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Tsushima R, Maruhashi T, Kurihara Y, Hashikata T, Asari Y. Transarterial embolization to treat a massive hemothorax during mechanical circulatory support via puncturing of the extracorporeal membrane oxygenation circuit. CVIR Endovasc 2024; 7:48. [PMID: 38769160 PMCID: PMC11106222 DOI: 10.1186/s42155-024-00460-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 05/16/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Current guidelines recommend the use of mechanical circulatory support (MCS) for patients with cardiogenic shock that is refractory to medical therapy. Bleeding is the most common complication of MCS. Transarterial embolization (TAE) is often performed to treat this complication, because it is a less invasive hemostatic procedure. However, the TAE option needs to be carefully considered during MCS, as the access route may be limited during MCS. CASE PRESENTATION A man in his 70 s was diagnosed with acute myocardial infarction and underwent percutaneous coronary intervention via venoarterial extracorporeal membrane oxygenation (VA-ECMO) and Impella. During treatment in the intensive care unit, he suffered damage to a branch of the internal thoracic artery during a cardiac drainage procedure, which was subsequently treated via emergency TAE. An ECMO return cannula and an Impella sheath were inserted into the patient's right and left femoral arteries, respectively. An approach from the left brachial artery was selected, and the left internal thoracic artery was embolized. Subsequently, the patient required re-intervention to treat re-bleeding from another artery. Because it was difficult to target the target artery from the brachial one, owing to interference from the Impella catheter, the ECMO circuit near the return cannula was punctured and a guiding sheath was inserted. The ECMO flow and the patient's blood pressure decreased following placement of this guiding sheath. We were thus able to maintain the patient's blood pressure by increasing the infusion fluids and Impella flow, and embolize the target artery using a gelatin sponge to achieve hemostasis. CONCLUSION When TAE is difficult to perform during MCS using an approach from the upper extremities, a lower extremity approach with a sheath inserted into the ECMO circuit may represent a viable alternative.
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Affiliation(s)
- Ryota Tsushima
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1KitasatoMinami-Ku, Sagamihara-City, Kanagawa-ken, 252-0375, Japan
| | - Takaaki Maruhashi
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1KitasatoMinami-Ku, Sagamihara-City, Kanagawa-ken, 252-0375, Japan.
| | - Yutaro Kurihara
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1KitasatoMinami-Ku, Sagamihara-City, Kanagawa-ken, 252-0375, Japan
| | - Takehiro Hashikata
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1KitasatoMinami-Ku, Sagamihara-City, Kanagawa-ken, 252-0375, Japan
| | - Yasushi Asari
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1KitasatoMinami-Ku, Sagamihara-City, Kanagawa-ken, 252-0375, Japan
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Merdler I, Case BC, Pahuja M, Hayat F, Isaac I, Gadodia R, Chitturi KR, Reddy PK, Cellamare M, Ben-Dor I, Waksman R. Is there additional value in adding Impella to veno-arterial extracorporeal membrane oxygenation in patients with cardiogenic shock? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00485-8. [PMID: 38782613 DOI: 10.1016/j.carrev.2024.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024]
Affiliation(s)
- Ilan Merdler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Brian C Case
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Mohit Pahuja
- Section of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Fatima Hayat
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Imad Isaac
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Ritika Gadodia
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Kalyan R Chitturi
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Pavan K Reddy
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Matteo Cellamare
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA.
