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Justin A Fried
- Department of Medicine, Division of Cardiology, Columbia University Medical Center/New York-Presbyterian Hospital, 622 West 168th Street, PH Building, 4th Floor, Room 129, New York, NY, 10032, USA.
| | - Amirali Masoumi
- Department of Medicine, Division of Cardiology, Columbia University Medical Center/New York-Presbyterian Hospital, 622 West 168th Street, PH Building, 4th Floor, Room 129, New York, NY, 10032, USA
| | - Koji Takeda
- Department of Surgery, Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY, USA
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY, USA
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15
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Chakaramakkil MJ, Sivathasan C. ECMO in cardiogenic shock and bridge to heart transplant. Indian J Thorac Cardiovasc Surg 2020; 37:319-326. [PMID: 33967452 DOI: 10.1007/s12055-020-00923-2] [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: 10/15/2019] [Revised: 12/31/2019] [Accepted: 01/02/2020] [Indexed: 10/25/2022] Open
Abstract
Purpose The aim of this review is to discuss the role of extracorporeal membrane oxygenation (ECMO) in cardiogenic shock and its use to bridge patients to heart transplantation. Methods and results Consideration of published literature reveals indications for ECMO in cardiogenic shock and tools for patient selection, adequate evidence of its efficacy, its advantages when compared with other temporary mechanical circulatory support devices and details of its use as a bridge to decision, bridge to recovery, bridge to bridge (durable ventricular assist device) and bridge to heart transplant. Conclusion ECMO is invaluable in treating patients with medically refractory profound cardiogenic shock and allows for cardiac recovery or planning for permanent heart replacement treatments.
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Affiliation(s)
- Mathew Jose Chakaramakkil
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, 5 Hospital drive, Singapore, 169609 Singapore
| | - Cumaraswamy Sivathasan
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, 5 Hospital drive, Singapore, 169609 Singapore
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Malick W, Fried JA, Masoumi A, Nair A, Zuver A, Huang A, Haythe J, Farr M, Rabbani L, Karmpaliotis D, Kirtane AJ, Topkara VK, Takeda K, Garan AR. Comparison of the Hemodynamic Response to Intra-Aortic Balloon Counterpulsation in Patients With Cardiogenic Shock Resulting from Acute Myocardial Infarction Versus Acute Decompensated Heart Failure. Am J Cardiol 2019; 124:1947-1953. [PMID: 31648782 DOI: 10.1016/j.amjcard.2019.09.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 09/03/2019] [Accepted: 09/06/2019] [Indexed: 10/25/2022]
Abstract
The intra-aortic balloon pump (IABP) neither benefits nor harms patients with acute myocardial infarction (AMI) with cardiogenic shock (CS) but may stabilize those with chronic heart failure who decompensate into CS. We sought to compare its hemodynamic effects in these 2 populations. We performed a retrospective analysis of the hemodynamic effects of IABP for AMI or acute decompensated heart failure (ADHF) patients with hemodynamic evidence of CS. The primary outcome was cardiac output (CO) change following insertion. In total, 205 patients were treated for CS resulting from AMI (73; 35.6%) or ADHF (132; 64.4%). At baseline, both cohorts had significant hemodynamic compromise with mean arterial pressure 75.6 ± 12.3 mm Hg, CO 3.02 ± 0.84 L/min, and cardiac power index 0.26 ± 0.06 W/m2; these parameters were nearly identical between groups though ADHF-CS patients had a higher pre-IABP mean pulmonary artery (PA) pressure than AMI-CS patients. After IABP insertion, ADHF-CS patients had moderate CO augmentation whereas AMI-CS experienced almost no improvement (0.58 ± 0.79 L/min vs 0.12 ± 1.00 L/min; p = 0.0009). Intracardiac filling pressures were reduced by similar amounts in both cohorts. Systemic vascular resistance was reduced in patients with ADHF-CS but not in those with AMI-CS. In conclusion, following IABP insertion, ADHF-CS patients experience roughly a 5-fold greater CO augmentation compared with AMI-CS patients. Pre-IABP PA pressure differences and differential systemic vascular resistance reduction may explain these results and shed light on recent evidence supporting IABP use in ADHF-CS and curbing it in AMI-CS.
