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Arjomandi Rad A, Ansaripour A, Magouliotis DE, Abbasciano RG, Koulouroudias M, Viviano A, Rosendahl U, Athanasiou T, Kourliouros A. Surgical Strategies in Reoperation of the Proximal Aorta and Arch for Patients with Previous Frozen Elephant Trunk. J Clin Med 2024; 13:4063. [PMID: 39064105 PMCID: PMC11278031 DOI: 10.3390/jcm13144063] [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: 04/11/2024] [Revised: 06/27/2024] [Accepted: 07/02/2024] [Indexed: 07/28/2024] Open
Abstract
Background: The frozen elephant trunk (FET) technique is increasingly utilized for aortic arch replacement in cases of aortic dissections and aneurysms. This rise in usage has led to more patients needing redo aortic surgeries due to progression of existing conditions, FET-related complications, or new valvular/coronary diseases. This article aims to evaluate surgical techniques to minimize risks during these reoperations, including a case study of a complex redo surgery. Methods: A comprehensive examination of surgical strategies was conducted, focusing on preoperative preparation, cannulation site identification, cerebral and cardiac protective measures, and pitfalls to avoid. The importance of adapting to the modified anatomical landscape post-FET is emphasized. A detailed case study of a patient undergoing complex redo FET surgery is included. Results: The article identified key surgical strategies for reoperation in patients with prior FET, highlighting the importance of meticulous preoperative planning and execution. Techniques to minimize risks include detailed imaging for planning, strategic cannulation for optimal perfusion, multidisciplinary approaches as well as careful fail-safe measures. The case study demonstrates the practical application of these strategies in a high-risk scenario. The evidence underscores the necessity for individualized patient management and the development of standardized protocols. Conclusions: The FET technique, while effective for initial aortic arch repairs, often necessitates complex reoperations. Adopting advanced surgical strategies and multidisciplinary planning can significantly mitigate risks associated with these procedures. Future research should focus on refining these techniques and establishing standardized protocols to improve patient outcomes.
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Affiliation(s)
- Arian Arjomandi Rad
- Medical Sciences Division, University of Oxford, Oxford OX3 9DU, UK
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK;
| | - Ali Ansaripour
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK;
| | - Dimitrios E. Magouliotis
- Department of Cardiothoracic Surgery, University Hospital of Larissa, School of Medical Sciences, 413 34 Larissa, Greece;
| | - Riccardo G. Abbasciano
- Department of Cardiothoracic Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W12 0HS, UK (A.V.); (T.A.)
| | | | - Alessandro Viviano
- Department of Cardiothoracic Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W12 0HS, UK (A.V.); (T.A.)
| | - Ulrich Rosendahl
- Department of Cardiothoracic Surgery, Royal Brompton Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London SW3 6NP, UK;
| | - Thanos Athanasiou
- Department of Cardiothoracic Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W12 0HS, UK (A.V.); (T.A.)
| | - Antonios Kourliouros
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK;
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Sá MP, Jacquemyn X, Hess N, Brown JA, Caldonazo T, Kirov H, Doenst T, Serna-Gallegos D, Kaczorowski D, Sultan I. Extracorporeal life support after surgical repair for acute type a aortic dissection: A systematic review and meta-analysis. Perfusion 2024:2676591241253464. [PMID: 38730556 DOI: 10.1177/02676591241253464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2024]
Abstract
BACKGROUND The use of extracorporeal life support (ECLS) in patients after surgical repair for acute type A aortic dissection (ATAAD) has not been well documented. METHODS We performed a systematic review and meta-analysis to assess the outcomes of ECLS after surgery for ATAAD with data published by October 2023 in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and the Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guidelines. The protocol was registered in PROSPERO (CRD42023479955). RESULTS Twelve observational studies met our eligibility criteria, including 280 patients. Mean age was 55.0 years and women represented 25.3% of the overall population. Although the mean preoperative left ventricle ejection fraction was 59.8%, 60.8% of patients developed left ventricle failure and 34.0% developed biventricular failure. Coronary involvement and malperfusion were found in 37.1% and 25.6%, respectively. Concomitant coronary bypass surgery was performed in 38.5% of patients. Regarding ECLS, retrograde flow (femoral) was present in 39.9% and central cannulation was present in 35.4%. In-hospital mortality was 62.8% and pooled estimate of successful weaning was 50.8%. Neurological complications, bleeding and renal failure were found in 25.9%, 38.7%, and 65.5%, respectively. CONCLUSION ECLS after surgical repair for ATAAD remains associated with high rates of in-hospital death and complications, but it still represents a chance of survival in critical situations. ECLS remains a salvage attempt and surgeons should not try to avoid ECLS at all costs after repairing an ATAAD case.
