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Saito S, Okubo S, Matsuoka T, Hirota S, Yokoyama S, Kanazawa Y, Takei Y, Tezuka M, Tsuchiya G, Konishi T, Shibasaki I, Ogata K, Fukuda H. Impella - Current issues and future expectations for the percutaneous, microaxial flow left ventricular assist device. J Cardiol 2024; 83:228-235. [PMID: 37926367 DOI: 10.1016/j.jjcc.2023.10.008] [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: 07/19/2023] [Revised: 10/04/2023] [Accepted: 10/27/2023] [Indexed: 11/07/2023]
Abstract
The importance of temporary mechanical circulatory support for treating acute heart failure with cardiogenic shock is increasingly recognized, and Impella (Abiomed, Danvers, MA, USA) has received particular attention in this regard. Impella is an axial flow left ventricular assist device (LVAD) built into the tip of a catheter. It is inserted via a peripheral artery and implanted into the left ventricle. Although the morphology of Impella is different from a typical LVAD, it has similar actions and effects as an LVAD in terms of left ventricular drainage and aortic blood delivery. Impella increases mean arterial pressure (MAP) and systemic blood flow, thereby improving peripheral organ perfusion and promoting recovery from multiple organ failure. In addition, left ventricular unloading with increased MAP increases coronary perfusion and decreases myocardial oxygen demand, thereby promoting myocardial recovery. Impella is also useful as a mechanical vent of the left ventricle in patients supported with veno-arterial extracorporeal membrane oxygenation. Indications for Impella include emergency use for cardiogenic shock and non-emergent use during high-risk percutaneous coronary intervention and ventricular tachycardia ablation. Its intended uses for cardiogenic shock include bridge to recovery, durable device, heart transplantation, and heart surgery. Prophylactic use of Impella in high-risk patients undergoing open heart surgery to prevent postcardiotomy cardiogenic shock is also gaining attention. While there have been many case reports and retrospective studies on the benefits of Impella, there is little evidence based on sufficiently large randomized controlled trials (RCTs). Currently, several RCTs are now ongoing, which are critical to determine when, for whom, and how these devices should be used. In this review, we summarize the principles, physiology, indications, and complications of the Impella support and discuss current issues and future expectations for the device.
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Affiliation(s)
- Shunsuke Saito
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan.
| | - Shohei Okubo
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Taiki Matsuoka
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Shotaro Hirota
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Shohei Yokoyama
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Yuta Kanazawa
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Yusuke Takei
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Masahiro Tezuka
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Go Tsuchiya
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Taisuke Konishi
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Ikuko Shibasaki
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Koji Ogata
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Hirotsugu Fukuda
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
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Delmas C, Barbosa H, David CH, Bouisset F, Piriou PG, Roubille F, Leick J, Pavlov M, Leurent G, Potapov EV, Linke A, Mierke J, Lanmüller P, Mangner N. Impella for the Management of Ventricular Septal Defect Complicating Acute Myocardial Infarction: A European Multicenter Registry. ASAIO J 2023; 69:e491-e499. [PMID: 37935014 DOI: 10.1097/mat.0000000000002060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
Ventricular septal defect (VSD) is a rare but severe complication of myocardial infarction (MI). Temporary mechanical circulatory support (MCS) can be used as a bridge to VSD closure, heart transplantation, or ventricular assist device. We describe the use of Impella device in this context based on a multicenter European retrospective registry (17 centers responded). Twenty-eight post-MI VSD patients were included (Impella device were 2.5 for 1 patient, CP for 20, 5.0 for 5, and unknown for 2). All patients were in cardiogenic shock with multiple organ failure (SAPS II 41 [interquantile range {IQR} = 27-53], lactate 4.0 ± 3.5 mmol/L) and catecholamine support (dobutamine 55% and norepinephrine 96%). Additional temporary MCS was used in 14 patients (50%), mainly extracorporeal life support (ECLS) (n = 9, 32%). Severe bleedings were frequent (50%). In-hospital and 1 year mortalities were 75%. Ventricular septal defect management was surgical for 36% of patients, percutaneous for 21%, and conservative for 43%. Only surgically managed patients survived (70% in-hospital survival). Type and combination of temporary MCS used were not associated with mortality (Impella alone or in combination with intra-aortic balloon pump [IABP] or ECLS, p = 0.84). Impella use in patients with post-MI VSD is feasible but larger prospective registries are necessary to further elucidate potential benefits of left ventricular unloading in this setting.
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Affiliation(s)
- Clement Delmas
- From the Intensive Cardiac Care Unit, Cardiology Department, Rangueil University Hospital, Toulouse, France
| | - Hélène Barbosa
- From the Intensive Cardiac Care Unit, Cardiology Department, Rangueil University Hospital, Toulouse, France
| | - Charles-Henri David
- Cardiovascular Surgery Department, Nantes University Hospital, Nantes, France
| | - Frédéric Bouisset
- From the Intensive Cardiac Care Unit, Cardiology Department, Rangueil University Hospital, Toulouse, France
| | | | - François Roubille
- Cardiology Department INI-CRT PhyMedExp INSERM CNRS CHU de Montpellier, Université de Montpellier, Montpellier, France
| | - Juergen Leick
- Herzzentrum Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | | | | | - Evgenij V Potapov
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité, Germany/Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Axel Linke
- Department of Internal Medicine and Cardiology, Heart Center Dresden, Technische Universität Dresden, Dresden, Germany
| | - Johannes Mierke
- Department of Internal Medicine and Cardiology, Heart Center Dresden, Technische Universität Dresden, Dresden, Germany
| | - Pia Lanmüller
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité, Germany/Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Norman Mangner
- Department of Internal Medicine and Cardiology, Heart Center Dresden, Technische Universität Dresden, Dresden, Germany
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Horio M, Kashiwazaki D, Tomita T, Maruyama K, Hamada S, Hori E, Nakamura M, Kinugawa K, Kuroda S. Intracerebral Hematoma in Patients With Impella Ventricular Assist Device Placement for Cardiogenic Shock: Report of Three Cases. Cureus 2023; 15:e48863. [PMID: 38106739 PMCID: PMC10724407 DOI: 10.7759/cureus.48863] [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: 11/15/2023] [Indexed: 12/19/2023] Open
Abstract
Despite the clear benefits of Impella in patients with cardiogenic shock, bleeding is a possible complication. Herein, we report three cases of intracerebral hemorrhage in patients with Impella implantation for cardiogenic shock, which were treated with hematoma evacuation. We present the clinical features, diagnosis, and management (hematoma evacuation) of patients with the Impella device (Abiomed, Danvers, Massachusetts) who developed intracerebral hemorrhage. Case one was a 56-year-old man who presented with chest pain and loss of consciousness, was diagnosed with acute myocardial infarction, and underwent urgent percutaneous coronary intervention and Impella placement. After eight days, the patient developed anisocoria. Computed tomography revealed a left intracerebral hemorrhage. An emergency hematoma evacuation was successfully performed (intraoperative blood loss: 2600 mL). Case two was a 54-year-old male who presented with persistent chest pain and loss of consciousness, was diagnosed with acute myocardial infarction, and underwent an emergency percutaneous coronary intervention with Impella implantation and venoarterial extracorporeal membrane oxygenation. The patient developed intracerebral hemorrhage after 26 days. Hematoma evacuation was successfully performed (intraoperative blood loss: 380 mL). Case three was a 52-year-old male who presented with dyspnea and hypotension, was diagnosed with dilated cardiomyopathy, and underwent Impella implantation and venoarterial extracorporeal membrane oxygenation, followed by which the patient developed subcortical hematoma. An emergency hematoma evacuation was performed (intraoperative blood loss: 3205 mL). The patient died 14 days after admission. Intracerebral hemorrhage is a potential cause of morbidity associated with Impella placement. Although hematoma evacuation is optimal, the bleeding tends to increase.
