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Sponga S, Vendramin I, Salman J, Ferrara V, De Manna ND, Lechiancole A, Warnecke G, Dralov A, Haverich A, Ius F, Bortolotti U, Livi U, Avsar M. Heart Transplantation in High-Risk Recipients Employing Donor Marginal Grafts Preserved With Ex-Vivo Perfusion. Transpl Int 2023; 36:11089. [PMID: 37547752 PMCID: PMC10401590 DOI: 10.3389/ti.2023.11089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 07/10/2023] [Indexed: 08/08/2023]
Abstract
Extending selection criteria to face donor organ shortage in heart transplantation (HTx) may increase the risk of mortality. Ex-vivo normothermic perfusion (EVP) limits ischemic time allowing assessment of graft function. We investigated the outcome of HTx in 80 high-risk recipients transplanted with marginal donor and EVP-preserved grafts, from 2016 to 2021. The recipients median age was 57 years (range, 13-75), with chronic renal failure in 61%, impaired liver function in 11% and previous cardiac surgery in 90%; 80% were mechanically supported. Median RADIAL score was 3. Mean graft ischemic time was 118 ± 25 min, "out-of-body" time 420 ± 66 min and median cardiopulmonary bypass (CPB) time 228 min (126-416). In-hospital mortality was 11% and ≥moderate primary graft dysfunction 16%. At univariable analysis, CPB time and high central venous pressure were risk factors for mortality. Actuarial survival at 1 and 3 years was 83% ± 4%, and 72% ± 7%, with a median follow-up of 16 months (range 2-43). Recipient and donor ages, pre-HTx extracorporeal life support and intra-aortic balloon pump were risk factors for late mortality. In conclusion, the use of EVP allows extension of the graft pool by recruitment of marginal donors to successfully perform HTx even in high-risk recipients.
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Affiliation(s)
- Sandro Sponga
- Department of Medicine, University of Udine, Udine, Italy
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Igor Vendramin
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Jawad Salman
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | | | | | | | - Gregor Warnecke
- Department of Cardiac Surgery, Heidelberg Medical School, Heidelberg, Germany
| | - Andriy Dralov
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Uberto Bortolotti
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Ugolino Livi
- Department of Medicine, University of Udine, Udine, Italy
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Murat Avsar
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Muacevic A, Adler JR, Upadhyay HV, Konat A, Zalavadia P, Padaniya A, Patel P, Patel N, Prajjwal P, Sharma K. Mechanical Assist Device-Assisted Percutaneous Coronary Intervention: The Use of Impella Versus Extracorporeal Membrane Oxygenation as an Emerging Frontier in Revascularization in Cardiogenic Shock. Cureus 2023; 15:e33372. [PMID: 36751242 PMCID: PMC9898582 DOI: 10.7759/cureus.33372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 01/06/2023] Open
Abstract
The extracorporeal membrane oxygenation (ECMO) procedure aids in the provision of prolonged cardiopulmonary support, whereas the Impella device (Abiomed, Danvers, MA) is a ventricular assist device that maintains circulation by pumping blood into the aorta from the left ventricle. Blood is circulated in parallel with the heart by Impella. It draws blood straight into the aorta from the left ventricle, hence preserving the physiological flow. ECMO bypasses the left atrium and the left ventricle, and the end consequence is a non-physiological flow. In this article, we conducted a detailed analysis of various publications in the literature and examined various modalities pertaining to the use of ECMO and Impella for cardiogenic shocks, such as efficacy, clinical outcomes, cost-effectiveness, device-related complications, and limitations. The Impella completely unloads the left ventricle, thereby significantly reducing the effort of the heart. Comparatively, ECMO only stabilizes a patient with cardiogenic shock for a short stretch of time and does not lessen the efforts of the left ventricle ("unload" it). In the acute setting, both devices reduced left ventricular end-diastolic pressure and provided adequate hemodynamic support. By comparing patients on Impella to those receiving ECMO, it was found that patients on Impella were associated with better clinical results, quicker recovery, limited complications, and reduced healthcare costs; however, there is a lack of conclusive studies performed demonstrating the reduction in long-term mortality rates. Considering the effectiveness of given modalities and taking into account the various studies described in the literature, Impella has reported better clinical outcomes although more clinical trials are needed for establishing the effectiveness of these interventional approaches in revascularization in cardiogenic shock.
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3
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Karpasiti T. A Narrative Review of Nutrition Therapy in Patients Receiving Extracorporeal Membrane Oxygenation. ASAIO J 2022; 68:763-771. [PMID: 34324446 DOI: 10.1097/mat.0000000000001540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The use of extracorporeal membrane oxygenation (ECMO) in patients with severe cardiorespiratory failure has seen significant growth in the last decade. Despite this, there is paucity of data surrounding the optimum nutritional management for ECMO patients. This review aimed to describe current nutrition practices in patients receiving ECMO, critically appraise available studies and identify areas for future research. A literature search was conducted in PubMed, MEDLINE, and CINAHL Plus to identify all randomized trials and observational studies published between July 2000 and July 2020 investigating nutrition practices in critically ill adults receiving ECMO. The primary outcomes were nutritional adequacy, gastrointestinal complications, and physical function. Secondary outcomes included mortality, length of stay, and duration on ECMO support. From a total of 31 studies identified, 12 met the inclusion criteria. Nine observational studies were reviewed following eligibility assessment. Early enteral nutrition was deemed safe and feasible for ECMO patients; however, meeting nutritional targets was challenging. Utilizing alternative nutrition routes is an option, although risks and benefits should be taken into consideration. Data on gastrointestinal complications and other clinical outcomes were inconsistent, and no data were identified investigating the effects of nutrition on the physical and functional recovery of ECMO patients. Nutrition therapy in ECMO patients should be provided in line with current guidelines for nutrition in critical illness until further data are available. Further prospective, randomized studies investigating optimum nutrition practices and effects on clinical and functional outcomes are urgently required.
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Affiliation(s)
- Terpsi Karpasiti
- From the Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
- Barts Health NHS Trust, St Bartholomew's Hospital, West Smithfield, London, United Kingdom
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4
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Kops SA, White SC, Klewer SE, Andrews JG, Seckeler MD. ECMO in adults with congenital heart disease - Analysis of a national discharge database. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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5
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An Optimal H-Infinity Controller for Left Ventricular Assist Devices Based on a Starling-like Controller: A Simulation Study. MATHEMATICS 2022. [DOI: 10.3390/math10050731] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Left ventricular assist devices (LVADs) are emerging innovations that provide a feasible alternative treatment for heart failure (HF) patients to enhance their quality of life. In this work, a novel physiological control system to optimize LVAD pump speed using an H-infinity controller was developed. The controller regulates the calculated target pump flow vs. measured pump flow to meet the changes in metabolic demand. The method proposes the implementation of the Frank–Starling mechanism (FSM) approach to control the speed of an LVAD using the left ventricle end-diastolic volume (Vlved) parameter (preload). An operating point was proposed to move between different control lines within the safe area to achieve the FSM. A proportional–integral (PI) controller was used to control the gradient angle between control lines to obtain the flow target. A lumped parameter model of the cardiovascular system was used to evaluate the proposed method. Exercise and rest scenarios were assessed under multi-physiological conditions of HF patients. Simulation results demonstrated that the control system was stable and feasible under different physiological states of the cardiovascular system (CVS). In addition, the proposed controller was able to keep hemodynamic variables within an acceptable range of the mean pump flow (Qp) (max = 5.2 L/min and min = 3.2 L/min) during test conditions.
