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Enríquez-Vázquez D, Barge-Caballero E, González-Vílchez F, Almenar-Bonet L, García-Cosío Carmena MD, González-Costello J, Gómez-Bueno M, Castel-Lavilla MÁ, Díaz-Molina B, Martínez-Sellés M, Mirabet-Pérez S, de la Fuente-Galán L, Hervás-Sotomayor D, Rangel-Sousa D, Garrido-Bravo IP, Blasco-Peiró T, Rábago Juan-Aracil G, Muñiz J, Crespo-Leiro MG. Impact of left ventricular unloading on postheart transplantation outcomes in patients bridged with VA-ECMO. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2025; 78:494-503. [PMID: 39393768 DOI: 10.1016/j.rec.2024.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Accepted: 09/23/2024] [Indexed: 10/13/2024]
Abstract
INTRODUCTION AND OBJECTIVES The impact of preoperative left ventricular (LV) unloading on postoperative outcomes in patients bridged with venoarterial extracorporeal membrane oxygenation (VA-ECMO) to heart transplantation (HT) is unknown. Our aim was to compare posttransplant outcomes in patients bridged to HT with VA-ECMO, with or without the use of different mechanical strategies for LV decompression. METHODS We conducted a retrospective analysis of the postoperative outcomes of consecutive HT candidates bridged with VA-ECMO, with or without concomitant LV unloading. Patients were included from 16 Spanish centers from 2010 to 2020. The primary endpoint was 1-year post-HT survival, which was assessed using Cox regression. RESULTS Overall, 245 patients underwent high-emergency HT while supported with VA-ECMO. A mechanical strategy for LV unloading was used in 133 (54.3%) patients, with the intra-aortic balloon pump being the most commonly used method (n=112; 84.2%). One-year posttransplant survival was 74.4% in the LV unloading group and 59.8% in the control group (P=.025). In multivariate analyses, preoperative LV unloading was independently associated with lower 1-year mortality (adjusted HR, 0.50; 95%CI, 0.32-0.78; P=.003). This association was observed both in patients managed with an intra-aortic balloon pump alone (adjusted HR, 0.52; 95%CI, 0.32-0.84; P=.007) and with other strategies for mechanical LV unloading (adjusted HR, 0.43; 95%CI, 0.19-0.97; P=.042). No significant differences were found between groups regarding other postoperative complications. CONCLUSIONS Preoperative LV unloading was independently associated with increased 1-year posttransplant survival in candidates bridged with VA-ECMO.
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Affiliation(s)
- Daniel Enríquez-Vázquez
- Servicio de Cardiología, Complejo Hospitalario Universitario de A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain. https://twitter.com/@danienriquezv
| | - Eduardo Barge-Caballero
- Servicio de Cardiología, Complejo Hospitalario Universitario de A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
| | | | - Luis Almenar-Bonet
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Politécnico La Fe, Valencia, Spain
| | - María Dolores García-Cosío Carmena
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - José González-Costello
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario de Bellvitge, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Manuel Gómez-Bueno
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - María Ángeles Castel-Lavilla
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Beatriz Díaz-Molina
- Servicio de Cardiología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Manuel Martínez-Sellés
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Facultad de Ciencias Biomédicas y de la Salud, Universidad Europea, Villaviciosa de Odón, Madrid, España; Facultad de Medicina, Universidad Complutense, Madrid, España
| | - Sonia Mirabet-Pérez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Luis de la Fuente-Galán
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - Diego Rangel-Sousa
- Servicio de Cardiología, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Iris P Garrido-Bravo
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Teresa Blasco-Peiró
- Servicio de Cardiología, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Javier Muñiz
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Facultad de Ciencias de la Salud, Universidad de A Coruña, A Coruña, Spain
| | - María G Crespo-Leiro
- Servicio de Cardiología, Complejo Hospitalario Universitario de A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Facultad de Ciencias de la Salud, Universidad de A Coruña, A Coruña, Spain
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AlGhamdi M, Saiydoun G, Lebreton G, Mazzucotelli JP. Percutaneous atrial septostomy for left ventricular unloading in patients on peripheral venoarterial extracorporeal membrane oxygenation: A systematic review and meta-analysis. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2025; 54:100542. [PMID: 40276546 PMCID: PMC12019464 DOI: 10.1016/j.ahjo.2025.100542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2024] [Revised: 01/27/2025] [Accepted: 04/06/2025] [Indexed: 04/26/2025]
Abstract
Background This study systematically reviewed the safety and efficacy of atrial septostomy as a left ventricular (LV) unloading intervention in paediatric and adult patients undergoing peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO). Methods The PubMed, Cochrane, and Google Scholar online databases were searched, and studies describing patients who received VA-ECMO for refractory cardiogenic shock and underwent atrial septostomy for LV unloading were included. Laboratory experiments, animal studies, and patients who received ECMO with a method other than atrial septostomy for LV unloading were excluded. Results From the 12 studies analysed, data were collected on 197 patients, including 97 (49 %) males and 75 (38 %) females (data unavailable for 25 patients) with ages ranging from 3.65 days to 70 years. VA-ECMO duration was 1.71 to 40 days (P < 0.001). Weaning from VA-ECMO with LV discharge was achieved successfully in 126 (64 %) patients, with 60 (30.5 %) in recovery (P = 0.006) and 66 (33.5 %) converted to a ventricular assistant device or transplantation. Additionally, 54 (27.4 %) patients experienced unsuccessful weaning. During atrial septostomy for LV unloading, 14 (7.1 %) patients experienced complications, whereas 180 (91.4 %) did not (P = 0.250). After LV unloading in patients receiving VA-ECMO, 60 (30.5 %) experienced early mortality (P = 0.286). Conclusion VA-ECMO-assisted percutaneous atrial septostomy is a viable, safe, and successful alternative for LV unloading in both children and adults with refractory cardiogenic shock. However, further studies with larger sample sizes are required to comprehensively assess the morbidity and mortality associated with this approach.
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Affiliation(s)
- Mohammed AlGhamdi
- Cardiac Surgery Division, King Abdulaziz University, Jeddah, Saudi Arabia
- Cardiac Surgery Division, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
- Department of Cardiac Surgery, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Strasbourg, France
| | - Gabriel Saiydoun
- Cardiac Surgery Division, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Guillaume Lebreton
- Cardiac Surgery Division, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Jean-Philippe Mazzucotelli
- Department of Cardiac Surgery, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Strasbourg, France
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Unoki T, Nakayama T, Saku K, Matsushita H, Inamori T, Matsuura J, Toyofuku T, Sato T, Konami Y, Suzuyama H, Inoue M, Horio E, Kodama K, Taguchi E, Nishikawa T, Sawamura T, Nakao K, Sakamoto T, Okumura K, Koyama J. Impact of ECPELLA support on 1-year outcomes and myocardial damage in patients with acute myocardial infarction and refractory cardiogenic shock: A single-center retrospective observational study. J Cardiol 2025; 85:352-359. [PMID: 39689743 DOI: 10.1016/j.jjcc.2024.12.003] [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: 09/16/2024] [Revised: 12/09/2024] [Accepted: 12/11/2024] [Indexed: 12/19/2024]
Abstract
BACKGROUND Venoarterial-extracorporeal membrane oxygenation (VA-ECMO) is a vital mechanical circulatory support for treating patients with refractory cardiogenic shock (CS). VA-ECMO can improve end-organ perfusion; however, it increases left ventricular (LV) afterload, resulting in further myocardial damage. ECPELLA, a combination of VA-ECMO and Impella (Abiomed Inc., Danvers, MA, USA) treatments, is an emerging modality to optimize end-organ perfusion and LV unloading. The impact of ECPELLA in refractory CS has not been established. We aimed to investigate the effects of ECPELLA on acute-phase LV damage and outcomes in patients with acute myocardial infarction (AMI) and refractory CS and compare them with those of VA-ECMO with an intra-aortic balloon pump (IABP). METHODS This single-center retrospective observational study included 90 consecutive patients with AMI and refractory CS who received VA-ECMO between January 2012 and December 2022. Of these, 44 and 46 received ECPELLA and VA-ECMO with IABP, respectively. We assessed the serum creatine kinase myocardial band (CK-MB) levels and 1-year mortality. RESULTS No significant differences were observed in the baseline characteristics and time from onset to reperfusion between the two groups. Compared with VA-ECMO with IABP, ECPELLA produced lower peak CK-MB levels (265 IU/L vs. 500 IU/L, p = 0.016) and a smaller area under the curve of CK-MB during the first 3 days (274 IU/L × d vs. 534 IU/L × d, p = 0.025). ECPELLA was associated with significantly lower 1-year mortality (64% vs 91%; p = 0.001). Cox proportional hazards analysis revealed that ECPELLA was inversely and independently associated with 1-year mortality (hazard ratio: 0.38, 95% confidence interval: 0.23-0.64; p < 0.001). CONCLUSIONS Our findings suggest that ECPELLA may offer myocardial protection and be associated with improved 1-year mortality in patients with AMI and refractory CS. Further prospective studies are needed to confirm these observations and better understand the potential benefits of ECPELLA in this population.
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Affiliation(s)
- Takashi Unoki
- Intensive Care Unit, Saiseikai Kumamoto Hospital, Kumamoto, Kumamoto, Japan; Department of Circulatory Dynamics, National Cerebral and Cardiovascular Center Research, Osaka, Osaka, Japan; Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan.
| | - Tomoko Nakayama
- Intensive Care Unit, Saiseikai Kumamoto Hospital, Kumamoto, Kumamoto, Japan
| | - Keita Saku
- Department of Circulatory Dynamics, National Cerebral and Cardiovascular Center Research, Osaka, Osaka, Japan
| | - Hiroki Matsushita
- Department of Circulatory Dynamics, National Cerebral and Cardiovascular Center Research, Osaka, Osaka, Japan
| | - Taiji Inamori
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Junya Matsuura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Takaaki Toyofuku
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Tomohide Sato
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Yutaka Konami
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Hiroto Suzuyama
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Masayuki Inoue
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Eiji Horio
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Kazuhisa Kodama
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Eiji Taguchi
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Takuya Nishikawa
- Department of Research Promotion and Management, National Cerebral and Cardiovascular Center Research, Osaka, Osaka, Japan
| | - Tadashi Sawamura
- Intensive Care Unit, Saiseikai Kumamoto Hospital, Kumamoto, Kumamoto, Japan
| | - Koichi Nakao
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Tomohiro Sakamoto
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Junjiro Koyama
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
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Abuelazm M, Nawlo A, Ibrahim AA, Amin AM, Mahmoud A, Elshenawy S, Alabdallat YJ, Turkmani M, Abdelazeem B, Caccamo M. Early left ventricular unloading during extracorporeal membrane oxygenation in cardiogenic shock: A systematic review and meta-analysis. Artif Organs 2025; 49:556-570. [PMID: 39494489 PMCID: PMC11974487 DOI: 10.1111/aor.14898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 09/26/2024] [Accepted: 10/14/2024] [Indexed: 11/05/2024]
Abstract
BACKGROUND Left ventricular (LV) unloading is a crucial intervention to decrease the harmful consequences of extracorporeal membrane oxygenation (ECMO) on hemodynamic status in cardiogenic shock (CS) patients. However, a lingering question preoccupies experts: Should we intervene early or wait until clinical deterioration caused by increasing afterload is detected? METHODS A systematic review and meta-analysis synthesizing studies, which were retrieved by systematically searching PubMed, Web of Science, SCOPUS, and Cochrane through December 2023. We used R V. 4.3 to pool dichotomous data using risk ratio (RR) and continuous data using mean difference (MD) with a 95% confidence interval (CI). PROSPERO ID CRD42024501643. RESULTS Eight studies with 2.117 patients were included. Early/prophylactic LV unloading was associated with a lower incidence of all-cause mortality [RR: 0.87 with 95% CI (0.79, 0.95), p < 0.01]. However, there was no significant difference between the two groups regarding cardiac mortality [RR: 1.01 with 95% CI (0.68, 1.48), p = 0.98], non-cardiac mortality [RR: 0.86 with 95% CI (0.46, 1.62), p = 0.64], and in-hospital mortality [RR: 0.95 with 95% CI (0.86, 1.05), p = 0.30]. There was no significant difference between the two groups regarding ECMO weaning, myocardial recovery, ECMO duration, and length of hospitalization. CONCLUSION Early/prophylactic LV unloading during ECMO for CS patients was associated with a decreased incidence of all-cause mortality and sepsis or infection, with no effect on ECMO weaning, myocardial recovery, ECMO duration, and hospital length of stay.