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Affiliation(s)
- Mitsuki Horio
- Department of Neurosurgery, Toyama University Hospital, Toyama, JPN
| | | | - Takahiro Tomita
- Department of Neurosurgery, Toyama University Hospital, Toyama, JPN
| | | | - Saori Hamada
- Department of Neurosurgery, Toyama University Hospital, Toyama, JPN
| | - Emiko Hori
- Department of Neurosurgery, Toyama University Hospital, Toyama, JPN
| | - Makiko Nakamura
- Department of Internal Medicine, Toyama University Hospital, Toyama, JPN
| | - Koichiro Kinugawa
- Department of Internal Medicine, Toyama University Hospital, Toyama, JPN
| | - Satoshi Kuroda
- Department of Neurosurgery, Toyama University Hospital, Toyama, JPN
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Thevathasan T, Landmesser U, Skurk C. Reply to Letter: Potential problems with concomitant therapy with Impella® and veno-arterial extracorporeal membrane oxygenation in patients with cardiac arrest. Resuscitation 2023; 190:109915. [PMID: 37506816 DOI: 10.1016/j.resuscitation.2023.109915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023]
Affiliation(s)
- Tharusan Thevathasan
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; Berlin Institute of Health (BIH), Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany.
| | - Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; Berlin Institute of Health (BIH), Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany
| | - Carsten Skurk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany.
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Heart Lung Transplant 2023; 42:e1-e64. [PMID: 36805198 DOI: 10.1016/j.healun.2022.10.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 10/28/2022] [Indexed: 02/08/2023] Open
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Card Fail 2023; 29:304-374. [PMID: 36754750 DOI: 10.1016/j.cardfail.2022.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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Toda K, Ako J, Hirayama A, Kinugawa K, Kobayashi Y, Ono M, Nishimura T, Sato N, Shindo T, Takayama M, Yasukochi S, Shiose A, Sawa Y. Three-year experience of catheter-based micro-axial left ventricular assist device, Impella, in Japanese patients: the first interim analysis of Japan registry for percutaneous ventricular assist device (J-PVAD). J Artif Organs 2023; 26:17-23. [PMID: 35467195 DOI: 10.1007/s10047-022-01328-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 03/22/2022] [Indexed: 11/29/2022]
Abstract
Catheter-based micro-axial ventricular assist device Impella® (Abiomed, Danvers, MA) has been used in Japanese patients with drug-refractory acute heart failure (AHF) since 2017. This is the first interim analysis of the ongoing Japan Registry for Percutaneous Ventricular Assist Device (J-PVAD) to investigate the safety and efficacy of Impella support. Between October 2017 and January 2020, 823 Japanese patients, who were treated with the Impella 2.5, CP, or 5.0 pump, were enrolled. The primary endpoints were safety profiles and cumulative 30-day survival. Among them, 44.8% of patients were acute myocardial infarction with cardiogenic shock. The Impella pumps were unable to implant in 4 patients. The Impella 2.5, CP, and 5.0 pumps were used in 72.4%, 6.2%, and 16.6%, respectively, and mean support duration was 8.1 ± 10.2 days. Combination use of Impella and venoarterial extracorporeal membrane oxygenation (VA-ECMO) was applied for 387 patients (47.3%). Pump stop occurred 22 patients (2.7%). Major adverse events included hemolysis (11.2%), hemorrhage/hematoma (6.1%), peripheral ischemia (1.6%), and stroke (1.6%). The overall 30-day survival was 62.2%. Survival of patients with single Impella support was significantly higher than patients with Impella combined with VA-ECMO support (81.1% vs 49.6%; p < 0.01), who had lower blood pressure, lower left ventricular ejection fraction, and higher degree of inotropic support. Results suggest that short-term outcome of Impella support for Japanese patients was favorable with acceptable safety profiles.
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Affiliation(s)
- Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-Oka, Suita, Osaka, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, School of Medicine, Kitasato University, Kanagawa, Japan
| | | | - Koichiro Kinugawa
- The Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Takashi Nishimura
- Department of Cardiovascular and Thoracic Surgery, Graduate School of Medicine, Ehime University, Ehime, Japan
| | - Naoki Sato
- Department of Cardiology, Kawaguchi Cardiovascular and Respiratory Hospital, Saitama, Japan
| | - Takahiro Shindo
- Division of Cardiology, National Center for Child Health and Development, Tokyo, Japan
| | | | - Satoshi Yasukochi
- Department of Pediatric Cardiology, Nagano Children's Hospital, Nagano, Japan
| | - Akira Shiose
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medicine, Fukuoka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-Oka, Suita, Osaka, Japan.
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Deconinck SJ, Nix C, Barth S, Bennek-Schöpping E, Rauch A, Schelpe AS, Roose E, Feys HB, Pareyn I, Vandenbulcke A, Muia J, Vandenbriele C, Susen S, Meyns B, Tersteeg C, Jacobs S, De Meyer SF, Vanhoorelbeke K. ADAMTS13 inhibition to treat acquired von Willebrand syndrome during mechanical circulatory support device implantation. J Thromb Haemost 2022; 20:2797-2809. [PMID: 36128768 PMCID: PMC9669188 DOI: 10.1111/jth.15889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/31/2022] [Accepted: 09/18/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Acquired von Willebrand syndrome (aVWS) is common in patients with mechanical circulatory support (MCS) devices. In these patients, the high shear stress in the device leads to increased shear-induced proteolysis of von Willebrand factor (VWF) by A Disintegrin And Metalloprotease with Thrombospondin type 1 repeats, number 13 (ADAMTS13). As a result, the high molecular weight (HMW) VWF multimers are lost, leading to a decreased VWF function and impaired hemostasis that could explain the bleeding complications that are frequently observed in these patients. To counteract this abnormal VWF degradation by ADAMTS13, we developed a novel targeted therapy, using an anti-ADAMTS13 monoclonal antibody (mAb) that inhibits the shear-induced proteolysis of VWF by ADAMTS13. METHODS Human or bovine blood was circulated through in vitro MCS device systems with either inhibitory anti-ADAMTS13 mAb 3H9 or 17C7 (20 μg/ml) or control anti-ADAMTS13 mAb 5C11 or phosphate buffered saline (PBS). VWF multimers and function (collagen binding activity) were determined at different time points. Next, Impella pumps were implanted in calves and the calves were injected with PBS and subsequently treated with mAb 17C7. VWF, ADAMTS13, and blood parameters were determined. RESULTS We demonstrated that blocking ADAMTS13 could prevent the loss of HMW VWF multimers in in vitro MCS device systems. Importantly, our antibody could reverse aVWS in a preclinical Impella-induced aVWS calf model. CONCLUSION Hence, inhibition of ADAMTS13 could become a novel therapeutic strategy to manage aVWS in MCS device patients.
