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Wang R, Zhou M, Man Y, Zhu Y, Ding W, Liu Q, Sun B, Yan L, Zhang Y, Zhou H, Wang L. Lung ultrasound to evaluate pulmonary changes in patients with cardiogenic shock undergoing extracorporeal membrane oxygenation: a retrospective study. BMC Anesthesiol 2023; 23:181. [PMID: 37231331 DOI: 10.1186/s12871-023-02134-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 05/10/2023] [Indexed: 05/27/2023] Open
Abstract
PURPOSE The aim of the study was to evaluate the value of lung ultrasound (LUS) in patients with cardiogenic shock treated by venoarterial extracorporeal membrane oxygenation (VA-ECMO). METHODS A retrospective study was conducted in Xuzhou Central Hospital from September 2015 to April 2022. Patients with cardiogenic shock who received VA-ECMO treatment were enrolled in this study. The LUS score was obtained at the different time points of ECMO. RESULTS Twenty-two patients were divided into a survival group (n = 16) and a nonsurvival group (n = 6). The intensive care unit (ICU) mortality was 27.3% (6/22). The LUS scores in the nonsurvival group were significantly higher than those in the survival group after 72 h (P < 0.05). There was a significant negative correlation between LUS scores and PaO2/FiO2 and LUS scores and pulmonary dynamic compliance(Cdyn) after 72 h of ECMO treatment (P < 0.001). ROC curve analysis showed that the area under the ROC curve (AUC) of T72-LUS was 0.964 (95% CI 0.887 ~ 1.000, P < 0.01). CONCLUSION LUS is a promising tool for evaluating pulmonary changes in patients with cardiogenic shock undergoing VA-ECMO. TRIAL REGISTRATION The study had been registered in the Chinese Clinical Trial Registry(NO.ChiCTR2200062130 and 24/07/2022).
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Affiliation(s)
- Rongguo Wang
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, China
| | - Meiyan Zhou
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, China
| | - Yuanyuan Man
- Department of Respiratory, Xuzhou Central Hospital, Xuzhou, China
| | - Yangzi Zhu
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, China
| | - Wenping Ding
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, China
| | - Qian Liu
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, China
| | - Bin Sun
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, China
| | - Li Yan
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, China
| | - Yan Zhang
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, China
| | - Hai Zhou
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, China
| | - Liwei Wang
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, China.
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Magder S, Slobod D, Assanangkornchai N. Right Ventricular Limitation: A Tale of Two Elastances. Am J Respir Crit Care Med 2023; 207:678-692. [PMID: 36257049 DOI: 10.1164/rccm.202106-1564so] [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: 11/16/2022] Open
Abstract
Right ventricular (RV) dysfunction is a commonly considered cause of low cardiac output in critically ill patients. Its management can be difficult and requires an understanding of how the RV limits cardiac output. We explain that RV stroke output is caught between the passive elastance of the RV walls during diastolic filling and the active elastance produced by the RV in systole. These two elastances limit RV filling and stroke volume and consequently limit left ventricular stroke volume. We emphasize the use of the term "RV limitation" and argue that limitation of RV filling is the primary pathophysiological process by which the RV causes hemodynamic instability. Importantly, RV limitation can be present even when RV function is normal. We use the term "RV dysfunction" to indicate that RV end-systolic elastance is depressed or diastolic elastance is increased. When RV dysfunction is present, RV limitation occurs at lowerpulmonary valve opening pressures and lower stroke volume, but stroke volume and cardiac output still can be maintained until RV filling is limited. We use the term "RV failure" to indicate the condition in which RV output is insufficient for tissue needs. We discuss the physiological underpinnings of these terms and implications for clinical management.
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Affiliation(s)
- Sheldon Magder
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada; and
| | - Douglas Slobod
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada; and
| | - Nawaporn Assanangkornchai
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada; and
- Faculty of Medicine, Prince of Songkla University, Hatyai, Thailand
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3
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Honore PM, Barreto Gutierrez L, Kugener L, Redant S, Attou R, Gallerani A, De Bels D. Risk of harlequin syndrome during bi-femoral peripheral VA-ECMO: should we pay more attention to the watershed or try to change the venous cannulation site? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:450. [PMID: 32690070 PMCID: PMC7372641 DOI: 10.1186/s13054-020-03168-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/12/2020] [Indexed: 11/23/2022]
Affiliation(s)
- Patrick M Honore
- ICU Department, Centre Hospitalier Universitaire Brugmann, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium.