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Affiliation(s)
| | - Ahmad Nawlo
- Division of Infectious Diseases, Department of MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | | | | | | | | | | | - Mustafa Turkmani
- Faculty of MedicineMichigan State UniversityEast LansingMichiganUSA
- Department of Internal MedicineMcLaren Health CareOaklandMichiganUSA
| | - Basel Abdelazeem
- Department of CardiologyWest Virginia UniversityMorgantownWest VirginiaUSA
| | - Marco Caccamo
- Department of CardiologyWest Virginia UniversityMorgantownWest VirginiaUSA
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Calhoun A, Lee MH, Pisano DV, Karavas A, Ortoleva J. Variability in triggers for mechanical left ventricular unloading in VA-ECMO: A literature search. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2025; 57:24-31. [PMID: 40053855 PMCID: PMC11888587 DOI: 10.1051/ject/2024031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 10/21/2024] [Indexed: 03/09/2025]
Abstract
BACKGROUND Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) is a means of supporting the lungs or the heart and lungs in patients with hemodynamic compromise that is refractory to conventional measures. VA-ECMO is most commonly deployed in a percutaneous fashion with femoral arterial and venous access. While VA-ECMO, particularly in a femoral-femoral configuration, provides both hemodynamic and ventilatory support, it also causes increased afterload on the left ventricle (LV) which in turn may result in LV distension (LVD). LV thrombus formation, ventricular arrhythmias, pulmonary edema, and pulmonary hemorrhage are clinical manifestations of LVD. LV unloading is a means of preventing LVD and its sequelae. If less invasive methods fail to achieve adequate LV unloading, invasive mechanical methods are pursued such as intra-aortic balloon pump counter-pulsation, atrial septostomy, surgical venting, left atrial cannulation, and percutaneous transvalvular micro-axial pump placement. METHODS We sought to review indicators of LVD, thresholds, and options for mechanical venting strategies. A Pubmed search was performed to identify current literature about LV unloading for VA ECMO. This was categorized and summarized to determine commonly reported thresholds for mechanical LV unloading. RESULTS Multiple physiologic and radiographic indicators were reported without uniformity. Common indicators included increased pulmonary artery catheter pressures, decreased Aortic Line Pulse Pressure, as well as multiple Echocardiographic, and radiographic indicators. CONCLUSION Although there has been significant interest in the topic, there is currently limited uniformity in thresholds for when to initiate and escalate mechanical LV unloading. While the method of LV unloading is an active area of investigation, the threshold for which to initiate invasive venting strategies is largely unexplored.
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Affiliation(s)
- Anthony Calhoun
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Department of Perfusion, Boston Medical Center 732 Harrison Ave 3rd Floor Boston MA 02118 USA
| | - Min-Ho Lee
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Perfusion Services, Children’s Hospital of Philadelphia 3401 Civic Center Blvd Philadelphia PA 19104 USA
| | - Dominic V. Pisano
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Department of Anesthesiology, Boston Medical Center 750 Albany Street, Floor 2R, Power Plant Building Boston MA 02118 USA
| | - Alexandros Karavas
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Division of Cardiac Surgery, Boston Medical Center 750 Albany Street Boston MA 02118 USA
| | - Jamel Ortoleva
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Department of Anesthesiology, Boston Medical Center 750 Albany Street, Floor 2R, Power Plant Building Boston MA 02118 USA
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Batista N, Nguyen SN, Miltiades AN. Pro: Use of Temporary Ventricular Assist Devices for Left Ventricular Unloading During Venoarterial Extracorporeal Membrane Oxygenation Support. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00919-4. [PMID: 39632204 DOI: 10.1053/j.jvca.2024.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2024] [Revised: 11/01/2024] [Accepted: 11/15/2024] [Indexed: 12/07/2024]
Affiliation(s)
- Naralys Batista
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY.
| | - Stephanie N Nguyen
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Andrea N Miltiades
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY
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7
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Goffer EM, Lamberti KK, Spognardi A, Edelman ER, Keller SP. Steady Flow Left Ventricle Unloading Is Superior to Pulsatile Pressure Augmentation Venting During Venoarterial Extracorporeal Membrane Oxygenation Support. ASAIO J 2024; 70:929-937. [PMID: 38588597 PMCID: PMC11458817 DOI: 10.1097/mat.0000000000002208] [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] [Indexed: 04/10/2024] Open
Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) shunts venous blood to the systemic arterial circulation to provide end-organ perfusion while increasing afterload that may impede left ventricle (LV) ejection and impair cardiac recovery. To maintain flow across the aortic valve and reduce risk of lethal clot formation, secondary mechanical circulatory support (MCS) devices are increasingly used despite limited understanding of their effects on cardiac function. This study sought to quantify the effects of VA-ECMO and combined with either intraaortic balloon pump (IABP) or percutaneous ventricular assist device (pVAD) on LV physiologic state and perfusion metrics in a porcine model of acute cardiogenic shock. Shock was induced through serial left anterior descending artery microbead embolization followed by initiation of VA-ECMO support and then placement of either IABP or pVAD. Hemodynamic measurements, LV pressure-volume loops, and carotid artery blood flow were evaluated before and after institution of combined MCS. The IABP decreased LV end-diastolic pressure by a peak of 15% while slightly increasing LV stroke work compared with decreases of more than 60% and 50% with the pVAD, respectively. The pVAD also demonstrated increased coronary perfusion and systemic pressure gradients in comparison to the IABP. Combined support with VA-ECMO and pVAD improves cardiovascular state in comparison to IABP.
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Affiliation(s)
- Efrat M. Goffer
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA
| | - Kimberly K. Lamberti
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA
| | | | - Elazer R. Edelman
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Steven P. Keller
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD
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Nishimura T, Hirata Y, Ise T, Iwano H, Izutani H, Kinugawa K, Kitai T, Ohno T, Ohtani T, Okumura T, Ono M, Satomi K, Shiose A, Toda K, Tsukamoto Y, Yamaguchi O, Fujino T, Hashimoto T, Higashi H, Higashino A, Kondo T, Kurobe H, Miyoshi T, Nakamoto K, Nakamura M, Saito T, Saku K, Shimada S, Sonoda H, Unai S, Ushijima T, Watanabe T, Yahagi K, Fukushima N, Inomata T, Kyo S, Minamino T, Minatoya K, Sakata Y, Sawa Y. JCS/JSCVS/JCC/CVIT 2023 guideline focused update on indication and operation of PCPS/ECMO/IMPELLA. J Cardiol 2024; 84:208-238. [PMID: 39098794 DOI: 10.1016/j.jjcc.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/06/2024]
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9
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Nishimura T, Hirata Y, Ise T, Iwano H, Izutani H, Kinugawa K, Kitai T, Ohno T, Ohtani T, Okumura T, Ono M, Satomi K, Shiose A, Toda K, Tsukamoto Y, Yamaguchi O, Fujino T, Hashimoto T, Higashi H, Higashino A, Kondo T, Kurobe H, Miyoshi T, Nakamoto K, Nakamura M, Saito T, Saku K, Shimada S, Sonoda H, Unai S, Ushijima T, Watanabe T, Yahagi K, Fukushima N, Inomata T, Kyo S, Minamino T, Minatoya K, Sakata Y, Sawa Y. JCS/JSCVS/JCC/CVIT 2023 Guideline Focused Update on Indication and Operation of PCPS/ECMO/IMPELLA. Circ J 2024; 88:1010-1046. [PMID: 38583962 DOI: 10.1253/circj.cj-23-0698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Affiliation(s)
- Takashi Nishimura
- Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine
| | - Yasutaka Hirata
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo
| | - Takayuki Ise
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | | | - Hironori Izutani
- Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine
| | | | - Takeshi Kitai
- Department of Heart Failure and Transplantation, National Cerebral and Cardiovascular Center
| | - Takayuki Ohno
- Division of Cardiovascular Surgery, Mitsui Memorial Hospital
| | - Tomohito Ohtani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo
| | - Kazuhiro Satomi
- Department of Cardiovascular Medicine, Tokyo Medical University Hospital
| | - Akira Shiose
- Department of Cardiovascular Surgery, Kyushu University Hospital
| | - Koichi Toda
- Department of Thoracic and Cardiovascular Surgery, Dokkyo Medical University Saitama Medical Center
| | - Yasumasa Tsukamoto
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Osamu Yamaguchi
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine
| | - Takeo Fujino
- Department of Advanced Cardiopulmonary Failure, Faculty of Medical Sciences, Kyushu University
| | - Toru Hashimoto
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University
| | - Haruhiko Higashi
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine
| | | | - Toru Kondo
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Hirotsugu Kurobe
- Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine
| | - Toru Miyoshi
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine
| | - Kei Nakamoto
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Makiko Nakamura
- Second Department of Internal Medicine, University of Toyama
| | - Tetsuya Saito
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Keita Saku
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center
| | - Shogo Shimada
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | - Hiromichi Sonoda
- Department of Cardiovascular Surgery, Kyushu University Hospital
| | - Shinya Unai
- Department of Thoracic & Cardiovascular Surgery, Cleveland Clinic
| | - Tomoki Ushijima
- Department of Cardiovascular Surgery, Kyushu University Hospital
| | - Takuya Watanabe
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | | | | | - Takayuki Inomata
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences
| | - Shunei Kyo
- Tokyo Metropolitan Institute for Geriatrics and Gerontology
| | - Tohru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
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10
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Kang J, Lee K, Lee HS, Lee H, Ahn H, Han J, Yang H, Park KW, Lee H, Kang H, Koo B, Kim H, Cho H. Differential effect of left ventricular unloading according to the aetiology of cardiogenic shock. ESC Heart Fail 2024; 11:338-348. [PMID: 38012086 PMCID: PMC10804165 DOI: 10.1002/ehf2.14584] [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: 06/20/2023] [Revised: 10/04/2023] [Accepted: 10/31/2023] [Indexed: 11/29/2023] Open
Abstract
AIMS Evidence for the effectiveness of left ventricular (LV) unloading in patients who received venoaterial extracorporeal membrane oxygenation (VA-ECMO) for acute myocardial infarction (AMI) or non-AMI induced cardiogenic shock (CS) is limited. The aim of the present study was to compare the effect of LV unloading in AMI-induced and non-AMI-induced CS. METHODS AND RESULTS This is a single-centre retrospective observational study of patients with CS undergoing VA-ECMO from January 2011 to March 2019. Patients were classified as AMI-induced and non-AMI-induced CS. The association of LV unloading with 90-day mortality in both groups was analysed using Cox proportional hazard regression analysis. RESULTS Of the 128 CS patients, 71 (55.5%) patients received VA-ECMO due to AMI-induced CS, and the remaining 57 (44.5%) received VA-ECMO due to non-AMI-induced CS. The modality of LV unloading was predominantly with IABP (94.5%). In the AMI-induced CS group, LV unloading did not reduce 90-day mortality (adjusted hazard ratio 1.96, 95% confidence interval 0.90-4.27, P = 0.089). However, in the non-AMI-induced CS group, LV unloading combined with VA-ECMO significantly reduced 90-day mortality (adjusted hazard ratio 0.37, 95% confidence interval 0.14-0.96, P = 0.041; P for interaction = 0.029) as compared with those who received VA-ECMO alone. CONCLUSIONS LV unloading with VA-ECMO may reduce 90-day mortality compared with VA-ECMO alone in patients with non-AMI-induced CS, but not in AMI-induced CS.