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Affiliation(s)
- Shannen J Deconinck
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Christoph Nix
- Abiomed Europe GmbH, Neuenhofer Weg 3, Aachen, D-52074
| | - Svenja Barth
- Abiomed Europe GmbH, Neuenhofer Weg 3, Aachen, D-52074
| | | | - Antoine Rauch
- University of Lille, INSERM U1011-EGID, Lille, France
- CHU Lille, Hematology Transfusion, Lille, France
| | - An-Sofie Schelpe
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Elien Roose
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Hendrik B Feys
- Transfusion Research Center, Belgian Red Cross-Flanders, Ghent, Belgium
- Ghent University, Faculty of Medicine and Health Sciences, Ghent, Belgium
| | - Inge Pareyn
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Aline Vandenbulcke
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Joshua Muia
- Department of Biochemistry and Microbiology, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma
| | | | - Sophie Susen
- University of Lille, INSERM U1011-EGID, Lille, France
- CHU Lille, Hematology Transfusion, Lille, France
| | - Bart Meyns
- Department of Clinical Cardiac Surgery, University Hospitals Leuven, Belgium
| | - Claudia Tersteeg
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Steven Jacobs
- Department of Clinical Cardiac Surgery, University Hospitals Leuven, Belgium
| | - Simon F De Meyer
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
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Overview of Mechanical Circulatory Support for the Management of Post-Myocardial Infarction Ventricular Septal Rupture. J Cardiol 2022; 81:491-497. [PMID: 36503063 DOI: 10.1016/j.jjcc.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/16/2022] [Accepted: 11/21/2022] [Indexed: 12/13/2022]
Abstract
Post-myocardial infarction ventricular septal rupture (PIVSR) is becoming increasingly rare in the percutaneous coronary intervention era; however, the mortality rates remain high. Surgical repair is the gold standard treatment for PIVSR but is associated with surgical difficulty and high mortality. Therefore, the timing of surgery is controversial (i.e. either undertake emergency surgery or wait for resolution of organ failure and scarring of the infarcted area). Although long-term medical management is usually ineffective, several mechanical circulatory support (MCS) devices have been used to postpone surgery to an optimal timing. Recently, in addition to venous arterial extracorporeal membrane oxygenation (VA-ECMO), new MCS devices, such as Impella (Abiomed Inc., Boston, MA, USA), have been developed. Impella is a pump catheter that pumps blood directly from the left ventricle, in a progressive fashion, into the ascending aorta. VA-ECMO is a temporary MCS system that provides complete and rapid cardiopulmonary support, with concurrent hemodynamic support and gas exchange. When left and right heart failure and/or respiratory failure occur in cardiogenic shock or PIVSR after acute myocardial infarction, ECpella (Impella and VA-ECMO) is often introduced, as it can provide circulatory and respiratory assistance in a shorter period. This review outlines the basic concepts of MCS in PIVSR treatment strategies and its role as a bridge device, and discusses the efficacy and complications of ECpella therapy and the timing of surgery.
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Munoz Tello C, Jamil D, Tran HHV, Mansoor M, Butt SR, Satnarine T, Ratna P, Sarker A, Ramesh AS, Mohammed L. The Therapeutic Use of Impella Device in Cardiogenic Shock: A Systematic Review. Cureus 2022; 14:e30045. [PMID: 36381689 PMCID: PMC9637443 DOI: 10.7759/cureus.30045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 10/07/2022] [Indexed: 06/16/2023] Open
Abstract
Impella (Abiomed, Danvers, MA) devices nowadays have been linked to cardiogenic shock (CS) due to the importance of their use as therapeutic instruments. This study aims to review pathophysiologic mechanisms of cardiogenic shock and the implementation of Impella to overcome this condition. To investigate several different types of studies and analyze the use of Impella device in cardiogenic shock and the outcomes of heart malfunctioning and determine its positive and negative impacts as a therapeutic tool in cardiac ischemia and use as a resource in critical patients, we conducted a systematic review through different databases (PubMed, ScienceDirect, and Google Scholar) following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist and used the Medical Subjects Heading (MeSH) search strategy to obtain significant articles. We found 883 papers in total, and after removing duplicates, applying inclusion/exclusion criteria, and finding the most significant information, we ended up with 30 articles that were reviewed containing information about the impact of Impella device in cardiogenic shock in different locations. The study strongly concludes that Impella device in the setting of cardiogenic shock has more advantages than disadvantages in terms of outcomes and complications as a non-pharmacologic tool. Improvements in left ventricular ejection fraction and signs and symptoms of cardiogenic shock criteria were determinants. Nevertheless, complications during the implementation and use of the device were established; in this manner, the evaluation and treatment of each patient separately are imperative. Consequently, more studies on this relevant topic are needed.
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Affiliation(s)
- Carlos Munoz Tello
- General Medicine, Universidad Católica de Cuenca, Cuenca, ECU
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Dawood Jamil
- Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Hadrian Hoang-Vu Tran
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Mafaz Mansoor
- General Practice, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Samia Rauf Butt
- General Practice, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | | | - Pranuthi Ratna
- Medicine, Kamineni Academy of Medical Sciences and Research Centre (KAMSRC), Hyderabad, IND
| | - Aditi Sarker
- General Practice, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Adarsh Srinivas Ramesh
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Lubna Mohammed
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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11
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Lüsebrink E, Binzenhöfer L, Kellnar A, Müller C, Scherer C, Schrage B, Joskowiak D, Petzold T, Braun D, Brunner S, Peterss S, Hausleiter J, Zimmer S, Born F, Westermann D, Thiele H, Schäfer A, Hagl C, Massberg S, Orban M. Venting during venoarterial extracorporeal membrane oxygenation. Clin Res Cardiol 2022; 112:464-505. [PMID: 35986750 PMCID: PMC10050067 DOI: 10.1007/s00392-022-02069-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 07/12/2022] [Indexed: 11/03/2022]
Abstract
AbstractCardiogenic shock and cardiac arrest contribute pre-dominantly to mortality in acute cardiovascular care. Here, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has emerged as an established therapeutic option for patients suffering from these life-threatening entities. VA-ECMO provides temporary circulatory support until causative treatments are effective and enables recovery or serves as a bridging strategy to surgical ventricular assist devices, heart transplantation or decision-making. However, in-hospital mortality rate in this treatment population is still around 60%. In the recently published ARREST trial, VA-ECMO treatment lowered mortality rate in patients with ongoing cardiac arrest due to therapy refractory ventricular fibrillation compared to standard advanced cardiac life support in selected patients. Whether VA-ECMO can reduce mortality compared to standard of care in cardiogenic shock has to be evaluated in the ongoing prospective randomized studies EURO-SHOCK (NCT03813134) and ECLS-SHOCK (NCT03637205). As an innate drawback of VA-ECMO treatment, the retrograde aortic flow could lead to an elevation of left ventricular (LV) afterload, increase in LV filling pressure, mitral regurgitation, and elevated left atrial pressure. This may compromise myocardial function and recovery, pulmonary hemodynamics—possibly with concomitant pulmonary congestion and even lung failure—and contribute to poor outcomes in a relevant proportion of treated patients. To overcome these detrimental effects, a multitude of venting strategies are currently engaged for both preventive and emergent unloading. This review aims to provide a comprehensive and structured synopsis of existing venting modalities and their specific hemodynamic characteristics. We discuss in detail the available data on outcome categories and complication rates related to the respective venting option.
