1
|
Rozencwajg S, Wu EL, Heinsar S, Stevens M, Chinchilla J, Fraser JF, Pauls JP. A mock circulation loop to evaluate differential hypoxemia during peripheral venoarterial extracorporeal membrane oxygenation. Perfusion 2024; 39:66-75. [PMID: 35038287 DOI: 10.1177/02676591211056567] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Peripheral veno-arterial extracorporeal membrane oxygenation (VA ECMO) creates a retrograde flow along the aorta competing with the left ventricle (LV) in the so-called 'mixing zone' (MZ). Detecting it is essential to understand which of the LV or the ECMO flow perfuses the upper body - particularly the brain and the coronary arteries - in case of differential hypoxemia (DH). METHODS We described a mock circulation loop (MCL) that enabled experimental research on DH. We recreated the three clinical situations relevant to clinicians: where the brain is either totally perfused by the ECMO or the LV or both. In a second step, we used this model to investigate two scenarios to diagnose DH: (i) pulse pressure and (ii) thermodilution via injection of cold saline in the ECMO circuit. RESULTS The presented MCL was able to reproduce the three relevant mixing zones within the aortic arch, thus allowing to study DH. Pulse pressure was unable to detect location of the MZ. However, the thermodilution method was able to detect whether the brain was totally perfused by the ECMO or not. CONCLUSION We validated an in-vitro differential hypoxemia model of cardiogenic shock supported by VA ECMO. This MCL could be used as an alternative to animal studies for research scenarios.
Collapse
Affiliation(s)
- Sacha Rozencwajg
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, AU-QLD, Australia
- Sorbonne Université, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Medical ICU, Pitié-Salpêtrière University Hospital, Paris, France
| | - Eric L Wu
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, AU-QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, AU-QLD, Australia
| | - Silver Heinsar
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, AU-QLD, Australia
| | - Michael Stevens
- Graduate School of Biomedical Engineering, UNSW Sydney, AU -NSW, Australia
| | - Josh Chinchilla
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, AU-QLD, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, AU-QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, AU-QLD, Australia
| | - Jo P Pauls
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, AU-QLD, Australia
- School of Engineering and Built Environment, Griffith University, Southport, AU-QLD, Australia
| |
Collapse
|
2
|
Ostadal P, Vondrakova D, Popkova M, Hrachovina M, Kruger A, Janotka M, Naar J, Kittnar O, Neuzil P, Mlcek M. Aortic stenosis and mitral regurgitation modify the effect of venoarterial extracorporeal membrane oxygenation on left ventricular function in cardiogenic shock. Sci Rep 2022; 12:17076. [PMID: 36224296 PMCID: PMC9556561 DOI: 10.1038/s41598-022-21501-z] [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: 07/17/2022] [Accepted: 09/28/2022] [Indexed: 01/04/2023] Open
Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is widely used in the treatment of patients experiencing cardiogenic shock (CS). However, increased VA-ECMO blood flow (EBF) may significantly impair left ventricular (LV) performance. The objective of the present study was to assess the effect of VA-ECMO on LV function in acute CS with concomitant severe aortic stenosis (AS) or mitral regurgitation (MR) in a porcine model. Eight female swine (45 kg) underwent VA-ECMO implantation under general anaesthesia and mechanical ventilation. Acute CS was induced by global myocardial hypoxia. Subsequently, severe AS was simulated by obstruction of the aortic valve, while severe MR was induced by mechanical destruction of the mitral valve. Haemodynamic and LV performance variables were measured at different rates of EBF rates (ranging from 1 to 4 L/min), using arterial and venous catheters, a pulmonary artery catheter, and LV pressure-volume catheter. Data are expressed as median (interquartile range). Myocardial hypoxia resulted in declines in cardiac output to 2.7 (1.9-3.1) L/min and LV ejection fraction to 15.2% (10.5-19.3%). In severe AS, increasing EBF from 1 to 4 L/min was associated with a significant elevation in mean arterial pressure (MAP), from 33.5 (24.2-34.9) to 56.0 (51.9-73.3) mmHg (P ˂ 0.01). However, LV volumes (end-diastolic, end-systolic, stroke) remained unchanged, and LV end-diastolic pressure (LVEDP) significantly decreased from 24.9 (21.2-40.0) to 19.1 (15.2-29.0) mmHg (P ˂ 0.01). In severe MR, increasing EBF resulted in a significant elevation in MAP from 49.0 (28.0-53.4) to 72.5 (51.4-77.1) mmHg (P ˂ 0.01); LV volumes remained stable and LVEDP increased from 17.1 (13.7-19.1) to 20.8 (16.3-25.6) mmHg (P ˂ 0.01). Results of this study indicate that the presence of valvular heart disease may alleviate negative effect of VA-ECMO on LV performance in CS. Severe AS fully protected against LV overload, and partial protection was also detected with severe MR, although at the cost of increased LVEDP and, thus, higher risk for pulmonary oedema.