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Affiliation(s)
- Jeehoon Kang
- Department of Internal Medicine and Cardiovascular CenterSeoul National University Hospital and Seoul National University College of MedicineSeoulRepublic of Korea
| | - Kyu‐Sun Lee
- Department of Internal Medicine and Cardiovascular CenterEulji University Hospital and Eulji University School of MedicineDaejeonRepublic of Korea
| | | | - Huijin Lee
- Department of Internal Medicine and Cardiovascular CenterSeoul National University Hospital and Seoul National University College of MedicineSeoulRepublic of Korea
| | - Hyojeong Ahn
- Department of Internal Medicine and Cardiovascular CenterSeoul National University Hospital and Seoul National University College of MedicineSeoulRepublic of Korea
| | - Jung‐Kyu Han
- Department of Internal Medicine and Cardiovascular CenterSeoul National University Hospital and Seoul National University College of MedicineSeoulRepublic of Korea
| | - Han‐Mo Yang
- Department of Internal Medicine and Cardiovascular CenterSeoul National University Hospital and Seoul National University College of MedicineSeoulRepublic of Korea
| | - Kyung Woo Park
- Department of Internal Medicine and Cardiovascular CenterSeoul National University Hospital and Seoul National University College of MedicineSeoulRepublic of Korea
| | - Hae‐Young Lee
- Department of Internal Medicine and Cardiovascular CenterSeoul National University Hospital and Seoul National University College of MedicineSeoulRepublic of Korea
| | - Hyun‐Jae Kang
- Department of Internal Medicine and Cardiovascular CenterSeoul National University Hospital and Seoul National University College of MedicineSeoulRepublic of Korea
| | - Bon‐Kwon Koo
- Department of Internal Medicine and Cardiovascular CenterSeoul National University Hospital and Seoul National University College of MedicineSeoulRepublic of Korea
| | - Hyo‐Soo Kim
- Department of Internal Medicine and Cardiovascular CenterSeoul National University Hospital and Seoul National University College of MedicineSeoulRepublic of Korea
| | - Hyun‐Jai Cho
- Department of Internal Medicine and Cardiovascular CenterSeoul National University Hospital and Seoul National University College of MedicineSeoulRepublic of Korea
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11
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Bouillot E, Cherpin A, Remacle Bonnet A, Bonello L, Peyron F. [Temporary circulatory assistance by Impella™ in interventional cardiology: Observational study and medico-economic assessment after four years of use]. ANNALES PHARMACEUTIQUES FRANÇAISES 2024; 82:110-120. [PMID: 37923010 DOI: 10.1016/j.pharma.2023.10.012] [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: 07/24/2023] [Revised: 10/20/2023] [Accepted: 10/27/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVES During life-threatening emergencies or risky cardiologic interventions, pharmacology can be limited and the use of appropriate medical devices is then necessary. The Impella™ catheter, CP and 2.5, has been referenced for the exclusive use of the interventional cardiology technical platform at Hôpital Nord (AP-HM) in the absence of rapid access to the Extracorporeal Circulation unit. It is a temporary mechanical circulatory support device mainly indicated in refractory cardiogenic shock and coronary angioplasty at high risk of hemodynamic instability. The objective of this study, observational and retrospective, is to carry out a clinical and economic assessment linked to the use of this device over a period of four years (2017-2020). METHODS The criteria relating to the 71 patients (51 Impella™ CP and 20 Impella™ 2.5) and their clinical evolution as well as the costs and valuation of the stays were determined. RESULTS In particular, the Impella™ CP enabled myocardial recovery in 18 out of 51 patients and it was an intermediary in the context of heavier care for 11 patients. The balance between expenditure and valuation shows a deficit of -819,937 euros over the study period, with however a probable margin for improvement. CONCLUSIONS The Impella™ is of clinical interest under very specific conditions. Its high cost and the absence of inclusion on the list of reimbursements in addition to Homogeneous Groups of Stays represent a significant financial burden for health care establishments. Thus, optimizing the rating of future stays is a necessity.
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Affiliation(s)
- Elodie Bouillot
- Pharmacie à usage intérieur, AP-HM Nord, chemin des Bourrely, 13915 Marseille cedex 20, France.
| | - Amélie Cherpin
- Pharmacie à usage intérieur, AP-HM Nord, chemin des Bourrely, 13915 Marseille cedex 20, France
| | - Anne Remacle Bonnet
- Service d'information médicale, AP-HM Nord, chemin des Bourrely, 13915 Marseille cedex 20, France
| | - Laurent Bonello
- Service de cardiologie, AP-HM Nord, chemin des Bourrely, 13915 Marseille cedex 20, France
| | - Florence Peyron
- Pharmacie à usage intérieur, AP-HM Nord, chemin des Bourrely, 13915 Marseille cedex 20, France
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12
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Fujita K, Ueno M, Yasuda M, Mizutani K, Miyoshi T, Nakazawa G. Haemodynamic effects of inhaled nitric oxide in acute myocardial infarction complicated by right heart failure under ECPELLA support: case report. Eur Heart J Case Rep 2023; 7:ytad369. [PMID: 37575534 PMCID: PMC10422691 DOI: 10.1093/ehjcr/ytad369] [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: 12/07/2022] [Revised: 07/12/2023] [Accepted: 07/31/2023] [Indexed: 08/15/2023]
Abstract
Background Recently, mechanical support obtained with the combination of venoarterial extracorporeal membrane oxygenation (VA-ECMO) and an Impella device, together referred to as ECPELLA, has been shown to be effective for acute myocardial infarction with cardiogenic shock. However, methods for withdrawing VA-ECMO in acute myocardial infarction cases complicated by right ventricular dysfunction are yet to be established. Here, we report the effective use of inhaled nitric oxide during the weaning of VA-ECMO from the ECPELLA management of a patient with acute myocardial infarction with cardiogenic shock. Case summary An 81-year-old man with an acute extensive anterior wall myocardial infarction with cardiogenic shock was supported with ECPELLA to improve his haemodynamics. During ECPELLA, the Impella device could not maintain sufficient flow. Echocardiography revealed a small left ventricle and an enlarged right ventricle, indicating acute right heart failure. Inhaled nitric oxide was initiated to reduce right ventricle afterload, which decreased pulmonary artery pressure from 34/20 to 27/13 mmHg, improved right and left ventricle sizes, and stabilized the Impella support. Afterward, VA-ECMO could be withdrawn because the Impella alone was sufficient for haemodynamic support. Discussion Inhaled nitric oxide improved right ventricle performance in a patient with severe myocardial infarction with right heart failure supported by ECPELLA. Thus, we suggest that inhaled nitric oxide facilitates the weaning of VA-ECMO from patients with refractory right ventricular dysfunction who are supported by ECPELLA.
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Affiliation(s)
- Kosuke Fujita
- Department of Cardiology, Kindai University Hospital, 377-2 Onohigashi Osakasayamashi, 589-8511 Osaka, Japan
| | - Masafumi Ueno
- Department of Cardiology, Kindai University Hospital, 377-2 Onohigashi Osakasayamashi, 589-8511 Osaka, Japan
| | - Masakazu Yasuda
- Department of Cardiology, Kindai University Hospital, 377-2 Onohigashi Osakasayamashi, 589-8511 Osaka, Japan
| | - Kazuki Mizutani
- Department of Cardiology, Kindai University Hospital, 377-2 Onohigashi Osakasayamashi, 589-8511 Osaka, Japan
| | - Tatsuya Miyoshi
- Department of Cardiology, Kindai University Hospital, 377-2 Onohigashi Osakasayamashi, 589-8511 Osaka, Japan
| | - Gaku Nakazawa
- Department of Cardiology, Kindai University Hospital, 377-2 Onohigashi Osakasayamashi, 589-8511 Osaka, Japan
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13
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Saeed O, Nunez JI, Jorde UP. Pulmonary Protection from Left Ventricular Distension During Venoarterial Extracorporeal Membrane Oxygenation: Review and Management Algorithm. Lung 2023; 201:119-134. [PMID: 37043003 DOI: 10.1007/s00408-023-00616-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 03/22/2023] [Indexed: 04/13/2023]
Abstract
The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in adults for refractory cardiogenic shock has risen exponentially during the prior decade. Although VA-ECMO provides cardiopulmonary support, it can alter left ventricular (LV) loading conditions leading to LV distension, which makes the lungs susceptible to congestion and promotes intracardiac thrombosis. These conditions can be alleviated by pharmacologic and mechanical unloading, but gaps in knowledge remain on optimal timing and methods of this approach. This review provides an overview of the epidemiology of VA-ECMO, describes pathophysiology and methods for monitoring and reducing LV loading and summarizes contemporary studies examining the association between LV unloading and adverse events. We offer a simple protocol for implementing LV unloading during VA-ECMO to provide pulmonary protection and improve outcomes.
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Affiliation(s)
- Omar Saeed
- Department of Medicine, Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, 3400 Bainbridge Avenue, Bronx, NY, 10023, USA.
| | - Jose I Nunez
- Department of Medicine, Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, 3400 Bainbridge Avenue, Bronx, NY, 10023, USA
| | - Ulrich P Jorde
- Department of Medicine, Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, 3400 Bainbridge Avenue, Bronx, NY, 10023, USA
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14
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Au SY, Fong KM, Tsang CFS, Chan KCA, Wong CY, Ng WYG, Lee KYM. Veno-arterial extracorporeal membrane oxygenation with concomitant Impella versus concomitant intra-aortic-balloon-pump for cardiogenic shock. Perfusion 2023; 38:51-57. [PMID: 34318736 DOI: 10.1177/02676591211033947] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
INTRODUCTION The intra-aortic balloon pump (IABP) and Impella are left ventricular unloading devices with peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) in place and later serve as bridging therapy when VA-ECMO is terminated. We aimed to determine the potential differences in clinical outcomes and rate of complications between the two combinations of mechanical circulatory support. METHODS This was a retrospective, single institutional cohort study conducted in the intensive care unit (ICU) of Queen Elizabeth Hospital, Hong Kong. Inclusion criteria included all patients aged ⩾18 years, who had VA-ECMO support, and who had left ventricular unloading by either IABP or Impella between January 1, 2018 and October 31, 2020. Patients <18 years old, with central VA-ECMO, who did not require left ventricular unloading, or who underwent surgical venting procedures were excluded. The primary outcome was ECMO duration. Secondary outcomes included length of stay (LOS) in the ICU, hospital LOS, mortality, and complication rate. RESULTS Fifty-two patients with ECMO + IABP and 14 patients with ECMO + Impella were recruited. No statistically significant difference was observed in terms of ECMO duration (2.5 vs 4.6 days, p = 0.147), ICU LOS (7.7 vs 10.8 days, p = 0.367), and hospital LOS (14.8 vs 16.5 days, p = 0.556) between the two groups. No statistically significant difference was observed in the ECMO, ICU, and hospital mortalities between the two groups. Specific complications related to the ECMO and Impella combination were also noted. CONCLUSIONS Impella was not shown to offer a statistically significant clinical benefit compared with IABP in conjunction with ECMO. Clinicians should be aware of the specific complications of using Impella.