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6
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Justus A, Burrell A, Anstey C, Cornmell G, Brodie D, Shekar K. The Association of Oxygenation, Carbon Dioxide Removal, and Mechanical Ventilation Practices on Survival During Venoarterial Extracorporeal Membrane Oxygenation. Front Med (Lausanne) 2021; 8:756280. [PMID: 34869455 PMCID: PMC8636903 DOI: 10.3389/fmed.2021.756280] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/25/2021] [Indexed: 01/01/2023] Open
Abstract
Introduction: Oxygenation and carbon dioxide removal during venoarterial extracorporeal membrane oxygenation (VA ECMO) depend on a complex interplay of ECMO blood and gas flows, native lung and cardiac function as well as the mechanical ventilation strategy applied. Objective: To determine the association of oxygenation, carbon dioxide removal, and mechanical ventilation practices with in-hospital mortality in patients who received VA ECMO. Methods: Single center, retrospective cohort study. All consecutive patients who received VA ECMO in a tertiary ECMO referral center over a 5-year period were included. Data on demographics, ECMO and ventilator support details, and blood gas parameters for the duration of ECMO were collected. A multivariable logistic time-series regression model with in-hospital mortality as the primary outcome variable was used to analyse the data with significant factors at the univariate level entered into the multivariable regression model. Results: Overall, 52 patients underwent VA ECMO: 26/52 (50%) survived to hospital discharge. The median PaO2 for the duration of ECMO support was 146 mmHg [IQR 131-188] and PaCO2 was 37.2 mmHg [IQR 35.3, 39.9]. Patients who survived to hospital discharge had a significantly lower median PaO2 (117 [98, 140] vs. 154 [105, 212] mmHg, P = 0.04) and higher median PaCO2 (38.3 [36.1, 41.1] vs. 36.3 [34.5, 37.8] mmHg, p = 0.03). Survivors also had significantly lower median VA ECMO blood flow rate (EBFR, 3.6 [3.3, 4.2] vs. 4.3 [3.8, 5.2] L/min, p = < 0.001) and greater measured minute ventilation (7.04 [5.63, 8.35] vs. 5.32 [4.43, 6.83] L/min, p = 0.01). EBFR, PaO2, PaCO2, and minute ventilation, however, were not independently associated with death in a multivariable analysis. Conclusion: This exploratory analysis in a small group of VA ECMO supported patients demonstrated that hyperoxemia was common during VA ECMO but was not independently associated with increased mortality. Survivors also received lower EBFR and had greater minute ventilation, but this was also not independently associated with survival. These findings highlight that interactions between EBFR, PaO2, and native lung ventilation may be more relevant than their individual association with survival. Further research is indicated to determine the optimal ECMO and ventilator settings on outcomes in VA ECMO.
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Affiliation(s)
- Angelo Justus
- Adult Intensive Care, Sunshine Coast University Hospital, Sunshine Coast, QLD, Australia
| | - Aidan Burrell
- Australian and New Zealand Intensive Care-Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
| | - Chris Anstey
- School of Medicine, Griffith University, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - George Cornmell
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, United States
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, United States
| | - Kiran Shekar
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
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Excessive unbound cefazolin concentrations in critically ill patients receiving veno-arterial extracorporeal membrane oxygenation (vaECMO): an observational study. Sci Rep 2021; 11:16981. [PMID: 34417526 PMCID: PMC8379255 DOI: 10.1038/s41598-021-96654-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 08/11/2021] [Indexed: 12/28/2022] Open
Abstract
The scope of extracorporeal membrane oxygenation (ECMO) is expanding, nevertheless, pharmacokinetics in patients receiving cardiorespiratory support are fairly unknown leading to unpredictable drug concentrations. Currently, there are no clear guidelines for antibiotic dosing during ECMO. This study aims to evaluate the pharmacokinetics (PK) of cefazolin in patients undergoing ECMO treatment. Total and unbound plasma cefazolin concentration of critically ill patients on veno-arterial ECMO were determined. Observed PK was compared to dose recommendations calculated by an online available, free dosing software. Concentration of cefazolin varied broadly despite same dosage in all patients. The mean total and unbound plasma concentration were high showing significantly (p = 5.8913 E−09) greater unbound fraction compared to a standard patient. Cefazolin clearance was significantly (p = 0.009) higher in patients with preserved renal function compared with CRRT. Based upon the calculated clearance, the use of dosing software would have led to lower but still sufficient concentrations of cefazolin in general. Our study shows that a “one size fits all” dosing regimen leads to excessive unbound cefazolin concentration in these patients. They exhibit high PK variability and decreased cefazolin clearance on ECMO appears to compensate for ECMO- and critical illness-related increases in volume of distribution.
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Abstract
Despite advances in cardiovascular care, managing cardiogenic shock caused by structural heart disease is challenging. Patients with cardiogenic shock are critically ill upon presentation and require early disease recognition and rapid escalation of care. Temporary mechanical circulatory support provides a higher level of care than current medical therapies such as vasopressors and inotropes. This review article focuses on the role of hemodynamic monitoring, mechanical circulatory support, and device selection in patients who present with cardiogenic shock due to structural heart disease. Early initiation of appropriate mechanical circulatory support may reduce morbidity and mortality.
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9
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Sacco A, Tavazzi G, Morici N, Viola G, Meani P, Oliva FG, Pappalardo F. Arterial elastance modulation by intra-aortic balloon counterpulsation in patients with acute decompensated heart failure and low-output state. J Cardiovasc Med (Hagerstown) 2021; 22:231-232. [PMID: 32858629 DOI: 10.2459/jcm.0000000000001088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Alice Sacco
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic, and Pediatric Sciences, Unit of Anaesthesia and Intensive Care, Fondazione Policlinico San Matteo, IRCCS, Pavia
| | - Nuccia Morici
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan
| | - Giovanna Viola
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan
| | - Paolo Meani
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan
| | - Fabrizio G Oliva
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan
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10
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Extracorporeal Gas Exchange for Acute Respiratory Distress Syndrome: Open Questions, Controversies and Future Directions. MEMBRANES 2021; 11:membranes11030172. [PMID: 33670987 PMCID: PMC7997339 DOI: 10.3390/membranes11030172] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 02/06/2023]
Abstract
Veno-venous extracorporeal membrane oxygenation (V-V ECMO) in acute respiratory distress syndrome (ARDS) improves gas exchange and allows lung rest, thus minimizing ventilation-induced lung injury. In the last forty years, a major technological and clinical improvement allowed to dramatically improve the outcome of patients treated with V-V ECMO. However, many aspects of the care of patients on V-V ECMO remain debated. In this review, we will focus on main issues and controversies on caring of ARDS patients on V-V ECMO support. Particularly, the indications to V-V ECMO and the feasibility of a less invasive extracorporeal carbon dioxide removal will be discussed. Moreover, the controversies on management of mechanical ventilation, prone position and sedation will be explored. In conclusion, we will discuss evidences on transfusions and management of anticoagulation, also focusing on patients who undergo simultaneous treatment with ECMO and renal replacement therapy. This review aims to discuss all these clinical aspects with an eye on future directions and perspectives.
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11
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Point-of-care testing of plasma free hemoglobin and hematocrit for mechanical circulatory support. Sci Rep 2021; 11:3788. [PMID: 33589647 PMCID: PMC7884396 DOI: 10.1038/s41598-021-83327-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 02/01/2021] [Indexed: 11/17/2022] Open
Abstract
Hematological analysis is essential for patients who are supported by a mechanical circulatory support (MCS). The laboratory methods used to analyze blood components are conventional and accurate, but they require a mandatory turn-around-time for laboratory results, and because of toxic substances, can also be hazardous to analysis workers. Here, a simple and rapid point-of-care device is developed for the measurement of plasma free hemoglobin (PFHb) and hematocrit (Hct), based on colorimetry. The device consists of camera module, minimized centrifuge system, and the custom software that includes the motor control algorithm for the centrifuge system, and the image processing algorithm for measuring the color components of blood from the images. We show that our device measured PFHb with a detection limit of 0.75 mg/dL in the range of (0–100) mg/dL, and Hct with a detection limit of 2.14% in the range of (20–50)%. Our device had a high correlation with the measurement method generally used in clinical laboratories (PFHb R = 0.999, Hct R = 0.739), and the quantitative analysis resulted in precision of 1.44 mg/dL for PFHb value of 14.5 mg/dL, 1.36 mg/dL for PFHb value of 53 mg/dL, and 1.24% for Hct 30%. Also, the device can be measured without any pre-processing when compared to the clinical laboratory method, so results can be obtained within 5 min (about an 1 h for the clinical laboratory method). Therefore, we conclude that the device can be used for point-of-care measurement of PFHb and Hct for MCS.