Graphical abstract
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12
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Takami Y, Hoshino N, Ishikawa H, Akita K, Sakurai Y, Amano K, Izawa H, Takagi Y. Thrombosed stuck mitral valve during advanced mechanical circulatory support for post-cardiotomy shock. J Cardiol Cases 2022; 25:282-284. [PMID: 35582073 PMCID: PMC9091497 DOI: 10.1016/j.jccase.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/10/2021] [Accepted: 11/08/2021] [Indexed: 10/19/2022] Open
Abstract
We report a case of mechanical prosthetic mitral valve thrombosis in a 52-year-old woman with previous diagnosis of dilated cardiomyopathy, who was supported with advanced mechanical circulatory support after urgent mechanical mitral valve replacement (MVR) and tricuspid annuloplasty. Difficult weaning from cardiopulmonary bypass needed support with veno-arterial extracorporeal membranous oxygenation and Impella (Abiomed Inc, Danvers, MA, USA), so-called ECPELLA. Temporary discontinuation of heparin and massive blood transfusion were necessary due to four times of reoperation for bleeding during ECPELLA support. Poor recovery of cardiac function needed escalation from ECPELLA to extracorporeal biventricular assist device (ex-BiVAD) using two centrifugal pumps on Day 12. After gradual decrease in the left ventricular assist device flow, transesophageal echocardiography and fluoroscopic images revealed the stuck leaflets of the mitral prosthesis. Therefore, the patient underwent re-MVR with a bioprosthesis on Day 18, followed by continued assistance with ex-BiVAD. The patient was finally weaned from ex-BiVAD on Day 28 and was transferred to the referral hospital for rehabilitation. She was alive in good general condition at 2-year follow-up. It is important to balance the effects of anticoagulation on advanced mechanical circulatory support with ECPELLA, against the side effects of bleeding, especially in post-cardiotomy patients with bleeding tendency. .
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Affiliation(s)
- Yoshiyuki Takami
- Department of Cardiovascular Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Naoki Hoshino
- Department of Cardiology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Hiroshi Ishikawa
- Department of Cardiovascular Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kiyotoshi Akita
- Department of Cardiovascular Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yusuke Sakurai
- Department of Cardiovascular Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kentaro Amano
- Department of Cardiovascular Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Hideo Izawa
- Department of Cardiology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yasushi Takagi
- Department of Cardiovascular Surgery, Fujita Health University School of Medicine, Toyoake, Japan
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13
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Impact of the Severity of Acquired von Willebrand Syndrome on the Short-Term Prognosis in Patients with Temporary Mechanical Circulatory Support. Medicina (B Aires) 2022; 58:medicina58020238. [PMID: 35208560 PMCID: PMC8880578 DOI: 10.3390/medicina58020238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 01/30/2022] [Accepted: 02/02/2022] [Indexed: 11/30/2022] Open
Abstract
Background and Objectives: Acquired von Willebrand syndrome (AVWS) develops not only in patients with durable ventricular assist devices but also in patients receiving temporary mechanical circulatory support (MCS). However, its prognostic implication remains unknown. Materials and Methods: Patients who received temporary MCS in our institute between August 2018 and September 2021 were included in this prospective study and the von Willebrand factor multimer analyses were performed following the initiation of temporary MCS supports. The von Willebrand factor large-multimer index was calculated as a normalized ratio of large-multimer proportion among total von Willebrand factor. Association between the large-multimer index and the 30-day survival was investigated. Results: A total of 31 patients (69 years old, 52% men) were included. Median large-multimer index was 63.0% (56.9%, 75.6%). The index was lowest in patients with extracorporeal membrane oxygenation than those receiving support from other devices. A lower index (<59.9%) was associated with lower 30-day survival (41.7% versus 94.7%, p = 0.001) with an odds ratio 0.044 (95% confidence interval 0.002–0.805, p = 0.035) adjusted for other potential confounders. Conclusions: An advanced AVWS was associated with lower short-term survival in patients with temporary MCS. The clinical implication of AVWS-guided temporary MCS management remains the next concern.
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Saito S, Shibasaki I, Matsuoka T, Niitsuma K, Hirota S, Kanno Y, Kanazawa Y, Tezuka M, Takei Y, Tsuchiya G, Konishi T, Ogata K, Fukuda H. OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2022; 35:6562976. [PMID: 35373286 PMCID: PMC9297506 DOI: 10.1093/icvts/ivac088] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/18/2022] [Accepted: 03/22/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Shunsuke Saito
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
- Corresponding author. Department of Cardiovascular Surgery, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Shimotsugagun, Tochigi 321-0293, Japan. Tel: +81-282-86-1111; fax: +81-282-86-2022; e-mail: (S. Saito)
| | - Ikuko Shibasaki
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Taiki Matsuoka
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Ken Niitsuma
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Shotaro Hirota
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Yasuyuki Kanno
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Yuta Kanazawa
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Masahiro Tezuka
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Yusuke Takei
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Go Tsuchiya
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Taisuke Konishi
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Koji Ogata
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Hirotsugu Fukuda
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
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15
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Oezkur M, Reda S, Rühl H, Theuerkauf N, Kreyer S, Duerr GD, Charitos E, Silaschi M, Medina M, Zimmer S, Putensen C, Treede H. Role of acquired von Willebrand syndrome in the development of bleeding complications in patients treated with Impella RP devices. Sci Rep 2021; 11:23722. [PMID: 34887445 PMCID: PMC8660831 DOI: 10.1038/s41598-021-02833-8] [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: 07/25/2021] [Accepted: 11/16/2021] [Indexed: 11/09/2022] Open
Abstract
Axial flow pumps are standard treatment in cases of cardiogenic shock and high-risk interventions in cardiology and cardiac surgery, although the optimal anticoagulation strategy remains unclear. We evaluated whether laboratory findings could predict bleeding complications and acquired von Willebrand syndrome (avWS) among patients who were treated using axial flow pumps. We retrospectively evaluated 60 consecutive patients who received Impella devices (Impella RP: n = 20, Impella CP/5.0: n = 40; Abiomed Inc., Danvers, USA) between January 2019 and December 2020. Thirty-two patients (53.3%) experienced major or fatal bleeding complications (Bleeding Academic Research Consortium score of > 3) despite intravenous heparin being used to maintain normal activated partial thromboplastin times (40–50 s). Extensive testing was performed for 28 patients with bleeding complications (87.5%). Relative to patients with left ventricular support, patients with right ventricular support were less likely to develop avWS (87.5% vs. 58.8%, p = 0.035). Bleeding was significantly associated with avWS (odds ratio [OR]: 20.8, 95% confidence interval [CI]: 3.3–128.5; p = 0.001) and treatment duration (OR: 1.3, 95% CI 1.09–1.55; p = 0.003). Patients with avWS had longer Impella treatment than patients without avWS (2 days [1–4.7 days] vs. 7.3 days [3.2–13.0 days]). Bleeding complications during Impella support were associated with avWS in our cohort, while aPTT monitoring was not sufficient to prevent bleeding complications. A more targeted anticoagulation monitoring might be needed for patients who receive Impella devices.