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Affiliation(s)
- Shek-Yin Au
- Intensive Care Unit, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Ka-Man Fong
- Intensive Care Unit, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Chun-Fung Sunny Tsang
- Cardiology Services, Department of Medicine, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Ka-Chun Alan Chan
- Cardiology Services, Department of Medicine, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Chi Yuen Wong
- Cardiology Services, Department of Medicine, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | | | - Kang Yin Michael Lee
- Cardiology Services, Department of Medicine, Queen Elizabeth Hospital, Kowloon, Hong Kong
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15
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Sommer P, Nunnally M. Mechanical circulatory support in the intensive care unit. Int Anesthesiol Clin 2022; 60:46-54. [PMID: 35993668 DOI: 10.1097/aia.0000000000000381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Philip Sommer
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Langone Health, New York, New York
| | - Mark Nunnally
- Departments of Anesthesiology, Perioperative Care and Pain Medicine, Medicine, Surgery, Neurology, NYU Langone Medical Center, New York, New York
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16
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Mechanical Left Ventricular Unloading in Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation. J Am Coll Cardiol 2022; 79:1239-1250. [DOI: 10.1016/j.jacc.2022.01.032] [Citation(s) in RCA: 136] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 01/06/2022] [Accepted: 01/18/2022] [Indexed: 12/21/2022]
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17
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Attinger-Toller A, Bossard M, Cioffi GM, Tersalvi G, Madanchi M, Bloch A, Kobza R, Cuculi F. Ventricular Unloading Using the Impella TM Device in Cardiogenic Shock. Front Cardiovasc Med 2022; 9:856870. [PMID: 35402561 PMCID: PMC8984099 DOI: 10.3389/fcvm.2022.856870] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 02/21/2022] [Indexed: 12/02/2022] Open
Abstract
Cardiogenic shock (CS) remains a leading cause of hospital death. However, the use of mechanical circulatory support has fundamentally changed CS management over the last decade and is rapidly increasing. In contrast to extracorporeal membrane oxygenation as well as counterpulsation with an intraaortic balloon pump, ventricular unloading by the Impella™ device actively reduces ventricular volume as well as pressure and augments systemic blood flow at the same time. By improving myocardial oxygen supply and enhancing systemic circulation, the Impella device potentially protects myocardium, facilitates ventricular recovery and may interrupt the shock spiral. So far, the evidence supporting the use of Impella™ in CS patients derives mostly from observational studies, and there is a need for adequate randomized trials. However, the Impella™ device appears a promising technology for management of CS patients. But a profound understanding of the device, its physiologic impact and clinical application are all important when evaluating CS patients for percutaneous circulatory support. This review provides a comprehensive overview of the percutaneous assist device Impella™. Moreover, it highlights in depth the rationale for ventricular unloading in CS and describes practical aspects to optimize care for patients requiring hemodynamic support.
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Affiliation(s)
- Adrian Attinger-Toller
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland,*Correspondence: Adrian Attinger-Toller
| | - Matthias Bossard
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | | | - Gregorio Tersalvi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Mehdi Madanchi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Andreas Bloch
- Department of Intensive Care Medicine, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Richard Kobza
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Florim Cuculi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
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18
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Hussey PT, von Mering G, Nanda NC, Ahmed MI, Addis DR. Echocardiography for extracorporeal membrane oxygenation. Echocardiography 2022; 39:339-370. [PMID: 34997645 PMCID: PMC9195253 DOI: 10.1111/echo.15266] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/16/2021] [Accepted: 11/06/2021] [Indexed: 02/03/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) provides advanced cardiopulmonary life support for patients in cardiac and/or respiratory failure. Echocardiography provides essential diagnostic and anatomic information prior to ECMO initiation, allows for safe and efficient ECMO cannula positioning, guides optimization of flow, provides a modality for rapid troubleshooting and patient evaluation, and facilitates decision-making for eventual weaning of ECMO support. Currently, guidelines for echocardiographic assessment in this clinical context are lacking. In this review, we provide an overview of echocardiographic considerations for advanced imagers involved in the care of these complex patients. We focus predominately on new cannulas and complex cannulation techniques, including a special focus on double lumen cannulas and a section discussing indirect left ventricular venting. Echocardiography is tremendously valuable in providing optimal care in these challenging clinical situations. It is imperative for imaging physicians to understand the pertinent anatomic considerations, the often complicated physiological and hemodynamic context, and the limitations of the imaging modality.
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Affiliation(s)
- Patrick T. Hussey
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesiology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Gregory von Mering
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Navin C. Nanda
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Mustafa I. Ahmed
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Dylan R. Addis
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesiology, Division of Molecular and Translational Biomedicine, and the UAB Comprehensive Cardiovascular Center, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
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19
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Rali AS, Hall EJ, Dieter R, Ranka S, Civitello A, Bacchetta MD, Shah AS, Schlendorf K, Lindenfeld J, Chatterjee S. Left Ventricular Unloading during Extracorporeal Life Support: Current Practice. J Card Fail 2021; 28:1326-1336. [PMID: 34936896 DOI: 10.1016/j.cardfail.2021.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/24/2021] [Accepted: 12/06/2021] [Indexed: 11/29/2022]
Abstract
Veno-arterial extracorporeal life support (VA-ECLS) is a powerful tool that can provide complete cardiopulmonary support for patients with refractory cardiogenic shock. However, VA-ECLS increases left ventricular afterload resulting in greater myocardial oxygen demand, which can impair myocardial recovery and worsen pulmonary edema. These complications can be ameliorated by various LV venting strategies to unload the LV. Evidence suggests that LV venting improves outcomes in VA-ECLS, but there is a paucity of randomized trials to help guide optimal strategy and the timing of venting. In this review, we discuss the available evidence regarding LV venting in VA-ECLS, explain important hemodynamic principles involved, and propose a practical approach to LV venting in VA-ECLS.
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Key Words
- Atrial septal defect, BNP
- Brain natriuretic peptide, CS
- Cardiogenic shock, IABP
- Extracorporeal life support, left ventricular unloading, left ventricular venting, cardiogenic shock, Abbreviations, ASD
- Intra-aortic balloon pump, LA
- Left atrium, LV
- Left ventricle, LVAD
- Left ventricular assist device, MCS
- Mechanical circulatory support, PAC
- Percutaneous ventricular assist device, RV
- Pulmonary artery catheter, PCWP
- Pulmonary capillary wedge pressure, P-VAD
- Right ventricle, VA-ECLS
- Veno-arterial extracorporeal life support
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Affiliation(s)
- Aniket S Rali
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Eric J Hall
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Raymond Dieter
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sagar Ranka
- Department of Cardiovascular Diseases, University of Kansas Medical Center, Kansas City, Kansas
| | - Andrew Civitello
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Department of Cardiology, Texas Heart Institute, Houston, Texas
| | - Matthew D Bacchetta
- Division of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashish S Shah
- Division of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kelly Schlendorf
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - JoAnn Lindenfeld
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Subhasis Chatterjee
- Divisions of General and Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College Medicine, Houston, Texas; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
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20
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Ibrahim M, Acker MA, Szeto W, Gutsche J, Williams M, Atluri P, Woods M, Richards T, Gardner TJ, McGarvey J, Epler M, Wald J, Rame E, Birati E, Bermudez C. Proposal for a trial of early left ventricular venting during venoarterial extracorporeal membrane oxygenation for cardiogenic shock. JTCVS OPEN 2021; 8:393-400. [PMID: 36004109 PMCID: PMC9390694 DOI: 10.1016/j.xjon.2021.07.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 07/26/2021] [Indexed: 11/07/2022]
Abstract
Objective Patients with profound cardiogenic shock may require venoarterial (VA) extracorporeal membrane oxygenation (ECMO) for circulatory support most commonly via the femoral vessels. The rate of cardiac recovery in this population remains low, possibly because peripheral VA-ECMO increases ventricular afterload. Whether direct ventricular unloading in peripheral VA-ECMO enhances cardiac recovery is unknown, but is being more frequently utilized. A randomized trial is warranted to evaluate the clinical effectiveness of percutaneous left ventricle venting to enhance cardiac recovery in the setting of VA-ECMO. Methods We describe the rationale, design, and initial testing of a randomized controlled trial of VA-ECMO with and without percutaneous left ventricle venting using a percutaneous micro-axial ventricular assist device. Results This is an ongoing prospective randomized controlled trial in adult patients with primary cardiac failure presenting in cardiogenic shock requiring peripheral VA-ECMO, designed to test the safety and effectiveness of percutaneous left ventricle venting in improving the rate of cardiac recovery. Conclusions The results of this nonindustry-sponsored trial will provide critical information on whether left ventricle unloading in peripheral VA-ECMO is safe and effective.
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21
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Comparison of Circulatory Unloading Techniques for Venoarterial Extracorporeal Membrane Oxygenation. ASAIO J 2021; 67:623-631. [PMID: 33074863 DOI: 10.1097/mat.0000000000001268] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Left ventricular (LV) distention and pulmonary congestion are major complications inherent to venoarterial extracorporeal membrane oxygenation (ECMO). This study aimed to quantitatively compare the hemodynamic differences between common circulatory unloading methods for ECMO. Ten circulatory unloading techniques were evaluated on a mock circulatory loop simulating acute LV failure supported by ECMO. Simulated unloading techniques included: surgical and percutaneous pulmonary artery (PA) venting, surgical left atrial venting, surgical and percutaneous LV venting, atrial septal defect, partial support ventricular assist device, intraaortic balloon pump, and temporary VAD with inline oxygenator (tVAD). The most LV unloading occurred with the surgically placed LV vent and tVAD, which reduced LV end-diastolic volume from 295 to 167 ml and 82 ml, respectively. Meanwhile, the PA surgical vent was the most effective at reducing mean PA pressure from 21.0 to 10.6 mm Hg, and the tVAD was most effective at reducing left atrial pressure from 13.3 to 4.4 mm Hg. The major limitation of this study was the use of a mock circulatory loop, which simulated lower left atrial pressure than is typically seen clinically. This study identified clinically significant hemodynamic variability between the different circulatory unloading techniques evaluated. However, the applicability of these techniques will vary with different patient disease etiology. Further studies on ECMO unloading will help to quantify hemodynamic benefits and establish treatment guidelines.