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12
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Grasselli G, Giani M, Scaravilli V, Fumagalli B, Mariani C, Redaelli S, Lucchini A, Zanella A, Patroniti N, Pesenti A, Foti G. Volatile Sedation for Acute Respiratory Distress Syndrome Patients on Venovenous Extracorporeal Membrane Oxygenation and Ultraprotective Ventilation. Crit Care Explor 2021; 3:e0310. [PMID: 33458679 PMCID: PMC7803679 DOI: 10.1097/cce.0000000000000310] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Supplemental Digital Content is available in the text. Patients on extracorporeal support for severe acute respiratory distress syndrome may require a prolonged period of deep sedation. In these patients, volatile sedation may represent a valid alternative to IV drugs. The aim of our study was to describe the feasibility of volatile sedation in a large cohort of acute respiratory distress syndrome patients undergoing venovenous extracorporeal membrane oxygenation and ultraprotective ventilation.
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Affiliation(s)
- Giacomo Grasselli
- Dipartimento di Fisiopatologia Medico Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy.,Dipartimento di Anestesia-Rianimazione e Emergenza Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Giani
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Monza, Italy.,Dipartimento di Emergenza-Urgenza, ASST Monza, Monza, Italy
| | - Vittorio Scaravilli
- Dipartimento di Fisiopatologia Medico Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy.,Dipartimento di Anestesia-Rianimazione e Emergenza Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Benedetta Fumagalli
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - Carminia Mariani
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - Sara Redaelli
- Dipartimento di Emergenza-Urgenza, ASST Monza, Monza, Italy
| | | | - Alberto Zanella
- Dipartimento di Fisiopatologia Medico Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy.,Dipartimento di Anestesia-Rianimazione e Emergenza Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicolò Patroniti
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università di Genova, Genova, Italy.,Dipartimento di Anestesia e Terapia Intensiva, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Antonio Pesenti
- Dipartimento di Fisiopatologia Medico Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy.,Dipartimento di Anestesia-Rianimazione e Emergenza Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Foti
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Monza, Italy.,Dipartimento di Emergenza-Urgenza, ASST Monza, Monza, Italy
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13
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Design, Manufacturing Technology and In-Vitro Evaluation of Original, Polyurethane, Petal Valves for Application in Pulsating Ventricular Assist Devices. Polymers (Basel) 2020; 12:polym12122986. [PMID: 33333728 PMCID: PMC7765235 DOI: 10.3390/polym12122986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/01/2020] [Accepted: 12/09/2020] [Indexed: 12/04/2022] Open
Abstract
Minimizing of the life-threatening thrombo-emboli formation in pulsatile heart assist devices by a new biomimetic heart valve design is presently one of the most important problems in medicine. As part of this work, an original valve structure was proposed intended for pneumatic, extracorporeal ventricular assist devices. The valve design allows for direct integration with other parts of the pulsating blood pump. Strengthening in the form of the titanium or steel frame has been introduced into the polyurethane lagging, which allows for maintaining material continuity and eliminating the risk of blood clotting. The prototype of the valve was made by the injection molding method assisted by numerical simulation of this process. The prototype was introduced into a modified pulsating, extracorporeal heart assist pump ReligaHeart EXT (developed for tilting disc valves) and examined in-vitro using the “artificial patient” model in order to determine hydrodynamic properties of the valve in the environment similar to physiological conditions. Fundamental blood tests, like hemolysis and thrombogenicity have been carried out. Very low backflow through the closed valve was observed despite their slight distortion due to pressure. On the basis of immunofluorescence tests, only slight activation of platelets was found on the inlet valve and slight increased risk of clotting of the outlet valve commissures as a result of poor valve leaflets assembling in the prototype device. No blood hemolysis was observed. Few of the clots formed only in places where the valve surfaces were not smooth enough.
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14
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Venoarterial Extracorporeal Membrane Oxygenation. Anesthesiology 2020; 133:708-710. [PMID: 32796200 DOI: 10.1097/aln.0000000000003487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Ni hIci T, Boardman HM, Baig K, Stafford JL, Cernei C, Bodger O, Westaby S. Mechanical assist devices for acute cardiogenic shock. Cochrane Database Syst Rev 2020; 6:CD013002. [PMID: 32496607 PMCID: PMC7271960 DOI: 10.1002/14651858.cd013002.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Cardiogenic shock (CS) is a state of critical end-organ hypoperfusion due to a primary cardiac disorder. For people with refractory CS despite maximal vasopressors, inotropic support and intra-aortic balloon pump, mortality approaches 100%. Mechanical assist devices provide mechanical circulatory support (MCS) which has the ability to maintain vital organ perfusion, to unload the failing ventricle thus reduce intracardiac filling pressures which reduces pulmonary congestion, myocardial wall stress and myocardial oxygen consumption. This has been hypothesised to allow time for myocardial recovery (bridge to recovery) or allow time to come to a decision as to whether the person is a candidate for a longer-term ventricular assist device (VAD) either as a bridge to heart transplantation or as a destination therapy with a long-term VAD. OBJECTIVES To assess whether mechanical assist devices improve survival in people with acute cardiogenic shock. SEARCH METHODS We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid) and Web of Science Core Collection in November 2019. In addition, we searched three trials registers in August 2019. We scanned reference lists and contacted experts in the field to obtain further information. There were no language restrictions. SELECTION CRITERIA Randomised controlled trials on people with acute CS comparing mechanical assist devices with best current intensive care management, including intra-aortic balloon pump and inotropic support. DATA COLLECTION AND ANALYSIS We performed data collection and analysis according to the published protocol. Primary outcomes were survival to discharge, 30 days, 1 year and secondary outcomes included, quality of life, major adverse cardiovascular events (30 days/end of follow-up), dialysis-dependent (30 days/end of follow-up), length of hospital stay and length of intensive care unit stay and major adverse events. We used the five GRADE considerations (study limitations, consistency of effect, imprecision, indirectness, and publication bias) to assess the quality of a body of evidence as it relates to the studies which contribute data to the meta-analyses for the prespecified outcomes Summary statistics for the primary endpoints were risk ratios (RR), hazard ratios (HRs) and odds ratios (ORs) with 95% confidence intervals (CIs). MAIN RESULTS The search identified five studies from 4534 original citations reviewed. Two studies included acute CS of all causes randomised to treatment using TandemHeart percutaneous VAD and three studies included people with CS secondary to acute myocardial infarction who were randomised to Impella CP or best medical management. Meta-analysis was performed only to assess the 30-day survival as there were insufficient data to perform any further meta-analyses. The results from the five studies with 162 participants showed mechanical assist devices may have little or no effect on 30-day survival (RR of 1.01 95% CI 0.76 to 1.35) but the evidence is very uncertain. Complications such as sepsis, thromboembolic phenomena, bleeding and major adverse cardiovascular events were not infrequent in both the MAD and control group across the studies, but these could not be pooled due to inconsistencies in adverse event definitions and reporting. We identified four randomised control trials assessing mechanical assist devices in acute CS that are currently ongoing. AUTHORS' CONCLUSIONS There is no evidence from this review of a benefit from MCS in improving survival for people with acute CS. Further use of the technology, risk stratification and optimising the use protocols have been highlighted as potential reasons for lack of benefit and are being addressed in the current ongoing clinical trials.