| | | | - Luc Kugener
- ICU Department, Centre Hospitalier Universitaire Brugmann, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Sebastien Redant
- ICU Department, Centre Hospitalier Universitaire Brugmann, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Rachid Attou
- ICU Department, Centre Hospitalier Universitaire Brugmann, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Andrea Gallerani
- ICU Department, Centre Hospitalier Universitaire Brugmann, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - David De Bels
- ICU Department, Centre Hospitalier Universitaire Brugmann, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
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Left Ventricular Hemodynamics with an Implanted Assist Device: An In Vitro Fluid Dynamics Study. Ann Biomed Eng 2019; 47:1799-1814. [DOI: 10.1007/s10439-019-02273-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 04/12/2019] [Indexed: 10/27/2022]
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Fux T, Holm M, Corbascio M, Lund LH, van der Linden J. VA‐ECMO Support in Nonsurgical Patients With Refractory Cardiogenic Shock: Pre‐Implant Outcome Predictors. Artif Organs 2018; 43:132-141. [DOI: 10.1111/aor.13331] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/26/2018] [Accepted: 06/22/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Thomas Fux
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
- Division of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
| | - Manne Holm
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
| | - Matthias Corbascio
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
- Heart and Vascular Theme Karolinska University Hospital Stockholm Sweden
| | - Lars H. Lund
- Department of Medicine Karolinska Institutet Stockholm Sweden
- Heart and Vascular Theme Karolinska University Hospital Stockholm Sweden
| | - Jan van der Linden
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
- Division of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
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Fux T, Holm M, Corbascio M, Lund LH, van der Linden J. Venoarterial extracorporeal membrane oxygenation for postcardiotomy shock: Risk factors for mortality. J Thorac Cardiovasc Surg 2018; 156:1894-1902.e3. [DOI: 10.1016/j.jtcvs.2018.05.061] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 05/10/2018] [Accepted: 05/14/2018] [Indexed: 10/14/2022]
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Insufficient left ventricular unloading after extracorporeal membrane oxygenation : A case-series observational study. Herz 2018; 45:186-191. [PMID: 29777285 DOI: 10.1007/s00059-018-4711-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 04/23/2018] [Accepted: 04/23/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a method widely used to support circulation in patients with fulminant myocarditis (FM). However, a common complication associated with ECMO is left ventricular (LV) overload. METHODS This case series observed the effects of intra-aortic balloon pump (IABP) and beta-blockers for the treatment of LV overload after ECMO. The cases of eight patients with FM who underwent ECMO from September 2009 to July 2016 were reviewed. RESULTS Six of the eight patients survived. After ECMO treatment, insufficient LV unloading occurred in six patients. Among these six patients, three experienced electrical storm but spontaneous circulation returned after interventions with beta-blockers and IABP. The survivors demonstrated full recovery of cardiac function. CONCLUSION Beta-blockers may prevent the occurrence of electrical storm, and IABP is feasible for the treatment of LV overload after ECMO application.
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Yamauchi T, Masai T, Fujii K, Sawa Y, Shirai S, Kamigaki M, Itou N. Long-term clinical results of acute myocardial infarction at the left main trunk requiring percutaneous cardiopulmonary support. J Artif Organs 2017; 20:303-310. [PMID: 28887708 DOI: 10.1007/s10047-017-0972-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 06/25/2017] [Indexed: 11/28/2022]
Abstract
The clinical results of patients with acute myocardial infarction (AMI) at the left main trunk (LMT) remain unclear, especially in cases requiring percutaneous cardiopulmonary support (PCPS). Twenty seven cases of AMI at the LMT requiring emergent PCPS were retrospectively investigated. These 27 patients were aged 44-83 years (65.6 ± 8.6 years) and 20 (81.5%) were men. Peak creatine kinase (CK) leakage ranged from 538 to 34,010 IU/l (13,553 ± 7656 IU/l). Eight (29.6%) patients were discharged without mechanical support. Ten (37.0%) patients underwent left ventricular assist device (LVAD) implantation, five of whom with preoperative organ failure could not survive more than 6 months after implantation. The other nine (33.3%) patients died of low output syndrome or brain damage. The overall survival rates were 53.7, 41.3, 33.0, and 28.3% at 3 months, 6 months, 1 year, and 2 years, respectively. Multivariate analysis showed that Killip class 3/4 at hospital arrival was an independent risk factor for hospital mortality (odds ratio 20.4). Patients with more than 5 days of PCPS support period (n = 6), ≥ 4 h to revascularization (n = 6) or maximum CK leakage ≥20,000 IU/dl (n = 3) were not associated with successful PCPS or IABP weaning. The long-term clinical outcomes of patients with LMT disease requiring PCPS is devastating. Rapid cardiopulmonary resuscitation and coronary revascularization and timely insertion of LVAD before the onset of complications might lead to better survival.
