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Keller SP, Whitman GJR, Grant MC. Temporary Mechanical Circulatory Support after Cardiac Surgery. J Cardiothorac Vasc Anesth 2024; 38:2080-2088. [PMID: 38955616 DOI: 10.1053/j.jvca.2024.06.014] [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: 03/17/2024] [Revised: 05/30/2024] [Accepted: 06/11/2024] [Indexed: 07/04/2024]
Abstract
Postcardiotomy shock in the cardiac surgical patient is a highly morbid condition characterized by profound myocardial impairment and decreased systemic perfusion inadequate to meet end-organ metabolic demand. Postcardiotomy shock is associated with significant morbidity and mortality. Poor outcomes motivate the increased use of mechanical circulatory support (MCS) to restore perfusion in an effort to prevent multiorgan injury and improve patient survival. Despite growing acceptance and adoption of MCS for postcardiotomy shock, criteria for initiation, clinical management, and future areas of clinical investigation remain a topic of ongoing debate. This article seeks to (1) define critical cardiac dysfunction in the patient after cardiotomy, (2) provide an overview of commonly used MCS devices, and (3) summarize the relevant clinical experience for various MCS devices available in the literature, with additional recognition for the role of MCS as a part of a modified approach to the cardiac arrest algorithm in the cardiac surgical patient.
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Affiliation(s)
- Steven P Keller
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Glenn J R Whitman
- Department of Surgery, Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael C Grant
- Department of Surgery, Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Anesthesiology and Critical Care Medicine, Divisions of Cardiac Anesthesia and Surgical Critical, The Johns Hopkins University School of Medicine, Baltimore, MD.
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Goffer EM, Lamberti KK, Spognardi AM, Edelman ER, Keller SP. Steady Flow Left Ventricle Unloading Is Superior to Pulsatile Pressure Augmentation Venting During Venoarterial Extracorporeal Membrane Oxygenation Support. ASAIO J 2024:00002480-990000000-00460. [PMID: 38588597 DOI: 10.1097/mat.0000000000002208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024] Open
Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) shunts venous blood to the systemic arterial circulation to provide end-organ perfusion while increasing afterload that may impede left ventricle (LV) ejection and impair cardiac recovery. To maintain flow across the aortic valve and reduce risk of lethal clot formation, secondary mechanical circulatory support (MCS) devices are increasingly used despite limited understanding of their effects on cardiac function. This study sought to quantify the effects of VA-ECMO and combined with either intraaortic balloon pump (IABP) or percutaneous ventricular assist device (pVAD) on LV physiologic state and perfusion metrics in a porcine model of acute cardiogenic shock. Shock was induced through serial left anterior descending artery microbead embolization followed by initiation of VA-ECMO support and then placement of either IABP or pVAD. Hemodynamic measurements, LV pressure-volume loops, and carotid artery blood flow were evaluated before and after institution of combined MCS. The IABP decreased LV end-diastolic pressure by a peak of 15% while slightly increasing LV stroke work compared with decreases of more than 60% and 50% with the pVAD, respectively. The pVAD also demonstrated increased coronary perfusion and systemic pressure gradients in comparison to the IABP. Combined support with VA-ECMO and pVAD improves cardiovascular state in comparison to IABP.