Collapse
Affiliation(s)
- Petr Ostadal
- grid.414877.90000 0004 0609 2583Cardiovascular Center, Na Homolce Hospital, Roentgenova 2, 15000 Prague, Czech Republic
| | - Dagmar Vondrakova
- grid.414877.90000 0004 0609 2583Cardiovascular Center, Na Homolce Hospital, Roentgenova 2, 15000 Prague, Czech Republic
| | - Michaela Popkova
- grid.4491.80000 0004 1937 116XDepartment of Physiology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Matej Hrachovina
- grid.4491.80000 0004 1937 116XDepartment of Physiology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Andreas Kruger
- grid.414877.90000 0004 0609 2583Cardiovascular Center, Na Homolce Hospital, Roentgenova 2, 15000 Prague, Czech Republic
| | - Marek Janotka
- grid.414877.90000 0004 0609 2583Cardiovascular Center, Na Homolce Hospital, Roentgenova 2, 15000 Prague, Czech Republic
| | - Jan Naar
- grid.414877.90000 0004 0609 2583Cardiovascular Center, Na Homolce Hospital, Roentgenova 2, 15000 Prague, Czech Republic
| | - Otomar Kittnar
- grid.4491.80000 0004 1937 116XDepartment of Physiology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Petr Neuzil
- grid.414877.90000 0004 0609 2583Cardiovascular Center, Na Homolce Hospital, Roentgenova 2, 15000 Prague, Czech Republic
| | - Mikulas Mlcek
- grid.4491.80000 0004 1937 116XDepartment of Physiology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| |
Collapse
|
3
|
Hála P, Kittnar O. Hemodynamic adaptation of heart failure to percutaneous venoarterial extracorporeal circulatory supports. Physiol Res 2020; 69:739-757. [PMID: 32901493 DOI: 10.33549/physiolres.934332] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Extracorporeal life support (ECLS) is a treatment modality that provides prolonged blood circulation, gas exchange and can partially support or fully substitute functions of heart and lungs in patients with severe but potentially reversible cardiopulmonary failure refractory to conventional therapy. Due to high-volume bypass, the extracorporeal flow is interacting with native cardiac output. The pathophysiology of circulation and ECLS support reveals significant effects on arterial pressure waveforms, cardiac hemodynamics, and myocardial perfusion. Moreover, it is still subject of research, whether increasing stroke work caused by the extracorporeal flow is accompanied by adequate myocardial oxygen supply. The left ventricular (LV) pressure-volume mechanics are reflecting perfusion and loading conditions and these changes are dependent on the degree of the extracorporeal blood flow. By increasing the afterload, artificial circulation puts higher demands on heart work with increasing myocardial oxygen consumption. Further, this can lead to LV distention, pulmonary edema, and progression of heart failure. Multiple methods of LV decompression (atrial septostomy, active venting, intra-aortic balloon pump, pulsatility of flow) have been suggested to relieve LV overload but the main risk factors still remain unclear. In this context, it has been recommended to keep the rate of circulatory support as low as possible. Also, utilization of detailed hemodynamic monitoring has been suggested in order to avoid possible harm from excessive extracorporeal flow.
Collapse
Affiliation(s)
- P Hála
- Department of Physiology, First Faculty of Medicine, Charles University, Prague, Czech Republic.
| | | |
Collapse
|
4
|
Hála P, Mlček M, Ošťádal P, Popková M, Janák D, Bouček T, Lacko S, Kudlička J, Neužil P, Kittnar O. Increasing venoarterial extracorporeal membrane oxygenation flow puts higher demands on left ventricular work in a porcine model of chronic heart failure. J Transl Med 2020; 18:75. [PMID: 32054495 PMCID: PMC7017528 DOI: 10.1186/s12967-020-02250-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 01/30/2020] [Indexed: 11/10/2022] Open
Abstract
Background Venoarterial extracorporeal membrane oxygenation (VA ECMO) is widely used in the treatment of circulatory failure, but repeatedly, its negative effects on the left ventricle (LV) have been observed. The purpose of this study is to assess the influence of increasing extracorporeal blood flow (EBF) on LV performance during VA ECMO therapy of decompensated chronic heart failure. Methods A porcine model of low-output chronic heart failure was developed by long-term fast cardiac pacing. Subsequently, under total anesthesia and artificial ventilation, VA ECMO was introduced to a total of five swine with profound signs of chronic cardiac decompensation. LV performance and organ specific parameters were recorded at different levels of EBF using a pulmonary artery catheter, a pressure–volume loop catheter positioned in the LV, and arterial flow probes on systemic arteries. Results Tachycardia-induced cardiomyopathy led to decompensated chronic heart failure with mean cardiac output of 2.9 ± 0.4 L/min, severe LV dilation, and systemic hypoperfusion. By increasing the EBF from minimal flow to 5 L/min, we observed a gradual increase of LV peak pressure from 49 ± 15 to 73 ± 11 mmHg (P = 0.001) and an improvement in organ perfusion. On the other hand, cardiac performance parameters revealed higher demands put on LV function: LV end-diastolic pressure increased from 7 ± 2 to 15 ± 3 mmHg, end-diastolic volume increased from 189 ± 26 to 218 ± 30 mL, end-systolic volume increased from 139 ± 17 to 167 ± 15 mL (all P < 0.001), and stroke work increased from 1434 ± 941 to 1892 ± 1036 mmHg*mL (P < 0.05). LV ejection fraction and isovolumetric contractility index did not change significantly. Conclusions In decompensated chronic heart failure, excessive VA ECMO flow increases demands and has negative effects on the workload of LV. To protect the myocardium from harm, VA ECMO flow should be adjusted with respect to not only systemic perfusion, but also to LV parameters.