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Affiliation(s)
- Takashi Yamauchi
- Department of Cardiovascular Surgery, KKR Sapporo Medical Center, 6-3-40 Ichijo Hiragishi, Toyohira, Sapporo, Hokkaido, 062-0931, Japan.
| | - Takafumi Masai
- Department of Cardiovascular Surgery, Sakurabashi Watanabe Hospital, 2-4-32 Umeda, Kitaku, Osaka, Osaka, 530-0001, Japan
| | - Kenji Fujii
- Department of Cardiology, Sakurabashi Watanabe Hospital, 2-4-32 Umeda, Kitaku, Osaka, Osaka, 530-0001, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Shinya Shirai
- Department of Cardiology, KKR Sapporo Medical Center, 6-3-40 Ichijo Hiragishi, Toyohira, Sapporo, Hokkaido, 062-0931, Japan
| | - Mitsunori Kamigaki
- Department of Cardiology, KKR Sapporo Medical Center, 6-3-40 Ichijo Hiragishi, Toyohira, Sapporo, Hokkaido, 062-0931, Japan
| | - Naofumi Itou
- Department of Cardiology, KKR Sapporo Medical Center, 6-3-40 Ichijo Hiragishi, Toyohira, Sapporo, Hokkaido, 062-0931, Japan
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Bréchot N, Demondion P, Santi F, Lebreton G, Pham T, Dalakidis A, Gambotti L, Luyt CE, Schmidt M, Hekimian G, Cluzel P, Chastre J, Leprince P, Combes A. Intra-aortic balloon pump protects against hydrostatic pulmonary oedema during peripheral venoarterial-extracorporeal membrane oxygenation. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2017; 7:62-69. [DOI: 10.1177/2048872617711169] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background: Increased left ventricular afterload during peripheral venoarterial-extracorporeal membrane oxygenation (VA-ECMO) support frequently causes hydrostatic pulmonary oedema. Because physiological studies demonstrated left ventricular afterload decrease during VA-ECMO assistance combined with the intra-aortic balloon pump (IABP), we progressively changed our standard practice systematically to associate an IABP with VA-ECMO. This study aimed to evaluate IABP efficacy in preventing pulmonary oedema in VA-ECMO-assisted patients. Methods: A retrospective single-centre study. Results: Among 259 VA-ECMO patients included, 104 received IABP. Weinberg radiological score-assessed pulmonary oedema was significantly lower in IABP+ than IABP– patients at all times after ECMO implantation. This protection against pulmonary oedema persisted when death and switching to central ECMO were used as competing risks (subhazard ratio 0.49, 95% confidence interval (CI) 0.33–0.75; P<0.001). Multivariable analysis retained IABP as being independently associated with a lower risk of radiological pulmonary oedema (odds ratio (OR) 0.4, 95% CI 0.2–0.7; P=0.001) and a trend towards lower mortality (OR 0.54, 95% CI 0.29–1.01; P=0.06). Finally, the time on ECMO free from mechanical ventilation increased in IABP+ patients (2.2±4.3 vs. 0.7±2.0 days; P=0.0003). Less frequent pulmonary oedema and more days off mechanical ventilation were also confirmed in 126 highly comparable IABP+ and IABP– patients, propensity score matched for receiving an IABP. Conclusions: Associating an IABP with peripheral VA-ECMO was independently associated with a lower frequency of hydrostatic pulmonary oedema and more days off mechanical ventilation under ECMO.
