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Fresiello L, Hermens JAJ, Pladet L, Meuwese CL, Donker DW. The physiology of venoarterial extracorporeal membrane oxygenation - A comprehensive clinical perspective. Perfusion 2024; 39:5S-12S. [PMID: 38651580 DOI: 10.1177/02676591241237639] [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: 04/25/2024]
Abstract
Venoarterial extracorporeal membrane oxygenation (VA ECMO) has become a standard of care for severe cardiogenic shock, refractory cardiac arrest and related impending multiorgan failure. The widespread clinical use of this complex temporary circulatory support modality is still contrasted by a lack of formal scientific evidence in the current literature. This might at least in part be attributable to VA ECMO related complications, which may significantly impact on clinical outcome. In order to limit adverse effects of VA ECMO as much as possible an indepth understanding of the complex physiology during extracorporeally supported cardiogenic shock states is critically important. This review covers all relevant physiological aspects of VA ECMO interacting with the human body in detail. This, to provide a solid basis for health care professionals involved in the daily management of patients supported with VA ECMO and suffering from cardiogenic shock or cardiac arrest and impending multiorgan failure for the best possible care.
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Affiliation(s)
- Libera Fresiello
- Cardiovascular and Respiratory Physiology, TechMed Center, University of Twente, Enschede, The Netherlands
| | - Jeannine A J Hermens
- Intensive Care Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lara Pladet
- Intensive Care Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christiaan L Meuwese
- Department of Cardiology, Thorax Center, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Intensive Care Adults, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Dirk W Donker
- Cardiovascular and Respiratory Physiology, TechMed Center, University of Twente, Enschede, The Netherlands
- Intensive Care Center, University Medical Center Utrecht, Utrecht, The Netherlands
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Beurton A, Michot M, Hérion FX, Rienzo M, Oddos C, Couffinhal T, Imbault J, Ouattara A. Systemic Hemodynamics, Cardiac Mechanics, and Signaling Pathways Induced by Extracorporeal Membrane Oxygenation in a Cardiogenic Shock Model. ASAIO J 2024; 70:177-184. [PMID: 38261663 DOI: 10.1097/mat.0000000000002139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024] Open
Abstract
Peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used in patients suffering from refractory cardiogenic shock (CS). Although considered life-saving, peripheral VA-ECMO may also be responsible for intracardiac hemodynamic changes, including left ventricular overload and dysfunction. Venoarterial extracorporeal membrane oxygenation may also increase myocardial wall stress and stroke work, possibly affecting the cellular cardioprotective and apoptosis signaling pathways, and thus the infarct size. To test this hypothesis, we investigated the effects of increasing the peripheral VA-ECMO blood flow (25-100% of the baseline cardiac output) on systemic and cardiac hemodynamics in a closed-chest CS model. Upon completion of the experiment, the hearts were removed for assessment of infarct size, histology, apoptosis measurements, and phosphorylation statuses of p38 and protein Kinase B (Akt), and extracellular signal-regulated kinase mitogen-activated protein kinases (ERK-MAPK). Peripheral VA-ECMO restored systemic perfusion but induced a significant and blood flow-dependent increase in left ventricular preload and afterload. Venoarterial extracorporeal membrane oxygenation did not affect infarct size but significantly decreased p38-MAPK phosphorylation and cardiac myocyte apoptosis in the border zone.
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Affiliation(s)
- Antoine Beurton
- From the CHU Bordeaux, Department of Cardiovascular Anesthesia and Critical Care, F-33000 Bordeaux, France
- Univ. Bordeaux, INSERM, Biology of cardiovascular diseases, U1034, F-33600 Pessac, France
| | - Maxime Michot
- Univ. Bordeaux, INSERM, Biology of cardiovascular diseases, U1034, F-33600 Pessac, France
| | - François-Xavier Hérion
- From the CHU Bordeaux, Department of Cardiovascular Anesthesia and Critical Care, F-33000 Bordeaux, France
- Univ. Bordeaux, INSERM, Biology of cardiovascular diseases, U1034, F-33600 Pessac, France
| | - Mario Rienzo
- Department of Anesthesia and Intensive Care, Private Hospital of Parly 2, Le Chesnay, France
| | - Claire Oddos
- From the CHU Bordeaux, Department of Cardiovascular Anesthesia and Critical Care, F-33000 Bordeaux, France
| | - Thierry Couffinhal
- Univ. Bordeaux, INSERM, Biology of cardiovascular diseases, U1034, F-33600 Pessac, France
| | - Julien Imbault
- From the CHU Bordeaux, Department of Cardiovascular Anesthesia and Critical Care, F-33000 Bordeaux, France
- Univ. Bordeaux, INSERM, Biology of cardiovascular diseases, U1034, F-33600 Pessac, France
| | - Alexandre Ouattara
- From the CHU Bordeaux, Department of Cardiovascular Anesthesia and Critical Care, F-33000 Bordeaux, France
- Univ. Bordeaux, INSERM, Biology of cardiovascular diseases, U1034, F-33600 Pessac, France
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3
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Myneni M, Cheema FH, Rajagopal K. Alterations in Coronary Blood Flow and the Risk of Left Ventricular Distension in Venoarterial Extracorporeal Membrane Oxygenation. ASAIO J 2023; 69:552-560. [PMID: 36867847 DOI: 10.1097/mat.0000000000001905] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
Abstract
Previous theoretical studies have suggested that veno-arterial extracorporeal membrane oxygenation (VA-ECMO) ought to consistently result in markedly increased left ventricular (LV) intracavitary pressures and volumes because of increased LV afterload. However, this phenomenon of LV distension does not universally occur and occurs only in a minority of cases. We sought to explain this discrepancy by considering the potential implications of VA-ECMO support on coronary blood flow and consequently improved LV contractility (the "Gregg" effect), in addition to the effects of VA-ECMO support upon LV loading conditions, in a lumped parameter-based theoretical circulatory model. We found that LV systolic dysfunction resulted in reduced coronary blood flow; VA-ECMO support augmented coronary blood flow proportionally to the circuit flow rate. On VA-ECMO support, a weak or absent Gregg effect resulted in increased LV end-diastolic pressures and volumes and increased end-systolic volume with decreased LV ejection fraction (LVEF), consistent with LV distension. In contrast, a more robust Gregg effect resulted in unaffected and/or even reduced LV end-diastolic pressure and volume, end-systolic volume, and unaffected or even increased LVEF. Left ventricular contractility augmentation proportional to coronary blood flow increased by VA-ECMO support may be an important contributory mechanism underlying why LV distension is observed only in a minority of cases.