Collapse
Affiliation(s)
- Pavel Hála
- Department of Physiology, First Faculty of Medicine, Charles University, Albertov 5, 128 00, Prague, Czech Republic. .,Department of Cardiology, Na Homolce Hospital, Prague, Czech Republic.
| | - Mikuláš Mlček
- Department of Physiology, First Faculty of Medicine, Charles University, Albertov 5, 128 00, Prague, Czech Republic
| | - Petr Ošťádal
- Department of Physiology, First Faculty of Medicine, Charles University, Albertov 5, 128 00, Prague, Czech Republic.,Department of Cardiology, Na Homolce Hospital, Prague, Czech Republic
| | - Michaela Popková
- Department of Physiology, First Faculty of Medicine, Charles University, Albertov 5, 128 00, Prague, Czech Republic
| | - David Janák
- Department of Physiology, First Faculty of Medicine, Charles University, Albertov 5, 128 00, Prague, Czech Republic.,Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Tomáš Bouček
- Department of Physiology, First Faculty of Medicine, Charles University, Albertov 5, 128 00, Prague, Czech Republic.,Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Stanislav Lacko
- Department of Physiology, First Faculty of Medicine, Charles University, Albertov 5, 128 00, Prague, Czech Republic
| | - Jaroslav Kudlička
- Department of Physiology, First Faculty of Medicine, Charles University, Albertov 5, 128 00, Prague, Czech Republic
| | - Petr Neužil
- Department of Physiology, First Faculty of Medicine, Charles University, Albertov 5, 128 00, Prague, Czech Republic.,Department of Cardiology, Na Homolce Hospital, Prague, Czech Republic
| | - Otomar Kittnar
- Department of Physiology, First Faculty of Medicine, Charles University, Albertov 5, 128 00, Prague, Czech Republic
| |
Collapse
|
5
|
Electrocardiogram-synchronized pulsatile extracorporeal life support preserves left ventricular function and coronary flow in a porcine model of cardiogenic shock. PLoS One 2018; 13:e0196321. [PMID: 29689088 PMCID: PMC5915277 DOI: 10.1371/journal.pone.0196321] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 04/11/2018] [Indexed: 11/20/2022] Open
Abstract
Introduction Veno-arterial extracorporeal life support (ECLS) is increasingly being used to treat rapidly progressing or severe cardiogenic shock. However, it has been repeatedly shown that increased afterload associated with ECLS significantly diminishes left ventricular (LV) performance. The objective of the present study was to compare LV function and coronary flow during standard continuous-flow ECLS support and electrocardiogram (ECG)-synchronized pulsatile ECLS flow in a porcine model of cardiogenic shock. Methods Sixteen female swine (mean body weight 45 kg) underwent ECLS implantation under general anesthesia and artificial ventilation. Subsequently, acute cardiogenic shock, with documented signs of tissue hypoperfusion, was induced by initiating global myocardial hypoxia. Hemodynamic cardiac performance variables and coronary flow were then measured at different rates of continuous or pulsatile ECLS flow (ranging from 1 L/min to 4 L/min) using arterial and venous catheters, a pulmonary artery catheter, an LV pressure-volume loop catheter, and a Doppler coronary guide-wire. Results Myocardial hypoxia resulted in declines in mean cardiac output to 1.7±0.7 L/min, systolic blood pressure to 64±22 mmHg, and LV ejection fraction (LVEF) to 22±7%. Synchronized pulsatile flow was associated with a significant reduction in LV end-systolic volume by 6.2 mL (6.7%), an increase in LV stroke volume by 5.0 mL (17.4%), higher LVEF by 4.5% (18.8% relative), cardiac output by 0.37 L/min (17.1%), and mean arterial pressure by 3.0 mmHg (5.5%) when compared with continuous ECLS flow at all ECLS flow rates (P<0.05). At selected ECLS flow rates, pulsatile flow also reduced LV end-diastolic pressure, end-diastolic volume, and systolic pressure. ECG-synchronized pulsatile flow was also associated with significantly increased (7% to 22%) coronary flow at all ECLS flow rates. Conclusion ECG-synchronized pulsatile ECLS flow preserved LV function and coronary flow compared with standard continuous-flow ECLS in a porcine model of cardiogenic shock.