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Affiliation(s)
- Mehmet Oezkur
- Department of Cardiovascular Surgery, University Hospital of Bonn, Bonn, Germany. .,Department of Cardiovascular Surgery, University Hospital Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany.
| | - Sara Reda
- Department of Haematology, University Hospital of Bonn, Bonn, Germany
| | - Heiko Rühl
- Department of Haematology, University Hospital of Bonn, Bonn, Germany
| | - Nils Theuerkauf
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Bonn, Bonn, Germany
| | - Stefan Kreyer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Bonn, Bonn, Germany
| | - Georg Daniel Duerr
- Department of Cardiovascular Surgery, University Hospital of Bonn, Bonn, Germany.,Department of Cardiovascular Surgery, University Hospital Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Efstratios Charitos
- Department of Cardiovascular Surgery, University Hospital of Bonn, Bonn, Germany
| | - Miriam Silaschi
- Department of Cardiovascular Surgery, University Hospital of Bonn, Bonn, Germany
| | - Marta Medina
- Department of Cardiovascular Surgery, University Hospital of Bonn, Bonn, Germany
| | - Sebastian Zimmer
- Department of Cardiology, University Hospital of Bonn, Bonn, Germany
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Bonn, Bonn, Germany
| | - Hendrik Treede
- Department of Cardiovascular Surgery, University Hospital of Bonn, Bonn, Germany.,Department of Cardiovascular Surgery, University Hospital Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
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16
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Zaiser AS, Fahrni G, Hollinger A, Knobel DT, Bovey Y, Zellweger NM, Buser A, Santer D, Pargger H, Gebhard CE, Siegemund M. Adverse Events of Percutaneous Microaxial Left Ventricular Assist Devices-A Retrospective, Single-Centre Cohort Study. J Clin Med 2021; 10:jcm10163710. [PMID: 34442010 PMCID: PMC8396891 DOI: 10.3390/jcm10163710] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/08/2021] [Accepted: 08/17/2021] [Indexed: 12/16/2022] Open
Abstract
Worldwide, the left ventricular assist device Impella® (Abiomed, Danvers, MA, USA) is increasingly implanted in patients with acute cardiogenic shock or undergoing high-risk cardiac interventions. Despite its long history of use, few studies have assessed its safety and possible complications associated with its use. All patients treated with a left-sided Impella® device at the University Hospital of Basel from 1 January 2011 to 31 December 2019 were enrolled. The primary endpoint was the composite rate of mortality and adverse events (bleeding, acute kidney injury, and limb ischemia). Out of 281 included patients, at least one adverse event was present in 262 patients (93%). Rates of in-hospital, 90-day, and one-year mortality were 48%, 47%, and 50%, respectively. BARC type 3 bleeding (62%) and hemolysis (41.6%) were the most common complications. AKI was observed in 50% of all patients. Renal replacement therapy was required in 97 (35%) of all patients. Limb ischemia occurred in 13% of cases. Bleeding and hemolysis are common Impella®-associated complications. Additionally, we found a high rate of AKI. A careful selection of patients receiving microaxial LV support and defining the indication for its use are essential measures to be taken for the benefits to outweigh potential complications.
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Affiliation(s)
- Anna S. Zaiser
- Intensive Care Unit, University Hospital Basel, 4031 Basel, Switzerland; (A.S.Z.); (A.H.); (D.T.K.); (Y.B.); (N.M.Z.); (H.P.); (M.S.)
| | - Gregor Fahrni
- Department of Cardiology, University Hospital Basel, 4031 Basel, Switzerland;
| | - Alexa Hollinger
- Intensive Care Unit, University Hospital Basel, 4031 Basel, Switzerland; (A.S.Z.); (A.H.); (D.T.K.); (Y.B.); (N.M.Z.); (H.P.); (M.S.)
- Department of Clinical Research, University of Basel, 4031 Basel, Switzerland
| | - Demian T. Knobel
- Intensive Care Unit, University Hospital Basel, 4031 Basel, Switzerland; (A.S.Z.); (A.H.); (D.T.K.); (Y.B.); (N.M.Z.); (H.P.); (M.S.)
| | - Yann Bovey
- Intensive Care Unit, University Hospital Basel, 4031 Basel, Switzerland; (A.S.Z.); (A.H.); (D.T.K.); (Y.B.); (N.M.Z.); (H.P.); (M.S.)
| | - Núria M. Zellweger
- Intensive Care Unit, University Hospital Basel, 4031 Basel, Switzerland; (A.S.Z.); (A.H.); (D.T.K.); (Y.B.); (N.M.Z.); (H.P.); (M.S.)
| | - Andreas Buser
- Regional Blood Transfusion Center SRK Basel and Department of Hematology, Transfusion Medicine, University Hospital Basel, 4031 Basel, Switzerland;
| | - David Santer
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland;
| | - Hans Pargger
- Intensive Care Unit, University Hospital Basel, 4031 Basel, Switzerland; (A.S.Z.); (A.H.); (D.T.K.); (Y.B.); (N.M.Z.); (H.P.); (M.S.)
| | - Caroline E. Gebhard
- Intensive Care Unit, University Hospital Basel, 4031 Basel, Switzerland; (A.S.Z.); (A.H.); (D.T.K.); (Y.B.); (N.M.Z.); (H.P.); (M.S.)
- Department of Clinical Research, University of Basel, 4031 Basel, Switzerland
- Correspondence: ; Tel.: +41-61-328-53-85
| | - Martin Siegemund
- Intensive Care Unit, University Hospital Basel, 4031 Basel, Switzerland; (A.S.Z.); (A.H.); (D.T.K.); (Y.B.); (N.M.Z.); (H.P.); (M.S.)
- Department of Clinical Research, University of Basel, 4031 Basel, Switzerland
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17
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Abstract
Acquired von Willebrand syndrome can occur in the setting of myeloproliferative neoplasms; plasma cell dyscrasias and other lymphoproliferative disorders; autoimmune conditions; and causes of increased shear forces, such as aortic stenosis or other structural heart disease and mechanical circulatory support. The depletion of von Willebrand factor, especially high-molecular-weight multimers, can lead to mucocutaneous bleeding and the formation of arteriovenous malformations, particularly in the gastrointestinal tract. Management focuses on correction of the underlying cause when possible, but may include intravenous immunoglobulins, von Willebrand factor concentrate, rituximab, or antiangiogenic therapy depending on the clinical context.