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Affiliation(s)
- Manoj Myneni
- From the Department of Clinical Sciences, College of Medicine, University of Houston, Houston, Texas
| | - Faisal H Cheema
- From the Department of Clinical Sciences, College of Medicine, University of Houston, Houston, Texas
| | - Keshava Rajagopal
- Division of Cardiac Surgery, Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University
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Improving Survival in Cardiogenic Shock-A Propensity Score-Matched Analysis of the Impact of an Institutional Allocation Protocol to Short-Term Mechanical Circulatory Support. LIFE (BASEL, SWITZERLAND) 2022; 12:life12111931. [PMID: 36431066 PMCID: PMC9692664 DOI: 10.3390/life12111931] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/08/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022]
Abstract
Temporary mechanical circulatory support (tMCS) is a life-saving treatment option for patients in cardiogenic shock (CS), but many aspects such as patient selection, initiation threshold and optimal modality selection remain unclear. This study describes a standard operating procedure (SOP) for tMCS allocation for CS patients and presents outcome data before and after implementation. Data from 421 patients treated for CS with tMCS between 2018 and 2021 were analyzed. In 2019, we implemented a new SOP for allocating CS patients to tMCS modalities. The association between the time of SOP implementation and the 30-day and 1-year survival as well as hospital discharge was evaluated. Of the 421 patients included, 189 were treated before (pre-SOP group) and 232 after implementation of the new SOP (SOP group). Causes of CS included acute myocardial infarction (n = 80, 19.0%), acute-on-chronic heart failure in patients with dilated or chronic ischemic heart failure (n = 139, 33.0%), valvular cardiomyopathy (n = 14, 3.3%) and myocarditis (n = 5, 1.2%); 102 patients suffered from postcardiotomy CS (24.2%). The SOP group was further divided into an SOP-adherent (SOP-A) and a non-SOP-adherent group (SOP-NA). The hospital discharge rate was higher in the SOP group (41.7% vs. 29.7%), and treating patients according to the SOP was associated with an improved 30-day survival (56.9% vs. 38.9%, OR 2.21, 95% CI 1.01-4.80, p = 0.044). Patient allocation according to the presented SOP significantly improved 30-day survival.
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Kim SH, Baumann S, Behnes M, Borggrefe M, Akin I. Patient Selection for Protected Percutaneous Coronary Intervention: Who Benefits the Most? Interv Cardiol Clin 2022; 11:455-464. [PMID: 36243490 DOI: 10.1016/j.iccl.2022.07.001] [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: 06/16/2023]
Abstract
The evolution of percutaneous coronary intervention (PCI) enables a complete revascularization of complex coronary lesions. However, simultaneously, patients are presenting nowadays with higher rates of comorbidities, which may lead to a lower physiologic tolerance for complex PCI. To avoid hemodynamic instability during PCI and achieve safe complete revascularization, protected PCI using mechanical circulatory support devices has been developed. However, which patients would benefit from the protected PCI is still in debate. Hence, this review provides practical approaches for the selection of patients by outlining current clinical data assessing utility of protected PCI in high-risk patients.
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Affiliation(s)
- Seung-Hyun Kim
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany.
| | - Stefan Baumann
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany
| | - Michael Behnes
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany
| | - Martin Borggrefe
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany
| | - Ibrahim Akin
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany
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Meani P, Kowalewski M, Raffa GM, Lorusso R. Unloading the left ventricle in venoarterial extracorporeal life support: The urgent need of speaking the same language! JTCVS OPEN 2022; 11:146-148. [PMID: 36172414 PMCID: PMC9510829 DOI: 10.1016/j.xjon.2022.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Paolo Meani
- Cardio-Thoracic Surgery Department, ECLS Centrum, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Mariusz Kowalewski
- Cardio-Thoracic Surgery Department, ECLS Centrum, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
- Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior in Warsaw, Warsaw, Poland
| | - Giuseppe Maria Raffa
- Cardio-Thoracic Surgery Department, ECLS Centrum, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, ISMETT-IRCCS, Palermo, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, ECLS Centrum, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
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Ott S, Leser L, Lanmüller P, Just IA, Leistner DM, Potapov E, O’Brien B, Klages J. Cardiogenic Shock Management and Research: Past, Present, and Future Outlook. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2021.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Although great strides have been made in the pathophysiological understanding, diagnosis and management of cardiogenic shock (CS), morbidity and mortality in patients presenting with the condition remain high. Acute MI is the commonest cause of CS; consequently, most existing literature concerns MI-associated CS. However, there are many more phenotypes of patients with acute heart failure. Medical treatment and mechanical circulatory support are well-established therapeutic options, but evidence for many current treatment regimens is limited. The issue is further complicated by the fact that implementing adequately powered, randomized controlled trials are challenging for many reasons. In this review, the authors discuss the history, landmark trials, current topics of medical therapy and mechanical circulatory support regimens, and future perspectives of CS management.
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Affiliation(s)
- Sascha Ott
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany; Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Laura Leser
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany
| | - Pia Lanmüller
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany; Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Isabell A Just
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany; Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - David Manuel Leistner
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany; Department of Cardiology, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany; Berlin Institute of Health, Berlin, Germany
| | - Evgenij Potapov
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany; Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Benjamin O’Brien
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany; Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany; William Harvey Research Institute, London, UK
| | - Jan Klages
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany
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Ricarte Bratti JP, Cavayas YA, Noly PE, Serri K, Lamarche Y. Modalities of Left Ventricle Decompression during VA-ECMO Therapy. MEMBRANES 2021; 11:membranes11030209. [PMID: 33809568 PMCID: PMC8002319 DOI: 10.3390/membranes11030209] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/04/2021] [Accepted: 03/12/2021] [Indexed: 12/22/2022]
Abstract
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used to sustain circulatory and respiratory support in patients with severe cardiogenic shock or refractory cardiac arrest. Although VA-ECMO allows adequate perfusion of end-organs, it may have detrimental effects on myocardial recovery. Hemodynamic consequences on the left ventricle, such as the increase of afterload, end-diastolic pressure and volume, can lead to left ventricular (LV) distention, increase of myocardial oxygen consumption and delayed LV function recovery. LV distention occurs in almost 50% of patients supported with VA-ECMO and is associated with an increase in morbidity and mortality. Thus, recognizing, preventing and treating LV distention is key in the management of these patients. In this review, we aim to discuss the pathophysiology of LV distention and to describe the strategies to unload the LV in patients supported with VA-ECMO.
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Affiliation(s)
- Juan Pablo Ricarte Bratti
- Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC H1T 1C8, Canada; (J.P.R.B.); (Y.A.C.); (P.E.N.); (K.S.)
| | - Yiorgos Alexandros Cavayas
- Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC H1T 1C8, Canada; (J.P.R.B.); (Y.A.C.); (P.E.N.); (K.S.)
- Hôpital Sacré-Coeur de Montréal, 5400. Gouin Blvd. West, Montreal, QC H4J 1C5, Canada
| | - Pierre Emmanuel Noly
- Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC H1T 1C8, Canada; (J.P.R.B.); (Y.A.C.); (P.E.N.); (K.S.)
| | - Karim Serri
- Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC H1T 1C8, Canada; (J.P.R.B.); (Y.A.C.); (P.E.N.); (K.S.)
- Hôpital Sacré-Coeur de Montréal, 5400. Gouin Blvd. West, Montreal, QC H4J 1C5, Canada
| | - Yoan Lamarche
- Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC H1T 1C8, Canada; (J.P.R.B.); (Y.A.C.); (P.E.N.); (K.S.)