Collapse
|
6
|
Hála P, Mlček M, Ošťádal P, Janák D, Popková M, Bouček T, Lacko S, Kudlička J, Neužil P, Kittnar O. Tachycardia-Induced Cardiomyopathy As a Chronic Heart Failure Model in Swine. J Vis Exp 2018. [PMID: 29553504 DOI: 10.3791/57030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
A stable and reliable model of chronic heart failure is required for many experiments to understand hemodynamics or to test effects of new treatment methods. Here, we present such a model by tachycardia-induced cardiomyopathy, which can be produced by rapid cardiac pacing in swine. A single pacing lead is introduced transvenously into fully anaesthetized healthy swine, to the apex of the right ventricle, and fixated. Its other end is then tunneled dorsally to the paravertebral region. There, it is connected to an in-house modified heart pacemaker unit that is then implanted in a subcutaneous pocket. After 4 - 8 weeks of rapid ventricular pacing at rates of 200 - 240 beats/min, physical examination revealed signs of severe heart failure - tachypnea, spontaneous sinus tachycardia, and fatigue. Echocardiography and X-ray showed dilation of all heart chambers, effusions, and severe systolic dysfunction. These findings correspond well to decompensated dilated cardiomyopathy and are also preserved after the cessation of pacing. This model of tachycardia-induced cardiomyopathy can be used for studying the pathophysiology of progressive chronic heart failure, especially hemodynamic changes caused by new treatment modalities like mechanical circulatory supports. This methodology is easy to perform and the results are robust and reproducible.
Collapse
Affiliation(s)
- Pavel Hála
- Department of Physiology, First Faculty of Medicine, Charles University; Department of Cardiology, Na Homolce Hospital;
| | - Mikuláš Mlček
- Department of Physiology, First Faculty of Medicine, Charles University
| | - Petr Ošťádal
- Department of Physiology, First Faculty of Medicine, Charles University; Department of Cardiology, Na Homolce Hospital
| | - David Janák
- Department of Physiology, First Faculty of Medicine, Charles University; Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University
| | - Michaela Popková
- Department of Physiology, First Faculty of Medicine, Charles University
| | - Tomáš Bouček
- Department of Physiology, First Faculty of Medicine, Charles University
| | - Stanislav Lacko
- Department of Physiology, First Faculty of Medicine, Charles University
| | - Jaroslav Kudlička
- Department of Physiology, First Faculty of Medicine, Charles University
| | - Petr Neužil
- Department of Physiology, First Faculty of Medicine, Charles University; Department of Cardiology, Na Homolce Hospital
| | - Otomar Kittnar
- Department of Physiology, First Faculty of Medicine, Charles University
| |
Collapse
|
7
|
Ostadal P, Mlcek M, Kruger A, Hala P, Lacko S, Mates M, Vondrakova D, Svoboda T, Hrachovina M, Janotka M, Psotova H, Strunina S, Kittnar O, Neuzil P. Increasing venoarterial extracorporeal membrane oxygenation flow negatively affects left ventricular performance in a porcine model of cardiogenic shock. J Transl Med 2015; 13:266. [PMID: 26275717 PMCID: PMC4537539 DOI: 10.1186/s12967-015-0634-6] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 08/11/2015] [Indexed: 11/11/2022] Open
Abstract
Background The aim of this study was to assess the relationship between extracorporeal blood flow (EBF) and left ventricular (LV) performance during venoarterial extracorporeal membrane oxygenation (VA ECMO) therapy. Methods Five swine (body weight 45 kg) underwent VA ECMO implantation under general anesthesia and artificial ventilation. Subsequently, acute cardiogenic shock with signs of tissue hypoxia was induced. Hemodynamic and cardiac performance parameters were then measured at different levels of EBF (ranging from 1 to 5 L/min) using arterial and venous catheters, a pulmonary artery catheter and a pressure–volume loop catheter introduced into the left ventricle. Results Myocardial hypoxia resulted in a decline in mean (±SEM) cardiac output to 2.8 ± 0.3 L/min and systolic blood pressure (SBP) to 60 ± 7 mmHg. With an increase in EBF from 1 to 5 L/min, SBP increased to 97 ± 8 mmHg (P < 0.001); however, increasing EBF from 1 to 5 L/min significantly negatively influences several cardiac performance parameters: cardiac output decreased form 2.8 ± 0.3 L/min to 1.86 ± 0.53 L/min (P < 0.001), LV end-systolic volume increased from 64 ± 11 mL to 83 ± 14 mL (P < 0.001), LV stroke volume decreased from 48 ± 9 mL to 40 ± 8 mL (P = 0.045), LV ejection fraction decreased from 43 ± 3 % to 32 ± 3 % (P < 0.001) and stroke work increased from 2096 ± 342 mmHg mL to 3031 ± 404 mmHg mL (P < 0.001). LV end-diastolic pressure and volume were not significantly affected. Conclusions The results of the present study indicate that higher levels of VA ECMO blood flow in cardiogenic shock may negatively affect LV function. Therefore, it appears that to mitigate negative effects on LV function, optimal VA ECMO blood flow should be set as low as possible to allow adequate tissue perfusion.