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3
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Balder JW, Szymanski MK, van Laake LW, van der Harst P, Meuwese CL, Ramjankhan FZ, van der Meer MG, Hermens JAJM, Voskuil M, de Waal EEC, Donker DW, Oerlemans MIFJ, Kraaijeveld AO. ECPELLA as a bridge-to-decision in refractory cardiogenic shock: a single-centre experience. Neth Heart J 2024:10.1007/s12471-024-01872-w. [PMID: 38713449 DOI: 10.1007/s12471-024-01872-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND In refractory cardiogenic shock, temporary mechanical support (tMCS) may be crucial for maintaining tissue perfusion and oxygen delivery. tMCS can serve as a bridge-to-decision to assess eligibility for left ventricular assist device (LVAD) implantation or heart transplantation, or as a bridge-to-recovery. ECPELLA is a novel tMCS configuration combining venoarterial extracorporeal membrane oxygenation with Impella. The present study presents the clinical parameters, outcomes, and complications of patients supported with ECPELLA. METHODS All patients supported with ECPELLA at University Medical Centre Utrecht between December 2020 and August 2023 were included. The primary outcome was 30-day mortality, and secondary outcomes were LVAD implantation/heart transplantation and safety outcomes. RESULTS Twenty patients with an average age of 51 years, and of whom 70% were males, were included. Causes of cardiogenic shock were acute heart failure (due to acute coronary syndrome, myocarditis, or after cardiac surgery) or chronic heart failure, respectively 70 and 30% of cases. The median duration of ECPELLA support was 164 h (interquartile range 98-210). In 50% of cases, a permanent LVAD was implanted. Cardiac recovery within 30 days was seen in 30% of cases and 30-day mortality rate was 20%. ECPELLA support was associated with major bleeding (40%), haemolysis (25%), vascular complications (30%), kidney failure requiring replacement therapy (50%), and Impella failure requiring extraction (15%). CONCLUSION ECPELLA can be successfully used as a bridge to LVAD implantation or as a bridge-to-recovery in patients with refractory cardiogenic shock. Despite a significant number of complications, 30-day mortality was lower than observed in previous cohorts.
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Affiliation(s)
- Jan-Willem Balder
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands.
| | - Mariusz K Szymanski
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Linda W van Laake
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Pim van der Harst
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Christiaan L Meuwese
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Intensive Care, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Faiz Z Ramjankhan
- Department of Cardiothoracic Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Manon G van der Meer
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jeannine A J M Hermens
- Department of Intensive Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Eric E C de Waal
- Department of Anaesthesiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Dirk W Donker
- Department of Intensive Care, University Medical Centre Utrecht, Utrecht, The Netherlands
- Cardiovascular and Respiratory Physiology, Tech Med Centre, University of Twente, Enschede, The Netherlands
| | | | - Adriaan O Kraaijeveld
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
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Ling RR, Low CJW, Ramanathan K. Mechanical Left-Ventricular Unloading in Extracorporeal Cardiopulmonary Resuscitation: A State of Clinical Equipoise. Crit Care Med 2024; 52:512-515. [PMID: 38381015 DOI: 10.1097/ccm.0000000000006179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Affiliation(s)
- Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre Singapore, National University Health System, Singapore
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Thevathasan T, Füreder L, Fechtner M, Mørk SR, Schrage B, Westermann D, Linde L, Gregers E, Andreasen JB, Gaisendrees C, Unoki T, Axtell AL, Takeda K, Vinogradsky AV, Gonçalves-Teixeira P, Lemaire A, Alonso-Fernandez-Gatta M, Sern Lim H, Garan AR, Bindra A, Schwartz G, Landmesser U, Skurk C. Left-Ventricular Unloading With Impella During Refractory Cardiac Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review and Meta-Analysis. Crit Care Med 2024; 52:464-474. [PMID: 38180032 PMCID: PMC10876179 DOI: 10.1097/ccm.0000000000006157] [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] [Indexed: 01/06/2024]
Abstract
