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Nelson DW, Sundararajan S, Klein E, Joyce LD, Durham LA, Joyce DL, Mohammed AA. Sustained Use of the Impella 5.0 Heart Pump Enables Bridge to Clinical Decisions in 34 Patients. Tex Heart Inst J 2021; 48:469168. [PMID: 34388239 DOI: 10.14503/thij-20-7260] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
We studied whether sustained hemodynamic support (>7 d) with the Impella 5.0 heart pump can be used as a bridge to clinical decisions in patients who present with cardiogenic shock, and whether such support can improve their outcomes. We retrospectively reviewed cases of patients who had Impella 5.0 support at our hospital from August 2017 through May 2019. Thirty-four patients (23 with cardiogenic shock and 11 with severely decompensated heart failure) underwent sustained support for a mean duration of 11.7 ± 9.3 days (range, ≤48 d). Of 29 patients (85.3%) who survived to next therapy, 15 were weaned from the Impella, 8 underwent durable left ventricular assist device placement, 4 were escalated to venoarterial extracorporeal membrane oxygenation support, and 2 underwent heart transplantation. The 30-day survival rate was 76.5% (26 of 34 patients). Only 2 patients had a major adverse event: one each had an ischemic stroke and flail mitral leaflet. None of the devices malfunctioned. Sustained hemodynamic support with the Impella 5.0 not only improved outcomes in patients who presented with cardiogenic shock, but also provided time for multidisciplinary evaluation of potential cardiac recovery, or the need for durable left ventricular assist device implantation or heart transplantation. Our study shows the value of using the Impella 5.0 as a bridge to clinical decisions.
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Affiliation(s)
- Daniel W Nelson
- Division of Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sakthi Sundararajan
- Division of Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Evan Klein
- Division of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lyle D Joyce
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lucian A Durham
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David L Joyce
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Asim A Mohammed
- Division of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Edwards MR, Forbes G, MacDonald N, Berdunov V, Mihaylova B, Dias P, Thomson A, Grocott MP, Mythen MG, Gillies MA, Sander M, Phan TD, Evered L, Wijeysundera DN, McCluskey SA, Aldecoa C, Ripollés-Melchor J, Hofer CK, Abukhudair H, Szczeklik W, Grigoras I, Hajjar LA, Kahan BC, Pearse RM. Optimisation of Perioperative Cardiovascular Management to Improve Surgical Outcome II (OPTIMISE II) trial: study protocol for a multicentre international trial of cardiac output-guided fluid therapy with low-dose inotrope infusion compared with usual care in patients undergoing major elective gastrointestinal surgery. BMJ Open 2019; 9:e023455. [PMID: 30647034 PMCID: PMC6341180 DOI: 10.1136/bmjopen-2018-023455] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Postoperative morbidity and mortality in older patients with comorbidities undergoing gastrointestinal surgery are a major burden on healthcare systems. Infections after surgery are common in such patients, prolonging hospitalisation and reducing postoperative short-term and long-term survival. Optimal management of perioperative intravenous fluids and inotropic drugs may reduce infection rates and improve outcomes from surgery. Previous small trials of cardiac-output-guided haemodynamic therapy algorithms suggested a modest reduction in postoperative morbidity. A large definitive trial is needed to confirm or refute this and inform widespread clinical practice. METHODS The Optimisation of Perioperative Cardiovascular Management to Improve Surgical Outcome II (OPTIMISE II) trial is a multicentre, international, parallel group, open, randomised controlled trial. 2502 high-risk patients undergoing major elective gastrointestinal surgery will be randomly allocated in a 1:1 ratio using minimisation to minimally invasive cardiac output monitoring to guide protocolised administration of intravenous fluid combined with low-dose inotrope infusion, or usual care. The trial intervention will be carried out during and for 4 hours after surgery. The primary outcome is postoperative infection of Clavien-Dindo grade II or higher within 30 days of randomisation. Participants and those delivering the intervention will not be blinded to treatment allocation; however, outcome assessors will be blinded when feasible. Participant recruitment started in January 2017 and is scheduled to last 3 years, within 50 hospitals worldwide. ETHICS/DISSEMINATION The OPTIMISE II trial has been approved by the UK National Research Ethics Service and has been approved by responsible ethics committees in all participating countries. The findings will be disseminated through publication in a widely accessible peer-reviewed scientific journal. TRIAL REGISTRATION NUMBER ISRCTN39653756.