- Hôpital Sacré-Coeur de Montréal, 5400. Gouin Blvd. West, Montreal, QC H4J 1C5, Canada
- Correspondence: ; Tel.: +1-514-376-3330
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Lui C, Fraser CD, Suarez-Pierre A, Zhou X, Higgins RSD, Zehr KJ, Choi CW, Kilic A. Evaluation of Extracorporeal Membrane Oxygenation Therapy as a Bridging Method. Ann Thorac Surg 2020; 112:68-74. [PMID: 33098881 DOI: 10.1016/j.athoracsur.2020.08.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 08/21/2020] [Accepted: 08/31/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND With the implementation of the new heart allocation system, heart transplantation teams are prompted to reevaluate management of patients requiring mechanical circulatory support. The purpose of our study is to compare the outcomes of patients supported with extracorporeal membrane oxygenation (ECMO) before transplantation. METHODS The United Network for Organ Sharing database was queried for all adult patients (aged 18 years or more) who required support with ECMO before heart transplantation from 2001 to 2018. Patients were stratified into patients who did not require ECMO before transplantation, who were weaned off ECMO before transplantation, who were bridged immediately to transplantation from ECMO, and who were bridged to a left ventricular assist device (LVAD) before transplantation. Demographics and outcomes including 1-year survival, postoperative stroke, postoperative renal failure requiring dialysis, episodes of rejection, and graft failure were compared. RESULTS Overall, 29,370 patients did not require ECMO before transplantation, 101 patients were weaned off ECMO before transplantation, 118 were bridged from ECMO directly to transplantation, and 55 patients were successfully bridged from ECMO to LVAD before transplantation. Kaplan-Meier survival estimates found a statistically significant decrease in 1-year survival for patients who were bridged from ECMO to transplantation compared with patients who were bridged to LVAD before subsequent transplantation (P < .001). CONCLUSIONS Our study suggests bridging ECMO patients to an LVAD before transplantation will result in improved 1-year survival compared with patients bridged to immediate transplantation. With the new heart allocation system, continued evaluation of outcomes is required to inform management strategies.
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Affiliation(s)
- Cecillia Lui
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Charles D Fraser
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alejandro Suarez-Pierre
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Xun Zhou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robert S D Higgins
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kenton J Zehr
- Heart and Vascular Institute, Detroit Medical Center, Detroit, Michigan
| | - Chun W Choi
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Kim SH, Baumann S, Behnes M, Borggrefe M, Akin I. Patient Selection for Protected Percutaneous Coronary Intervention: Who Benefits the Most? Cardiol Clin 2020; 38:507-516. [PMID: 33036713 DOI: 10.1016/j.ccl.2020.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The evolution of percutaneous coronary intervention (PCI) enables a complete revascularization of complex coronary lesions. However, simultaneously, patients are presenting nowadays with higher rates of comorbidities, which may lead to a lower physiologic tolerance for complex PCI. To avoid hemodynamic instability during PCI and achieve safe complete revascularization, protected PCI using mechanical circulatory support devices has been developed. However, which patients would benefit from the protected PCI is still in debate. Hence, this review provides practical approaches for the selection of patients by outlining current clinical data assessing utility of protected PCI in high-risk patients.
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Affiliation(s)
- Seung-Hyun Kim
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany.
| | - Stefan Baumann
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany
| | - Michael Behnes
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany
| | - Martin Borggrefe
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany
| | - Ibrahim Akin
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany
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Piechura LM, Coppolino A, Mody GN, Rinewalt DE, Keshk M, Ogawa M, Seethala R, Bohula EA, Morrow DA, Singh SK, Mallidi HR, Keller SP. Left ventricle unloading strategies in ECMO: A single-center experience. J Card Surg 2020; 35:1514-1524. [PMID: 32485030 PMCID: PMC7357854 DOI: 10.1111/jocs.14644] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) is a life-saving technology capable of restoring perfusion but is not without significant complications that limit its realizable therapeutic benefit. ECMO-induced hemodynamics increase cardiac afterload risking left ventricular distention and impaired cardiac recovery. To mitigate potentially harmful effects, multiple strategies to unload the left ventricle (LV) are used in clinical practice but data supporting the optimal approach is presently lacking. MATERIALS & METHODS We reviewed outcomes of our ECMO population from September 2015 through January 2019 to determine if our LV unloading strategies were associated with patient outcomes. We compared reactive (Group 1, n = 30) versus immediate (Group 2, n = 33) LV unloading and then compared patients unloaded with an Impella CP (n = 19) versus an intra-aortic balloon pump (IABP, n = 16), analyzing survival and ECMO-related complications. RESULTS Survival was similar between Groups 1 and 2 (33 vs 42%, P = .426) with Group 2 experiencing more clinically-significant hemorrhage (40 vs. 67%, P = .034). Survival and ECMO-related complications were similar between patients unloaded with an Impella versus an IABP. However, the Impella group exhibited a higher rate of survival (37%) than predicted by their median SAVE score (18%). DISCUSSION Based on this analysis, reactive unloading appears to be a viable strategy while venting with the Impella CP provides better than anticipated survival. Our findings correlate with recent large cohort studies and motivate further work to design clinical guidelines and future trial design.
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Affiliation(s)
- Laura M. Piechura
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Antonio Coppolino
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Gita N. Mody
- Division of Cardiothoracic Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Dan E. Rinewalt
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Mohammed Keshk
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Mitsugu Ogawa
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Raghu Seethala
- Department of Emergency Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Erin A. Bohula
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - David A. Morrow
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | | | - Hari R. Mallidi
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Steven P. Keller
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA
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Rajagopal K, Keller SP, Akkanti B, Bime C, Loyalka P, Cheema FH, Zwischenberger JB, El Banayosy A, Pappalardo F, Slaughter MS, Slepian MJ. Advanced Pulmonary and Cardiac Support of COVID-19 Patients: Emerging Recommendations From ASAIO-A "Living Working Document". ASAIO J 2020; 66:588-598. [PMID: 32358232 PMCID: PMC7217129 DOI: 10.1097/mat.0000000000001180] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The severe acute respiratory syndrome (SARS)-CoV-2 is an emerging viral pathogen responsible for the global coronavirus disease 2019 (COVID)-19 pandemic resulting in significant human morbidity and mortality. Based on preliminary clinical reports, hypoxic respiratory failure complicated by acute respiratory distress syndrome is the leading cause of death. Further, septic shock, late-onset cardiac dysfunction, and multiorgan system failure are also described as contributors to overall mortality. Although extracorporeal membrane oxygenation and other modalities of mechanical cardiopulmonary support are increasingly being utilized in the treatment of respiratory and circulatory failure refractory to conventional management, their role and efficacy as support modalities in the present pandemic are unclear. We review the rapidly changing epidemiology, pathophysiology, emerging therapy, and clinical outcomes of COVID-19; and based on these data and previous experience with artificial cardiopulmonary support strategies, particularly in the setting of infectious diseases, provide consensus recommendations from ASAIO. Of note, this is a "living document," which will be updated periodically, as additional information and understanding emerges.