OBJECTIVES Extracorporeal cardiopulmonary resuscitation (ECPR) is the implementation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) during refractory cardiac arrest. The role of left-ventricular (LV) unloading with Impella in addition to VA-ECMO ("ECMELLA") remains unclear during ECPR. This is the first systematic review and meta-analysis to characterize patients with ECPR receiving LV unloading and to compare in-hospital mortality between ECMELLA and VA-ECMO during ECPR. DATA SOURCES Medline, Cochrane Central Register of Controlled Trials, Embase, and abstract websites of the three largest cardiology societies (American Heart Association, American College of Cardiology, and European Society of Cardiology). STUDY SELECTION Observational studies with adult patients with refractory cardiac arrest receiving ECPR with ECMELLA or VA-ECMO until July 2023 according to the Preferred Reported Items for Systematic Reviews and Meta-Analysis checklist. DATA EXTRACTION Patient and treatment characteristics and in-hospital mortality from 13 study records at 32 hospitals with a total of 1014 ECPR patients. Odds ratios (ORs) and 95% CI were computed with the Mantel-Haenszel test using a random-effects model. DATA SYNTHESIS Seven hundred sixty-two patients (75.1%) received VA-ECMO and 252 (24.9%) ECMELLA. Compared with VA-ECMO, the ECMELLA group was comprised of more patients with initial shockable electrocardiogram rhythms (58.6% vs. 49.3%), acute myocardial infarctions (79.7% vs. 51.5%), and percutaneous coronary interventions (79.0% vs. 47.5%). VA-ECMO alone was more frequently used in pulmonary embolism (9.5% vs. 0.7%). Age, rate of out-of-hospital cardiac arrest, and low-flow times were similar between both groups. ECMELLA support was associated with reduced odds of mortality (OR, 0.53 [95% CI, 0.30-0.91]) and higher odds of good neurologic outcome (OR, 2.22 [95% CI, 1.17-4.22]) compared with VA-ECMO support alone. ECMELLA therapy was associated with numerically increased but not significantly higher complication rates. Primary results remained robust in multiple sensitivity analyses. CONCLUSIONS ECMELLA support was predominantly used in patients with acute myocardial infarction and VA-ECMO for pulmonary embolism. ECMELLA support during ECPR might be associated with improved survival and neurologic outcome despite higher complication rates. However, indications and frequency of ECMELLA support varied strongly between institutions. Further scientific evidence is urgently required to elaborate standardized guidelines for the use of LV unloading during ECPR.
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Affiliation(s)
- Tharusan Thevathasan
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
- Department of Cardiology and Angiology, Medical Faculty, University Heart Center Freiburg, Bad Krozingen, University of Freiburg, Freiburg, Germany
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Aneastesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
- Department of Cardiology and Intensive Care Unit, Saiseikai Kumamoto Hospital, Kumamoto, Japan
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Oporto, Portugal
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
- Cardiology Department, University Hospital of Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación biomédica en Red de Enfermadades Cardiovasculares (CIBER-CV), Madrid, Spain
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- Division of Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX
| | - Lisa Füreder
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
| | - Marie Fechtner
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
| | | | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology, Medical Faculty, University Heart Center Freiburg, Bad Krozingen, University of Freiburg, Freiburg, Germany
| | - Louise Linde
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Emilie Gregers
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jo Bønding Andreasen
- Department of Aneastesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | | | - Takashi Unoki
- Department of Cardiology and Intensive Care Unit, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Andrea L Axtell
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Koji Takeda
- Department of Surgery, Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY
| | - Alice V Vinogradsky
- Department of Surgery, Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY
| | | | - Anthony Lemaire
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Marta Alonso-Fernandez-Gatta
- Cardiology Department, University Hospital of Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación biomédica en Red de Enfermadades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Hoong Sern Lim
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Arthur Reshad Garan
- Division of Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Amarinder Bindra
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX
| | - Gary Schwartz
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX
| | - Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
- Department of Cardiology and Angiology, Medical Faculty, University Heart Center Freiburg, Bad Krozingen, University of Freiburg, Freiburg, Germany