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Affiliation(s)
- Arielle L Langer
- Division of Hematology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Nathan T Connell
- Division of Hematology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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18
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Lüsebrink E, Orban M, Kupka D, Scherer C, Hagl C, Zimmer S, Luedike P, Thiele H, Westermann D, Massberg S, Schäfer A, Orban M. Prevention and treatment of pulmonary congestion in patients undergoing venoarterial extracorporeal membrane oxygenation for cardiogenic shock. Eur Heart J 2021; 41:3753-3761. [PMID: 33099278 DOI: 10.1093/eurheartj/ehaa547] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 04/07/2020] [Accepted: 06/15/2020] [Indexed: 12/28/2022] Open
Abstract
Cardiogenic shock is still a major driver of mortality on intensive care units and complicates ∼10% of acute coronary syndromes with contemporary mortality rates up to 50%. In the meantime, percutaneous circulatory support devices, in particular venoarterial extracorporeal membrane oxygenation (VA-ECMO), have emerged as an established salvage intervention for patients in cardiogenic shock. Venoarterial extracorporeal membrane oxygenation provides temporary circulatory support until other treatments are effective and enables recovery or serves as a bridge to ventricular assist devices, heart transplantation, or decision-making. In this critical care perspective, we provide a concise overview of VA-ECMO utilization in cardiogenic shock, considering rationale, critical care management, as well as weaning aspects. We supplement previous literature by focusing on therapeutic issues related to the vicious circle of retrograde aortic VA-ECMO flow, increased left ventricular (LV) afterload, insufficient LV unloading, and severe pulmonary congestion limiting prognosis in a relevant proportion of patients receiving VA-ECMO treatment. We will outline different modifications in percutaneous mechanical circulatory support to meet this challenge. Besides a strategy of running ECMO at lowest possible flow rates, novel therapeutic options including the combination of VA-ECMO with percutaneous microaxial pumps or implementation of a venoarteriovenous-ECMO configuration based on an additional venous cannula supplying towards pulmonary circulation are most promising among LV unloading and venting strategies. The latter may even combine the advantages of venovenous and venoarterial ECMO therapy, providing potent respiratory and circulatory support at the same time. However, whether VA-ECMO can reduce mortality has to be evaluated in the urgently needed, ongoing prospective randomized studies EURO-SHOCK (NCT03813134), ANCHOR (NCT04184635), and ECLS-SHOCK (NCT03637205). These studies will provide the opportunity to investigate indication, mode, and effect of LV unloading in dedicated sub-analyses. In future, the Heart Teams should aim at conducting a dedicated randomized trial comparing VA-ECMO support with vs. without LV unloading strategies in patients with cardiogenic shock.
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Affiliation(s)
- Enzo Lüsebrink
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Mathias Orban
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Danny Kupka
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Clemens Scherer
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Christian Hagl
- Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Sebastian Zimmer
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Sigmund-Freud-Straße 25, 53127 Bonn, Germany
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45122 Essen, Germany
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Department of Internal Medicine/Cardiology, Leipzig Heart Institute, Strümpellstraße 39, 04289 Leipzig, Germany
| | - Dirk Westermann
- Klinik für Allgemeine und Interventionelle Kardiologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20251 Hamburg, Germany
| | - Steffen Massberg
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Andreas Schäfer
- Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Martin Orban
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
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19
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Nakamura M, Imamura T, Ueno H, Hori M, Ushijima R, Kinugawa K. Impact of the whole activated clotting time during Impella support on short-term prognosis. J Artif Organs 2021; 25:9-15. [PMID: 33987744 DOI: 10.1007/s10047-021-01271-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 04/26/2021] [Indexed: 11/24/2022]
Abstract
Impella (Abiomed, Danvers, MA, USA) is a percutaneous trans-catheter left ventricular assist device. Anticoagulant therapy targeting whole activated clotting time (ACT) between 160 and 180 s is recommended to prevent pump thrombosis during support. However, we sometimes experience fatal bleeding despite achieving the target ACT range. Consecutive patients who received Impella support in our institute between March 2018 and October 2020 were included in this retrospective study. The association between the averaged ACT levels during the Impella support and 30-day mortality was investigated. A total of 36 patients (71 years old, 61% males) were included. Most of the patients were managed within the recommended therapeutic range of ACT, and the average ACT level was 162 s. The higher ACT group (> 168 s) had older age, smaller body mass index, and higher serum creatinine compared with the lower ACT group (p < 0.05 for all). A higher ACT level was an independent risk factor of 30-day mortality with an adjusted hazard ratio of 1.085 (95% confidence interval 1.037-1.154) with a cut-off level of 168 s. There were only two thromboembolic events. Patients managed with higher ACT levels had a higher risk of 30-day mortality during Impella support. A low-dose heparin purge solution might be recommended in patients with high-risk for bleeding events.
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Affiliation(s)
- Makiko Nakamura
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan.
| | - Hiroshi Ueno
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Masakazu Hori
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Ryuichi Ushijima
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Koichiro Kinugawa
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
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20
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Shoskes A, Whitman G, Cho SM. Neurocritical Care of Mechanical Circulatory Support Devices. Curr Neurol Neurosci Rep 2021; 21:20. [PMID: 33694065 DOI: 10.1007/s11910-021-01107-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Mechanical circulatory support (MCS) devices have demonstrated improved survival outcomes in otherwise refractory cardiopulmonary failure but are associated with significant neurologic morbidity and mortality. This review aims to characterize MCS-associated brain injury and discuss the neurocritical care of this population. RECENT FINDINGS We found no practice guidelines or specific management strategies for the neurocritical care of patients with MCS devices. Acute brain injury was commonly observed in short-term and durable MCS devices. There is emerging evidence that a standardized neurological monitoring and management algorithm for MCS device-associated brain injury is feasible and potentially improves neurological outcomes. While MCS devices are associated with significant neurologic morbidity and mortality, there is scant evidence regarding optimal neuromonitoring and neurocritical care. With the increase in use of MCS devices for both short-term and durable applications, improved outcomes will depend on early identification and intervention of neurologic complications and further research into their pathophysiology.
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Affiliation(s)
- Aaron Shoskes
- Department of Neurology, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Glenn Whitman
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Sung-Min Cho
- Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Division of Neuroscience Critical Care, Johns Hopkins University, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA.