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Affiliation(s)
- Keshava Rajagopal
- From the Departments of Clinical and Biomedical Sciences, University of Houston College of Medicine, Houston, TX
- Houston Heart, HCA Houston Healthcare, Houston, TX
| | - Steven P. Keller
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Bindu Akkanti
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, McGovern Medical School, University of Texas-Houston, Houston, TX
| | - Christian Bime
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Arizona College of Medicine - Tucson and Banner Health, Tucson, AZ
| | | | - Faisal H. Cheema
- From the Departments of Clinical and Biomedical Sciences, University of Houston College of Medicine, Houston, TX
- Houston Heart, HCA Houston Healthcare, Houston, TX
- HCA Research Institute, Nashville, TN
| | - Joseph B. Zwischenberger
- Department of Surgery, University of Kentucky College of Medicine and Medical Center, Lexington, KY
| | - Aly El Banayosy
- Nazih Zuhdi Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK
| | | | - Mark S. Slaughter
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine and Jewish Hospital, Louisville, KY
| | - Marvin J. Slepian
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine and Jewish Hospital, Louisville, KY
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13
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Rajagopal K, Keller SP, Akkanti B, Bime C, Loyalka P, Cheema FH, Zwischenberger JB, El-Banayosy A, Pappalardo F, Slaughter MS, Slepian MJ. Advanced Pulmonary and Cardiac Support of COVID-19 Patients: Emerging Recommendations From ASAIO -a Living Working Document. Circ Heart Fail 2020; 13:e007175. [PMID: 32357074 PMCID: PMC7304497 DOI: 10.1161/circheartfailure.120.007175] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The severe acute respiratory syndrome-CoV-2 is an emerging viral pathogen responsible for the global coronavirus disease 2019 pandemic resulting in significant human morbidity and mortality. Based on preliminary clinical reports, hypoxic respiratory failure complicated by acute respiratory distress syndrome is the leading cause of death. Further, septic shock, late-onset cardiac dysfunction, and multiorgan system failure are also described as contributors to overall mortality. Although extracorporeal membrane oxygenation and other modalities of mechanical cardiopulmonary support are increasingly being utilized in the treatment of respiratory and circulatory failure refractory to conventional management, their role and efficacy as support modalities in the present pandemic are unclear. We review the rapidly changing epidemiology, pathophysiology, emerging therapy, and clinical outcomes of coronavirus disease 2019; and based on these data and previous experience with artificial cardiopulmonary support strategies, particularly in the setting of infectious diseases, provide consensus recommendations from American Society for Artificial Internal Organs. Of note, this is a living document, which will be updated periodically, as additional information and understanding emerges.
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Affiliation(s)
- Keshava Rajagopal
- University of Houston College of Medicine, Houston, TX
- Houston Heart, HCA Houston Healthcare, Houston, TX
| | - Steven P. Keller
- Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Bindu Akkanti
- University of Texas-Houston & Memorial Hermann-Texas Medical Center, Houston, TX
| | - Christian Bime
- University of Arizona College of Medicine and Banner Health, Tucson, AZ
| | | | - Faisal H. Cheema
- University of Houston College of Medicine, Houston, TX
- Houston Heart, HCA Houston Healthcare, Houston, TX
- HCA Research Institute, Nashville, TN
| | | | | | | | - Mark S. Slaughter
- University of Louisville School of Medicine and Jewish Hospital, Louisville, KY
| | - Marvin J. Slepian
- University of Arizona College of Medicine and Banner Health, Tucson, AZ
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14
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Guimaraes L, Del Val D, Bergeron S, O'Connor K, Bernier M, Rodés-Cabau J. Interatrial Shunting for Treating Acute and Chronic Left Heart Failure. Eur Cardiol 2020; 15:e18. [PMID: 32419849 PMCID: PMC7215499 DOI: 10.15420/ecr.2019.04] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 08/09/2019] [Indexed: 12/19/2022] Open
Abstract
The creation of an interatrial shunt has emerged as a new therapy to decompress the left atrium in patients with acute and chronic left heart failure (HF). Current data support the safety of this therapy, and promising preliminary efficacy results have been reported in patients who are refractory to optimal medical/device therapy. This article aims to provide an updated overview and clinical perspective on interatrial shunting for treating different HF conditions, and highlights the potential challenges and future directions of this therapy.
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Affiliation(s)
- Leonardo Guimaraes
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University Quebec City, Quebec, Canada
| | - David Del Val
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University Quebec City, Quebec, Canada
| | - Sebastien Bergeron
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University Quebec City, Quebec, Canada
| | - Kim O'Connor
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University Quebec City, Quebec, Canada
| | - Mathieu Bernier
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University Quebec City, Quebec, Canada
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15
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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.
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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
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16
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Simultaneous Venoarterial Extracorporeal Membrane Oxygenation and Percutaneous Left Ventricular Decompression Therapy with Impella Is Associated with Improved Outcomes in Refractory Cardiogenic Shock. ASAIO J 2020; 65:21-28. [PMID: 29489461 DOI: 10.1097/mat.0000000000000767] [Citation(s) in RCA: 156] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been used for refractory cardiogenic shock; however, it is associated with increased left ventricular afterload. Outcomes associated with the combination of a percutaneous left ventricular assist device (Impella) and VA-ECMO remains largely unknown. We retrospectively reviewed patients treated for refractory cardiogenic shock with VA-ECMO (2014-2016). The primary outcome was all-cause mortality within 30 days of VA-ECMO implantation. Secondary outcomes included duration of support, stroke, major bleeding, hemolysis, inotropic score, and cardiac recovery. Outcomes were compared between the VA-ECMO cohort and VA-ECMO + Impella (ECPELLA cohort). Sixty-six patients were identified: 36 VA-ECMO and 30 ECPELLA. Fifty-eight percent of VA-ECMO patients (n = 21) had surgical venting, as compared to 100% of the ECPELLA cohort (n = 30) which had Impella (±surgical vent). Both cohorts demonstrated relatively similar baseline characteristics except for higher incidence of ST-elevation myocardial infarction (STEMI) and percutaneous coronary intervention (PCI) in the ECPELLA cohort. Thirty-day all-cause mortality was significantly lower in the ECPELLA cohort (57% vs. 78%; hazard ratio [HR] 0.51 [0.28-0.94], log rank p = 0.02), and this difference remained intact after correcting for STEMI and PCI. No difference between secondary outcomes was observed, except for the inotrope score which was greater in VA-ECMO group by day 2 (11 vs. 0; p = 0.001). In the largest US-based retrospective study, the addition of Impella to VA-ECMO for patients with refractory cardiogenic shock was associated with lower all-cause 30 day mortality, lower inotrope use, and comparable safety profiles as compared with VA-ECMO alone.
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17
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Quessard A, Cadier G, Imbault J, Rey J, Pernot M, Ouattara A. Assistance ventriculaire gauche par Impella® : indications, gestion et complications. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2019-0093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
L’assistance monoventriculaire Impella® est une assistance microaxiale non pulsatile dépourvue de fonction d’oxygénation et/ou de décarboxylation. Sur le principe de la vis sans fin d’Archimède, elle aspire le sang dans le ventricule gauche pour le réinjecter dans la racine de l’aorte en regard des ostia coronaires. Selon le modèle utilisé, le débit d’assistance antérograde ainsi généré varie de 2,5 à 5 l/min. De par son mode de fonctionnement, l’assistance Impella® permet une décharge ventriculaire efficace. Ses indications sont l’angioplastie coronaire à haut risque et le choc cardiogénique réfractaire aux agents cardiovasoactifs. Chez le patient assisté par une extracorporeal life support (ECLS), la pompe Impella® permet de limiter le risque de surcharge ventriculaire. Chez le patient exclusivement assisté par Impella® soit d’emblée ou après une association avec l’ECLS, la voie d’abord axillaire permet sa réhabilitation active y compris la déambulation et l’activité physique. Elle se révèle alors une mise à l’épreuve cliniquement pertinente du ventricule droit en vue d’une assistance de longue durée de type left ventricular assist device.