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Aneastesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
- Department of Cardiology and Intensive Care Unit, Saiseikai Kumamoto Hospital, Kumamoto, Japan
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Oporto, Portugal
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
- Cardiology Department, University Hospital of Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación biomédica en Red de Enfermadades Cardiovasculares (CIBER-CV), Madrid, Spain
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- Division of Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX
| | - Carsten Skurk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
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Nishimura T, Toda K, Ako J, Hirayama A, Kinugawa K, Kobayashi Y, Ono M, Sato N, Shindo T, Shiose A, Takayama M, Yasukochi S, Sawa Y. Prevalence of bleeding events in real-world Japanese registry for Percutaneous Ventricular Assist Device. J Artif Organs 2024:10.1007/s10047-023-01429-5. [PMID: 38396197 DOI: 10.1007/s10047-023-01429-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 12/14/2023] [Indexed: 02/25/2024]
Abstract
PURPOSE Bleeding complication is a critical risk factor for outcomes of acute heart failure patients requiring mechanical circulatory support (MCS), including percutaneous catheter-type heart pumps (Impella). The Japanese registry for Percutaneous Ventricular Assist Device (J-PVAD) is an ongoing, large-scale, real-world registry to characterize Japanese patients requiring Impella. Here we analyzed bleeding complication profiles in patients who received Impella. METHODS All consecutive Japanese patients who received Impella from October 2017 to January 2020 were enrolled. The 30-day survival and bleeding complications were analyzed. RESULTS A total of 1344 patients were included: 653 patients received Impella alone, 685 patients received a combination of veno-arterial extracorporeal membrane oxygenation and Impella (ECPELLA), and 6 patients had failed Impella delivery. Overall 30-day survival was 67.0%, with Impella alone at 81.9% and ECPELLA at 52.7%. Overall bleeding/hematoma adverse events with a relation or not-excluded relation to Impella was 6.92%. Among them, the rates of hematoma and bleeding from medical device access sites were 1.41% and 4.09%, respectively. There was no difference between etiologies for these events. CONCLUSION This study represents the first 3-year survival and the safety profile focused on bleeding adverse events from the J-PVAD registry. The results show that the real-world frequency of bleeding adverse events for patients who received Impella was an expected range from previous reports, and future real-world studies should aim to expand this data set to improve outcomes and adverse events.
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Affiliation(s)
- Takashi Nishimura
- Department of Cardiovascular and Thoracic Surgery, Graduate School of Medicine, Ehime University, Ehime, Japan.
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, School of Medicine, Kitasato University, Kanagawa, Japan
| | | | - Koichiro Kinugawa
- The Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Naoki Sato
- Department of Cardiology, Kawaguchi Cardiovascular and Respiratory Hospital, Saitama, Japan
| | - Takahiro Shindo
- Division of Cardiology, National Center for Child Health and Development, Tokyo, Japan
| | - Akira Shiose
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medicine, Fukuoka, Japan
| | - Morimasa Takayama
- Department of Cardiovascular Internal Medicine, Sakakibara Heart Institute, Tokyo, Japan
| | - Satoshi Yasukochi
- Department of Pediatric Cardiology, Nagano Children's Hospital, Nagano, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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7
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Gandhi KD, Moras EC, Niroula S, Lopez PD, Aggarwal D, Bhatia K, Balboul Y, Daibes J, Correa A, Dominguez AC, Birati EY, Baran DA, Serrao G, Mahmood K, Vallabhajosyula S, Fox A. Left Ventricular Unloading With Impella Versus IABP in Patients With VA-ECMO: A Systematic Review and Meta-Analysis. Am J Cardiol 2023; 208:53-59. [PMID: 37812867 DOI: 10.1016/j.amjcard.2023.09.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 10/11/2023]
Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) use for circulatory support in cardiogenic shock results in increased left ventricular (LV) afterload. The use of concomitant Impella or intra-aortic balloon pump (IABP) have been proposed as adjunct devices for LV unloading. The authors sought to compare head-to-head efficacy and safety outcomes between the 2 LV unloading strategies. We conducted a search of Medline, EMBASE, and Cochrane databases to identify studies comparing the use of Impella to IABP in patients on VA-ECMO. The primary outcome of interest was in-hospital mortality. The secondary outcomes included transition to durable LV assist devices/cardiac transplantation, stroke, limb ischemia, need for continuous renal replacement therapy, major bleeding, and hemolysis. Pooled risk ratios (RRs) with 95% confidence interval and heterogeneity statistic I2 were calculated using a random-effects model. A total of 7 observational studies with 698 patients were included. Patients on VA-ECMO unloaded with Impella vs IABP had similar risk of short-term all-cause mortality, defined as either 30-day or in-hospital mortality- 60.8% vs 64.9% (RR 0.93 [0.71 to 1.21], I2 = 71%). No significant difference was observed in transition to durable LV assist devices/cardiac transplantation, continuous renal replacement therapy initiation, stroke, or limb ischemia between the 2 strategies. However, the use of VA-ECMO with Impella was associated with increased risk of major bleeding (57.2% vs 39.7%) (RR 1.66 [1.12 to 2.44], I2 = 82%) and hemolysis (31% vs 7%) (RR 4.61 [1.24 to 17.17], I2 = 66%) compared with VA-ECMO, along with IABP. In conclusion, in patients requiring VA-ECMO for circulatory support, the concomitant use of Impella or IABP had comparable short-term mortality. However, Impella use was associated with increased risk of major bleeding and hemolysis.
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Affiliation(s)
- Kruti D Gandhi
- Department of Internal Medicine, Mount Sinai Morningside/West, New York, New York
| | - Errol C Moras
- Department of Internal Medicine, Mount Sinai Morningside/West, New York, New York
| | - Shailesh Niroula
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, Michigan
| | - Persio D Lopez
- Mount Sinai Heart, Mount Sinai Morningside Hospital, New York, New York
| | - Devika Aggarwal
- Mount Sinai Heart, Mount Sinai Morningside Hospital, New York, New York
| | - Kirtipal Bhatia
- Mount Sinai Heart, Mount Sinai Morningside Hospital, New York, New York
| | - Yoni Balboul
- Department of Internal Medicine, Mount Sinai Morningside/West, New York, New York
| | - Joseph Daibes
- Mount Sinai Heart, Mount Sinai Morningside Hospital, New York, New York
| | - Ashish Correa
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai
| | | | - Edo Y Birati
- Poriya Medical Center, Bar-Ilan University, Israel
| | - David A Baran
- Heart, Vascular Thoracic Institute, Cleveland Clinic Florida, Weston, Florida
| | - Gregory Serrao
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai
| | - Kiran Mahmood
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Arieh Fox
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai.
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8
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Sugane H, Hoji H, Kawai K. Unexpected deformation of the right coronary artery during percutaneous coronary intervention with venoarterial extracorporeal membrane oxygenation combined with Impella: a case report. Eur Heart J Case Rep 2023; 7:ytad402. [PMID: 37637092 PMCID: PMC10456214 DOI: 10.1093/ehjcr/ytad402] [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: 12/30/2022] [Revised: 08/03/2023] [Accepted: 08/15/2023] [Indexed: 08/29/2023]
Abstract
Background The establishment of cautionary notes regarding percutaneous coronary intervention (PCI) with venoarterial extracorporeal membrane oxygenation combined with Impella (ECMELLA) is still lacking. Case summary A 68-year-old man was transferred to our hospital with cardiac arrest. ECMELLA insertion was performed via the bilateral femoral artery and vein for refractory ventricular fibrillation. Coronary angiography revealed an occluded lesion in the right coronary artery (RCA). Contrast injection was administered after confirming backflow through the guide catheter (GC) to avoid coronary dissection because the artery pressure was non-pulsatile during total circulation support. Prudent coronary angiography revealed a couple of accordion phenomena. Additionally, coronary angiography showed a shorter distance from the right border of the cardiac silhouette to the RCA and the venous line of extracorporeal membrane oxygenation than before PCI. This drastic change in the cardiac silhouette suggested that ECMELLA induced the collapse of the right heart system. Subsequently, a drug-eluting stent was implanted successfully. Final coronary angiography confirmed severe bending in the proximal segment of the RCA, which was absent in the reference coronary angiography. The patient had an uneventful course except for mild cognitive impairment. The computed tomography coronary angiography after ECMELLA removal indicated the RCA without deformation. Discussion In the present case, the collapse of the right heart system caused by ECMELLA resulted in RCA deformation. This case also underscored that contrast injection to the coronary artery in total circulation support should be administered after confirmation of backflow through a GC.