Collapse
Affiliation(s)
- Petr Ostadal
- Cardiovascular Center, Na Homolce Hospital, 15030, Prague, Czech Republic.
| | - Mikulas Mlcek
- Department of Physiology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic.
| | - Andreas Kruger
- Cardiovascular Center, Na Homolce Hospital, 15030, Prague, Czech Republic.
| | - Pavel Hala
- Cardiovascular Center, Na Homolce Hospital, 15030, Prague, Czech Republic.
| | - Stanislav Lacko
- Department of Physiology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic.
| | - Martin Mates
- Cardiovascular Center, Na Homolce Hospital, 15030, Prague, Czech Republic.
| | - Dagmar Vondrakova
- Cardiovascular Center, Na Homolce Hospital, 15030, Prague, Czech Republic.
| | - Tomas Svoboda
- Department of Physiology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic.
| | - Matej Hrachovina
- Department of Physiology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic.
| | - Marek Janotka
- Cardiovascular Center, Na Homolce Hospital, 15030, Prague, Czech Republic.
| | - Hana Psotova
- Cardiovascular Center, Na Homolce Hospital, 15030, Prague, Czech Republic.
| | - Svitlana Strunina
- Faculty of Biomedical Engineering, Czech Technical University in Prague, Prague, Czech Republic.
| | - Otomar Kittnar
- Department of Physiology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic.
| | - Petr Neuzil
- Cardiovascular Center, Na Homolce Hospital, 15030, Prague, Czech Republic.
| |
Collapse
|
8
|
Venoarterielle extrakorporale Membranoxygenierung am wachen Patienten. Anaesthesist 2015; 64:385-9. [DOI: 10.1007/s00101-015-0025-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 03/15/2015] [Accepted: 03/16/2015] [Indexed: 11/28/2022]
|
9
|
Shen J, Yu W, Shi J, Chen Q, Hu Y, Zhang J, Gao T, Xi F, Gong J, He C, Li N, Li J. Effect of venovenous extracorporeal membrane oxygenation on the heart in a healthy piglet model. J Cardiothorac Surg 2013; 8:163. [PMID: 23805777 PMCID: PMC3706349 DOI: 10.1186/1749-8090-8-163] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 06/07/2013] [Indexed: 12/12/2022] Open
Abstract
Background Cardiac function is important for patients treated by venovenous extracorporeal membrane oxygenation (VV ECMO), but data about the effect of VV ECMO on the heart in nonneonates is absent. We studied the effect of VV ECMO on cardiac performance, cardiomyocyte and mitochondria in an animal model. Methods Twelve farm piglets were randomly assigned into two groups: control group and ECMO group. In the ECMO group, ECMO cannulaes were placed and ECMO was instituted. Hemodynamics was recorded at baseline, 1 hour after induction, and every 4 hours thereafter, to assess the cardiac performance. All animals were monitored for 24 hours and were euthanized and myocardium was harvested. Myocardial histology, ultrastructure of cardiomyocyte and mitochondria were observed, and activities of mitochondrial complexes I-V were measured, to assess the effect to cardiomyocyte and mitochondria. Results Hemodynamics were stable in each group of animals throughout the experiment. Interstitial edema, disorderd and dissolved of focal myofilament, morphological deformations of mitochondria were observed in the ECMO group. The activities of mitochondrial complexes were decreased in the ECMO group, and complex I and IV reached significance. Conclusions VV ECMO therapy is associated with changes of ultrastructure and function of cardiomyocyte and mitochondria, inducing myocardium injury. However, the injury was mild and had no effect on the cardiac performance for healthy piglets.
Collapse
|
10
|
Kajimoto M, O'Kelly Priddy CM, Ledee DR, Xu C, Isern N, Olson AK, Portman MA. Extracorporeal membrane oxygenation promotes long chain fatty acid oxidation in the immature swine heart in vivo. J Mol Cell Cardiol 2013; 62:144-52. [PMID: 23727393 DOI: 10.1016/j.yjmcc.2013.05.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 05/18/2013] [Accepted: 05/21/2013] [Indexed: 12/29/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) supports infants and children with severe cardiopulmonary compromise. Nutritional support for these children includes provision of medium- and long-chain fatty acids (FAs). However, ECMO induces a stress response, which could limit the capacity for FA oxidation. Metabolic impairment could induce new or exacerbate existing myocardial dysfunction. Using a clinically relevant piglet model, we tested the hypothesis that ECMO maintains the myocardial capacity for FA oxidation and preserves myocardial energy state. Provision of 13-Carbon labeled medium-chain FA (octanoate), long-chain free FAs (LCFAs), and lactate into systemic circulation showed that ECMO promoted relative increases in myocardial LCFA oxidation while inhibiting lactate oxidation. Loading of these labeled substrates at high dose into the left coronary artery demonstrated metabolic flexibility as the heart preferentially oxidized octanoate. ECMO preserved this octanoate metabolic response, but also promoted LCFA oxidation and inhibited lactate utilization. Rapid upregulation of pyruvate dehydrogenase kinase-4 (PDK4) protein appeared to participate in this metabolic shift during ECMO. ECMO also increased relative flux from lactate to alanine further supporting the role for pyruvate dehydrogenase inhibition by PDK4. High dose substrate loading during ECMO also elevated the myocardial energy state indexed by phosphocreatine to ATP ratio. ECMO promotes LCFA oxidation in immature hearts, while maintaining myocardial energy state. These data support the appropriateness of FA provision during ECMO support for the immature heart.