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Affiliation(s)
| | - Henry Mp Boardman
- Radcliffe Department of Medicine, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kamran Baig
- Department of Cardiac Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jody L Stafford
- Perfusion/Cardiothoracic Surgery, University Hospital of Wales, Cardiff, UK
| | - Cristina Cernei
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Owen Bodger
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Stephen Westaby
- Cardiothoracic Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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16
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Gregory SD, Pauls JP, Wu EL, Stephens A, Steinseifer U, Tansley G, Fraser JF. An advanced mock circulation loop for in vitro cardiovascular device evaluation. Artif Organs 2020; 44:E238-E250. [PMID: 31951020 DOI: 10.1111/aor.13636] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 12/11/2019] [Accepted: 01/07/2020] [Indexed: 11/28/2022]
Abstract
Controlled and repeatable in vitro evaluation of cardiovascular devices using a mock circulation loop (MCL) is essential prior to in vivo or clinical trials. MCLs often consist of only a systemic circulation with no autoregulatory responses and limited validation. This study aimed to develop, and validate against human data, an advanced MCL with systemic, pulmonary, cerebral, and coronary circulations with autoregulatory responses. The biventricular MCL was constructed with pneumatically controlled hydraulic circulations with Starling responsive ventricles and autoregulatory cerebral and coronary circulations. Hemodynamic repeatability was assessed and complemented by validation using impedance cardiography data from 50 healthy humans. The MCL successfully simulated patient scenarios including rest, exercise, and left heart failure with and without cardiovascular device support. End-systolic pressure-volume relationships for respective healthy and heart failure conditions had slopes of 1.27 and 0.54 mm Hg mL-1 (left ventricle), and 0.18 and 0.10 mm Hg mL-1 (right ventricle), aligning with the literature. Coronary and cerebral autoregulation showed a strong correlation (R2 : .99) between theoretical and experimentally derived circuit flow. MCL repeatability was demonstrated with correlation coefficients being statistically significant (P < .05) for all simulated conditions while MCL hemodynamics aligned well with human data. This advanced MCL is a valuable tool for inexpensive and controlled evaluation of cardiovascular devices.
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Affiliation(s)
- Shaun D Gregory
- Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, VIC, Australia.,Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.,Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,School of Engineering and Built Environment, Griffith University, Southport, QLD, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Jo P Pauls
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,School of Engineering and Built Environment, Griffith University, Southport, QLD, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Eric L Wu
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Andrew Stephens
- Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, VIC, Australia.,Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Ulrich Steinseifer
- Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, VIC, Australia.,Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Geoff Tansley
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,School of Engineering and Built Environment, Griffith University, Southport, QLD, Australia
| | - John F Fraser
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia
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17
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Choi MS, Shim H, Cho YH. Mechanical Circulatory Support for Acute Heart Failure Complicated by Cardiogenic Shock. INTERNATIONAL JOURNAL OF HEART FAILURE 2020; 2:23-44. [PMID: 36263076 PMCID: PMC9536734 DOI: 10.36628/ijhf.2019.0015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 01/14/2020] [Accepted: 01/14/2020] [Indexed: 12/11/2022]
Abstract
Acute heart failure is a potentially life-threatening condition that can lead to cardiogenic shock, which is associated with hypotension and organ failure. Although there have been many studies on the treatment for cardiogenic shock, early mortality remains high at 40-50%. No new medicines for cardiogenic shock have been developed. Recently, there has been a gradual decline in the use of the intra-aortic balloon pump mainly due to a lack of adequate hemodynamic support. Extracorporeal membrane oxygenation and the percutaneous ventricular assist device have become more widely used in recent years. A thorough understanding of the mechanisms of such mechanical support devices and their hemodynamic effects, components of the devices, implantation technique, management, criteria for indications or contraindications of use, and clinical outcomes as well as multidisciplinary decision making may improve the outcomes in patients experiencing cardiogenic shock.
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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
| | - Hunbo Shim
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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18
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Mechanical Circulatory Support in Refractory Vasodilatory Septic Shock: a Randomized Controlled Porcine Study. Shock 2020; 53:124-131. [DOI: 10.1097/shk.0000000000001329] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Buja LM, Ottaviani G, Ilic M, Zhao B, Lelenwa LC, Segura AM, Bai Y, Chen A, Akkanti B, Hussain R, Nathan S, Petrovic M, Radovancevic R, Gregoric ID, Kar B. Clinicopathological manifestations of myocarditis in a heart failure population. Cardiovasc Pathol 2019; 45:107190. [PMID: 31896440 DOI: 10.1016/j.carpath.2019.107190] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 11/23/2019] [Accepted: 11/26/2019] [Indexed: 12/20/2022] Open
Abstract
Myocarditis continues to present challenges in diagnosis and management. The goal of this study is to determine the occurrence and manifestations of myocarditis in a heart failure (HF) population. The analyzed patients had acute or persistent HF and were referred over a 6-year period to a quaternary HF center for advanced HF therapies including mechanical circulatory support, left ventricular assist device (LVAD) implantation, and/or heart transplantation. The histopathological diagnosis of myocarditis was made based on the presence of an inflammatory infiltrate of the myocardium, typically with associated cardiomyocyte (CMC) damage, combined as indicated with immunohistochemical and molecular biology characterization. The pathological findings were correlated with a panel of clinical parameters and clinical course of the patients. Myocarditis was identified in 36 patients, with initial diagnoses made in 10 (40%) of 25 by endomyocardial biopsy (EMB), 1 by atrial biopsy (maze procedure), 7 (2.1%) of 331 at LVAD implantation, and 18 (7.8%) of 229 in the explanted heart. There were 20 cases of lymphocytic myocarditis, 4 cases of giant cell myocarditis, 3 cases of eosinophilic myocarditis, and 9 cases of lymphohistocytic with granulomas myocarditis - cardiac sarcoidosis. EMB was performed in 25 patients and was positive in 10 (40%) of cases. Myocarditis was found in 23 explanted hearts including 18 cases de novo and 5 cases with a previously positive specimen. Of the 23 explanted hearts, 21 were nonischemic cardiomyopathy and 2 were ischemic cardiomyopathy. Our findings show that, in patients presenting to a quaternary medical center, myocarditis can be manifest as acute HF as well as a complicating factor in chronic HF.
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Affiliation(s)
- Louis Maximilian Buja
- Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA; Cardiovascular Pathology Research Laboratory, Texas Heart Institute, CHI St. Luke's Hospital, Houston, TX, USA.