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21
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Chandrasekar B. Mechanical circulatory support with Impella in percutaneous coronary intervention: current status. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2021; 1:100002. [PMID: 38560363 PMCID: PMC10976289 DOI: 10.1016/j.ahjo.2020.100002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/25/2020] [Accepted: 11/11/2020] [Indexed: 04/04/2024]
Abstract
In patients with, or at risk of, hemodynamic instability during percutaneous coronary intervention, maintaining perfusion of vital organs is crucial. The intra-aortic balloon pump and Impella are the two most commonly used percutaneous mechanical circulatory support devices. Intra-aortic balloon pump has been in widespread use for over three decades. Mechanical circulatory support with Impella is being used increasingly often in patients with acute myocardial infarction complicated by cardiogenic shock, and in those undergoing high-risk percutaneous coronary intervention. Besides improving cardiac output and coronary perfusion, Impella has potential myocardial protective effects. Three key measures that determine the clinical utility of a device are clinical outcome, device-related complications, and cost impact. In this review, the current data on use of Impella in patients with acute myocardial infarction complicated by cardiogenic shock, in left ventricular unloading in acute myocardial infarction, and in those undergoing high-risk percutaneous coronary intervention is analyzed.
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22
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Desai R, Hanna B, Singh S, Gupta S, Deshmukh A, Kumar G, Sachdeva R, Berman AE. Percutaneous Ventricular Assist Device vs. Intra-Aortic Balloon Pump for Hemodynamic Support in Acute Myocardial Infarction-Related Cardiogenic Shock and Coexistent Atrial Fibrillation: A Nationwide Propensity-Matched Analysis'. Am J Med Sci 2020; 361:55-62. [PMID: 33008567 DOI: 10.1016/j.amjms.2020.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 08/04/2020] [Accepted: 08/10/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients suffering an acute myocardial infarction complicated by cardiogenic shock (AMICS) may experience clinical deterioration with concomitant atrial fibrillation (AF). Recent data suggest that percutaneous ventricular assist devices (pVADs) provide superior hemodynamic support over intra-aortic balloon pump (IABP) in AMICS. In patients with AF+AMICS, however, outcomes data comparing these two devices remain limited. METHODS Using the National Inpatient Sample datasets (2008-2014) and a propensity-score matched analysis, we compared the outcomes of AMICS+AF hospitalized patients undergoing PCI with pVAD vs. IABP support. RESULTS A total of 12,842 AMICS+AF patients were identified (pVAD=468, IABP=12,374). The matched groups (pVAD=443, IABP=443) were comparable in terms of mean age (70.3 ± 12.0 vs. 70.4 ± 11.0yrs, p = 0.92). The utilization of pVAD was higher in whites but lower in Medicare/Medicaid beneficiaries as compared to IABP. The pVAD group demonstrated higher rates of obesity (13.6% vs. 7.8%, p = 0.006) and dyslipidemia (48.4% vs. 41.8%, p = 0.05). There was no difference in the in-hospital mortality (40.5% vs. 36.8%, p = 0.25); however, pVAD group had a lower incidence of post-procedural MI and higher incidences of stroke (7.8% vs. 4.4%, p = 0.03), hemorrhage (5.6% vs. 2.3%, p = 0.01), discharges to home health care (13.5% vs. 10.1%, p<0.001) and to other facilities (29.1% vs. 24.9%, p<0.001) as compared to IABP group. There was no difference between the groups in terms of mean length of stay or hospital charges. CONCLUSIONS All-cause inpatient mortality was similar in AMICS+AF patients undergoing PCI who were treated with either pVAD or IABP. The pVAD group, however, experienced more complications while consuming greater healthcare resources.
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Affiliation(s)
- Rupak Desai
- Division of Cardiology, Atlanta VA Medical Center, Decatur, GA, United States
| | - Bishoy Hanna
- Division of Cardiology, Morehouse School of Medicine, Atlanta, GA, United States
| | - Sandeep Singh
- Division of Clinical Epidemiology, Biostatistics, and Bioinformatics, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Sonu Gupta
- Division of Cardiology, Morehouse School of Medicine, Atlanta, GA, United States
| | | | - Gautam Kumar
- Division of Cardiology, Atlanta VA Medical Center, Decatur, GA, United States; Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Rajesh Sachdeva
- Division of Cardiology, Atlanta VA Medical Center, Decatur, GA, United States; Division of Cardiology, Morehouse School of Medicine, Atlanta, GA, United States; Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States; Division of Cardiology, Medical College of Georgia, Augusta University, Augusta, GA, United States
| | - Adam E Berman
- Division of Cardiology, Medical College of Georgia, Augusta University, Augusta, GA, United States; Division of Health Economics and Modeling, Medical College of Georgia, Augusta University, Augusta, GA, United States.
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23
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Multi-Modal Characterization of the Coagulopathy Associated With Extracorporeal Membrane Oxygenation. Crit Care Med 2020; 48:e400-e408. [DOI: 10.1097/ccm.0000000000004286] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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24
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Bhatia M, Kumar PA. Pro: Venoarterial Extracorporeal Membrane Oxygenation Is Superior to Impella for Cardiogenic Shock. J Cardiothorac Vasc Anesth 2020; 34:278-282. [DOI: 10.1053/j.jvca.2019.06.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 06/30/2019] [Indexed: 11/11/2022]
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25
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Nakamura M, Imamura T, Ueno H, Kinugawa K. Current indication and practical management of percutaneous left ventricular assist device support therapy in Japan. J Cardiol 2019; 75:228-232. [PMID: 31870578 DOI: 10.1016/j.jjcc.2019.12.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 12/02/2019] [Indexed: 11/17/2022]
Abstract
Impella (Abiomed, Danvers, MA, USA) is a recently-innovated (commercially available from 2017 in Japan) percutaneous left ventricular assist device which is inserted percutaneously and transfers blood from the left ventricle to the ascending aorta, improving systemic circulation and end-organ dysfunction as well as unloading left ventricle in patients with cardiogenic shock. Impella has not yet shown a significant survival benefit in patients with cardiogenic shock compared to intra-aortic balloon pump in randomized control trials, but gives powerful circulatory support immediately with minimally invasive manner when used in appropriate patients at optimal timing with adequate management. In this review article, we will introduce and discuss optimal and practical management of Impella therapy in Japan.
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Affiliation(s)
- Makiko Nakamura
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan.
| | - Hiroshi Ueno
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Koichiro Kinugawa
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
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26
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Rios SA, Bravo CA, Weinreich M, Olmedo W, Villablanca P, Villela MA, Ramakrishna H, Hirji S, Robles OA, Mahato P, Gluud C, Bhatt DL, Jorde UP. Meta-Analysis and Trial Sequential Analysis Comparing Percutaneous Ventricular Assist Devices Versus Intra-Aortic Balloon Pump During High-Risk Percutaneous Coronary Intervention or Cardiogenic Shock. Am J Cardiol 2018; 122:1330-1338. [PMID: 30146099 DOI: 10.1016/j.amjcard.2018.07.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/15/2018] [Accepted: 07/16/2018] [Indexed: 01/21/2023]
Abstract
The intra-aortic balloon pump (IABP) and percutaneous ventricular assist devices (pVAD) are commonly used in different clinical scenarios. The goal of this study was to carry out a meta-analysis and Trial Sequential Analysis (TSA) comparing the IABP versus pVAD (TandemHeart and the Impella) during high-risk percutaneous coronary intervention (PCI) or cardiogenic shock (CS). Using PubMed, Cochrane Central Register of Controlled Trials, and EMBASE we searched for randomized clinical trials (RCTs) and nonrandomized studies that compared pVAD versus IABP in patients who underwent high-risk PCI or with CS. We included 5 RCTs and 1 nonrandomized study comparing pVAD versus IABP. Based on the RCTs, we demonstrated no difference in short-term (6 months) (risk ratio [RR] 1.09, 95% confidence interval [CI] 0.79 to 1.52; p = 0.59) or long-term (12 months) (RR 1.00, 95% CI 0.57 to 1.76; p = 1.00) all-cause mortality. The use of pVAD seemed associated with more adverse events (acute kidney injury, limb ischemia, infection, major bleeding, and vascular injury) compared with IABP (RR 1.65, 95% CI 1.14 to 2.39; p = 0.008) but this was not supported by TSA (random-effects RR 1.66, 95% CI 0.89 to 3.09; p = 0.11; TSA-adjusted CI 0.13 to 21.3). In conclusion there were no differences in short or long-term mortality when using IABP versus pVAD for high-risk PCI or CS. IABP showed superiority over pVAD in terms of risk of harm. However, further RCTs are needed to establish more conclusively the role of these modalities of mechanical circulatory support during high-risk PCI or CS.