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22
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Amacher SA, Quitt J, Hammel E, Zenklusen U, Darwisch A, Siegemund M. Case Report: Left Ventricular Unloading Using a Mechanical CPR Device in a Prolonged Accidental Hypothermic Cardiac Arrest Treated by VA-ECMO - a Novel Approach. Front Cardiovasc Med 2021; 8:707663. [PMID: 34250052 PMCID: PMC8263907 DOI: 10.3389/fcvm.2021.707663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 06/03/2021] [Indexed: 11/17/2022] Open
Abstract
We recently treated a 36-year-old previously healthy male with a prolonged hypothermic (lowest temperature 22.3°C) cardiac arrest after an alcohol intoxication with a return of spontaneous circulation after 230min of mechanical cardiopulmonary resuscitation and rewarming by veno-arterial ECMO with femoral cannulation and retrograde perfusion of the aortic arch. Despite functional veno-arterial ECMO, we continued mechanical cardiopulmonary resuscitation (Auto Pulse™ device, ZOLL Medical Corporation, Chelmsford, USA) until return of spontaneous circulation to prevent left ventricular distention from persistent ventricular fibrillation. The case was further complicated by extensive trauma caused by mechanical cardiopulmonary resuscitation (multiple rib fractures, significant hemothorax, and a liver laceration requiring massive transfusion), lung failure necessitating a secondary switch to veno-venous ECMO, and acute kidney injury with the need for renal replacement therapy. Shortly after return of spontaneous circulation, the patient was already following commands and could be discharged 3 weeks later without neurologic, cardiac, or renal sequelae and being entirely well. Prolonged accidental hypothermic cardiac arrest might present with excellent outcomes when supported with veno-arterial ECMO. Until return of spontaneous circulation, one might consider continuing with mechanical cardiopulmonary resuscitation in addition to ECMO to allow some left ventricular unloading. However, the clinician should keep in mind that prolonged mechanical cardiopulmonary resuscitation may cause severe injuries.
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Affiliation(s)
- Simon A. Amacher
- Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| | - Jonas Quitt
- Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| | - Eva Hammel
- Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| | - Urs Zenklusen
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Ayham Darwisch
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Martin Siegemund
- Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
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French A, Sodha NR. Commentary: Distension Kills: Venting the Left Ventricle During Venoarterial ECMO Support. Semin Thorac Cardiovasc Surg 2021; 33:733-734. [PMID: 33600971 DOI: 10.1053/j.semtcvs.2021.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 01/05/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Amy French
- Division of Cardiology, Alpert Medical School, Brown University, Providence, Rhode Island
| | - Neel R Sodha
- Division of Cardiothoracic Surgery, Alpert Medical School, Brown University, Providence, Rhode Island.
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Pingpoh C, Salama A, Diab N, Kreibich M, Puiu P, Czerny M, Benk C, Beyersdorf F, Siepe M. Postcardiotomy mechanical support in patients with mitral valve prostheses is associated with poor survival. Int J Artif Organs 2020; 45:127-133. [PMID: 33339476 DOI: 10.1177/0391398820982621] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIMS To elaborate on early survival in patients with mitral valve replacement requiring temporary extracorporeal life support system (ECLS). METHODS We analyzed survival, significant bleeding, wound infection, and ECLS duration in 421 from 14,400 patients with postoperative need for ECLS from January 2008 to December 2017 at our institution. Finally, patients were stratified according to the type of surgery performed: the mitral group (mitral valve replacement) n = 63 and the control group (any cardiac surgery excluding the mitral valve) n = 358. In order to adjust for preoperative patient characteristics, a propensity matching analysis was performed. Differences in in-hospital mortality were analyzed accordingly. RESULTS In-hospital mortality was significantly higher in the mitral group as compared to the control group before and after adjustment (p < 0.001). Median duration of ECLS was 4 days in both groups. Perioperative bleeding (p < 0.001) and wound infection (p < 0.001) also showed significant worse outcome parameters in the mitral group. The main causes of death in the mitral group were multiorgan failure, n = 48 (76%), stroke, n = 7 (12%), and intracardiac thrombus formation, n = 5 (10%). CONCLUSIONS ECLS is associated with a high in-hospital mortality rate in patients after mitral valve replacement.
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Affiliation(s)
- Clarence Pingpoh
- Department of Cardiovascular Surgery, University Heart Center Freiburg Bad Krozingen, Freiburg, Germany.,Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Alaa Salama
- Faculty of Medicine, University of Basel, Basel, Switzerland.,Department of Intensive Care, University Hospital Basel, Basel, Switzerland
| | - Nawras Diab
- Department of Cardiovascular Surgery, University Heart Center Freiburg Bad Krozingen, Freiburg, Germany.,Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Maximillian Kreibich
- Department of Cardiovascular Surgery, University Heart Center Freiburg Bad Krozingen, Freiburg, Germany.,Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Paul Puiu
- Department of Cardiovascular Surgery, University Heart Center Freiburg Bad Krozingen, Freiburg, Germany.,Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg Bad Krozingen, Freiburg, Germany.,Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Christoph Benk
- Department of Cardiovascular Surgery, University Heart Center Freiburg Bad Krozingen, Freiburg, Germany.,Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg Bad Krozingen, Freiburg, Germany.,Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, University Heart Center Freiburg Bad Krozingen, Freiburg, Germany.,Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
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25
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Lim HS. The Physiologic Basis and Clinical Outcomes of Combined Impella and Veno-Arterial Extracorporeal Membrane Oxygenation Support in Cardiogenic Shock. Cardiol Ther 2020; 9:245-255. [PMID: 32424689 PMCID: PMC7584716 DOI: 10.1007/s40119-020-00175-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Indexed: 12/17/2022] Open
Abstract
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides effective hemodynamic support in cardiogenic shock, but in some cases may be complicated by left ventricular (LV) distension and pulmonary edema. The Impella, a catheter-mounted microaxial pump has been used to unload the LV. Recent studies have compared the clinical outcomes of VA-ECMO to the combination of Impella and VA-ECMO. The purpose of this review is threefold: firstly, to discuss the physiological effects of Impella support in addition to VA-ECMO, secondly to review published studies on the outcome of this combined support, and thirdly to provide a practical overview of the approach to combining Impella and VA-ECMO.
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Affiliation(s)
- Hoong Sern Lim
- University Hospital Birmingham, Edgbaston, Birmingham, UK.
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26
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Kumar A, Keshavamurthy S, Humar R, Gomez Abraham J, Toyoda Y. Successful use of venoarterial extracorporeal membrane oxygenation in acute myocarditis due to necrotizing fasciitis. Chirurgia (Bucur) 2020. [DOI: 10.23736/s0394-9508.19.05033-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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27
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Currently Available Options for Mechanical Circulatory Support for the Management of Cardiogenic Shock. Cardiol Clin 2020; 38:527-542. [PMID: 33036715 DOI: 10.1016/j.ccl.2020.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cardiogenic shock (CS) is a complex condition with a high risk for morbidity and mortality. Mechanical circulatory support (MCS) devices were developed to support patients with CS in cases refractory to treatment with vasoactive medications. Current devices include intra-aortic balloon pumps, intravascular microaxial pumps, percutaneous LVAD, percutaneous RVAD, and VA ECMO. Data from limited observational studies and clinical trials show a clear difference in the level of hemodynamic support offered by each device. However, at this point, there are insufficient clinical trial data to guide MCS selection and, until ongoing clinical trials are completed, use of the right device for the right patient depends largely on clinical judgment.
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28
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Nishihara T, Kudamatsu N, Hamada T, Nakata Y, Yamamoto W, Nandate H, Namiguchi K, Nishimura T, Izutani H, Yorozuya T. A case report of thrombotic complete obstruction of the ascending aorta as a complication of Venoarterial extracorporeal membrane oxygenation support: steps to prevent thrombosis. J Cardiothorac Surg 2020; 15:185. [PMID: 32703249 PMCID: PMC7379763 DOI: 10.1186/s13019-020-01239-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is an essential device in the field of emergency and intensive-care medicine. However, long-term use of VA-ECMO has various severe complications, including thrombosis. CASE PRESENTATION A 60-year-old man underwent his third aortic root replacement using a homograft because of infectious endocarditis. Although the operation was difficult because of severe adhesion caused by the two previous interventions, aortic root replacement using a homograft was performed. At the time of withdrawal from cardiopulmonary bypass, the maintenance of hemodynamics was difficult because of bleeding from the surgical site, leading to hypovolemic shock. Cardiac function subsequently deteriorated; therefore, VA-ECMO was established and the operation was finished. Three days later, thrombus was formed inside the homograft and completely occluded ascending aorta. Evacuation of hematoma was performed, however, cardiac function was not ameliorated. Eventually, the patient had brain infarction and died. To prevent thrombus formation in very severe low cardiac output cases under VA-ECMO management after surgery, to prevent the stagnation of the blood flow from VA-ECMO will be necessary because anticoagulant therapy will be difficult. Impella ventricular assist device which is recently used widely generates anterograde blood flow and effectively prevents stagnation. CONCLUSIONS To prevent thrombus formation in cases of very severe low cardiac output, Impella® should be combinatorially introduced from the beginning of VA-ECMO establishment to prevent thrombosis.
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Affiliation(s)
- Tasuku Nishihara
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Ehime, 791-0295, Japan.
| | - Natsuko Kudamatsu
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Ehime, 791-0295, Japan
| | - Taisuke Hamada
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Ehime, 791-0295, Japan
| | - Yukihiro Nakata
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Ehime, 791-0295, Japan
| | - Waichi Yamamoto
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Ehime, 791-0295, Japan
| | - Hideyuki Nandate
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Ehime, 791-0295, Japan
| | - Kenji Namiguchi
- Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Takashi Nishimura
- Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Hironori Izutani
- Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Toshihiro Yorozuya
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Ehime, 791-0295, Japan
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29
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Balloon Pump Counterpulsation Part II: Perioperative Hemodynamic Support and New Directions. Anesth Analg 2020; 131:792-807. [DOI: 10.1213/ane.0000000000004999] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Predictors of Successful Weaning From Veno-Arterial Extracorporeal Membrane Oxygenation After Coronary Revascularization for Acute Myocardial Infarction Complicated by Cardiac Arrest: A Retrospective Multicenter Study. Shock 2020; 51:690-697. [PMID: 30080744 DOI: 10.1097/shk.0000000000001220] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIM While veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been utilized to resuscitate and stabilize hemodynamics in patients of acute myocardial infarction (AMI) complicated by cardiac arrest (CA), it is essential to predict the possibility of weaning from ECMO to determine further strategies, including use of ventricular assist device. We aimed to determine predictors of successful weaning from VA-ECMO in the early phase of ECMO treatment. METHODS We identified consecutive patients of AMI complicated by CA treated with VA-ECMO and percutaneous coronary intervention (PCI). Clinical data within 48 h after ECMO initiation were assessed and multiple logistic regression analysis was performed to determine independent predictors of weaning outcome. RESULTS Fifty-five patients were analyzed. While 28 (51%) patients were successfully weaned from VA-ECMO, 27 (49%) failed to wean. Multivariate analysis identified post-PCI thrombolysis in myocardial infarction (TIMI) flow grade (P = 0.046), mean arterial pressure (MAP) at 4 h after ECMO initiation (P = 0.010), and serum lactate at 24 h (P = 0.015) as independent predictors of successful weaning. Left ventricular ejection fraction (LVEF) at 24 and 48 h was significantly greater in the successful weaning group (P = 0.014, P = 0.025, respectively). CONCLUSIONS Successful weaning from VA-ECMO was predicted by post-PCI TIMI flow grade, MAP at 4 h, and serum lactate at 24 h after VA-ECMO initiation in patients of AMI complicated by CA. Furthermore, in patients who failed to wean from ECMO, LVEF did not recover within 48 h. In such patients, adjunctive use of other circulatory mechanical devices must be considered.