| | - Giulia Ottaviani
- Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA; Lino Rossi Research Center, Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Milica Ilic
- Center for Advanced Heart Failure, Cardiopulmonary Support and Transplantation Program, Memorial Hermann Heart & Vascular Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, TX, USA
| | - Bihong Zhao
- Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Laura C Lelenwa
- Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Ana Maria Segura
- Cardiovascular Pathology Research Laboratory, Texas Heart Institute, CHI St. Luke's Hospital, Houston, TX, USA
| | - Yu Bai
- Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Alice Chen
- Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Bindu Akkanti
- Center for Advanced Heart Failure, Cardiopulmonary Support and Transplantation Program, Memorial Hermann Heart & Vascular Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, TX, USA
| | - Rahat Hussain
- Center for Advanced Heart Failure, Cardiopulmonary Support and Transplantation Program, Memorial Hermann Heart & Vascular Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, TX, USA
| | - Sriram Nathan
- Center for Advanced Heart Failure, Cardiopulmonary Support and Transplantation Program, Memorial Hermann Heart & Vascular Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, TX, USA
| | - Marija Petrovic
- Center for Advanced Heart Failure, Cardiopulmonary Support and Transplantation Program, Memorial Hermann Heart & Vascular Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, TX, USA
| | - Rajko Radovancevic
- Center for Advanced Heart Failure, Cardiopulmonary Support and Transplantation Program, Memorial Hermann Heart & Vascular Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, TX, USA
| | - Igor D Gregoric
- Center for Advanced Heart Failure, Cardiopulmonary Support and Transplantation Program, Memorial Hermann Heart & Vascular Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, TX, USA
| | - Biswajit Kar
- Center for Advanced Heart Failure, Cardiopulmonary Support and Transplantation Program, Memorial Hermann Heart & Vascular Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, TX, USA
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20
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See Hoe LE, Bartnikowski N, Wells MA, Suen JY, Fraser JF. Hurdles to Cardioprotection in the Critically Ill. Int J Mol Sci 2019; 20:E3823. [PMID: 31387264 PMCID: PMC6695809 DOI: 10.3390/ijms20153823] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 07/26/2019] [Accepted: 08/03/2019] [Indexed: 02/07/2023] Open
Abstract
Cardiovascular disease is the largest contributor to worldwide mortality, and the deleterious impact of heart failure (HF) is projected to grow exponentially in the future. As heart transplantation (HTx) is the only effective treatment for end-stage HF, development of mechanical circulatory support (MCS) technology has unveiled additional therapeutic options for refractory cardiac disease. Unfortunately, despite both MCS and HTx being quintessential treatments for significant cardiac impairment, associated morbidity and mortality remain high. MCS technology continues to evolve, but is associated with numerous disturbances to cardiac function (e.g., oxidative damage, arrhythmias). Following MCS intervention, HTx is frequently the destination option for survival of critically ill cardiac patients. While effective, donor hearts are scarce, thus limiting HTx to few qualifying patients, and HTx remains correlated with substantial post-HTx complications. While MCS and HTx are vital to survival of critically ill cardiac patients, cardioprotective strategies to improve outcomes from these treatments are highly desirable. Accordingly, this review summarizes the current status of MCS and HTx in the clinic, and the associated cardiac complications inherent to these treatments. Furthermore, we detail current research being undertaken to improve cardiac outcomes following MCS/HTx, and important considerations for reducing the significant morbidity and mortality associated with these necessary treatment strategies.
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Affiliation(s)
- Louise E See Hoe
- Critical Care Research Group, The Prince Charles Hospital, Chermside 4032, Australia.
- Faculty of Medicine, University of Queensland, Chermside 4032, Australia.
| | - Nicole Bartnikowski
- Critical Care Research Group, The Prince Charles Hospital, Chermside 4032, Australia
- Science and Engineering Faculty, Queensland University of Technology, Chermside 4032, Australia
| | - Matthew A Wells
- Critical Care Research Group, The Prince Charles Hospital, Chermside 4032, Australia
- School of Medical Science, Griffith University, Southport 4222, Australia
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Chermside 4032, Australia
- Faculty of Medicine, University of Queensland, Chermside 4032, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Chermside 4032, Australia
- Faculty of Medicine, University of Queensland, Chermside 4032, Australia
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Abstract
PURPOSE OF REVIEW Temporary circulatory support (TCS) with short-term mechanical circulatory support (MCS) devices is increasingly used as a salvage therapy for patients with refractory cardiogenic shock. This article provides an overview of current devices, their indications and management, and discusses results of recent case series and trials. RECENT FINDINGS Percutaneous active MCS devices (Impella, TandemHeart…) and venoarterial extracorporeal membrane oxygenation (VA-ECMO) are utilized as a bridge to 'decision' that includes weaning after cardiac function recovery, transplantation, long-term MCS and withdrawal in case of futility. VA-ECMO is considered the first-line TCS since it allows rapid improvement in oxygenation, is less expensive, and is also suitable for patients with biventricular failure. Combining Impella or intra-aortic balloon pump support with ECMO might decrease left ventricular pressure and improve outcomes. Sepsis-associated cardiomyopathy, massive pulmonary embolism, arrhythmic storm and Takotsubo-like cardiomyopathy are among emerging indications for TCS. SUMMARY TCS have become the cornerstone of the management of patients with cardiogenic shock, although the evidence supporting their efficacy is limited. VA-ECMO is considered the first-line option, with a growing number of accepted and emerging indications. Randomized clinical trials are now needed to determine the respective place of different MCS devices in cardiogenic shock treatment strategies.
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22
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Riordan B, Holecek W, Koopman JD. Cardiac Surgery and Mechanical Circulatory Support. PHYSICIAN ASSISTANT CLINICS 2019. [DOI: 10.1016/j.cpha.2018.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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23
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Avtaar Singh SS, Banner NR, Rushton S, Simon AR, Berry C, Al-Attar N. ISHLT Primary Graft Dysfunction Incidence, Risk Factors, and Outcome: A UK National Study. Transplantation 2019; 103:336-343. [DOI: 10.1097/tp.0000000000002220] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background
Heart transplantation (HTx) remains the most effective long-term treatment for advanced heart failure. Primary graft dysfunction (PGD) continues to be a potentially life-threatening early complication. In 2014, a consensus statement released by International Society for Heart and Lung Transplantation (ISHLT) established diagnostic criteria for PGD. We studied the incidence of PGD across the United Kingdom.
Methods
We analyzed the medical records of all adult patients who underwent HTx between October 2012 and October 2015 in the 6 UK heart transplant centers Preoperative donor and recipient characteristics, intraoperative details, and posttransplant complications were compared between the PGD and non-PGD groups using the ISHLT definition. Multivariable analysis was performed using logistic regression.
Results
The incidence of ISHLT PGD was 36%. Thirty-day all-cause mortality in those with and without PGD was 31 (19%) versus 13 (4.5%) (P = 0.0001). Donor, recipient, and operative factors associated with PGD were recipient diabetes mellitus (P = 0.031), recipient preoperative bilateral ventricular assist device (P < 0.001), and preoperative extracorporeal membranous oxygenation (P = 0.023), female donor to male recipient sex mismatch (P = 0.007), older donor age (P = 0.010), and intracerebral haemorrhage/thrombosis in donor (P = 0.023). Intraoperatively, implant time (P = 0.017) and bypass time (P < 0.001) were significantly longer in the PGD cohort. Perioperatively, patients with PGD received more blood products (P < 0.001). Risk factors identified by multivariable logistic regression were donor age (P = 0.014), implant time (P = 0.038), female: male mismatch (P = 0.033), recipient diabetes (P = 0.051) and preoperative ventricular assist device/extracorporeal membranous oxygenation support (P = 0.012).
Conclusions
This is the first national study to examine the incidence and significance of PGD after HTx using the ISHLT definition. PGD remains a frequent early complication of HTx and is associated with increased mortality.
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Affiliation(s)
| | - Nicholas R. Banner
- Transplant and Mechanical Circulatory Support, Harefield Hospital, London, United Kingdom
| | - Sally Rushton
- Statistics and Clinical Studies, National Health Service Blood and Transplant (NHSBT), Bristol, United Kingdom
| | - Andre R. Simon
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom
| | | | - Nawwar Al-Attar
- Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, United Kingdom
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24
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Yao H, Samoukovic G, Farias E, Cimone S, Churchill-Smith M, Jayaraman D. Safety and Flight Considerations for Mechanical Circulatory Support Devices During Air Medical Transport and Evacuation: A Systematic Narrative Review of the Literature. Air Med J 2019; 38:106-114. [PMID: 30898281 DOI: 10.1016/j.amj.2018.11.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 09/08/2018] [Accepted: 11/16/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The air medical transportation industry has seen a steady rise in the use of mechanical circulatory support devices (eg, intra-aortic balloon pumps, ventricular assist devices, and extracorporeal membrane oxygenation) during transport missions, either for definitive management or repatriation. As these complex devices become more common, the industry will have to adapt to support their use in their clientele. The goal of this narrative review was to assess our current experiences regarding mechanical circulatory support devices in air medical transportation and to identify important factors to ensure successful transport. METHODS We conducted a systematic search on MEDLINE and Embase using the following search terms: aeromedical transportation, air transportation, intra-aortic balloon pump, ventricular assist device, and extracorporeal membrane oxygenation. Results were cross-referenced to identify articles addressing both air medical transport and mechanical circulatory support devices. RESULTS After a systematic review of the available literature, 49 articles addressing mechanical support devices transported by rotary wing and fixed wing aircraft were reviewed. In summary, our review encompassed 811 total aerial transports (152 by balloon pumps, 12 by ventricular assist devices, and 647 by extracorporeal membrane oxygenation). We found air medical transportation with these devices carried out in the public, private, or military sectors, to be safe, with low rates of serious adverse events. Dedicated training sessions focused on device troubleshooting and problem-solving during transport, optimal medical crew composition, predeparture logistical preparations, and on-demand specialist consultation can improve mission success. CONCLUSION We report that air medical transportation of patients supported by mechanical circulatory support devices is safe. Complications can be mitigated by training and addressed either during the predeparture or in-transportation phase.