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Affiliation(s)
- Nicolas Bréchot
- Medical-Surgical ICU, Hôpital Pitié–Salpêtrière, France
- INSERM U1050, Centre Interdisciplinaire de Recherche en Biologie, France
| | - Pierre Demondion
- Cardiac Surgery Department, Hôpital Pitié–Salpêtrière, France
- Sorbonne University, Institute of Cardiometabolism and Nutrition, France
| | - Francesca Santi
- Cardiac Surgery Department, Hôpital Pitié–Salpêtrière, France
| | - Guillaume Lebreton
- Cardiac Surgery Department, Hôpital Pitié–Salpêtrière, France
- Sorbonne University, Institute of Cardiometabolism and Nutrition, France
| | - Tai Pham
- Saint Michael’s Hospital, Interdepartmental Division of Critical Care, Canada
- University Paris Diderot, Sorbonne Paris Cité, France
| | | | | | - Charles-Edouard Luyt
- Medical-Surgical ICU, Hôpital Pitié–Salpêtrière, France
- Sorbonne University, Institute of Cardiometabolism and Nutrition, France
| | - Matthieu Schmidt
- Medical-Surgical ICU, Hôpital Pitié–Salpêtrière, France
- Sorbonne University, Institute of Cardiometabolism and Nutrition, France
| | - Guillaume Hekimian
- Medical-Surgical ICU, Hôpital Pitié–Salpêtrière, France
- Sorbonne University, Institute of Cardiometabolism and Nutrition, France
| | - Philippe Cluzel
- Sorbonne University, Institute of Cardiometabolism and Nutrition, France
- Radiology Department, Hôpital Pitié–Salpêtrière, France
| | - Jean Chastre
- Medical-Surgical ICU, Hôpital Pitié–Salpêtrière, France
- Sorbonne University, Institute of Cardiometabolism and Nutrition, France
| | - Pascal Leprince
- Cardiac Surgery Department, Hôpital Pitié–Salpêtrière, France
- Sorbonne University, Institute of Cardiometabolism and Nutrition, France
| | - Alain Combes
- Medical-Surgical ICU, Hôpital Pitié–Salpêtrière, France
- Sorbonne University, Institute of Cardiometabolism and Nutrition, France
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Sayed S, Schimmer C, Shade I, Leyh R, Aleksic I. Combined pulmonary and left ventricular support with veno-pulmonary ECMO and impella 5.0 for cardiogenic shock after coronary surgery. J Cardiothorac Surg 2017; 12:38. [PMID: 28532425 PMCID: PMC5440892 DOI: 10.1186/s13019-017-0594-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 05/10/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mechanical circulatory support is a common practice nowadays in the management of patients after cardiogenic shock due to myocardial infarction. The single or combined use of one or more devices for mechanical support depends not only on the advantage or disadvantage of these devices but also on the timing of use of these devices before the development of multi organ failure. In our case we used more than one tool for mechanical circulatory support during the prolonged and complicated course of our patient with postcardiotomy cardiogenic shock after coronary artery bypass surgery. CASE PRESENTATION We describe the combined use of Impella 5.0 and veno- pulmonary extra corporeal membrane oxygenation (VP-ECMO) for biventricular failure in a 52 years-old man. He presented with cardiogenic shock after inferior wall ST-elevation myocardial infarction. After emergency coronary artery bypass surgery and failure to wean from extracorporeal circulation we employed V-P ECMO and consecutively Impella 5.0 to manage the primarily failing right and secondarily failing left ventricles. He remained hemodynamically stable on both Impella 5.0 and VP-ECMO until Heart Mate II left ventricular assist device implantation on the 14th postoperative day. Right sided support was weaned on 66th postoperative day. The patient remained in the intensive care unit for 77 days. During his prolonged stay, he underwent renal replacement therapy and tracheostomy with complete recovery. Six months later, he was successfully heart transplanted and has completed three and half years of unremarkable follow up. CONCLUSIONS The combined use of VP ECMO and Impella 5.0 is effective in the management of postcardiotomy biventricular failure as a bridge for further mechanical support or heart transplantation.
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Affiliation(s)
- Sameh Sayed
- Department of Cardiothoracic Surgery, Zentrum Operative Medizine, University of Würzburg, Oberdürrbacher Str.6, 97080, Würzburg, Germany. .,Department of Cardiothoracic Surgery, Assiut University, Assiut, Egypt.
| | - Christoph Schimmer
- Department of Cardiothoracic Surgery, Zentrum Operative Medizine, University of Würzburg, Oberdürrbacher Str.6, 97080, Würzburg, Germany
| | - Ina Shade
- Department of Cardiothoracic Surgery, Zentrum Operative Medizine, University of Würzburg, Oberdürrbacher Str.6, 97080, Würzburg, Germany
| | - Rainer Leyh
- Department of Cardiothoracic Surgery, Zentrum Operative Medizine, University of Würzburg, Oberdürrbacher Str.6, 97080, Würzburg, Germany
| | - Ivan Aleksic
- Department of Cardiothoracic Surgery, Zentrum Operative Medizine, University of Würzburg, Oberdürrbacher Str.6, 97080, Würzburg, Germany
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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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12
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Lindfors M, Frenckner B, Sartipy U, Bjällmark A, Broomé M. Venous Cannula Positioning in Arterial Deoxygenation During Veno-Arterial Extracorporeal Membrane Oxygenation-A Simulation Study and Case Report. Artif Organs 2016; 41:75-81. [PMID: 27086941 PMCID: PMC5297996 DOI: 10.1111/aor.12700] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 12/16/2015] [Accepted: 12/30/2015] [Indexed: 12/23/2022]
Abstract
Venoarterial extracorporeal membrane oxygenation (VA‐ECMO) is indicated in reversible life‐threatening circulatory failure with or without respiratory failure. Arterial desaturation in the upper body is frequently seen in patients with peripheral arterial cannulation and severe respiratory failure. The importance of venous cannula positioning was explored in a computer simulation model and a clinical case was described. A closed‐loop real‐time simulation model has been developed including vascular segments, the heart with valves and pericardium. ECMO was simulated with a fixed flow pump and a selection of clinically relevant venous cannulation sites. A clinical case with no tidal volumes due to pneumonia and an arterial saturation of below 60% in the right hand despite VA‐ECMO flow of 4 L/min was described. The case was compared with simulation data. Changing the venous cannulation site from the inferior to the superior caval vein increased arterial saturation in the right arm from below 60% to above 80% in the patient and from 64 to 81% in the simulation model without changing ECMO flow. The patient survived, was extubated and showed no signs of hypoxic damage. We conclude that venous drainage from the superior caval vein improves upper body arterial saturation during veno‐arterial ECMO as compared with drainage solely from the inferior caval vein in patients with respiratory failure. The results from the simulation model are in agreement with the clinical scenario.