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Renal dysfunction and cardiogenic shock complicating acute coronary syndromes. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2019; 7:687-688. [PMID: 30480482 DOI: 10.1177/2048872618819089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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18
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Cheng YT, Garan AR, Sanchez J, Kurlansky P, Ando M, Cevasco M, Yuzefpolskaya M, Colombo PC, Naka Y, Takayama H, Takeda K. Midterm Outcomes of Bridge-to-Recovery Patients After Short-Term Mechanical Circulatory Support. Ann Thorac Surg 2019; 108:524-530. [PMID: 30851259 DOI: 10.1016/j.athoracsur.2019.01.060] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 12/30/2018] [Accepted: 01/21/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND The use of short-term mechanical circulatory support (ST-MCS) has increased for refractory cardiogenic shock. However, there are scant data about bridge-to-recovery patients. METHODS We retrospectively reviewed 502 patients with cardiogenic shock who received venoarterial extracorporeal membrane oxygenation or a temporary surgical ventricular assist device as ST-MCS between 2010 and 2016. There were 178 patients (35.5%) who survived through device explantation. Of these, 149 patients (29.7%) survived to discharge and were included for analysis. The primary outcome was midterm survival without undergoing heart replacement therapy. RESULTS In our bridge-to-recovery cohort, 101 patients (67.8%) were men, and the median age was 59 years (interquartile range, 51 to 67 years). Etiology of cardiogenic shock included postcardiotomy shock in 35.6% of patients (n = 53), allograft failure in 26.8% (n = 40), acute myocardial infarction (AMI) in 24.2% (n = 36), and other acute decompensated heart failure in 14.4% (n = 20). There were 24 major events (16.1%) recorded, including 21 patients who died and 3 patients who received heart replacement therapy during median follow-up of 306 days (interquartile range, 58.25 to 916.75 days). Overall freedom from event at 3 years was 74.2%. In subgroup analysis, AMI patients had a significantly worse freedom-from-event rate at 40.4% (p < 0.001). By univariate Cox analysis, AMI etiology (p = 0.003), length of ST-MCS (p = 0.06), blood urea nitrogen (p = 0.012), and left ventricular ejection fraction (p = 0.005) at discharge were predictors for adverse events. CONCLUSIONS The overall midterm outcome of patients explanted from ST-MCS is favorable except for AMI patients.
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Affiliation(s)
- Yi-Tso Cheng
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York; Department of Surgery, Buddhist Tzu Chi General Hospital, Hualien, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Arthur R Garan
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Joseph Sanchez
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Paul Kurlansky
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Masahiko Ando
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Marisa Cevasco
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Melana Yuzefpolskaya
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Paolo C Colombo
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Hiroo Takayama
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York.
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Nakagawa S, Garan AR, Takeda K, Takayama H, Topkara VK, Yuzefpolskaya M, Yuill L, Lin SX, Colombo PC, Naka Y, Blinderman CD. Palliative Care Consultation in Cardiogenic Shock Requiring Short-Term Mechanical Circulatory Support: A Retrospective Cohort Study. J Palliat Med 2019; 22:432-436. [PMID: 30615561 DOI: 10.1089/jpm.2018.0393] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Little is known about palliative care consultation (PCC) for patients with cardiogenic shock requiring short-term mechanical circulatory support (STMCS). OBJECTIVE To describe the utilization of PCC in this population. DESIGN Retrospective cohort study in a university medical center intensive care unit (ICU). SETTING/PARTICIPANTS In total, 195 patients aged >18 years with cardiogenic shock requiring STMCS were included. The cohort was divided into three categories: no PCC, early PCC (within seven days of STMCS), and late PCC (eight or more days after STMCS). Follow-up occurred during the index hospitalization. RESULTS Mean age was 59.3 ± 13.9 years; 67.9% were men. Mean follow-up period was 33.8 ± 37.7 days. Overall inpatient mortality was 52.3%. Ninety-four patients (48.2%) received PCC; 49 (25.1%) and 45 (23.1%) received early and late PCCs, respectively. STMCS duration, ICU stay after STMCS, and hospital stay after STMCS were significantly shorter in the no PCC group than the early PCC group (4 vs. 12 days, p < 0.001; 11 vs. 19 days, p = 0.004; and 16 vs. 19 days, p = 0.031; respectively). ICU stay after STMCS and hospital stay after STMCS were significantly shorter in the early PCC group than the late PCC group (19 vs. 38 days, p < 0.001; 19 vs. 49 days, p < 0.001; respectively). However, time from initial PCC to discharge was not significantly different between early and late PCC groups (18 vs. 31 days, p = 0.13). CONCLUSIONS PCC was utilized in almost half of patients with cardiogenic shock requiring STMCS. PCC tends to occur toward the end of life regardless of the duration of STMCS. The optimal PCC timing remained unclear.
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Affiliation(s)
- Shunichi Nakagawa
- 1 Adult Palliative Care, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Arthur R Garan
- 2 Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Koji Takeda
- 3 Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Hiroo Takayama
- 3 Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Veli K Topkara
- 2 Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Melana Yuzefpolskaya
- 2 Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Lauren Yuill
- 4 Adult Palliative Care, Department of Care Coordination and Social Work, NewYork Presbyterian Hospital, New York, New York
| | - Susan X Lin
- 5 Center for Family and Community Medicine, Columbia University Medical Center, New York, New York
| | - Paolo C Colombo
- 2 Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Yoshifumi Naka
- 3 Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Craig D Blinderman
- 1 Adult Palliative Care, Department of Medicine, Columbia University Medical Center, New York, New York
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20
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Position paper for the organization of ECMO programs for cardiac failure in adults. Intensive Care Med 2018; 44:717-729. [DOI: 10.1007/s00134-018-5064-5] [Citation(s) in RCA: 144] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 01/12/2018] [Indexed: 02/06/2023]
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