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Affiliation(s)
- Mark R Edwards
- Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Acute, Critical & Perioperative Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | - Gordon Forbes
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Neil MacDonald
- Department of Perioperative and Pain Medicine, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Vladislav Berdunov
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Borislava Mihaylova
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | | | - Ann Thomson
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Michael Pw Grocott
- Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Acute, Critical & Perioperative Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | - Monty G Mythen
- University College London Hospitals NIHR Biomedical Research Centre, London, UK
| | - Mike A Gillies
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Michael Sander
- Department of Anaesthesiology and Intensive Care Medicine, UKGM University Hospital Gießen, Justus-Liebig-University Giessen, Gießen, Germany
| | - Tuong D Phan
- St Vincent's Hospital Melbourne, and Anaesthesia, Perioperative and Pain Medicine Unit, University of Melbourne, Melbourne, Australia
| | - Lisbeth Evered
- St Vincent's Hospital Melbourne, and Anaesthesia, Perioperative and Pain Medicine Unit, University of Melbourne, Melbourne, Australia
| | - Duminda N Wijeysundera
- Department of Anesthesia, Toronto General Hospital and University of Toronto, Toronto, Canada
| | - Stuart A McCluskey
- Department of Anesthesia, Toronto General Hospital and University of Toronto, Toronto, Canada
| | - Cesar Aldecoa
- Hospital Universitario Rio Hortega, Valladolid, Spain
| | | | - Christoph K Hofer
- Institute of Anaesthesiology and Intensive Care Medicine, Triemli City Hospital, Zurich, Switzerland
| | | | - Wojciech Szczeklik
- Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Ioana Grigoras
- Regional Institute of Oncology Iasi, "Grigore T Popa" University of Medicine and Pharmacy Iasi, Iasi, Romania
| | - Ludhmila A Hajjar
- Intensive Care Unit, Department of Cardiopneumology, University of Sao Paulo, São Paulo, Brazil
| | - Brennan C Kahan
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
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Kilic T, Sahin T, Karauzum K, Ural E, Pedersen WR. New Pulmonary Valvuloplasty Technique by Use of an Hourglass-Shaped Balloon in 3 Adults with Severe Pulmonary Valve Stenosis. Tex Heart Inst J 2018; 45:76-83. [PMID: 29844739 DOI: 10.14503/thij-16-6018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Percutaneous balloon pulmonary valvuloplasty is the preferred therapy for pulmonary valve stenosis. However, the designs of the cylindrical balloons historically used for valvuloplasty have limitations, especially in patients who have large pulmonary annular diameters. The hourglass-shaped V8 Aortic Valvuloplasty Balloon may prove to be an effective alternative. The balloon has 2 large bulbous segments that are separated by a narrowed waist. The geometric shape is maintained throughout inflation, improving fixation and enabling broader leaflet opening. We present our first experience with the V8 balloon in 3 adults who had severe, symptomatic pulmonary valve stenosis. In addition to describing their cases, we detail our sizing technique for pulmonary valvuloplasty with the V8 balloon. Our successful results suggest that the V8 balloon is efficient and safe for balloon pulmonary valvuloplasty in adults with severe pulmonary valve stenosis.