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Affiliation(s)
- Michel Pompeu Sá
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Xander Jacquemyn
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Nicholas Hess
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - James A Brown
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Tulio Caldonazo
- Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
| | - Hristo Kirov
- Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
| | - Derek Serna-Gallegos
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David Kaczorowski
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Koziol KJ, Isath A, Rao S, Gregory V, Ohira S, Van Diepen S, Lorusso R, Krittanawong C. Extracorporeal Membrane Oxygenation (VA-ECMO) in Management of Cardiogenic Shock. J Clin Med 2023; 12:5576. [PMID: 37685643 PMCID: PMC10488419 DOI: 10.3390/jcm12175576] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/13/2023] [Accepted: 08/17/2023] [Indexed: 09/10/2023] Open
Abstract
Cardiogenic shock is a critical condition of low cardiac output resulting in insufficient systemic perfusion and end-organ dysfunction. Though significant advances have been achieved in reperfusion therapy and mechanical circulatory support, cardiogenic shock continues to be a life-threatening condition associated with a high rate of complications and excessively high patient mortality, reported to be between 35% and 50%. Extracorporeal membrane oxygenation can provide full cardiopulmonary support, has been increasingly used in the last two decades, and can be used to restore systemic end-organ hypoperfusion. However, a paucity of randomized controlled trials in combination with high complication and mortality rates suggest the need for more research to better define its efficacy, safety, and optimal patient selection. In this review, we provide an updated review on VA-ECMO, with an emphasis on its application in cardiogenic shock, including indications and contraindications, expected hemodynamic and echocardiographic findings, recommendations for weaning, complications, and outcomes. Furthermore, specific emphasis will be devoted to the two published randomized controlled trials recently presented in this setting.
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Affiliation(s)
- Klaudia J. Koziol
- School of Medicine, New York Medical College and Westchester Medical Center, Valhalla, NY 10595, USA
| | - Ameesh Isath
- Department of Cardiology, Westchester Medical Center, Valhalla, NY 10595, USA
| | - Shiavax Rao
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD 21218, USA
| | - Vasiliki Gregory
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD 21218, USA
| | - Suguru Ohira
- Division of Cardiothoracic Surgery, New York Medical College and Westchester Medical Center, Valhalla, NY 10595, USA
| | - Sean Van Diepen
- Division of Cardiology and Critical Care, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, 6202 AZ Maastricht, The Netherlands
| | - Chayakrit Krittanawong
- Cardiology Division, NYU Langone Health and NYU School of Medicine, New York, NY 10016, USA
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Yu J, Yu W, Zeng H, Gao J, Xiong J. Case report: Surgery combined with extracorporeal membrane oxygenation for a patient with type A aortic dissection complicated with myocardial infarction after percutaneous coronary intervention. Front Cardiovasc Med 2023; 10:1205373. [PMID: 37485265 PMCID: PMC10360360 DOI: 10.3389/fcvm.2023.1205373] [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: 04/13/2023] [Accepted: 06/22/2023] [Indexed: 07/25/2023] Open
Abstract
Background Aortic dissection (AD) is a severe cardiovascular disease characterized by aortic rupture, aortic valve insufficiency, aortic branch lumen stenosis, and occlusion. Acute ST-segment elevation myocardial infarction may be the primary manifestation when aortic dissection affects the coronary artery, leading to delayed or missed diagnosis of aortic dissection, and preventing patients from receiving timely and comprehensive treatment. Simultaneous aortic repair and coronary artery bypass grafting surgery are controversial because of their high mortality rates. Personalized and optimal treatment plans for patients should be taken seriously based on their different conditions and