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27
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Goldfarb M, Czer LS, Lam LD, Moriguchi J, Arabia FA, Volod O. High Molecular Weight von Willebrand Factor Multimer Loss and Bleeding in Patients with Short-Term Mechanical Circulatory Support Devices: A Case Series. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2018; 50:77-82. [PMID: 29921985 PMCID: PMC6002638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 04/02/2018] [Indexed: 06/08/2023]
Abstract
Acquired von Willebrand syndrome (VWS) due to loss of high-molecular-weight multimers (HMWMs) has been reported with longer term mechanical devices and is associated with mucosal bleeding, a primary hemostasis type of bleeding. However, little is known whether a similar defect occurs in patients with short-term mechanical circulatory support (STMCS) devices. We reviewed von Willebrand factor (VWF) profiles in patients with STMCS devices who underwent VWS workup from December 2015 to March 2017 at an academic quaternary care hospital. There were a total of 18 patients (57.0 ± 12.7 years old; 83.3% male) including nine with mucosal bleeding and nine with decreasing hemoglobin. The STMCS devices included Impella (n = 11), Impella and right ventricular assist device (n = 2), and an extracorporeal membrane oxygenator (n = 5). The mean HMWM by quantitative VWF multimer analysis was 3.6% ± 1.3% (normal cutoff: 18-34%). In all 10 cases in which VWF activity, fibrinogen, factor VIII, or VWF antigen level were obtained, they were either normal or elevated. All cases demonstrated high normal or elevated levels of low molecular weight multimers (LMWMs). These findings are consistent with type 2 VWS (qualitative defect). This is the first study that quantitatively describes STMCS device-associated HMWM loss, which may contribute to mucosal bleeding. This finding may have implications for intraoperative management during implantation of longer term devices or heart transplantation or other surgery while on STMCS.
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Affiliation(s)
- Michael Goldfarb
- Divisions of Cardiology and Pulmonary and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Lawrence S. Czer
- Cedars-Sinai Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Lee D. Lam
- Cedars-Sinai Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Jaime Moriguchi
- Cedars-Sinai Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Francisco A. Arabia
- Cedars-Sinai Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Oksana Volod
- Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California
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28
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Sieweke JT, Pfeffer TJ, Berliner D, König T, Hallbaum M, Napp LC, Tongers J, Kühn C, Schmitto JD, Hilfiker-Kleiner D, Schäfer A, Bauersachs J. Cardiogenic shock complicating peripartum cardiomyopathy: Importance of early left ventricular unloading and bromocriptine therapy. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 9:173-182. [PMID: 29792513 DOI: 10.1177/2048872618777876] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Acute peripartum cardiomyopathy complicated by cardiogenic shock is a rare but life-threatening disease. A prolactin fragment is considered causal for the pathogenesis of peripartum cardiomyopathy. This analysis sought to investigate the role of early percutaneous mechanical circulatory support with micro-axial flow-pumps and/or veno-arterial extracorporeal membrane oxygenation in combination with the prolactin inhibitor bromocriptine in refractory cardiogenic shock complicating peripartum cardiomyopathy. METHODS AND RESULTS In this single-centre analysis, five peripartum cardiomyopathy patients with refractory cardiogenic shock received mechanical circulatory support with either Impella CP microaxial pump only (n=2) or in combination with veno-arterial extracorporeal membrane oxygenation (n=3) in the setting of biventricular failure. All patients were mechanically ventilated. In all cases mechanical circulatory support was combined with bromocriptine therapy and early administration of levosimendan. All patients survived the acute phase of refractory cardiogenic shock. Mechanical circulatory support using a micro-axial pump allowed to significantly reduce catecholamine dosage. Remarkably, early left ventricular support with micro-axial flow-pumps resulted in myocardial recovery whereas delayed Impella (mechanical circulatory support) implantation was associated with poor left ventricular recovery. CONCLUSION Mechanical circulatory support in patients with refractory cardiogenic shock complicating peripartum cardiomyopathy was associated with a 30-day survival of 100% and a favourable outcome. Notably, early left ventricular unloading combined with bromocriptine therapy was associated with left ventricular recovery. Therefore, an immediate transfer to a tertiary hospital experienced in mechanical circulatory support in combination with bromocriptine treatment seems indispensable for successful treatment of peripartum cardiomyopathy complicated by cardiogenic shock.
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Affiliation(s)
| | | | - Dominik Berliner
- Department of Cardiology and Angiology, Hannover Medical School, Germany
| | - Tobias König
- Department of Cardiology and Angiology, Hannover Medical School, Germany
| | | | - L Christian Napp
- Department of Cardiology and Angiology, Hannover Medical School, Germany
| | - Jörn Tongers
- Department of Cardiology and Angiology, Hannover Medical School, Germany
| | - Christian Kühn
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Germany
| | - Jan D Schmitto
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Germany
| | | | - Andreas Schäfer
- Department of Cardiology and Angiology, Hannover Medical School, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Germany
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29
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Pantin E, Kahan A, Chiricolo A, Levin D, Batsides G, Papp D. Intra-Arterial Fibrinous Sheath Development as a Potential Complication of the Impella Ventricular Assist Device. J Cardiothorac Vasc Anesth 2018; 33:501-505. [PMID: 29580794 DOI: 10.1053/j.jvca.2018.02.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Enrique Pantin
- Department of Anesthesiology, Rutgers - Robert Wood Johnson Medical School, New Brunswick, NJ.
| | - Alexander Kahan
- Department of Anesthesiology, Rutgers - Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Antonio Chiricolo
- Department of Anesthesiology, Rutgers - Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Danielle Levin
- Department of Anesthesiology, Rutgers - Robert Wood Johnson Medical School, New Brunswick, NJ
| | - George Batsides
- Department of Surgery, Rutgers - Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Denes Papp
- Department of Anesthesiology, Rutgers - Robert Wood Johnson Medical School, New Brunswick, NJ
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