Collapse
Affiliation(s)
- Masaki Kajimoto
- Center for Developmental Therapeutics, Seattle Children's Research Institute, Seattle, WA, USA
| | | | | | | | | | | | | |
Collapse
|
11
|
Bauer F, Coutant V, Bernard M, Stepowski D, Tron C, Cribier A, Bessou JP, Eltchaninoff H. Patients With Severe Aortic Stenosis and Reduced Ejection Fraction: Earlier Recovery of Left Ventricular Systolic Function After Transcatheter Aortic Valve Implantation Compared With Surgical Valve Replacement. Echocardiography 2013; 30:865-70. [DOI: 10.1111/echo.12171] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
12
|
Bělohlávek J, Mlček M, Huptych M, Svoboda T, Havránek Š, Ošt'ádal P, Bouček T, Kovárník T, Mlejnský F, Mrázek V, Bělohlávek M, Aschermann M, Linhart A, Kittnar O. Coronary versus carotid blood flow and coronary perfusion pressure in a pig model of prolonged cardiac arrest treated by different modes of venoarterial ECMO and intraaortic balloon counterpulsation. Crit Care 2012; 16:R50. [PMID: 22424292 PMCID: PMC3964801 DOI: 10.1186/cc11254] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Revised: 02/24/2012] [Accepted: 03/16/2012] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) is increasingly used in cardiac arrest (CA). Adequacy of carotid and coronary blood flows (CaBF, CoBF) and coronary perfusion pressure (CoPP) in ECMO treated CA is not well established. This study compares femoro-femoral (FF) to femoro-subclavian (FS) ECMO and intraaortic balloon counterpulsation (IABP) contribution based on CaBF, CoBF, CoPP, myocardial and brain oxygenation in experimental CA managed by ECMO. METHODS In 11 female pigs (50.3 ± 3.4 kg), CA was randomly treated by FF versus FS ECMO ± IABP. Animals under general anesthesia had undergone 15 minutes of ventricular fibrillation (VF) with ECMO flow of 5 to 10 mL/kg/min simulating low-flow CA followed by continued VF with ECMO flow of 100 mL/kg/min. CaBF and CoBF were measured by a Doppler flow wire, cerebral and peripheral oxygenation by near infrared spectroscopy. CoPP, myocardial oxygen metabolism and resuscitability were determined. RESULTS CaBF reached values > 80% of baseline in all regimens. CoBF > 80% was reached only by the FF ECMO, 90.0% (66.1, 98.6). Addition of IABP to FF ECMO decreased CoBF to 60.7% (55.1, 86.2) of baseline, P = 0.004. FS ECMO produced 70.0% (49.1, 113.2) of baseline CoBF, significantly lower than FF, P = 0.039. Addition of IABP to FS did not change the CoBF; however, it provided significantly higher flow, 76.7% (71.9, 111.2) of baseline, compared to FF + IABP, P = 0.026. Both brain and peripheral regional oxygen saturations decreased after induction of CA to 23% (15.0, 32.3) and 34% (23.5, 34.0), respectively, and normalized after ECMO institution. For brain saturations, all regimens reached values exceeding 80% of baseline, none of the comparisons between respective treatment approaches differed significantly. After a decline to 15 mmHg (9.5, 20.8) during CA, CoPP gradually rose with time to 68 mmHg (43.3, 84.0), P = 0 .003, with best recovery on FF ECMO. Resuscitability of the animals was high, both 5 and 60 minutes return of spontaneous circulation occured in eight animals (73%). CONCLUSIONS In a pig model of CA, both FF and FS ECMO assure adequate brain perfusion and oxygenation. FF ECMO offers better CoBF than FS ECMO. Addition of IABP to FF ECMO worsens CoBF. FF ECMO, more than FS ECMO, increases CoPP over time.