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Affiliation(s)
- Han Yao
- Department of Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada.
| | - Gordan Samoukovic
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | | | - Sam Cimone
- SkyService Air Ambulance, Montreal, Quebec, Canada
| | | | - Dev Jayaraman
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
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Cheng V, Abdul-Aziz MH, Roberts JA, Shekar K. Overcoming barriers to optimal drug dosing during ECMO in critically ill adult patients. Expert Opin Drug Metab Toxicol 2019; 15:103-112. [PMID: 30582435 DOI: 10.1080/17425255.2019.1563596] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION One major challenge to achieving optimal patient outcome in extracorporeal membrane oxygenation (ECMO) is the development of effective dosing strategies in this critically ill patient population. Suboptimal drug dosing impacts on patient outcome as patients on ECMO often require reversal of the underlying pathology with effective pharmacotherapy in order to be liberated of the life-support device. Areas covered: This article provides a concise review of the effective use of antibiotics, analgesics, and sedative by characterizing the specific changes in PK secondary to the introduction of the ECMO support. We also discuss the barriers to achieving optimal pharmacotherapy in patients on ECMO and also the current and potential research that can be undertaken to address these clinical challenges. Expert opinion: Decreased bioavailability due to sequestration of drugs in the ECMO circuit and ECMO induced PK alterations are both significant barriers to optimal drug dosing. Evidence-based drug choices may minimize sequestration in the circuit and would enable safety and efficacy to be maintained. More work to characterize ECMO related pharmacodynamic alterations such as effects of ECMO on hepatic cytochrome system are still needed. Novel techniques to increase target site concentrations should also be explored.
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Affiliation(s)
- Vesa Cheng
- a Faculty of Medicine , University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland , Brisbane , Australia
| | - Mohd H Abdul-Aziz
- a Faculty of Medicine , University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland , Brisbane , Australia.,b School of Pharmacy , International Islamic University Malaysia , Kuantan , Malaysia
| | - Jason A Roberts
- a Faculty of Medicine , University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland , Brisbane , Australia.,c Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Australia.,d Department of Pharmacy , Royal Brisbane and Women's Hospital , Brisbane , Australia.,e Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy , The University of Queensland , Brisbane , Australia
| | - Kiran Shekar
- f Adult Intensive Care Services , The Prince Charles Hospital , Chermside , Australia.,g Critical Care Research Group , Centre of Research Excellence for Advanced Cardio-respiratory Therapies Improving OrgaN Support (ACTIONS) and the University of Queensland , Brisbane , Australia.,h Faculty of Health Sciences and Medicine , Bond University , Gold Coast , Australia
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Abstract
Cardiogenic shock (CS) represents an advanced state of morbidity along the pathophysiologic pathway of end-organ hypoperfusion caused by reduced cardiac output and blood pressure. Acute coronary syndromes remain the most common cause of CS. The spectrum of hypoperfusion states caused by low cardiac output ranges from pre-CS to refractory CS and can be characterized by an array of hemodynamic parameters. This review provides the foundation for a hemodynamic understanding of CS including the use of hemodynamic monitoring for diagnosis and treatment, the cardiac and vascular determinants of CS, and a hemodynamic approach to risk stratification and management of CS.
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Affiliation(s)
- Ariel Furer
- Internal Medicine T, Tel-Aviv Sourasky Medical Center, 6 Wiezmann street, Tel Aviv 64239, Israel.
| | - Jeffrey Wessler
- Division of Cardiology, Columbia University, 161 Fort Washington Avenue, New York, NY 10032-3784, USA
| | - Daniel Burkhoff
- Division of Cardiology, Columbia University, 161 Fort Washington Avenue, New York, NY 10032-3784, USA; Cardiovascular Research Foundation, 1700 Broadway, New York, NY 10019, USA
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27
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Zainab A, Tuazon D, Uddin F, Ratnani I. How New Support Devices Change Critical Care Delivery. Methodist Debakey Cardiovasc J 2018; 14:101-109. [PMID: 29977466 DOI: 10.14797/mdcj-14-2-101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Mechanical support devices are used to support failing cardiac, respiratory, or both systems. Since Gibbon developed the cardiopulmonary bypass in 1953, collaborative efforts by medical centers, bioengineers, industry, and the National Institutes of Health have led to development of mechanical devices to support heart, lung, or both. These devices are used as a temporary or long-term measures for acute collapse of circulatory system and/or respiratory failure. Patients are managed on these support devices as a bridge to recovery, bridge to long term devices, or bridge to transplant. The progress in development of these devices has improved mortality and quality of life in select groups of patients. Care of these patients requires a multidisciplinary team approach, which includes cardiac surgeons, critical care physicians, cardiologists, pulmonologists, nursing staff, and perfusionists. Using a team approach improves outcomes in these patients.
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28
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Khoo DPY, Cookson AN, Gill HS, Fraser KH. Normal fluid stresses are prevalent in rotary ventricular assist devices: A computational fluid dynamics analysis. Int J Artif Organs 2018; 41:738-751. [DOI: 10.1177/0391398818792757] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Despite the evolution of ventricular assist devices, ventricular assist device patients still suffer from complications due to the damage to blood by fluid dynamic stress. Since rotary ventricular assist devices are assumed to exert mainly shear stress, studies of blood damage are based on shear flow experiments. However, measurements and simulations of cell and protein deformation show normal and shear stresses deform, and potentially damage, cells and proteins differently. The aim was to use computational fluid dynamics to assess the prevalence of normal stress, in comparison with shear stress, in rotary ventricular assist devices. Our calculations showed normal stresses do occur in rotary ventricular assist devices: the fluid volumes experiencing normal stress above 10 Pa were 0.011 mL (0.092%) and 0.027 mL (0.39%) for the HeartWare HVAD and HeartMate II (HMII), and normal stresses over 100 Pa were present. However, the shear stress volumes were up to two orders of magnitude larger than the normal stress volumes. Considering thresholds for red blood cell and von Willebrand factor deformation by normal and shear stresses, the fluid volumes causing deformation by normal stress were between 2.5 and 5 times the size of those causing deformation by shear stress. The exposure times to the individual normal stress deformation regions were around 1 ms. The results clearly show, for the first time, that while blood within rotary ventricular assist devices experiences more shear stress at much higher magnitudes as compared with normal stress, there is sufficient normal stress exposure present to cause deformation of, and potentially damage to, the blood components. This study is the first to quantify the fluid stress components in real blood contacting devices.