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Abstract
Left atrial pressure indicates the left ventricular filling pressure in patients who have systolic or diastolic left ventricular dysfunction or valvular heart disease. The use of indirect surrogate methods to determine left atrial pressure has been essential in the modern evaluation and treatment of cardiovascular disease because of the difficulty and inherent risks associated with direct methods (typically the transseptal approach). One method that has been widely used to determine left atrial pressure indirectly is Swan-Ganz catheterization, in which a balloon-flotation technique is applied to measure pulmonary capillary wedge pressure; however, this approach has been associated with several limitations and potential risks. Measuring left ventricular end-diastolic pressure has also been widely used as a simple means to estimate filling pressures but remains a surrogate for the gold standard of directly measuring left atrial pressure. We describe a simple, low-risk method to directly measure left atrial pressure that involves the use of standard coronary catheterization techniques during a transradial procedure.
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Bolin EH, Maskatia SA, Tate AL, Petit CJ. Older Age at Completion of Fontan Procedure Is Associated with Improved Percentage of Predicted Maximum Oxygen Uptake. Tex Heart Inst J 2015; 42:333-40. [PMID: 26413015 DOI: 10.14503/thij-14-4178] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
We tested the hypothesis that later completion of the Fontan procedure is associated with improved exercise capacity in the current period of staged single-ventricle palliation. We performed a retrospective study, in Fontan patients, of exercise stress test data from April 2003 through March 2011. Patients were included if they had received staged palliations in accordance with current surgical strategy, defined as the performance of a superior cavopulmonary connection at ≤1 year of age, followed in subsequent years by Fontan completion. Patients with a pacemaker or respiratory exchange ratio <1 were excluded. Early and late Fontan groups were created on the basis of whether Fontan completion had been performed at <4 or ≥ 4 years of age. The primary predictor variable was age at Fontan completion, and the primary marker of exercise performance was the percentage of predicted maximum oxygen consumption. During the study period, 55 patients were identified (mean age, 11.7 ± 2.8 yr). Older age at Fontan completion correlated positively with higher percentages of predicted maximum oxygen consumption (R=0.286, P=0.034). Patients in whom Fontan completion was performed at ≥4 years of age had higher percentages of predicted maximum oxygen consumption than did those in whom completion was at <4 years of age (84.4 ± 21.5 vs 72.9 ± 18.1; P=0.041). Later Fontan completion might be associated with improved exercise capacity in patients palliated in accordance with contemporary surgical strategy.
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Downs EA, Isbell JM. Impact of hemodynamic monitoring on clinical outcomes. Best Pract Res Clin Anaesthesiol 2014; 28:463-76. [PMID: 25480775 DOI: 10.1016/j.bpa.2014.09.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 09/25/2014] [Accepted: 09/29/2014] [Indexed: 01/19/2023]
Abstract
In recent years, there has been a tremendous growth in available hemodynamic monitoring devices to support clinical decision-making in the operating room and intensive care unit. In addition to the "tried and true" heart rate and blood pressure monitors, there are several newer applications of existing technologies including arterial waveform analysis, intraoperative and bedside critical care echocardiography, esophageal Doppler, and tissue oximetry, among others. Several monitoring devices demonstrate positive effect on outcomes, especially when used in conjunction with specific goal-directed therapy protocols to achieve a desired clinical effect. Other devices remain in the validation stage, awaiting comprehensive comparison to established techniques. While these new technologies offer promising advances in intraoperative and critical care, they are often quite costly and many devices lack strong evidence for widespread adoption into clinical practice. In this review, we highlight the current data on clinical outcomes with the use of available hemodynamic monitoring devices.
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Affiliation(s)
- Emily A Downs
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA 22908, USA.
| | - James M Isbell
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA 22908, USA.