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18
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Guerrero-Miranda CY, Hall SA. Cardiac catheterization and percutaneous intervention procedures on extracorporeal membrane oxygenation support. Ann Cardiothorac Surg 2019; 8:123-128. [PMID: 30854321 DOI: 10.21037/acs.2018.11.08] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is used to support critically ill patients when conventional therapies have failed. ECMO has been available for four decades and has gained use as a rescue therapy in severe refractory hypoxic disorders and in patients with refractory cardiogenic shock (RCS). Over recent years, several percutaneous cardiac interventions and implant devices have been developed that are now used frequently in conjunction with ECMO in order to maintain organ perfusion. Here, we review the literature on VA-ECMO cannulation location, the use of VA-ECMO in interventions (e.g., coronary interventions and structural heart interventions) and percutaneous cardiac device implantation in VA-ECMO recipients with RCS.
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Affiliation(s)
- Cesar Y Guerrero-Miranda
- Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, TX, USA.,Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX, USA.,Department of Internal Medicine, Texas A & M University Health Science Center, Dallas, TX, USA
| | - Shelley A Hall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, TX, USA.,Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX, USA.,Department of Internal Medicine, Texas A & M University Health Science Center, Dallas, TX, USA
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19
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Left Ventricular Distension in Veno-arterial Extracorporeal Membrane Oxygenation: From Mechanics to Therapies. ASAIO J 2019; 65:1-10. [DOI: 10.1097/mat.0000000000000789] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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20
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21
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First successful experience of ECPR to heart transplant at a tertiary care institute. Indian J Thorac Cardiovasc Surg 2018. [DOI: 10.1007/s12055-017-0563-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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22
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Ouattara A, Rémy A, Quessard A. ExtraCorporeal Life support for refractory cardiogenic shock: "An efficient system support of peripheral organs more than real ventricular assist device…". Anaesth Crit Care Pain Med 2018; 37:195-196. [PMID: 29578079 DOI: 10.1016/j.accpm.2018.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Alexandre Ouattara
- Université Bordeaux, Inserm, UMR 1034, biology of cardiovascular diseases, 33600 Pessac, France; CHU Bordeaux, department of anaesthesia and critical care, Magellan Medico-Surgical Centre, 33000 Bordeaux, France.
| | - Alain Rémy
- CHU Bordeaux, department of anaesthesia and critical care, Magellan Medico-Surgical Centre, 33000 Bordeaux, France
| | - Astrid Quessard
- CHU Bordeaux, department of anaesthesia and critical care, Magellan Medico-Surgical Centre, 33000 Bordeaux, France
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23
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Borowski A, Korb H. Experience with Uni- (LVAD) and Biventricular (ECMO) Circulatory Support in Postcardiotomy Pediatric Patients. Int J Artif Organs 2018. [DOI: 10.1177/039139889702001208] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In six pediatric patients with postoperative low-output-syndrome (LOS), uni-(LVAD) and biventricular (ECMO) assist systems with Biomedicus centrifugal pump were used. ECMO was applied in 5 children aged between 3 days and 16 years, one infant with an age of 16 months was implanted with LVAD. One patient from the ECMO-group and the patient with LVAD-support survived. Analysis of vital organ functions during ECMO and LVAD support are presented and characteristics of both support systems for use in pediatric patients with postcardiotomy LOS based on worldwide experience discussed. In conclusion, both, uni- (LVAD) and biventricular circulatory support (ECMO) using Biomedicus centrifugal pump can be safely applied for management of postcardiotomy LOS even in neonates, however, ECMO support in comparison to LVAD is a more aggressive approach associated with a higher complication rate.
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Affiliation(s)
- A. Borowski
- Clinic of Heart Surgery, University of Cologne - Germany
| | - H. Korb
- Clinic of Heart Surgery, University of Cologne - Germany
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24
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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.
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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
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25
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Prasad A, Ghodsizad A, Brehm C, Kozak M, Körner M, El Banayosy A, Singbartl K. Refractory Pulmonary Edema and Upper Body Hypoxemia During Veno-Arterial Extracorporeal Membrane Oxygenation-A Case for Atrial Septostomy. Artif Organs 2018; 42:664-669. [PMID: 29344963 DOI: 10.1111/aor.13082] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 10/09/2017] [Accepted: 10/24/2017] [Indexed: 11/29/2022]
Abstract
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides mechanical circulatory support for patients with advanced cardiogenic shock, facilitating myocardial recovery and limiting multi-organ failure. In patients with severely limited left ventricular ejection, peripheral VA-ECMO can further increase left ventricular and left atrial pressures (LAP). Failure to decompress the left heart under these circumstances can result in pulmonary edema and upper body hypoxemia, that is, myocardial and cerebral ischemia. Atrial septostomy can decrease LAP in these situations. However, the effects of atrial septostomy on upper body oxygenation remain unknown. After IRB approval, we identified 9 out of 242 adult VA-ECMO patients between January 2011 and June 2016 who also underwent atrial septostomy for refractory pulmonary edema/upper body hypoxemia. We analyzed LAP/pulmonary capillary wedge pressure (PCWP), right atrial pressures (RAPs), Pa O2 /Fi O2 ratios (blood samples from right radial artery), intrathoracic volume status, and resolution of pulmonary edema before and up to 48 h after septostomy. There were no procedure-related complications. Thirty-day survival was 44%. LAP/PCWP decreased by approximately 40% immediately following septostomy and remained so for at least 24 h. Pa O2 /Fi O2 ratios significantly increased from 0.49 (0.38-2.12) before to 5.35 (3.01-7.69) immediately after septostomy and continued so for 24 h, 6.6 (4.49-10.93). Radiographic measurements also indicated a significant improvement in thoracic intravascular volume status after atrial septostomy. Atrial septostomy reduces LAP and improves upper body oxygenation and intrathoracic vascular volume status in patients developing severe refractory pulmonary edema while undergoing peripheral VA-ECMO. Atrial septostomy therefore appears safe and suitable to reduce the risk of upper body ischemia under these circumstances.