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Affiliation(s)
- Dominica PY Khoo
- Department of Mechanical Engineering, University of Bath, Bath, UK
| | - Andrew N Cookson
- Department of Mechanical Engineering, University of Bath, Bath, UK
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29
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Fiedler AG, Dalia A, Axtell AL, Ortoleva J, Thomas SM, Roy N, Villavicencio MA, D'Alessandro DA, Cudemus G. Impella Placement Guided by Echocardiography Can Be Used as a Strategy to Unload the Left Ventricle During Peripheral Venoarterial Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2018; 32:2585-2591. [PMID: 30007550 DOI: 10.1053/j.jvca.2018.05.019] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVE At the authors' institution, before 2015, patients cannulated for peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) did not undergo left ventricular (LV) decompression with the use of an LV vent. After 2015, the authors' institution began using the Impella device to vent the left ventricle in patients on VA-ECMO. The authors hypothesized that survival outcomes would improve in patients on VA-ECMO with the use of an Impella for LV venting. DESIGN Retrospective, chart based review study. SETTING Single center, university-based hospital. PARTICIPANTS All adult patients at the authors' institution who required VA-ECMO between January 2015 and May 2017. INTERVENTION An Impella (Abiomed, Danvers, MA) device was placed percutaneously in patients cannulated for VA-ECMO as a mechanism to provide LV venting and decompression, therefore unloading the heart. MEASUREMENTS AND MAIN RESULTS Manual chart review was conducted, and a survival analysis was performed. It was observed that patients on VA-ECMO in whom an Impella was implanted had improved survival and an improvement in LV function as demonstrated by echocardiography compared with patients maintained on VA-ECMO alone. CONCLUSIONS Patients on VA-ECMO plus Impella implantation demonstrated improved survival compared with patients treated with VA-ECMO alone. Key echocardiographic characteristics such as improved LV function after Impella placement and LV cavity size reduction during therapy may help predict those patients who may benefit most from this cannulation strategy.
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Affiliation(s)
- Amy G Fiedler
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Adam Dalia
- Division of Cardiac Anesthesiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andrea L Axtell
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jamel Ortoleva
- Division of Cardiac Anesthesiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Sunu M Thomas
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Nathalie Roy
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - David A D'Alessandro
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Gaston Cudemus
- Division of Cardiac Anesthesiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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30
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Lee JA, Tchantchaleishvili V, Vidula H. Cardiac Hemochromatosis Treated With Prolonged Extracorporeal Membrane Oxygenation Support and Chelation Therapy. Artif Organs 2018; 42:575-576. [PMID: 29878536 DOI: 10.1111/aor.13076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 09/12/2017] [Accepted: 10/06/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Junsoo Alex Lee
- Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | | | - Himabindu Vidula
- Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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31
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Ahuja A, Shekar K. Patient selection for VV ECMO: have we found the crystal ball? J Thorac Dis 2018; 10:S1979-S1981. [PMID: 30023096 DOI: 10.21037/jtd.2018.05.83] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Abhilasha Ahuja
- Adult Intensive Care Services, the Prince Charles Hospital, Brisbane, Queensland, Australia.,Critical Care Research Group, Brisbane, Australia.,Centre of Research Excellence for Advanced Cardio-respiratory Therapies Improving OrgaN Support (ACTIONS), Brisbane, Australia
| | - Kiran Shekar
- Adult Intensive Care Services, the Prince Charles Hospital, Brisbane, Queensland, Australia.,Critical Care Research Group, Brisbane, Australia.,Centre of Research Excellence for Advanced Cardio-respiratory Therapies Improving OrgaN Support (ACTIONS), Brisbane, Australia.,University of Queensland, Brisbane, Queensland, Australia.,Bond University, Gold Coast, Queensland, Australia
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32
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Hsu S, Thiruvengadam SK, Sciortino CM, Russell SD, Schulman SP. Predictors of intra-aortic balloon pump hemodynamic failure in non-acute myocardial infarction cardiogenic shock. Am Heart J 2018; 199:181-191. [PMID: 29754660 PMCID: PMC5955398 DOI: 10.1016/j.ahj.2017.11.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 11/18/2017] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To characterize patient profile and hemodynamic profile of those undergoing intra-aortic balloon pump (IABP) for cardiogenic shock and define predictors of hemodynamic failure of IABP support. BACKGROUND Clinical characteristics of IABP support in cardiogenic shock not related to acute myocardial infarction (AMI) remain poorly characterized. METHODS We retrospectively studied a cohort of 74 patients from 2010 to 2015 who underwent IABP insertion for cardiogenic shock complicating acute decompensated heart failure not due to AMI. RESULTS In the overall cohort, which consisted primarily of patients with chronic systolic heart failure (89%), IABP significantly augmented cardiac index and lowered systemic vascular resistance (P<.05). Despite this improvement, 28% of these patients died (24%) or require urgent escalation in mechanical circulatory support (MCS) (4%). Multivariable regression revealed that baseline left ventricular cardiac power index (LVCPI), a measure of LV power output derived from cardiac index and mean arterial pressure (P=.01), and history of ischemic cardiomyopathy (P=.003) were significantly associated with the composite adverse-event endpoint of death or urgent MCS escalation. An IABP Failure risk score using baseline LVCPI <0.28 W/m2 and ischemic history predicted 28-day adverse events with excellent discrimination. CONCLUSION Despite hemodynamic improvements with IABP support, patients with non-AMI cardiogenic shock still suffer poor outcomes. Patients with ischemic cardiomyopathy and low LVPCI fared significantly worse. These patients may warrant closer observation or earlier consideration of more advanced hemodynamic support.
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Affiliation(s)
- Steven Hsu
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
| | | | - Christopher M Sciortino
- Division of Cardiothoracic Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Stuart D Russell
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Steven P Schulman
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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33
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34
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Ni hlci T, Boardman HMP, Baig K, Aifesehi PE, Stafford JL, Cernei C, Bodger O, Westaby S. Mechanical assist devices for acute cardiogenic shock. Hippokratia 2018. [DOI: 10.1002/14651858.cd013002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Tamara Ni hlci
- Morriston Hospital; Cardiothoracic Surgery; Swansea UK SA6 6NL
| | - Henry MP Boardman
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust; Radcliffe Department of Medicine; Headley Way Oxford UK OX3 9DU
| | - Kamran Baig
- Guy's and St Thomas' NHS Foundation Trust; Department of Cardiac Surgery; London UK SE1 7EH
| | - Paul E Aifesehi
- The Johns Hopkins Hospital; Division of Cardiac Surgery; 1800 Orleans Street Baltimore MD USA 21218
| | - Jody L Stafford
- University Hospital of Wales; Perfusion/Cardiothoracic Surgery; Cardiff UK
| | - Cristina Cernei
- Swansea University; Swansea University Medical School; Swansea UK
| | - Owen Bodger
- Swansea University; Swansea University Medical School; Swansea UK
| | - Stephen Westaby
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust; Cardiothoracic Surgery; Headley Way Oxford UK OX3 9DU
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35
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Molteni A, Masri ZPH, Low KWQ, Yousef HN, Sienz J, Fraser KH. Experimental measurement and numerical modelling of dye washout for investigation of blood residence time in ventricular assist devices. Int J Artif Organs 2018; 41:201-212. [DOI: 10.1177/0391398817752877] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Ventricular assist devices have become the standard therapy for end-stage heart failure. However, their use is still associated with severe adverse events related to the damage done to the blood by fluid dynamic stresses. This damage relates to both the stress magnitude and the length of time the blood is exposed to that stress. We created a dye washout technique which combines experimental and numerical approaches to measure the washout times of ventricular assist devices. The technique was used to investigate washout characteristics of three commercially available and clinically used ventricular assist devices: the CentriMag, HVAD and HeartMate II. The time taken to reach 5% dye concentration at the outlet (T05) was used as an indicator of the total residence time. At a typical level of cardiac support, 5 L/min and 100 mmHg, T05 was 0.93, 0.28 and 0.16 s for CentriMag, HVAD and HeartMate II, respectively, and increased to 5.06, 1.64 and 0.96 s for reduced cardiac support of 1 L/min. Regional variations in washout characteristics are described in this article. While the volume of the flow domain plays a large role in the differences in T05 between the ventricular assist devices, after standardising for ventricular assist device volume, the secondary flow path was found to increase T05 by 35%. The results explain quantitatively, for the first time, why the CentriMag, which exerts low shear stress magnitude, has still been found to cause acquired von Willebrand Syndrome in patients.