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Affiliation(s)
- Hiroki Sugane
- Department of Cardiology, Chikamori Hospital, Kochi, Japan
| | - Haruki Hoji
- Department of Cardiology, Chikamori Hospital, Kochi, Japan
| | - Kazuya Kawai
- Department of Cardiology, Chikamori Hospital, Kochi, Japan
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Di Nardo M, MacLaren G, Schellongowski P, Azoulay E, DeZern AE, Gutierrez C, Antonelli M, Antonini MV, Beutel G, Combes A, Diaz R, Fawzy Hassan I, Fowles JA, Jeong IS, Kochanek M, Liebregts T, Lueck C, Moody K, Moore JA, Munshi L, Paden M, Pène F, Puxty K, Schmidt M, Staudacher D, Staudinger T, Stemmler J, Stephens RS, Vande Vusse L, Wohlfarth P, Lorusso R, Amodeo A, Mahadeo KM, Brodie D. Extracorporeal membrane oxygenation in adults receiving haematopoietic cell transplantation: an international expert statement. THE LANCET. RESPIRATORY MEDICINE 2023; 11:477-492. [PMID: 36924784 DOI: 10.1016/s2213-2600(22)00535-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/16/2022] [Accepted: 12/16/2022] [Indexed: 03/16/2023]
Abstract
Combined advances in haematopoietic cell transplantation (HCT) and intensive care management have improved the survival of patients with haematological malignancies admitted to the intensive care unit. In cases of refractory respiratory failure or refractory cardiac failure, these advances have led to a renewed interest in advanced life support therapies, such as extracorporeal membrane oxygenation (ECMO), previously considered inappropriate for these patients due to their poor prognosis. Given the scarcity of evidence-based guidelines on the use of ECMO in patients receiving HCT and the need to provide equitable and sustainable access to ECMO, the European Society of Intensive Care Medicine, the Extracorporeal Life Support Organization, and the International ECMO Network aimed to develop an expert consensus statement on the use of ECMO in adult patients receiving HCT. A steering committee with expertise in ECMO and HCT searched the literature for relevant articles on ECMO, HCT, and immune effector cell therapy, and developed opinion statements through discussions following a Quaker-based consensus approach. An international panel of experts was convened to vote on these expert opinion statements following the Research and Development/University of California, Los Angeles Appropriateness Method. The Appraisal of Guidelines for Research and Evaluation statement was followed to prepare this Position Paper. 36 statements were drafted by the steering committee, 33 of which reached strong agreement after the first voting round. The remaining three statements were discussed by all members of the steering committee and expert panel, and rephrased before an additional round of voting. At the conclusion of the process, 33 statements received strong agreement and three weak agreement. This Position Paper could help to guide intensivists and haematologists during the difficult decision-making process regarding ECMO candidacy in adult patients receiving HCT. The statements could also serve as a basis for future research focused on ECMO selection criteria and bedside management.