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Abstract
Peripheral veno-arterial extra corporeal life support (V-A ECLS) is an effective tool in treating refractory cardiogenic shock (RCS). Despite additional use of intra-aortic balloon pump, insufficient left ventricular unloading is a likely complication. We present herein our experience combining V-A ECLS and Impella to treat symptomatic, critical patients. A retrospective single-center review analyzed patients with V-A ECLS and intra-aortic balloon pump for RCS and subsequently benefiting from Impella implantation, between 2011 and 2015. From 1248 cases, 31 critical patients (2.5%) with a median SOFA score = 12 (7-15) were included. Median age was 53 years, and 74% were male. RCS resulted from myocardial ischemia (52%) and idiopathic dilated myocardiopathy (23%). Forty-seven percentage of patients were treated previously for chronic Heart Failure with reduced Ejection Fraction (HFrEF). Median time between V-A ECLS and Impella implantation was 84 hours (24-186). The Impella median support duration was 8 days (5-10). ECLS and Impella were weaned simultaneously in 26% of patients, 33% were switched to a long-term assistance, and 10% were transplanted. Overall, day-30 survival was 53%. Factors including diabetes, patients aged over 60 years, surgery using extracorporeal circulation, adrenalin infusion, acute myocardial infarction, and chronic HFrEF are associated with day-30 mortality. Chronic HFrEF was an independent risk factor for the day-30 mortality [hazard ratio = 5.28 (1.38-20.21), P = 0.015]. Impella and V-A ECLS combination is a promising association for critical patients presenting symptomatic insufficient LV unloading, for weaning V-A ECLS or testing the right ventricle before a switch to left ventricle assist device support.
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32
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Sachedina AK, Ajluni SC, Jumean MF. The use of a sentinel cerebral protection system during Impella
CP
removal in a patient with left ventricular thrombus. Catheter Cardiovasc Interv 2020; 96:504-506. [DOI: 10.1002/ccd.28956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 01/18/2020] [Accepted: 04/25/2020] [Indexed: 12/31/2022]
Affiliation(s)
- Ayaaz K. Sachedina
- Center for Advanced Heart Failure University of Texas Health Science Center of Houston Houston Texas USA
| | - Steven C. Ajluni
- McGovern Medical School The University of Texas Health Science Center at Houston Houston Texas USA
| | - Marwan F. Jumean
- Center for Advanced Heart Failure University of Texas Health Science Center of Houston Houston Texas USA
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33
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Hu W, Zhou J, Chen L, Huang J, Hu W, Zhu Y, Yuan T. Insufficient left ventricular unloading after extracorporeal membrane oxygenation : A case-series observational study. Herz 2020; 45:186-191. [PMID: 29777285 DOI: 10.1007/s00059-018-4711-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 04/23/2018] [Accepted: 04/23/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a method widely used to support circulation in patients with fulminant myocarditis (FM). However, a common complication associated with ECMO is left ventricular (LV) overload. METHODS This case series observed the effects of intra-aortic balloon pump (IABP) and beta-blockers for the treatment of LV overload after ECMO. The cases of eight patients with FM who underwent ECMO from September 2009 to July 2016 were reviewed. RESULTS Six of the eight patients survived. After ECMO treatment, insufficient LV unloading occurred in six patients. Among these six patients, three experienced electrical storm but spontaneous circulation returned after interventions with beta-blockers and IABP. The survivors demonstrated full recovery of cardiac function. CONCLUSION Beta-blockers may prevent the occurrence of electrical storm, and IABP is feasible for the treatment of LV overload after ECMO application.
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Affiliation(s)
- W Hu
- Department of Critical Care Medicine, The Affiliated Hangzhou Hospital of Nanjing Medical University, 310006, Zhejiang, China
| | - J Zhou
- Department of Cardiac Rehabilitation, Zhejiang Hospital, 310013, Zhejiang, China
| | - L Chen
- Department of Electrocardiogram and Cardiac function, The Affiliated Hangzhou Hospital of Nanjing Medical University, 310006, Zhejiang, China
| | - J Huang
- Department of Cardiology, The Affiliated Hangzhou Hospital of Nanjing Medical University, 310006, Zhejiang, China.
| | - W Hu
- Department of Critical Care Medicine, The Affiliated Hangzhou Hospital of Nanjing Medical University, 310006, Zhejiang, China
| | - Y Zhu
- Department of Critical Care Medicine, The Affiliated Hangzhou Hospital of Nanjing Medical University, 310006, Zhejiang, China
| | - T Yuan
- Department of Critical Care Medicine, Zhejiang Hospital, 310013, Zhejiang, China
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34
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Krishnan S, Schmidt GA. Hemodynamic monitoring in the extracorporeal membrane oxygenation patient. Curr Opin Crit Care 2020; 25:285-291. [PMID: 30865613 DOI: 10.1097/mcc.0000000000000602] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Hemodynamic monitoring in ECMO patients requires familiarity with the underlying pathophysiology and circulatory mechanics of extracorporeal flow. This review discusses the various monitoring modalities relevant to the management of patients on venovenous ECMO (VV ECMO) and venoarterial (VA ECMO). We emphasize tools to judge the adequacy of perfusion, predict the response to fluid boluses, measure right ventricular function, assess left ventricular distention (for VA ECMO), and monitor the process of weaning from ECMO. We emphasize how differences between VV ECMO and VA ECMO are reflected in distinct approaches to monitoring. RECENT FINDINGS Point-of-care ultrasound and near-infrared spectroscopy can play a significant role in monitoring of global and regional perfusion. SUMMARY Recent literature in hemodynamic monitoring of ECMO patients is discussed, with comparison of VV ECMO and VA ECMO. Many common monitoring tools lack validity during ECMO: by taking into account the unique physiology of the ECMO circulation, selected methods can aid in the care of these complex patients.
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Affiliation(s)
| | - Gregory A Schmidt
- Division of Pulmonary Diseases, Critical Care, and Occupational Medicine, University of Iowa, Iowa City, USA
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35
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Tonna JE, McKellar SH, Selzman CH, Drakos S, Koliopoulou AG, Taleb I, Stoddard GJ, Stehlik J, Welt FGP, Fair JF, Stoddard K, Youngquist ST. Exploratory analysis of myocardial function after extracorporeal cardiopulmonary resuscitation vs conventional cardiopulmonary resuscitation. BMC Res Notes 2020; 13:137. [PMID: 32143688 PMCID: PMC7060522 DOI: 10.1186/s13104-020-04982-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 02/26/2020] [Indexed: 02/27/2023] Open
Abstract
Objective Ventricular unloading is associated with myocardial recovery. We sought to evaluate the association of extracorporeal cardiopulmonary resuscitation (ECPR) on myocardial function after cardiac arrest. We conducted a retrospective exploratory analysis, comparing ejection fraction (EF) after adult cardiac arrest, between ECPR and conventional CPR. Results Among 1119 cases of cardiac arrest, 116 had an echocardiogram post-return of spontaneous circulation (ROSC) and were included. Thirty-eight patients had ≥ 2 echocardiograms. ECPR patients had differences in age, hypertension and chronic heart failure. ECPR patients had a lower EF post-ROSC (24% vs 45%; p < 0.01) and were more likely to undergo percutaneous coronary intervention (25% vs 3%; p < 0.01). In multivariate analysis, only ECPR use (β-coeff: 10.4 [95% CI 3.68–17.13]; p < 0.01) independently predicted improved myocardial function. In this exploratory study, EF after cardiac arrest may be more likely to improve among ECPR patients than CCPR patients. Our methodology should be replicated to confirm or refute the validity of our findings.
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Affiliation(s)
- Joseph E Tonna
- Division of Emergency Medicine, University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT, 84132, USA. .,Division of Cardiothoracic Surgery, University of Utah School of Medicine, 30 N 1900 E, 3C127, Salt Lake City, UT, 84132, USA.
| | - Stephen H McKellar
- Division of Cardiothoracic Surgery, University of Utah School of Medicine, 30 N 1900 E, 3C127, Salt Lake City, UT, 84132, USA
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, University of Utah School of Medicine, 30 N 1900 E, 3C127, Salt Lake City, UT, 84132, USA
| | - Stavros Drakos
- Division of Cardiology, University of Utah School of Medicine, Salt Lake City, USA
| | - Antigone G Koliopoulou
- Division of Cardiothoracic Surgery, University of Utah School of Medicine, 30 N 1900 E, 3C127, Salt Lake City, UT, 84132, USA
| | - Iosif Taleb
- Division of Cardiology, University of Utah School of Medicine, Salt Lake City, USA
| | - Gregory J Stoddard
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, USA
| | - Josef Stehlik
- Division of Cardiology, University of Utah School of Medicine, Salt Lake City, USA
| | - Frederick G P Welt
- Division of Cardiology, University of Utah School of Medicine, Salt Lake City, USA
| | - James F Fair
- Division of Emergency Medicine, University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT, 84132, USA
| | | | - Scott T Youngquist
- Division of Emergency Medicine, University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT, 84132, USA
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Barge-Caballero G, Castel-Lavilla MA, Almenar-Bonet L, Garrido-Bravo IP, Delgado JF, Rangel-Sousa D, González-Costello J, Segovia-Cubero J, Farrero-Torres M, Lambert-Rodríguez JL, Crespo-Leiro MG, Hervás-Sotomayor D, Portolés-Ocampo A, Martínez-Sellés M, De la Fuente-Galán L, Rábago-Juan-Aracil G, González-Vílchez F, Mirabet-Pérez S, Muñiz J, Barge-Caballero E. Venoarterial extracorporeal membrane oxygenation with or without simultaneous intra-aortic balloon pump support as a direct bridge to heart transplantation: results from a nationwide Spanish registry. Interact Cardiovasc Thorac Surg 2020; 29:670-677. [PMID: 31257414 DOI: 10.1093/icvts/ivz155] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 05/14/2019] [Accepted: 05/19/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To investigate the potential clinical benefit of an intra-aortic balloon pump (IABP) in patients supported with venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a bridge to heart transplantation (HT). METHODS We studied 169 patients who were listed for urgent HT under VA-ECMO support at 16 Spanish institutions from 2010 to 2015. The clinical outcomes of patients under simultaneous IABP support (n = 73) were compared to a control group of patients without IABP support (n = 96). RESULTS There were no statistically significant differences between the IABP and control groups with regard to the cumulative rates of transplantation (71.2% vs 81.2%, P = 0.17), death during VA-ECMO support (20.6% vs 14.6%, P = 0.31), transition to a different mechanical circulatory support device (5.5% vs 5.2%, P = 0.94) or weaning from VA-ECMO support due to recovery (2.7% vs 0%, P = 0.10). There was a higher incidence of bleeding events in the IABP group (45.2% vs 25%, P = 0.006; adjusted odds ratio 2.18, 95% confidence interval 1.02-4.67). In-hospital postoperative mortality after HT was 34.6% in the IABP group and 32.5% in the control group (P = 0.80). One-year survival after listing for urgent HT was 53.3% in the IABP group and 52.2% in the control group (log rank P = 0.75). Multivariate adjustment for potential confounders did not change this result (adjusted hazard ratio 0.94, 95% confidence interval 0.56-1.58). CONCLUSIONS In our study, simultaneous IABP therapy in transplant candidates under VA-ECMO support did not significantly reduce morbidity or mortality.