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Affiliation(s)
- Amit Prasad
- Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, PA, USA
| | - Ali Ghodsizad
- Division of Cardiothoracic Surgery, University of Miami, Miami, FL, USA
| | - Christoph Brehm
- Heart and Vascular Institute, Penn State Health, Hershey, PA, USA
| | - Mark Kozak
- Heart and Vascular Institute, Penn State Health, Hershey, PA, USA
| | - Michael Körner
- INTEGRIS Nazih Zuhdi Transplant Institute Baptist Medical Center, Oklahoma City, OK, USA
| | - Aly El Banayosy
- INTEGRIS Nazih Zuhdi Transplant Institute Baptist Medical Center, Oklahoma City, OK, USA
| | - Kai Singbartl
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ, USA
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26
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Koth AM, Axelrod DM, Reddy S, Roth SJ, Tacy TA, Punn R. Institution of Veno-arterial Extracorporeal Membrane Oxygenation Does Not Lead to Increased Wall Stress in Patients with Impaired Myocardial Function. Pediatr Cardiol 2017; 38:539-546. [PMID: 28005156 DOI: 10.1007/s00246-016-1546-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 12/01/2016] [Indexed: 11/24/2022]
Abstract
The effect of veno-arterial extracorporeal membrane oxygenation (VA ECMO) on wall stress in patients with cardiomyopathy, myocarditis, or other cardiac conditions is unknown. We set out to determine the circumferential and meridional wall stress (WS) in patients with systemic left ventricles before and during VA ECMO. We established a cohort of patients with impaired myocardial function who underwent VA ECMO therapy from January 2000 to November 2013. Demographic and clinical data were collected and inotropic score calculated. Measurements were taken on echocardiograms prior to the initiation of VA ECMO and while on full-flow VA ECMO, in order to derive wall stress (circumferential and meridional), VCFc, ejection fraction, and fractional shortening. A post hoc sub-analysis was conducted, separating those with pulmonary hypertension (PH) and those with impaired systemic output. Thirty-three patients met inclusion criteria. The patients' median age was 0.06 years (range 0-18.7). Eleven (33%) patients constituted the organ failure group (Gr2), while the remaining 22 (66%) patients survived to discharge (Gr1). WS and all other echocardiographic measures were not different when comparing patients before and during VA ECMO. Ejection and shortening fraction, WS, and VCFc were not statistically different comparing the survival and organ failure groups. The patients' position on the VCFc-WS curve did not change after the initiation of VA ECMO. Those with PH had decreased WS as well as increased EF after ECMO initiation, while those with impaired systemic output showed no difference in those parameters with initiation of ECMO. The external workload on the myocardium as indicated by WS is unchanged by the institution of VA ECMO support. Furthermore, echocardiographic measures of cardiac function do not reflect the changes in ventricular performance inherent to VA ECMO support. These findings are informative for the interpretation of echocardiograms in the setting of VA ECMO. ECMO may improve ventricular mechanics in those with PH as the primary diagnosis.
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Affiliation(s)
- Andrew M Koth
- Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital at Stanford, Stanford University School of Medicine, 750 Welch Road, Suite # 325, Palo Alto, CA, 94304, USA.
| | - David M Axelrod
- Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital at Stanford, Stanford University School of Medicine, 750 Welch Road, Suite # 325, Palo Alto, CA, 94304, USA
| | - Sushma Reddy
- Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital at Stanford, Stanford University School of Medicine, 750 Welch Road, Suite # 325, Palo Alto, CA, 94304, USA
| | - Stephen J Roth
- Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital at Stanford, Stanford University School of Medicine, 750 Welch Road, Suite # 325, Palo Alto, CA, 94304, USA
| | - Theresa A Tacy
- Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital at Stanford, Stanford University School of Medicine, 750 Welch Road, Suite # 325, Palo Alto, CA, 94304, USA
| | - Rajesh Punn
- Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital at Stanford, Stanford University School of Medicine, 750 Welch Road, Suite # 325, Palo Alto, CA, 94304, USA
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Rescigno G, Aratari C, Matteucci MLS, Massi F, Capestro F, D'Alfonso A, Torracca L. Management of transapical left venting during adult peripheral extracorporeal membrane oxygenation. ACTA ACUST UNITED AC 2017. [DOI: 10.3402/mcs.v2i0.5981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Giuseppe Rescigno
- Department of Cardiac SurgeryOspedali Riuniti di Ancona Ancona Italy
| | - Carlo Aratari
- Department of Cardiac SurgeryOspedali Riuniti di Ancona Ancona Italy
| | | | - Francesco Massi
- Department of Cardiac SurgeryOspedali Riuniti di Ancona Ancona Italy
| | - Filippo Capestro
- Department of Cardiac SurgeryOspedali Riuniti di Ancona Ancona Italy
| | | | - Lucia Torracca
- Department of Cardiac SurgeryOspedali Riuniti di Ancona Ancona Italy
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HÁLA P, MLČEK M, OŠŤÁDAL P, JANÁK D, POPKOVÁ M, BOUČEK T, LACKO S, KUDLIČKA J, NEUŽIL P, KITTNAR O. Regional Tissue Oximetry Reflects Changes in Arterial Flow in Porcine Chronic Heart Failure Treated With Venoarterial Extracorporeal Membrane Oxygenation. Physiol Res 2016; 65:S621-S631. [DOI: 10.33549/physiolres.933532] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Venoarterial extracorporeal membrane oxygenation (VA ECMO) is widely used in treatment of decompensated heart failure. Our aim was to investigate its effects on regional perfusion and tissue oxygenation with respect to extracorporeal blood flow (EBF). In five swine, decompensated low-output chronic heart failure was induced by long-term rapid ventricular pacing. Subsequently, VA ECMO was introduced and left ventricular (LV) volume, aortic blood pressure, regional arterial flow and tissue oxygenation were continuously recorded at different levels of EBF. With increasing EBF from minimal to 5 l/min, mean arterial pressure increased from 47±22 to 84±12 mm Hg (P<0.001) and arterial blood flow increased in carotid artery from 211±72 to 479±58 ml/min (P<0.01) and in subclavian artery from 103±49 to 296±54 ml/min (P<0.001). Corresponding brain and brachial tissue oxygenation increased promptly from 57±6 to 74±3 % and from 37±6 to 77±6 %, respectively (both P<0.01). Presented results confirm that VA ECMO is a capable form of heart support. Regional arterial flow and tissue oxygenation suggest that partial circulatory support may be sufficient to supply brain and peripheral tissue by oxygen.
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Affiliation(s)
- P. HÁLA
- Department of Physiology, First Faculty of Medicine, Charles University, Prague, Czech Republic
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Experimental Venoarterial Extracorporeal Membrane Oxygenation Induces Left Ventricular Dysfunction. ASAIO J 2016; 62:518-24. [DOI: 10.1097/mat.0000000000000392] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Briceno N, Kapur NK, Perera D. Percutaneous mechanical circulatory support: current concepts and future directions. Heart 2016; 102:1494-507. [DOI: 10.1136/heartjnl-2015-308562] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Rihal CS, Naidu SS, Givertz MM, Szeto WY, Burke JA, Kapur NK, Kern M, Garratt KN, Goldstein JA, Dimas V, Tu T. 2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care (Endorsed by the American Heart Association, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; Affirmation of Value by the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d'intervention). J Card Fail 2016; 21:499-518. [PMID: 26036425 DOI: 10.1016/j.cardfail.2015.03.002] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Although historically the intra-aortic balloon pump has been the only mechanical circulatory support device available to clinicians, a number of new devices have become commercially available and have entered clinical practice. These include axial flow pumps, such as Impella(®); left atrial to femoral artery bypass pumps, specifically the TandemHeart; and new devices for institution of extracorporeal membrane oxygenation. These devices differ significantly in their hemodynamic effects, insertion, monitoring, and clinical applicability. This document reviews the physiologic impact on the circulation of these devices and their use in specific clinical situations. These situations include patients undergoing high-risk percutaneous coronary intervention, those presenting with cardiogenic shock, and acute decompensated heart failure. Specialized uses for right-sided support and in pediatric populations are discussed and the clinical utility of mechanical circulatory support devices is reviewed, as are the American College of Cardiology/American Heart Association clinical practice guidelines.