Collapse
Affiliation(s)
- Jan Bělohlávek
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, U Nemocnice 2, Prague 2, 128 00, Czech Republic
| | - Mikuláš Mlček
- Department of Physiology, 1st Faculty of Medicine, Charles University in Prague, Albertov 5, Prague 2, 128 00, Czech Republic
| | - Michal Huptych
- BioDat Research Group, Department of Cybernetics, Faculty of Electrical Engineering, Czech Technical University in Prague, Karlovo namesti 13, Prague 2, 121 35, Czech Republic
| | - Tomáš Svoboda
- Department of Physiology, 1st Faculty of Medicine, Charles University in Prague, Albertov 5, Prague 2, 128 00, Czech Republic
| | - Štěpán Havránek
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, U Nemocnice 2, Prague 2, 128 00, Czech Republic
| | - Petr Ošt'ádal
- Department of Cardiology, Na Homolce Hospital, Roentgenova 2/37, Prague 5, 150 30, Czech Republic
| | - Tomáš Bouček
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, U Nemocnice 2, Prague 2, 128 00, Czech Republic
| | - Tomáš Kovárník
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, U Nemocnice 2, Prague 2, 128 00, Czech Republic
| | - František Mlejnský
- 2nd Department of Surgery, Cardiovascular Surgery, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, U Nemocnice 2, Prague 2, 128 00, Czech Republic
| | - Vratislav Mrázek
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, U Nemocnice 2, Prague 2, 128 00, Czech Republic
| | - Marek Bělohlávek
- Translational Ultrasound Research Laboratory, Division of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Michael Aschermann
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, U Nemocnice 2, Prague 2, 128 00, Czech Republic
| | - Aleš Linhart
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, U Nemocnice 2, Prague 2, 128 00, Czech Republic
| | - Otomar Kittnar
- Department of Physiology, 1st Faculty of Medicine, Charles University in Prague, Albertov 5, Prague 2, 128 00, Czech Republic
| |
Collapse
|
13
|
Priddy CMO, Kajimoto M, Ledee DR, Bouchard B, Isern N, Olson AK, Des Rosiers C, Portman MA. Myocardial oxidative metabolism and protein synthesis during mechanical circulatory support by extracorporeal membrane oxygenation. Am J Physiol Heart Circ Physiol 2012. [PMID: 23203964 DOI: 10.1152/ajpheart.00672.2012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) provides essential mechanical circulatory support necessary for survival in infants and children with acute cardiac decompensation. However, ECMO also causes metabolic disturbances, which contribute to total body wasting and protein loss. Cardiac stunning can also occur, which prevents ECMO weaning, and contributes to high mortality. The heart may specifically undergo metabolic impairments, which influence functional recovery. We tested the hypothesis that ECMO alters oxidative metabolism and protein synthesis. We focused on the amino acid leucine and integration with myocardial protein synthesis. We used a translational immature swine model in which we assessed in heart 1) the fractional contribution of leucine (FcLeucine) and pyruvate to mitochondrial acetyl-CoA formation by nuclear magnetic resonance and 2) global protein fractional synthesis (FSR) by gas chromatography-mass spectrometry. Immature mixed breed Yorkshire male piglets (n = 22) were divided into four groups based on loading status (8 h of normal circulation or ECMO) and intracoronary infusion [(13)C(6),(15)N]-L-leucine (3.7 mM) alone or with [2-(13)C]-pyruvate (7.4 mM). ECMO decreased pulse pressure and correspondingly lowered myocardial oxygen consumption (∼40%, n = 5), indicating decreased overall mitochondrial oxidative metabolism. However, FcLeucine was maintained and myocardial protein FSR was marginally increased. Pyruvate addition decreased tissue leucine enrichment, FcLeucine, and Fc for endogenous substrates as well as protein FSR. The heart under ECMO shows reduced oxidative metabolism of substrates, including amino acids, while maintaining 1) metabolic flexibility indicated by ability to respond to pyruvate and 2) a normal or increased capacity for global protein synthesis.