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Affiliation(s)
- Gonzalo Barge-Caballero
- Complejo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | | | | | - Iris P Garrido-Bravo
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Juan F Delgado
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Hospital Universitario Doce de Octubre, Instituto de Investigación i+12, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | | | | | - Javier Segovia-Cubero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | | | | | - María G Crespo-Leiro
- Complejo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | | | | | - Manuel Martínez-Sellés
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Hospital General Universitario Gregorio Marañón, Universidad Complutense, Universidad Europea, Madrid, Spain
| | - Luis De la Fuente-Galán
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Hospital Clínico Universitario, Valladolid, Spain
| | | | | | | | - Javier Muñiz
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña (UDC), INIBIC, A Coruña, Spain
| | - Eduardo Barge-Caballero
- Complejo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
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Abstract
Supplemental Digital Content is available in the text. Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is widely used in cardiogenic shock. It provides systemic perfusion, but left ventricular (LV) unloading is suboptimal. Using a closed-loop, real-time computer model of the human cardiovascular system, cardiogenic shock supported by peripheral VA ECMO was simulated, and effects of various adjunct LV unloading interventions were quantified. After VA ECMO initiation (4 L/min) in cardiogenic shock (baseline), hemodynamics improved (increased to 85 mm Hg), while LV overload occurred (10% increase in end-diastolic volume [EDV], and 5 mm Hg increase in pulmonary capillary wedge pressure [PCWP]). Decreasing afterload (65 mm Hg mean arterial pressure) and circulating volume (−800 mL) reduced LV overload (12% decrease in EDV and 37% decrease in PCWP) compared with baseline. Additional intra-aortic balloon pumping only marginally decreased cardiac loading. Instead, adjunct Impella™ enhanced LV unloading (23% decrease in EDV and 41% decrease in PCWP). Alternative interventions, for example, left atrial/ventricular venting, yielded substantial unloading. We conclude that real-time simulations may provide quantitative clinical measures of LV overload, depending on the degree of VA ECMO support and adjunct management. Simulations offer insights into individualized LV unloading interventions in cardiogenic shock supported by VA ECMO as a proof of concept for potential future applications in clinical decision support, which may help to improve individualized patient management in complex cardiovascular disease.
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38
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Etchill E, Whitman GJR. Commentary: Postcardiotomy shock: Are stones still unturned? J Thorac Cardiovasc Surg 2020; 160:1217-1218. [PMID: 31987618 DOI: 10.1016/j.jtcvs.2019.10.180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 10/28/2019] [Accepted: 10/29/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Eric Etchill
- Department of Surgery, Division of Cardiac Surgery, Johns Hopkins School of Medicine, Baltimore, Md
| | - Glenn J R Whitman
- Department of Surgery, Division of Cardiac Surgery, Johns Hopkins School of Medicine, Baltimore, Md.
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39
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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: 0.2] [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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40
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Capoccia M, Maybauer MO. Extra-corporeal membrane oxygenation in aortic surgery and dissection: A systematic review. World J Crit Care Med 2019; 8:135-147. [PMID: 31942440 PMCID: PMC6957356 DOI: 10.5492/wjccm.v8.i8.135] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/29/2019] [Accepted: 11/30/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Very little is known about the role of extracorporeal membrane oxygenation (ECMO) for the management of patients undergoing major aortic surgery with particular reference to aortic dissection.
AIM To review the available literature to determine if there was any evidence.
METHODS A systematic literature search through PubMed and EMBASE was undertaken according to specific key words.
RESULTS The search resulted in 29 publications relevant to the subject: 1 brief communication, 1 surgical technique report, 1 invited commentary, 1 retrospective case review, 1 observational study, 4 retrospective reviews, 13 case reports and 7 conference abstracts. A total of 194 patients were included in these publications of whom 77 survived.
CONCLUSION Although there is no compelling evidence for or against the use of ECMO in major aortic surgery or dissection, it is enough to justify its use in this patient population despite current adverse attitude.
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Affiliation(s)
- Massimo Capoccia
- Department of Aortic and Cardiac Surgery, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London SW3 6NP, United Kingdom
| | - Marc O Maybauer
- Department of Anaesthesia, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester M13 9WL, United Kingdom
- Department of Anaesthesiology and Intensive Care Medicine, Phillips University, Marburg 35037, Germany
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane QLD 4032, Queensland, Australia
- Advanced Critical Care and Transplant Institute, Integris Baptist Medical Centre, Oklahoma City, OK 73112, United States
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41
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Kim S, Kim JS, Shin JS, Shin HJ. How small is enough for the left heart decompression cannula during extracorporeal membrane oxygenation? Acute Crit Care 2019; 34:263-268. [PMID: 31795624 PMCID: PMC6895469 DOI: 10.4266/acc.2019.00577] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 11/04/2019] [Indexed: 11/30/2022] Open
Abstract
Background Left ventricular (LV) distension is a recognizable problem accompanied by subsequent complications during venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, no gold standard for LV decompression has been established, and no minimal flow requirement has been designated. Thus, we evaluated the efficacy of the 8-Fr Mullins sheath for left heart decompression during VA-ECMO in adult patients. Methods Left heart decompression was performed when severe pulmonary edema was detected on chest radiography or when no generation of pulse pressure followed severe LV dysfunction in patients receiving VA-ECMO. We punctured the interatrial septum and inserted an 8-Fr Mullins sheath into the left atrium via the femoral vein. The sheath was connected to the venous catheter used for ECMO. The catheter was maintained during VA-ECMO. Results The left heart decompression procedure was performed in seven of 35 patients who received VA-ECMO between February 2017 and June 2018. Three patients had acute myocardial infarction; three, fulminant myocarditis; and one, dilated cardiomyopathy. Four patients showed noticeable improvement of pulmonary edema within 3 days, and three patients with a pulse pressure of <10 mm Hg showed an increase in pulse pressure of >20 mm Hg within 24 hours from the left heart decompression procedure. All seven patients were successfully weaned from VA-ECMO. No complications related to the left heart decompression procedure occurred. Conclusions An 8-Fr sheath may be a possible option for left heart decompression in adult patients with LV distension under VA-ECMO who are expecting recovery of LV function.
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Affiliation(s)
- Sua Kim
- Department of Critical Care Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea.,Division of Cardiology, Department of Internal Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Jin Seok Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Jae Seung Shin
- Department of Thoracic and Cardiovascular Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Hong Ju Shin
- Department of Thoracic and Cardiovascular Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
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Singh G, Hudson D, Shaw A. Medical Optimization and Liberation of Adult Patients From VA-ECMO. Can J Cardiol 2019; 36:280-290. [PMID: 32036869 DOI: 10.1016/j.cjca.2019.10.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 10/31/2019] [Accepted: 10/31/2019] [Indexed: 12/30/2022] Open
Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) can be an efficacious cardiopulmonary support for adults as rescue from refractory cardiogenic shock. It is best employed as a bridging strategy to recovery or alternative support rather than sustained, long-term mechanical circulatory support. The purpose of this paper is to discuss strategies to optimize patient management on VA-ECMO and approaches to promote successful separation from support. Rapid medical optimization will assist in reducing the time on VA-ECMO, thereby improving the likelihood of patient salvage. Suitably trained physicians and personnel, guided by structured protocols, can promote excellence in team care and provision of consistent management. Focusing on anticoagulation, careful neurologic monitoring, prevention of leg ischemia, awareness of differential hypoxemia, optimizing mechanical ventilation, identifying and timely intervention for left-ventricular distension (LVD), along with a strategic weaning algorithm, can prevent significant morbidity and mortality. LVD physiology, diagnosis, and risk factors are reviewed. Indications for LV decompression, along with medical and mechanical management options, are elucidated.
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Affiliation(s)
- Gurmeet Singh
- Critical Care Medicine, Edmonton, Alberta, Canada; Cardiac Surgery, Edmonton, Alberta, Canada; Adult ECMO Program, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada; University of Alberta, Edmonton, Alberta, Canada.
| | - Darren Hudson
- Critical Care Medicine, Edmonton, Alberta, Canada; University of Alberta, Edmonton, Alberta, Canada
| | - Andrew Shaw
- Department of Anesthesiology and Pain Medicine, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada; University of Alberta, Edmonton, Alberta, Canada
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43
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Al-Fares AA, Randhawa VK, Englesakis M, McDonald MA, Nagpal AD, Estep JD, Soltesz EG, Fan E. Optimal Strategy and Timing of Left Ventricular Venting During Veno-Arterial Extracorporeal Life Support for Adults in Cardiogenic Shock. Circ Heart Fail 2019; 12:e006486. [DOI: 10.1161/circheartfailure.119.006486] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background:
Veno-arterial extracorporeal life support (VA-ECLS) is widely used to treat refractory cardiogenic shock. However, increased left ventricular (LV) afterload in VA-ECLS can worsen pulmonary congestion and compromise myocardial recovery. Our objectives were to explore the efficacy, safety, and optimal timing of adjunctive LV venting strategies.
Methods:
A systematic search was performed on Medline, EMBASE, PubMed, CDSR, CCRCT, CINAHL, ClinicalTrials.Gov, and WHO ICTRP from inception until January 2019 for all relevant studies, including LV venting. Data were analyzed for mortality and weaning from VA-ECLS on the basis of timing of LV venting, along with adverse complications.
Results:
A total of 7995 patients were included from 62 observational studies, wherein 3458 patients had LV venting during VA-ECLS. LV venting significantly improved weaning from VA-ECLS (odds ratio, 0.62 [95% CI, 0.47–0.83];
P
=0.001) and reduced short-term (30 day; risk ratio [RR], 0.86 [95% CI, 0.77–0.96];
P
=0.008) but not in-hospital (RR, 0.92 [95% CI, 0.83–1.01]
P
=0.09) or long-term (6 months; RR, 0.96 [95% CI, 0.90–1.03];
P
=0.27) mortality. Early (<12 hours; RR, 0.86 [95% CI, 0.75–0.99];
P
=0.03) but not late (≥12 hours; RR, 0.99 [95% CI, 0.71–1.38];
P
=0.93) LV venting significantly reduced short-term mortality. Patients with LV venting spent more time on VA-ECLS (3.6 versus 2.8 days,
P
<0.001), and mechanical ventilation (7.1 versus 4.6 days,
P
=0.013). With the exception of hemolysis (RR, 2.18 [95% CI, 1.58–3.01];
P
<0.00001), overall adverse events did not differ.
Conclusions:
LV venting, especially if done early (<12 hours), appears to be associated with an increased success of weaning and reduced short-term mortality. Future studies are required to delineate the importance of any or early LV venting adjuncts on mortality and morbidity outcomes.