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Ma TS, Bozkurt B, Paniagua D, Kar B, Ramasubbu K, Rothe CF. Central venous pressure and pulmonary capillary wedge pressure: fresh clinical perspectives from a new model of discordant and concordant heart failure. Tex Heart Inst J 2011; 38:627-638. [PMID: 22199422 PMCID: PMC3233309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Heart-failure phenotypes include pulmonary and systemic venous congestion. Traditional heart-failure classification systems include the Forrester hemodynamic subsets, which use 2 indices: pulmonary capillary wedge pressure (PCWP) and cardiac index. We hypothesized that changes in PCWP and central venous pressure (CVP), and in the phenotypes of heart failure, might be better evaluated by cardiovascular modeling. Therefore, we developed a lumped-parameter cardiovascular model and analyzed forms of heart failure in which the right and left ventricles failed disproportionately (discordant ventricular failure) versus equally (concordant failure). At least 10 modeling analyses were carried out to the equilibrium state. Acute discordant pump failure was characterized by a "passive" volume movement, with fluid accumulation and pressure elevation in the circuit upstream of the failed pump. In biventricular failure, less volume was mobilized. These findings negate the prevalent teaching that pulmonary congestion in left ventricular failure results primarily from the "backing up" of elevated left ventricular filling pressure. They also reveal a limitation of the Forrester classification: that PCWP and cardiac index are not independent indices of circulation. Herein, we propose a system for classifying heart-failure phenotypes on the basis of discordant or concordant heart failure. A surrogate marker, PCWP-CVP separation, in a simplified situation without complex valvular or pulmonary disease, shows that discordant left and right ventricular failures are characterized by differences of ≥ 4 and ≤ 0 mmHg, respectively. We validated the proposed model and classification system by using published data on patients with acute and chronic heart failure.
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Affiliation(s)
- Tony S Ma
- Section of Cardiology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas 77030, USA.
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Suradi H, Breall JA. Successful use of the Impella device in giant cell myocarditis as a bridge to permanent left ventricular mechanical support. Tex Heart Inst J 2011; 38:437-440. [PMID: 21841879 PMCID: PMC3147205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Idiopathic giant cell myocarditis is a rare condition with a poor prognosis. Patients with giant cell myocarditis typically die of refractory ventricular arrhythmias or progressive congestive heart failure in about 3 months. The benefit of immunosuppressive therapy varies among patients with giant cell myocarditis, and no factors that would predict which patients will respond to therapy have been identified. Mechanical circulatory support devices, from intra-aortic balloon pumps to more permanent systems, have been used for ventricular support in cases of acute heart failure.Herein, we describe a case of giant cell myocarditis in a previously healthy 44-year-old woman who presented with cardiogenic shock. She was supported hemodynamically with the Impella Recover LP 2.5 left ventricular assist device until a permanent device could be surgically implanted. To our knowledge, this is the 1st reported case of the successful use of the Impella device for hemodynamic support in a patient with giant cell myocarditis until more definitive treatment could be instituted.
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Affiliation(s)
- Hussam Suradi
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN 46208, USA.
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Baldwin RT, Radovancević B, Duncan JM, Wampler RK, Frazier OH. Management of patients supported on the Hemopump cardiac assist system. Tex Heart Inst J 1992; 19:81-6. [PMID: 15227419 PMCID: PMC326258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
The Hemopump Cardiac Assist System is a relatively new intraarterial, axial-flow circulatory assist device that offers temporary left ventricular support to patients in refractory cardiogenic shock, without requiring major surgery for insertion. Use of the Hemopump is associated with a low complication rate. Device-related morbidity is extremely rare. Because the Hemopump is safe for use in community hospitals, the number of patients supported by this device is expected to increase. In this report, we present general guidelines for the care of patients supported by the Hemopump. We describe techniques for the management of afterload reduction, supravalvular dislodgement, device malfunction, ventricular ectopy, intracardiac shunting, and inflow cannula obstruction.
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Affiliation(s)
- R T Baldwin
- The Section of Cardiovascular Surgery, Division of Transplantation, Texas Heart Institute at St. Luke's Episcopal Hospital, Houston, Texas 77225-0345, USA
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