Collapse
|
14
|
|
15
|
Pyles LA, Gustafson RA, Fortney J, Einzig S. Extracorporeal membrane oxygenation induced cardiac dysfunction in newborn lambs. J Cardiovasc Transl Res 2010; 3:625-34. [PMID: 20848344 DOI: 10.1007/s12265-010-9215-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Accepted: 08/05/2010] [Indexed: 10/19/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is routinely used to support cardiopulmonary failure in infants and children. Suboptimal outcomes for primary cardiac support suggest a need for investigation of the impact of ECMO on the heart. Twenty-four newborn lambs received a brief period of ECMO support to investigate the hypothesis that ECMO produces cardiac dysfunction in newborn lamb. Dorset newborn lambs, 4-7 days of age, were exposed to ECMO for 5 min at a 100 ml/kg flow rate and quickly weaned off. Measurements included echocardiographic mean left ventricular (LV) velocity of circumferential fiber shortening corrected for heart rate (mVCFc), LV shortening fraction, and peak systolic wall stress plus hemodynamic measurement of LV maximum rate of pressure change with time (LV dp/dt max), maximum rate of pressure change divided by developed pressure (LV dp/dtP), right atrial pressure, pulmonary capillary wedge pressure, mean pulmonary artery pressure, LV peak and end-diastolic pressure, and aortic pressure. These measures were also obtained after an exposure to 5 min of ECMO and immediate disconnect for 5 min, followed by ECMO administration for 1 h again, followed by discontinuation of ECMO. LV mVCFc is decreased after exposure to 5 min of ECMO support despite a decrease in LV peak systolic wall stress that provides afterload reduction. LV mVCFc is inversely related to peak systolic wall stress at a significance level of p < 0.0001. The time period after initiation of ECMO is a significant factor in the model (p = 0.0097). Time [baseline] was different from the other time points with p = 0.0010. Average mVCFc at baseline is 1.27 ± 0.35 and decreases to 1.01 ± 0.42 after 5 min of ECMO that is then withdrawn. Peak systolic wall stress decreases from 36.0 ± 13.1 at baseline to 29.8 ± 12.1 after 5 min of ECMO. LV dp/dt max decreases from 1,769 ± 453 mmHg/s at baseline to 1,311 ± 513 mmHg/s after exposure to 5 min of ECMO (p = 0.0005). Baseline LV dp/dt max is different from each point after start of ECMO. Diastolic LVdp/dt min increased from -1,340 ± 477 mmHg/s to -908 ± 393 mmHg/s at 5 min. Echocardiographic mVCFc, when considered in isolation or as a function of LV peak systolic wall stress, shows diminished LV function after ECMO. Hemodynamic measurement of LV dp/dt max and LV dp/dt min confirms the observation. Separation of the humoral from mechanical effect of ECMO with the short exposure to the extracorporeal circuit shows that an immediate decrement of LV function occurs at initiation of ECMO, a finding that has not been stressed with previous studies of extracorporeal support. This implies a potentially outcome-limiting deleterious effect for the patient who requires ECMO support for the heart rather than the lungs. We should continue to strive to understand and ameliorate this deleterious effect of the extracorporeal circulation circuit.
Collapse
Affiliation(s)
- Lee A Pyles
- Department of Pediatrics, University of Minnesota Amplatz Children's Hospital, 420 Delaware St., Minneapolis, MN 55455, USA.
| | | | | | | |
Collapse
|
16
|
Duncan BW. Mechanical cardiac support in the young. Short-term support: ECMO. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2006:75-82. [PMID: 16638551 DOI: 10.1053/j.pcsu.2006.02.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Although based on technology developed several decades ago, extracorporeal membrane oxygenation (ECMO) retains great clinical relevance in the management of advanced pediatric cardiorespiratory disease. Largely because of its widespread use in pediatric patients with respiratory failure, familiarity with this technology has established ECMO as the most commonly used form of mechanical circulatory support in children. Clinical applications and technical aspects of ECMO support continue to evolve, ensuring the ongoing importance of this modality for pediatric circulatory support.
Collapse
Affiliation(s)
- Brian W Duncan
- Pediatric and Congenital Heart Surgery, Children's Hospital, The Cleveland Clinic, Cleveland, OH 44195, USA.
| |
Collapse
|
17
|
|
18
|
Cohen G, Permut L. Decision making for mechanical cardiac assist in pediatric cardiac surgery. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2005:41-50. [PMID: 15818357 DOI: 10.1053/j.pcsu.2005.02.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The practice of pediatric cardiac surgery has evolved to the point where the majority of patients operated on represent the most complex end of the spectrum of congenital heart disease. Given this, the potential role for mechanical cardiac assist will continue to expand. Although extracorporeal membrane oxygenation remains the mainstay of mechanical circulatory assist, the increased use of centrifugal ventricular assist devices is changing the approach to the treatment of acute cardiac failure. A range of newly developed implantable and paracorporeal devices is beginning to make its way into the clinical practice of pediatric cardiac surgery. This article addresses the different types of support available for mechanical cardiac assist and the clinical considerations in selecting the appropriate device.
Collapse
Affiliation(s)
- Gordon Cohen
- Department of Pediatric Cardiothoracic Surgery, Children's Heart Center, Children's Hospital & Regional Medical Center, Seattle, Washington 98105, USA
| | | |
Collapse
|
19
|
Chang AC, McKenzie ED. Mechanical cardiopulmonary support in children and young adults: extracorporeal membrane oxygenation, ventricular assist devices, and long-term support devices. Pediatr Cardiol 2005; 26:2-28. [PMID: 15156301 DOI: 10.1007/s00246-004-0715-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- A C Chang
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin, MC 19345-C, Houston, TX 77030, USA.
| | | |
Collapse
|
20
|
Abstract
Mechanical circulatory support is assuming an expanding role in the practice of congenital cardiac surgery. Extracorporeal membrane oxygenation and centrifugal ventricular assist devices are still the mainstay of mechanical circulatory support for children; however, newly developed pulsatile, paracorporeal ventricular assist devices designed for pediatric applications are achieving increased utilization. In addition, several new, continuous flow devices that are under development as fully implantable systems for adults, ultimately may be useful for pediatric patients.
Collapse
Affiliation(s)
- Brian W Duncan
- Pediatric and Congenital Heart Surgery, Cleveland Clinic Children's Hospital, Ohio 44195, USA.
| |
Collapse
|