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Affiliation(s)
- Matteo Di Nardo
- Paediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Health System, Singapore
| | - Peter Schellongowski
- Intensive Care Unit 13i2, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital, University of Paris, Paris, France
| | - Amy E DeZern
- Division of Hematologic Malignancies, Sidney Kimmel Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Cristina Gutierrez
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Marta V Antonini
- Anaesthesia and Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy; Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | - Gernot Beutel
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Alain Combes
- Institute of Cardiometabolism and Nutrition, INSERM, UMRS_1166-ICAN, Sorbonne Université, Paris, France; Service de médecine intensive-réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
| | | | | | - Jo-Anne Fowles
- Division of Surgery, Transplant and Anaesthetics, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - In-Seok Jeong
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Matthias Kochanek
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Center of Integrated Oncology, Aachen-Bonn-Cologne-Dusseldorf, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Tobias Liebregts
- Department of Hematology and Stem Cell Transplantation, West-German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Catherina Lueck
- Department of Hematology and Stem Cell Transplantation, West-German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Karen Moody
- Division of Pediatrics, Palliative and Supportive Care Section, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jessica A Moore
- Section of Integrated Ethics in Cancer Care, Department of Critical Care and Respiratory Care, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Sinai Health System/University Health Network, University of Toronto, Toronto, ON, Canada
| | - Matthew Paden
- Division of Critical Care, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Frédéric Pène
- Service de Médecine Intensive-Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Centre & Université Paris Cité, Paris, France
| | - Kathryn Puxty
- Department of Critical Care, NHS Greater Glasgow and Clyde, Glasgow, UK; School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Matthieu Schmidt
- Institute of Cardiometabolism and Nutrition, INSERM, UMRS_1166-ICAN, Sorbonne Université, Paris, France; Service de médecine intensive-réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
| | - Dawid Staudacher
- Interdisciplinary Medical Intensive Care (IMIT), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas Staudinger
- Intensive Care Unit 13i2, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Joachim Stemmler
- Department of Hematology and Oncology, University Hospital, LMU Munich, Munich, Germany
| | - R Scott Stephens
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and Department of Oncology, Johns Hopkins University, Baltimore, MD, USA
| | - Lisa Vande Vusse
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Philipp Wohlfarth
- Stem Cell Transplantation Unit, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Antonio Amodeo
- Cardiac Surgery Unit, Department of Paediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Kris M Mahadeo
- Pediatric Transplant and Cellular Therapy, Duke University, Durham, NC, USA
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MA, USA
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Meertens MM, Tichelbäcker T, Macherey-Meyer S, Heyne S, Braumann S, Nießen SF, Baldus S, Adler C, Lee S. Meta-analysis of extracorporeal membrane oxygenation in combination with intra-aortic balloon pump vs. extracorporeal membrane oxygenation only in patients with cardiogenic shock due to acute myocardial infarction. Front Cardiovasc Med 2023; 9:1104357. [PMID: 36741852 PMCID: PMC9889933 DOI: 10.3389/fcvm.2022.1104357] [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: 11/21/2022] [Accepted: 12/29/2022] [Indexed: 01/20/2023] Open
Abstract
Background Incidence and mortality of cardiogenic shock (CS) in patients with acute myocardial infarction (AMI) remain high despite substantial therapy improvements in acute percutaneous coronary intervention over the last decades. Unloading the left ventricle in patients with Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can be performed by using an intra-aortic balloon pumps' (IABP) afterload reduction, which might be especially beneficial in AMI patients with CS. Objective The objective of this meta-analysis was to assess the effect of VA-ECMO + IABP vs. VA-ECMO treatment on the mortality of patients with CS due to AMI. Methods A systematic literature search was performed using EMBASE, COCHRANE, and MEDLINE databases. Studies comparing the effect of VA-ECMO + IABP vs. VA-ECMO on mortality of patients with AMI were included. Meta-analyses were performed to analyze the effect of the chosen treatment on 30-day/in-hospital mortality. Results Twelve studies were identified by the literature search, including a total of 5,063 patients, 81.5% were male and the mean age was 65.9 years. One thousand one hundred and thirty-six patients received treatment with VA-ECMO in combination with IABP and 2,964 patients received VA-ECMO treatment only. The performed meta-analysis showed decreased mortality at 30-days/in-hospital after VA-ECMO + IABP compared to VA-ECMO only for patients with cardiogenic shock after AMI (OR 0.36, 95% CI 0.30-0.44, P≤0.001). Combination of VA-ECMO + IABP was associated with higher rates of weaning success (OR 0.29, 95% CI 0.16-0.53, P < 0.001) without an increase of vascular access complications (OR 0.85, 95% CI 0.35-2.08, P = 0.72). Conclusion In this meta-analysis, combination therapy of VA-ECMO + IABP was superior to VA-ECMO only therapy in patients with CS due to AMI. In the absence of randomized data, these results are hypothesis generating only.