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Affiliation(s)
- Charanjit S Rihal
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
| | - Srihari S Naidu
- Division of Cardiology, Winthrop University Hospital, Mineola, New York
| | - Michael M Givertz
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Wilson Y Szeto
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James A Burke
- Division of Cardiology, Lehigh Valley Heart Specialists, Allentown, Pennsylvania
| | - Navin K Kapur
- Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Morton Kern
- Division of Cardiology, UCI Medical Center, Orange, California
| | - Kirk N Garratt
- Department of Cardiac and Vascular Services, Heart and Vascular Institute of New York, Lenox Hill Hospital, New York, New York
| | - James A Goldstein
- Division of Cardiology, Beaumont Heart Center Clinic, Royal Oak, Michigan
| | - Vivian Dimas
- Pediatric Cardiology, UT Southwestern, Dallas, Texas
| | - Thomas Tu
- Louisville Cardiology Group, Interventional Cardiology, Louisville, Kentucky
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Kapur NK, Zisa DC. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) fails to solve the haemodynamic support equation in cardiogenic shock. EUROINTERVENTION 2016; 11:1337-9. [DOI: 10.4244/eijv11i12a261] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care. J Am Coll Cardiol 2015; 65:e7-e26. [DOI: 10.1016/j.jacc.2015.03.036] [Citation(s) in RCA: 354] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Rihal CS, Naidu SS, Givertz MM, Szeto WY, Burke JA, Kapur NK, Kern M, Garratt KN, Goldstein JA, Dimas V, Tu T. 2015 SCAI/ACC/HFSA/STS clinical expert consensus statement on the use of percutaneous mechanical circulatory support devices in cardiovascular care (Endorsed by the American heart assocation, the cardiological society of India, and sociedad latino America. Catheter Cardiovasc Interv 2015; 85:E175-96. [DOI: 10.1002/ccd.25720] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 10/25/2014] [Indexed: 12/20/2022]
Affiliation(s)
| | - Srihari S. Naidu
- Division of Cardiology; Winthrop University Hospital; Mineola New York
| | | | - Wilson Y. Szeto
- Department of Surgery; University of Pennsylvania; Philadelphia Pennsylvania
| | - James A. Burke
- Division of Cardiology; Lehigh Valley Heart Specialists; Allentown, PA
| | | | - Morton Kern
- Division of Cardiology; UCI Medical Center; Orange CA
| | - Kirk N. Garratt
- Department of Cardiac and Vascular Services, Heart and Vascular Institute of New York; Lenox Hill Hospital; New York New York
| | - James A. Goldstein
- Division of Cardiology; Beaumont Heart Center Clinic; Royal Oak Michigan
| | - Vivian Dimas
- Pediatric Cardiology; UT Southwestern; Dallas Texas
| | - Thomas Tu
- Louisville Cardiology Group; Interventional Cardiology; Louisville Kentucky
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Abstract
OBJECTIVES Currently, there are no established echocardiographic or hemodynamic predictors of mortality after weaning venoarterial extracorporeal membrane oxygenation in children. We wished to determine which measurements predict mortality. DESIGN Over 3 years, we prospectively assessed six echo and six hemodynamic variables at 3-5 circuit rates while weaning extracorporeal membrane oxygenation flow. Hemodynamic measurements were heart rate, inotropic score, arteriovenous oxygen difference, pulse pressure, oxygenation index, and lactate. Echo variables included shortening/ejection fraction, outflow tract Doppler-derived stroke distance (velocity-time integral), degree of atrioventricular valve regurgitation, longitudinal strain (global longitudinal strain), and circumferential strain (global circumferential strain). SETTING Cardiovascular ICU at Lucille Packard Children's Hospital Stanford, CA. SUBJECTS Patients were stratified into those who died or required heart transplant (Gr1) and those who did not (Gr2). For each patient, we compared the change for each variable between full versus minimum extracorporeal membrane oxygenation flow for each group. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We enrolled 21 patients ranging in age from 0.02 to 15 years. Five had dilated cardiomyopathy, and 16 had structural heart disease with severe ventricular dysfunction. Thirteen of 21 patients (62%) comprised Gr1, including two patients with heart transplants. Eight patients constituted Gr2. Gr1 patients had a significantly greater increase in oxygenation index (35% mean increase; p < 0.01) off extracorporeal membrane oxygenation compared to full flow, but no change in velocity-time integral or arteriovenous oxygen difference. In Gr2, velocity-time integral increased (31% mean increase; p < 0.01), with no change in arteriovenous oxygen difference or oxygenation index. Pulse pressure increased modestly with flow reduction only in Gr1 (p < 0.01). CONCLUSION Failure to augment velocity-time integral or an increase in oxygenation index during the extracorporeal membrane oxygenation weaning is associated with poor outcomes in children. We propose that these measurements should be performed during extracorporeal membrane oxygenation wean, as they may discriminate who will require alternative methods of circulatory support for survival.
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Hacking DF, Best D, d'Udekem Y, Brizard CP, Konstantinov IE, Millar J, Butt W. Elective Decompression of the Left Ventricle in Pediatric Patients May Reduce the Duration of Venoarterial Extracorporeal Membrane Oxygenation. Artif Organs 2014; 39:319-26. [DOI: 10.1111/aor.12390] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Douglas F. Hacking
- Department of Paediatric Intensive Care; The Royal Children's Hospital; Melbourne Victoria Australia
- Department of Anaesthetics; Saint Vincent's Hospital; Melbourne Victoria Australia
| | - Derek Best
- Department of Paediatric Intensive Care; The Royal Children's Hospital; Melbourne Victoria Australia
| | - Yves d'Udekem
- Department of Cardiac Surgery; The Royal Children's Hospital; Melbourne Victoria Australia
| | - Christian P. Brizard
- Department of Cardiac Surgery; The Royal Children's Hospital; Melbourne Victoria Australia
| | - Igor E. Konstantinov
- Department of Cardiac Surgery; The Royal Children's Hospital; Melbourne Victoria Australia
| | - Johnny Millar
- Department of Paediatric Intensive Care; The Royal Children's Hospital; Melbourne Victoria Australia
| | - Warwick Butt
- Department of Paediatric Intensive Care; The Royal Children's Hospital; Melbourne Victoria Australia
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Kim C, Cho YH, Sung K, Yang JH. Transfromation of percutaneous extracorporeal life support to paracorporeal ventricular assist device: a case report. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2014; 47:409-12. [PMID: 25207254 PMCID: PMC4157508 DOI: 10.5090/kjtcs.2014.47.4.409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 11/24/2013] [Accepted: 11/26/2013] [Indexed: 11/16/2022]
Abstract
Percutaneous extracorporeal life support (P-ECLS) is a useful modality for the management of refractory cardiac or pulmonary failure. However, venoarterial P-ECLS may result in a complication of left ventricular distension. In this case report, we discuss a patient with drug-induced dilated cardiomyopathy managed with venoarterial P-ECLS and a left atrial vent catheter. The venoarterial P-ECLS was modified to a paracorporeal left ventricular assist device (LVAD) by removing the femoral venous cannula. After 28 days of hospitalization, the patient was successfully weaned from the paracorporeal LVAD and discharged home from the hospital.