treatment options. Case presentation A 42-year-old man who experienced 1 h of persistent precordialgia was admitted to a local second-level hospital for emergency treatment. Electrocardiogram (ECG) showed evidence of ST-segment elevation, and myocardial enzyme levels were CK-MB 18.35 ng/ml and troponin 0.42 ng/ml. The patient was treated for acute myocardial infarction (AMI) and urgently sent to the interventional catheter room. Coronary angiography showed stenosis of the starting part of the right coronary artery trunk. Thus, stent implantation was performed, and the stenosis section recovered patency; however, postoperative precordialgia was not alleviated. Computed tomography angiography (CTA) revealed a type A AD. The patient was immediately transferred to a higher-level hospital, underwent emergency surgery with cardiopulmonary bypass (CPB) ascending aorta replacement, SUN's procedure (total arch replacement and stented elephant trunk implantation), and simultaneous implantation of extracorporeal membrane oxygenation (ECMO), and regained consciousness within intensive care unit care. ECMO was discontinued when hemodynamics stabilized. The patient ultimately recovered well and was discharged. Conclusion This case demonstrated that precordialgia is not limited to myocardial infarction but may also be accompanied by aortic dissection. Percutaneous coronary intervention (PCI) can timely and effectively restore coronary artery perfusion, strive for the opportunity of aortic repair surgery, and can overcome pump failure caused by myocardial infarction, cardiopulmonary bypass, heart block time, and myocardial ischemia-reperfusion injury. Personalized treatment is crucial for patients with complex type A aortic dissection.
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Affiliation(s)
- Junjian Yu
- Department of Cardiac and Vascular Surgery, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Wenbo Yu
- The First Clinical Medical College of Gannan Medical University, Ganzhou, China
| | - Hui Zeng
- Department of Thoracic and Cardiac Surgery, Ningdu County People's Hospital, Ganzhou, China
| | - Jianfeng Gao
- The First Clinical Medical College of Gannan Medical University, Ganzhou, China
| | - Jianxian Xiong
- Department of Cardiac and Vascular Surgery, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
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Tu GW, Chen YS, Huang M, Dobrilovic N, Luo Z. Editorial: Advances in extracorporeal life support in critically ill patients, volume II. Front Med (Lausanne) 2023; 10:1130962. [PMID: 36744133 PMCID: PMC9893482 DOI: 10.3389/fmed.2023.1130962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 01/09/2023] [Indexed: 01/20/2023] Open
Affiliation(s)
- Guo-wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China,*Correspondence: Guo-wei Tu ✉
| | - Yih-Sharng Chen
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei, Taiwan,Yih-Sharng Chen ✉
| | - Man Huang
- Department of Intensive Care Unit, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China,Man Huang ✉
| | - Nikola Dobrilovic
- Division of Cardiac Surgery, NorthShore University HealthSystem, Chicago, IL, United States,Nikola Dobrilovic ✉
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China,Department of Critical Care Medicine, Zhongshan Hospital (Xiamen), Fudan University, Xiamen, China,Zhe Luo ✉
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Anand S, Barry T, Arsanjani R, LeMond L. Echocardiography in Cardiac Assist Devices. Rev Cardiovasc Med 2022; 23:253. [PMID: 39076924 PMCID: PMC11266755 DOI: 10.31083/j.rcm2307253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/11/2022] [Accepted: 06/20/2022] [Indexed: 07/31/2024] Open
Abstract
In patients with medically refractory heart failure or cardiogenic shock, both temporary and durable mechanical circulatory support devices can be used to support cardiac circulation. Both transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) are widely available, relatively noninvasive, and avoid radiation exposure. Thus, echocardiography is an invaluable tool that provides vital information aiding in preprocedure evaluation, placement, management, and weaning of cardiac assist devices. The purpose of this article is to review the utility of both TTE and TEE in managing patients with cardiac assist devices.