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11
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Chiang CY, Lin CF, Liu PH, Chen FC, Chiu IM, Cheng FJ. Clinical Validation of the Shock Index, Modified Shock Index, Delta Shock Index, and Shock Index-C for Emergency Department ST-Segment Elevation Myocardial Infarction. J Clin Med 2022; 11:jcm11195839. [PMID: 36233705 PMCID: PMC9573755 DOI: 10.3390/jcm11195839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 09/23/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022] Open
Abstract
Background: ST-segment elevation myocardial infarction (STEMI) is a leading cause of death worldwide. A shock index (SI), modified SI (MSI), delta-SI, and shock index-C (SIC) are known predictors of STEMI. This retrospective cohort study was designed to compare the predictive value of the SI, MSI, delta-SI, and SIC with thrombolysis in myocardial infarction (TIMI) risk scales. Method: Patients > 20 years old with STEMI who underwent percutaneous coronary intervention (PCI) were included. Receiver operating characteristic (ROC) curve analysis with the Youden index was performed to calculate the optimal cutoff values for these predictors. Results: Overall, 1552 adult STEMI cases were analyzed. The thresholds for the emergency department (ED) SI, MSI, SIC, and TIMI risk scales for in-hospital mortality were 0.75, 0.97, 21.00, and 5.5, respectively. Accordingly, ED SIC had better predictive power than the ED SI and ED MSI. The predictive power was relatively higher than TIMI risk scales, but the difference did not achieve statistical significance. After adjusting for confounding factors, the ED SI > 0.75, MSI > 0.97, SIC > 21.0, and TIMI risk scales > 5.5 were statistically and significantly associated with in-hospital mortality of STEMI. Compared with the ED SI and MSI, SIC (>21.0) had better sensitivity (67.2%, 95% CI, 58.6−75.9%), specificity (83.5%, 95% CI, 81.6−85.4%), PPV (24.8%, 95% CI, 20.2−29.6%), and NPV (96.9%, 95% CI, 96.0−97.9%) for in-hospital mortality of STEMI. Conclusions: SIC had better discrimination ability than the SI, MSI, and delta-SI. Compared with the TIMI risk scales, the ACU value of SIC was still higher. Therefore, SIC might be a convenient and rapid tool for predicting the outcome of STEMI.
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Affiliation(s)
- Charng-Yen Chiang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan
| | - Chien-Fu Lin
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan
| | - Peng-Huei Liu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Fu-Cheng Chen
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan
| | - I-Min Chiu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan
| | - Fu-Jen Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan
- Correspondence: ; Tel.: +886-975-056-646
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12
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Cormican DS, Madden C, Rodrigue MF. Mechanical circulatory support: complications, outcomes, and future directions. Int Anesthesiol Clin 2022; 60:72-80. [PMID: 35960687 DOI: 10.1097/aia.0000000000000373] [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)
- Daniel S Cormican
- Cardiothoracic & Transplant Anesthesiology and Surgical Critical Care, Anesthesiology Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Claire Madden
- Surgical Critical Care, Surgery Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Marc F Rodrigue
- Cardiothoracic Anesthesiology, Anesthesiology Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
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13
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Han J, Grinstein J. To vent or not to vent: The critical role of left ventricular venting with extracorporeal membrane oxygenation support. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 40:142-143. [DOI: 10.1016/j.carrev.2022.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 04/19/2022] [Indexed: 11/03/2022]
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