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Affiliation(s)
- Abdulrahman A. Al-Fares
- Interdepartmental Division of Critical Care Medicine (A.A.A.-F., E.F.), Toronto General Hospital, University of Toronto, ON, Canada
- Extracorporeal Life Support Program (A.A.A.-F., E.F.), Toronto General Hospital, University of Toronto, ON, Canada
- Al-Amiri Hospital, Ministry of Health, Kuwait (A.A.A.-F.)
| | - Varinder K. Randhawa
- Departments of Cardiovascular Medicine (V.K.R., J.D.E.), Kaufman Center for Heart Failure, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Marina Englesakis
- Library and Information Services (M.E.), Toronto General Hospital, University of Toronto, ON, Canada
| | - Michael A. McDonald
- Division of Cardiology, Peter Munk Cardiac Centre (M.A.M.), Toronto General Hospital, University of Toronto, ON, Canada
| | - A. Dave Nagpal
- Divisions of Cardiac Surgery and Critical Care, London Health Sciences Center, ON, Canada (A.D.N.)
| | - Jerry D. Estep
- Departments of Cardiovascular Medicine (V.K.R., J.D.E.), Kaufman Center for Heart Failure, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Edward G. Soltesz
- Thoracic and Cardiovascular Surgery (E.G.S.), Kaufman Center for Heart Failure, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine (A.A.A.-F., E.F.), Toronto General Hospital, University of Toronto, ON, Canada
- Extracorporeal Life Support Program (A.A.A.-F., E.F.), Toronto General Hospital, University of Toronto, ON, Canada
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44
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McGugan PL. The Role of Venoarterial Extracorporeal Membrane Oxygenation in Postcardiotomy Cardiogenic Shock. Crit Care Nurs Clin North Am 2019; 31:419-436. [DOI: 10.1016/j.cnc.2019.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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45
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See Hoe LE, Bartnikowski N, Wells MA, Suen JY, Fraser JF. Hurdles to Cardioprotection in the Critically Ill. Int J Mol Sci 2019; 20:E3823. [PMID: 31387264 PMCID: PMC6695809 DOI: 10.3390/ijms20153823] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 07/26/2019] [Accepted: 08/03/2019] [Indexed: 02/07/2023] Open
Abstract
Cardiovascular disease is the largest contributor to worldwide mortality, and the deleterious impact of heart failure (HF) is projected to grow exponentially in the future. As heart transplantation (HTx) is the only effective treatment for end-stage HF, development of mechanical circulatory support (MCS) technology has unveiled additional therapeutic options for refractory cardiac disease. Unfortunately, despite both MCS and HTx being quintessential treatments for significant cardiac impairment, associated morbidity and mortality remain high. MCS technology continues to evolve, but is associated with numerous disturbances to cardiac function (e.g., oxidative damage, arrhythmias). Following MCS intervention, HTx is frequently the destination option for survival of critically ill cardiac patients. While effective, donor hearts are scarce, thus limiting HTx to few qualifying patients, and HTx remains correlated with substantial post-HTx complications. While MCS and HTx are vital to survival of critically ill cardiac patients, cardioprotective strategies to improve outcomes from these treatments are highly desirable. Accordingly, this review summarizes the current status of MCS and HTx in the clinic, and the associated cardiac complications inherent to these treatments. Furthermore, we detail current research being undertaken to improve cardiac outcomes following MCS/HTx, and important considerations for reducing the significant morbidity and mortality associated with these necessary treatment strategies.
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Affiliation(s)
- Louise E See Hoe
- Critical Care Research Group, The Prince Charles Hospital, Chermside 4032, Australia.
- Faculty of Medicine, University of Queensland, Chermside 4032, Australia.
| | - Nicole Bartnikowski
- Critical Care Research Group, The Prince Charles Hospital, Chermside 4032, Australia
- Science and Engineering Faculty, Queensland University of Technology, Chermside 4032, Australia
| | - Matthew A Wells
- Critical Care Research Group, The Prince Charles Hospital, Chermside 4032, Australia
- School of Medical Science, Griffith University, Southport 4222, Australia
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Chermside 4032, Australia
- Faculty of Medicine, University of Queensland, Chermside 4032, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Chermside 4032, Australia
- Faculty of Medicine, University of Queensland, Chermside 4032, Australia
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Relationship Between Time to Left Atrial Decompression and Outcomes in Patients Receiving Venoarterial Extracorporeal Membrane Oxygenation Support: A Multicenter Pediatric Interventional Cardiology Early-Career Society Study. Pediatr Crit Care Med 2019; 20:728-736. [PMID: 30985609 DOI: 10.1097/pcc.0000000000001936] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess the variation in timing of left atrial decompression and its association with clinical outcomes in pediatric patients supported with venoarterial extracorporeal membrane oxygenation across a multicenter cohort. DESIGN Multicenter retrospective study. SETTING Eleven pediatric hospitals within the United States. PATIENTS Patients less than 18 years on venoarterial extracorporeal membrane oxygenation who underwent left atrial decompression from 2004 to 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 137 patients (median age, 4.7 yr) were included. Cardiomyopathy was the most common diagnosis (47%). Cardiac arrest (39%) and low cardiac output (50%) were the most common extracorporeal membrane oxygenation indications. Median time to left atrial decompression was 6.2 hours (interquartile range, 3.8-17.2 hr) with the optimal cut-point of greater than or equal to 18 hours for late decompression determined by receiver operating characteristic curve. In univariate analysis, late decompression was associated with longer extracorporeal membrane oxygenation duration (median 8.5 vs 5 d; p = 0.02). In multivariable analysis taking into account clinical confounder and center effects, late decompression remained significantly associated with prolonged extracorporeal membrane oxygenation duration (adjusted odds ratio, 4.4; p = 0.002). Late decompression was also associated with longer duration of mechanical ventilation (adjusted odds ratio, 4.8; p = 0.002). Timing of decompression was not associated with in-hospital survival (p = 0.36) or overall survival (p = 0.42) with median follow-up of 3.2 years. CONCLUSIONS In this multicenter study of pediatric patients receiving venoarterial extracorporeal membrane oxygenation, late left atrial decompression (≥ 18 hr) was associated with longer duration of extracorporeal membrane oxygenation support and mechanical ventilation. Although no survival benefit was demonstrated, the known morbidities associated with prolonged extracorporeal membrane oxygenation use may justify a recommendation for early left atrial decompression.
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47
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Yang C, Peng G, Xu X, Wei B, Yang H, He J. The technique of intraoperative axillary artery cannulation for extracorporeal membrane oxygenation in lung transplantation. J Thorac Dis 2019; 11:2939-2944. [PMID: 31463123 DOI: 10.21037/jtd.2019.07.32] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background To show our experiences of using the axillary artery with a side graft as a cannulation technique for the inflow of veno-arterial extracorporeal membrane oxygenation (ECMO) in lung transplantation (LTx). This method can avoid complications associated with central and femoral vessel cannulation techniques, and be convenient for the use of intraoperative ECMO into the early postoperative period. Methods Between November 2016 and July 2017, we established intraoperative V/A-ECMO in 32 patients. Among these patients, 5 patients were performed on via axillary artery-percutaneous femoral vein cannulation (15.6%), 2 patients were performed on with veno-venous ECMO (V/V-ECMO) as a bridge to transplantation with hemodynamic instability during transplantation, and additional axillary artery cannulations were performed to establish veno-veno-arterial (V/V/A) ECMO. Mean age was 45.2±10.1 years (range, 26-71 years). Results In 7 patients undergoing ECMO support during operation, the ECMO was removed in 4 patients immediately after the procedure, 3 patients with "prolonged ECMO" were transferred to the ICU. There were no ECMO-related complications and no patients died. Conclusions Our protocol for V/A-ECMO cannulation that uses the axillary artery for arterial cannulation provides a safe and improved means for delivering V/A-ECMO support during LTx. Also, it is helpful for prolonging the intraoperative ECMO in the early postoperative period.
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Affiliation(s)
- Chao Yang
- Department of Thoracic and Transplant Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Guilin Peng
- Department of Thoracic and Transplant Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Xin Xu
- Department of Thoracic and Transplant Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Bing Wei
- Department of Thoracic and Transplant Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Hanyu Yang
- Department of Anaesthesiology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Jianxing He
- Department of Thoracic and Transplant Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
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48
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Hong E, Naseem T. Color Doppler Artifact Masking Iatrogenic Aortic Valve Injury Related to an Impella Device. J Cardiothorac Vasc Anesth 2019; 33:1584-1587. [DOI: 10.1053/j.jvca.2018.09.035] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Indexed: 11/11/2022]
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49
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Hu CS, Wu QH, Hu DY, Tkebuchava T. Treatment of chronic heart failure in the 21st century: A new era of biomedical engineering has come. Chronic Dis Transl Med 2019; 5:75-88. [PMID: 31367696 PMCID: PMC6656907 DOI: 10.1016/j.cdtm.2018.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Indexed: 12/11/2022] Open
Abstract
Chronic heart failure (CHF) is a challenging burden on public health. Therapeutic strategies for CHF have developed rapidly in the past decades from conventional medical therapy, which mainly includes administration of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and aldosterone antagonists, to biomedical engineering methods, which include interventional engineering, such as percutaneous balloon mitral valvotomy, percutaneous coronary intervention, catheter ablation, biventricular pacing or cardiac resynchronization therapy (CRT) and CRT-defibrillator use, and implantable cardioverter defibrillator use; mechanical engineering, such as left ventricular assistant device use, internal artery balloon counterpulsation, cardiac support device use, and total artificial heart implantation; surgical engineering, such as coronary artery bypass graft, valve replacement or repair of rheumatic or congenital heart diseases, and heart transplantation (HT); regenerate engineering, which includes gene therapy, stem cell transplantation, and tissue engineering; and rehabilitating engineering, which includes exercise training, low-salt diet, nursing, psychological interventions, health education, and external counterpulsation/enhanced external counterpulsation in the outpatient department. These biomedical engineering therapies have greatly improved the symptoms of CHF and life expectancy. To date, pharmacotherapy, which is based on evidence-based medicine, large-scale, multi-center, randomized controlled clinical trials, is still a major treatment option for CHF; the current interventional and mechanical device engineering treatment for advanced CHF is not enough owing to its individual status. In place of HT or the use of a total artificial heart, stem cell technology and gene therapy in regenerate engineering for CHF are very promising. However, each therapy has its advantages and disadvantages, and it is currently possible to select better therapeutic strategies for patients with CHF according to cost-efficacy analyses of these therapies. Taken together, we think that a new era of biomedical engineering for CHF has begun.
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Affiliation(s)
- Chun-Song Hu
- Jiangxi Academy of Medical Science, Hospital of Nanchang University, Nanchang University, Nanchang, Jiangxi 330006, China
- Institute of Cardiovascular Diseases, Nanchang University, Nanchang, Jiangxi 330006, China
| | - Qing-Hua Wu
- Institute of Cardiovascular Diseases, Nanchang University, Nanchang, Jiangxi 330006, China
| | - Da-Yi Hu
- Department of Cardiology, People's Hospital of Peking University, Beijing 100044, China
- Department of Cardiology, Tongji University School of Medicine, Shanghai 200032, China
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50
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Bhatia M, Kumar PA. Pro: Venoarterial Extracorporeal Membrane Oxygenation Should Always Include Placement of a Left Ventricular Vent. J Cardiothorac Vasc Anesth 2019; 33:1159-1162. [DOI: 10.1053/j.jvca.2018.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Indexed: 11/11/2022]
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