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Affiliation(s)
- Senthil Anand
- Department of Cardiology, Mayo Clinic Arizona, Scottsdale, AZ 85259, USA
| | - Timothy Barry
- Department of Cardiology, Mayo Clinic Arizona, Scottsdale, AZ 85259, USA
| | - Reza Arsanjani
- Department of Cardiology, Mayo Clinic Arizona, Scottsdale, AZ 85259, USA
| | - Lisa LeMond
- Department of Cardiology, Mayo Clinic Arizona, Scottsdale, AZ 85259, USA
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Hou JY, Li X, Yang SG, Zheng JL, Ma JF, Su Y, Zhang YJ, Guo KF, Tu GW, Luo Z. Veno-Arterial Extracorporeal Membrane Oxygenation for Patients Undergoing Heart Transplantation: A 7-Year Experience. Front Med (Lausanne) 2021; 8:774644. [PMID: 34988094 PMCID: PMC8720851 DOI: 10.3389/fmed.2021.774644] [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: 09/12/2021] [Accepted: 11/18/2021] [Indexed: 02/05/2023] Open
Abstract
Objective: Primary graft dysfunction (PGD) is the leading cause of early death after heart transplantation. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide temporary mechanical circulatory support and time for functional recovery of the transplanted heart. The purpose of this study was to analyze the timing and prognoses of VA-ECMO in patients with severe PGD after heart transplantation. Methods: A total of 130 patients underwent heart transplantation at the Zhongshan Hospital Affiliated with Fudan University between January 2014 and December 2020. All patients received basiliximab immunoinduction and a classic double vena cava anastomosis orthotopic heart transplantation. Among them, 29 patients (22.3%) developed severe PGD in the early postoperative period. VA-ECMO was performed in patients with difficulty weaning from cardiopulmonary bypass (CPB) or postoperative refractory cardiogenic shock. Patients were divided into two groups according to whether or not they were successfully weaned from VA-ECMO (patients who survived for 48 h after weaning and did not need VA-ECMO assistance again). The perioperative clinical data were recorded, and all patients were followed up until discharge. Early outcomes were compared between groups. Results: A total of 29 patients with VA-ECMO support after heart transplantation were included in this study. The proportion of patients receiving VA-ECMO was 22.3% (29/130). Nineteen patients (65.5%) needed VA-ECMO due to difficulty with weaning from CPB, and 10 patients required VA-ECMO for postoperative cardiogenic shock. Nineteen patients (65.5%) were successfully weaned from VA-ECMO. Overall, in-hospital mortality of VA-ECMO support patients was 55.2%. The main causes of death were ventricular fibrillation (four cases), major bleeding (three cases), infection (four cases), and graft failure (five cases). Conclusion: Despite advances in heart transplantation, severe PGD remains a lethal complication after heart transplantation. At present, the treatment for severe PGD after heart transplantation is a challenge. VA-ECMO provides an effective treatment for severe PGD after heart transplantation, which can promote graft function recovery.
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Affiliation(s)
- Jun-yi Hou
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xin Li
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shou-guo Yang
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ji-li Zheng
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jie-fei Ma
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
| | - Ying Su
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi-jie Zhang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ke-fang Guo
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- *Correspondence: Guo-wei Tu
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
- Shanghai Key Lab of Pulmonary Inflammation and Injury, Fudan University, Shanghai, China
- Zhe Luo
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