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Affiliation(s)
- Efrat M Goffer
- From the Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Kimberly K Lamberti
- From the Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | | | - Elazer R Edelman
- From the Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Steven P Keller
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
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Monaco F, Ajello S, Calabrò MG, Melisurgo G, Landoni G, Arata A, Lerose CC, Fumagalli E, Tomasso ND, Frontera A, Scandroglio AM, Della Bella P, Zangrillo A. Left Ventricular Unloading With an IABP in Patients Undergoing Ventricular Tachycardia Ablation With ECMO Support. J Cardiothorac Vasc Anesth 2021; 35:2686-2693. [PMID: 33487532 DOI: 10.1053/j.jvca.2020.12.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/27/2020] [Accepted: 12/28/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The authors investigated the preprocedural predictors of postprocedural intra-aortic balloon pump (IABP) need in patients undergoing transcatheter ventricular tachycardia (VT) ablation on venoarterial (VA) extracorporeal membrane oxygenation (ECMO). DESIGN Observational study. SETTING Hybrid operating room and intensive care unit of a teaching hospital. PATIENTS Participants were 121 consecutive patients with unstable VT undergoing transcatheter ablation with VA-ECMO. INTERVENTIONS In patients with postprocedural echocardiographic, radiographic, or hemodynamic signs of increased left ventricle afterload, an IABP was positioned. MEASUREMENTS AND MAIN RESULTS Patients in the IABP group were more frequently on angiotensin-converting enzyme inhibitors (58% v 37%; p = 0.03) and had lower median baseline ejection fraction (25% v 28% p = 0.05), larger end-diastolic diameter (69.7 mm ± 13.0 v 65.7 mm ± 11.3; p = 0.03), and more frequent ischemic etiology as the reason for dilated cardiomyopathy (76% v 47%; p = 0.04,) when compared with patients not requiring IABP. Postoperatively, the IABP group required longer mechanical ventilation (24 hours [20-56.5] v 23 hours [15-28]; p = 0.003), intensive care unit stay (78 hours [46-174] v 48 hours [24-72]; p < 0.001), and continuous renal replacement therapy (13.3% v 1.3%; p = 0.006). By multivariate analysis, end-diastolic diameter (odds ratio [OR]:1.08; confidence interval [CI]: 1.00-1.16; p = 0.049), ischemic dilated cardiomyopathy (OR: 8.40; CI: 2.15-32.88; p = 0.002), and more-than-moderate mitral regurgitation (OR: 4.83; CI: 1.22-19.22; p = 0.025) were independent predictors of need for IABP. CONCLUSIONS The need for an IABP to unload the left ventricle can be predicted by ventricular size, medium-severe mitral valvular defect, and ischemic etiology of the dilated cardiomyopathy.
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Affiliation(s)
- Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy Twitter: @SRAnesthesiaICU
| | - Silvia Ajello
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy Twitter: @SRAnesthesiaICU
| | - Maria Grazia Calabrò
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy Twitter: @SRAnesthesiaICU
| | - Giulio Melisurgo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy Twitter: @SRAnesthesiaICU
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy Twitter: @SRAnesthesiaICU; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
| | - Allegra Arata
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy Twitter: @SRAnesthesiaICU
| | - Caterina Cecilia Lerose
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy Twitter: @SRAnesthesiaICU
| | - Elisabetta Fumagalli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy Twitter: @SRAnesthesiaICU
| | - Nora Di Tomasso
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy Twitter: @SRAnesthesiaICU
| | - Antonio Frontera
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy Twitter: @SRAnesthesiaICU
| | - Anna Mara Scandroglio
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Della Bella
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy Twitter: @SRAnesthesiaICU; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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Piechura LM, Coppolino A, Mody GN, Rinewalt DE, Keshk M, Ogawa M, Seethala R, Bohula EA, Morrow DA, Singh SK, Mallidi HR, Keller SP. Left ventricle unloading strategies in ECMO: A single-center experience. J Card Surg 2020; 35:1514-1524. [PMID: 32485030 PMCID: PMC7357854 DOI: 10.1111/jocs.14644] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) is a life-saving technology capable of restoring perfusion but is not without significant complications that limit its realizable therapeutic benefit. ECMO-induced hemodynamics increase cardiac afterload risking left ventricular distention and impaired cardiac recovery. To mitigate potentially harmful effects, multiple strategies to unload the left ventricle (LV) are used in clinical practice but data supporting the optimal approach is presently lacking. MATERIALS & METHODS We reviewed outcomes of our ECMO population from September 2015 through January 2019 to determine if our LV unloading strategies were associated with patient outcomes. We compared reactive (Group 1, n = 30) versus immediate (Group 2, n = 33) LV unloading and then compared patients unloaded with an Impella CP (n = 19) versus an intra-aortic balloon pump (IABP, n = 16), analyzing survival and ECMO-related complications. RESULTS Survival was similar between Groups 1 and 2 (33 vs 42%, P = .426) with Group 2 experiencing more clinically-significant hemorrhage (40 vs. 67%, P = .034). Survival and ECMO-related complications were similar between patients unloaded with an Impella versus an IABP. However, the Impella group exhibited a higher rate of survival (37%) than predicted by their median SAVE score (18%). DISCUSSION Based on this analysis, reactive unloading appears to be a viable strategy while venting with the Impella CP provides better than anticipated survival. Our findings correlate with recent large cohort studies and motivate further work to design clinical guidelines and future trial design.
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Affiliation(s)
- Laura M. Piechura
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Antonio Coppolino
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Gita N. Mody
- Division of Cardiothoracic Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Dan E. Rinewalt
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Mohammed Keshk
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Mitsugu Ogawa
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Raghu Seethala
- Department of Emergency Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Erin A. Bohula
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - David A. Morrow
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | | | - Hari R. Mallidi
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Steven P. Keller
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA
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