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Affiliation(s)
- Chilsung Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Ji-Hyuk Yang
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
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Extracorporeal life support with an integrated left ventricular vent in children with a low cardiac output. Cardiol Young 2014; 24:654-60. [PMID: 23919969 DOI: 10.1017/s1047951113001017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The aim of this study was to evaluate our experience in central extracorporeal life support with an integrated left ventricular vent in children with cardiac failure. METHODS Eight children acquired extracorporeal life support with a left ventricular vent, either after cardiac surgery (n = 4) or during an acute cardiac illness (n = 4). The ascending aorta and right atrium were cannulated. The left ventricular vent was inserted through the right superior pulmonary vein and connected to the venous line on the extracorporeal life support such that active left heart decompression was achieved. RESULTS No patient died while on support, seven patients were successfully weaned from it and one patient was transitioned to a biventricular assist device. The median length of support was 6 days (range 5-10 days). One patient died while in the hospital, despite successful weaning from extracorporeal life support. No intra-cardiac thrombus or embolic stroke was observed. No patient developed relevant intracranial bleeding resulting in neurological dysfunction during and after extracorporeal life support. CONCLUSIONS In case of a low cardiac output and an insufficient inter-atrial shunt, additional left ventricular decompression via a vent could help avoid left heart distension and might promote myocardial recovery. In pulmonary dysfunction, separate blood gas analyses from the venous cannula and the left ventricular vent help detect possible coronary hypoxia when the left ventricle begins to recover. We recommend the use of central extracorporeal life support with an integrated left ventricular vent in children with intractable cardiac failure.
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Massetti M, Gaudino M, Crea F. How to transform peripheral extracorporeal membrane oxygenation in the simplest mid-term paracorporeal ventricular assist device. Int J Cardiol 2013; 166:551-3. [DOI: 10.1016/j.ijcard.2013.01.271] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2013] [Accepted: 01/21/2013] [Indexed: 11/15/2022]
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Kotani Y, Chetan D, Rodrigues W, Sivarajan VB, Gruenwald C, Guerguerian AM, Van Arsdell GS, Honjo O. Left Atrial Decompression During Venoarterial Extracorporeal Membrane Oxygenation for Left Ventricular Failure in Children: Current Strategy and Clinical Outcomes. Artif Organs 2012; 37:29-36. [DOI: 10.1111/j.1525-1594.2012.01534.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Aissaoui N, Guerot E, Combes A, Delouche A, Chastre J, Leprince P, Leger P, Diehl JL, Fagon JY, Diebold B. Two-Dimensional Strain Rate and Doppler Tissue Myocardial Velocities: Analysis by Echocardiography of Hemodynamic and Functional Changes of the Failed Left Ventricle during Different Degrees of Extracorporeal Life Support. J Am Soc Echocardiogr 2012; 25:632-40. [DOI: 10.1016/j.echo.2012.02.009] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Indexed: 10/28/2022]
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Puehler T, Philipp A, Haneya A, Camboni D, Schmid C. Extrakorporale Membranoxygenierung. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2011. [DOI: 10.1007/s00398-011-0865-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Left Ventricular Mechanical Support with Impella Provides More Ventricular Unloading in Heart Failure Than Extracorporeal Membrane Oxygenation. ASAIO J 2011; 57:169-76. [DOI: 10.1097/mat.0b013e31820e121c] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Use of the Percutaneous Left Ventricular Assist Device in Patients with Severe Refractory Cardiogenic Shock as a Bridge to Long-term Left Ventricular Assist Device Implantation. J Heart Lung Transplant 2008; 27:106-11. [DOI: 10.1016/j.healun.2007.10.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2007] [Revised: 10/24/2007] [Accepted: 10/25/2007] [Indexed: 11/20/2022] Open
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Hoefer D, Ruttmann E, Poelzl G, Kilo J, Hoermann C, Margreiter R, Laufer G, Antretter H. Outcome evaluation of the bridge-to-bridge concept in patients with cardiogenic shock. Ann Thorac Surg 2006; 82:28-33. [PMID: 16798182 DOI: 10.1016/j.athoracsur.2006.02.056] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2004] [Revised: 02/17/2006] [Accepted: 02/27/2006] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patients with cardiogenic shock can be stabilized by percutaneous implantation of extracorporeal membrane oxygenation (ECMO). If weaning from ECMO is impossible, the implantation of a ventricular assist device (VAD) is required. Patients either go for recovery of myocardial function (bridge to recovery) or for heart transplantation (bridge to transplant). METHODS One hundred thirty-one patients were supported with ECMO between March 1995 and November 2005. Reasons for ECMO implantation were acute heart failure, acute or chronic heart failure, and postcardiotomy heart failure. In 28 patients, subsequent VAD implantation was necessary (bridge to bridge concept). RESULTS Fourteen bridge to bridge patients (50%) became long-time survivors with a mean follow-up of 39 months. Risk factors for mortality were status post-cardiopulmonary resuscitation and elevated lactate and bilirubin levels before VAD implantation. Complications after ECMO and VAD implantation were bleeding and thromboembolic events. The most common cause of death was multiorgan failure. CONCLUSIONS Bridge to bridge is a successful concept for selected patients with cardiogenic shock. During ECMO support, patients can be evaluated for comorbidities. For patients with a combination of risk factors (status post-cardiopulmonary resuscitation, elevated lactate levels, and impaired liver function), VAD implantation should be considered very carefully.
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Affiliation(s)
- Daniel Hoefer
- Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria.
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46
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47
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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.
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48
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Abstract
An estimated 16 million Americans are afflicted with some degree of chronic obstructive pulmonary disease (COPD), accounting for 100,000 deaths per year. The only current treatment for chronic irreversible pulmonary failure is lung transplantation. Since the widespread success of single and double lung transplantation in the early 1990s, demand for donor lungs has steadily outgrown the supply. Unlike dialysis, which functions as a bridge to renal transplantation, or a ventricular assist device (VAD), which serves as a bridge to cardiac transplantation, no suitable bridge to lung transplantation exists. The current methods for supporting patients with lung disease, however, are not adequate or efficient enough to act as a bridge to transplantation. Although occasionally successful as a bridge to transplant, ECMO requires multiple transfusions and is complex, labor-intensive, time-limited, costly, non-ambulatory and prone to infection. Intravenacaval devices, such as the intravascular oxygenator (IVOX) and the intravenous membrane oxygenator (IMO), are surface area limited and currently provide inadequate gas exchange to function as a bridge-to-recovery or transplant. A successful artificial lung could realize a substantial clinical impact as a bridge to lung transplantation, a support device immediately post-lung transplant, and as rescue and/or supplement to mechanical ventilation during the treatment of severe respiratory failure.
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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.
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Affiliation(s)
- Brian W Duncan
- Pediatric and Congenital Heart Surgery, Cleveland Clinic Children's Hospital, Ohio 44195, USA.
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50
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Alpard SK, Zwischenberger JB. Extracorporeal membrane oxygenation for severe respiratory failure. CHEST SURGERY CLINICS OF NORTH AMERICA 2002; 12:355-78, vii. [PMID: 12122829 DOI: 10.1016/s1052-3359(02)00002-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The use of extracorporeal technology to accomplish gas exchange with or without cardiac support is based on the premise that "lung rest" facilitates repair and avoids the baso- or volutrauma of mechanical ventilator management. Extracorporeal membrane oxygenation (ECMO), a modified form of cardiopulmonary bypass, has been shown to decrease mortality of neonatal, pediatric and adult respiratory failure and is capable of total gas exchange. In neonates, over 20,638 patients have been treated with an overall survival of 77% in a population thought to have 78% mortality.
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Affiliation(s)
- Scott K Alpard
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA
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