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Affiliation(s)
| | - Zubair PH Masri
- Department of Mechanical Engineering, University of Bath, Bath, UK
| | - Kenny WQ Low
- Advanced Sustainable Manufacturing Technologies (ASTUTE) 2020 Operation, College of Engineering, Swansea University, Swansea, UK
| | - Haitham N Yousef
- Advanced Sustainable Manufacturing Technologies (ASTUTE) 2020 Operation, College of Engineering, Swansea University, Swansea, UK
| | - Johann Sienz
- Advanced Sustainable Manufacturing Technologies (ASTUTE) 2020 Operation, College of Engineering, Swansea University, Swansea, UK
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36
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Cheng V, Abdul-Aziz MH, Roberts JA, Shekar K. Optimising drug dosing in patients receiving extracorporeal membrane oxygenation. J Thorac Dis 2018; 10:S629-S641. [PMID: 29732181 DOI: 10.21037/jtd.2017.09.154] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Optimal pharmacological management during extracorporeal membrane oxygenation (ECMO) involves more than administering drugs to reverse underlying disease. ECMO is a complex therapy that should be administered in a goal-directed manner to achieve therapeutic endpoints that allow reversal of disease and ECMO wean, minimisation of complications (treatment of complications when they do occur), early interruption of sedation and rehabilitation, maximising patient comfort and minimising risks of delirium. ECMO can alter both the pharmacokinetics (PK) and pharmacodynamics (PD) of administered drugs and our understanding of these alterations is still evolving. Based on available data it appears that modern ECMO circuitry probably has a less significant impact on PK when compared with critical illness itself. However, these findings need further confirmation in clinical population PK studies and such studies are underway. The altered PD associated with ECMO is less understood and more research is indicated. Until robust dosing guidelines become available, clinicians will have to rely on the principles of drug dosing in critically ill and known PK alterations induced by ECMO itself. This article summarises the PK alterations and makes preliminary recommendations on possible dosing approaches.
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Affiliation(s)
- Vesa Cheng
- Faculty of Medicine, The University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia
| | - Mohd-Hafiz Abdul-Aziz
- Faculty of Medicine, The University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia.,School of Pharmacy, International Islamic University Malaysia, Kuantan, Malaysia
| | - Jason A Roberts
- Faculty of Medicine, The University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia
| | - Kiran Shekar
- Adult Intensive Care Services, the Prince Charles Hospital, Chermside, Australia.,Critical Care Research Group, Centre of Research Excellence for Advanced Cardio-respiratory Therapies Improving OrgaN Support (ACTIONS) and the University of Queensland, Brisbane, Australia
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37
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Sakota D, Fujiwara T, Ohuchi K, Kuwana K, Yamazaki H, Kosaka R, Nishida M, Mizuno T, Arai H, Maruyama O. Development of a real-time and quantitative thrombus sensor for an extracorporeal centrifugal blood pump by near-infrared light. BIOMEDICAL OPTICS EXPRESS 2018; 9:190-201. [PMID: 29359096 PMCID: PMC5772574 DOI: 10.1364/boe.9.000190] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 11/07/2017] [Accepted: 12/07/2017] [Indexed: 06/07/2023]
Abstract
We developed an optical thrombus sensor for a monopivot extracorporeal centrifugal blood pump. In this study, we investigated its quantitative performance for thrombus detection in acute animal experiments of left ventricular assist using the pump on pathogen-free pigs. Optical fibers were set in the driver unit of the pump. The incident light at the near-infrared wavelength of 810 nm was aimed at the pivot bearing, and the resulting scattered light was guided to the optical fibers. The detected signal was analyzed to obtain the thrombus formation level. As a result, real-time and quantitative monitoring of the thrombus surface area on the pivot bearing was achieved with an accuracy of 3.6 ± 2.3 mm2. In addition, the sensing method using the near-infrared light was not influenced by changes in the oxygen saturation and the hematocrit. It is expected that the developed sensor will be useful for optimal anticoagulation management for long-term extracorporeal circulation therapies.
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Affiliation(s)
- Daisuke Sakota
- Health Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), 1-2-1 Namiki, Tsukuba-shi, Ibaraki 305-8564, Japan
| | - Tatsuki Fujiwara
- Department of Cardiovascular Surgery, Tokyo Medical and Dental University Graduate School of Medical and Dental Sciences, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Katsuhiro Ohuchi
- Department of Advanced Surgical Technology Research and Development, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Katsuyuki Kuwana
- Senko Medical Instrument Mfg. Co., Ltd., 3-23-13 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Hiroyuki Yamazaki
- Optquest Co., Ltd., 1335 Haraichi, Ageo-shi, Saitama 362-0021, Japan
| | - Ryo Kosaka
- Health Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), 1-2-1 Namiki, Tsukuba-shi, Ibaraki 305-8564, Japan
| | - Masahiro Nishida
- Health Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), 1-2-1 Namiki, Tsukuba-shi, Ibaraki 305-8564, Japan
| | - Tomohiro Mizuno
- Department of Cardiovascular Surgery, Tokyo Medical and Dental University Graduate School of Medical and Dental Sciences, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
- Department of Advanced Surgical Technology Research and Development, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Tokyo Medical and Dental University Graduate School of Medical and Dental Sciences, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Osamu Maruyama
- Health Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), 1-2-1 Namiki, Tsukuba-shi, Ibaraki 305-8564, Japan
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38
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Sodhi N, Lasala JM. Mechanical Circulatory Support in Acute Decompensated Heart Failure and Shock. Interv Cardiol Clin 2017; 6:387-405. [PMID: 28600092 DOI: 10.1016/j.iccl.2017.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
An array of interventional therapeutics is available in the modern era, with uses depending on acute or chronic situations. This article focuses on support in acute decompensated heart failure and cardiogenic shock, including intra-aortic balloon pumps, continuous aortic flow augmentation, and extra-corporeal membrane oxygenation.
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Affiliation(s)
- Nishtha Sodhi
- Cardiovascular Division, Washington University, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | - John M Lasala
- Cardiovascular Division, Washington University, 660 South Euclid Avenue, St Louis, MO 63110, USA.
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39
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Capatos G. Case study: Complicated influenza pneumonia. Qatar Med J 2017. [PMCID: PMC5474644 DOI: 10.5339/qmj.2017.swacelso.76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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40
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Passagere Herzunterstützungssysteme. Notf Rett Med 2017. [DOI: 10.1007/s10049-016-0264-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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41
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Successful provision of inter-hospital extracorporeal cardiopulmonary resuscitation for acute post-partum pulmonary embolism. Int J Obstet Anesth 2017; 30:65-68. [PMID: 28209484 DOI: 10.1016/j.ijoa.2017.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 12/19/2016] [Accepted: 01/03/2017] [Indexed: 11/22/2022]
Abstract
Mortality during pregnancy in a well-resourced setting is rare, but acute pulmonary embolism is one of the leading causes. We present the successful use of extracorporeal cardiopulmonary resuscitation (eCPR) in a 22-year old woman who experienced cardiopulmonary collapse following urgent caesarean section in the setting of a sub-massive pulmonary embolus. Resources and personnel to perform eCPR were not available at the maternity hospital and were recruited from an adjacent pediatric hospital. Initial care used low blood flow extracorporeal membrane oxygenation (ECMO) with pediatric ECMO circuitry, which was optimized when the team from a nearby adult cardiac hospital arrived. Following ECMO support, the patient experienced massive hemorrhage which was managed with uterotonic agents, targeted transfusion, bilateral uterine artery embolisation and abdominal re-exploration. The patient was transferred to an adult unit where she remained on ECMO for five days. She was discharged home with normal cognitive function. This case highlights the role ECMO plays in providing extracorporeal respiratory or mechanical circulatory support in a high risk obstetric patient.
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