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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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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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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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Agarwal HS, Hardison DC, Saville BR, Donahue BS, Lamb FS, Bichell DP, Harris ZL. Residual lesions in postoperative pediatric cardiac surgery patients receiving extracorporeal membrane oxygenation support. J Thorac Cardiovasc Surg 2013; 147:434-41. [PMID: 23597724 DOI: 10.1016/j.jtcvs.2013.03.021] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 02/15/2013] [Accepted: 03/15/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective of this study was to examine the incidence and clinical outcomes of residual lesions in postoperative pediatric cardiac surgery patients receiving extracorporeal membrane oxygenation (ECMO) support. METHODS A retrospective observational study was undertaken at a pediatric heart institution. Postoperative pediatric cardiac surgery patients receiving ECMO support within 7 days of surgery during the past 7 years (2005-2011) were studied. A hemodynamically significant cardiac lesion on ECMO support that required intervention to decannulate successfully was defined as a residual lesion. Demographic data, complexity of cardiac defect, surgical data, indications for ECMO, echocardiographic findings, and cardiac catheterization results were studied. Evaluation of residual lesions based on duration of ECMO support, interventions undertaken, and clinical outcomes were also examined. RESULTS Residual lesions were evaluated in 43 of 119 postoperative patients placed on ECMO support. Lesions were detected in 35 patients (28%), predominantly in branch pulmonary arteries (n = 10), shunts (n = 7), and ventricular outflow tracts (n = 9). Echocardiography detected 7 residual lesions (20%) and cardiac catheterization detected 28 residual lesions (80%). Earlier detection of residual lesions during the first 3 days of ECMO support in 24 patients improved their rate of decannulation significantly (P = .004) and survival to hospital discharge (P = .035), compared with later detection (after 3 days of ECMO support) in 11 patients. CONCLUSIONS Residual lesions are present in approximately one-quarter of postoperative cardiac surgery patients requiring ECMO support. All postoperative pediatric cardiac surgery patients unable to be weaned off ECMO successfully should be evaluated actively for residual lesions, preferably by cardiac catheterization imaging. Earlier detection of residual lesions and reintervention are associated with improved clinical outcome.
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Affiliation(s)
- Hemant S Agarwal
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn.
| | - Daphne C Hardison
- ECMO Division, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Benjamin R Saville
- Division of Pediatric Cardiac Anesthesia, Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tenn
| | - Brian S Donahue
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn; Department of Anesthesia, Vanderbilt University Medical Center, Nashville, Tenn
| | - Fred S Lamb
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - David P Bichell
- Department of Cardio-Thoracic Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Zena L Harris
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
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