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Affiliation(s)
- Mattias Lindfors
- ECMO Department, Karolinska University Hospital.,Anaesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet
| | - Björn Frenckner
- ECMO Department, Karolinska University Hospital.,Division of Pediatric Surgery, Department of Women's and Children's Health, Karolinska Institutet
| | - Ulrik Sartipy
- Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital.,Department of Molecular Medicine and Surgery, Karolinska Institutet
| | - Anna Bjällmark
- Department of Molecular Medicine and Surgery, Karolinska Institutet.,Department of Medical Engineering, School of Technology and Health, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Michael Broomé
- ECMO Department, Karolinska University Hospital.,Anaesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet.,Department of Medical Engineering, School of Technology and Health, KTH Royal Institute of Technology, Stockholm, Sweden
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Rescue extracorporeal membrane oxygenation for refractory cardiogenic shock. Adv Cardiol 2015; 11:327-9. [PMID: 26677384 PMCID: PMC4679802 DOI: 10.5114/pwki.2015.55605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 07/11/2015] [Accepted: 07/27/2015] [Indexed: 11/25/2022]
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Refractory cardiogenic shock due to extensive anterior STEMI with covered left ventricular free wall rupture treated with awake VA-ECMO and LVAD as a double bridge to heart transplantation - collaboration of three cardiac centres. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2015; 159:681-7. [PMID: 26498212 DOI: 10.5507/bp.2015.044] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 09/10/2015] [Indexed: 11/23/2022] Open
Abstract
AIM To highlight an optimal collaborative strategy of three different levels of specialized care cardiac centres. BACKGROUND Refractory cardiogenic shock is a life-threatening condition. A myocardial recovery is not achieved in many cases despite all efforts and subsequently the heart transplantation remains an ultimate option. Thereby, the use of extracorporeal membrane oxygenation (ECMO) followed by a ventricular assist device in staged bridging provides an attractive approach. CASE REPORT We report on an optimal cooperation of PCI (percutaneous coronary intervention) centre with ELSO (extracorporeal life support organization) centre and transplant centre in a patient suffering from refractory cardiogenic shock due to acute myocardial infarction (RCSMI) complicated by left ventricle free wall rupture with pericardial tamponade. CONCLUSION The interhospital collaboration can be essential in the context of patients with RCSMI. The use of ECMO enables safe interhospital transport and gains time for further diagnostic and therapeutic steps in such critically ill patients.
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Jaguszewski M, Ghadri JR, Seifert B, Hiestand T, Herrera P, Gaemperli O, Landmesser U, Maier W, Nallamothu BK, Windecker S, Lüscher TF, Templin C. Drug-eluting stents vs. bare metal stents in patients with cardiogenic shock. J Cardiovasc Med (Hagerstown) 2015; 16:220-9. [DOI: 10.2459/jcm.0000000000000106] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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16
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Myat A, Patel N, Tehrani S, Banning AP, Redwood SR, Bhatt DL. Percutaneous Circulatory Assist Devices for High-Risk Coronary Intervention. JACC Cardiovasc Interv 2015; 8:229-244. [DOI: 10.1016/j.jcin.2014.07.030] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 07/17/2014] [Indexed: 10/24/2022]
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17
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Bogaev RC, Meyers DE. Medical Treatment of Heart Failure and Coronary Heart Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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18
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Seidler T. [Percutaneous mechanical circulatory support: options and importance]. Internist (Berl) 2014; 55:1267-77. [PMID: 25301025 DOI: 10.1007/s00108-014-3505-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
In cases of low cardiac output and chronic cardiac failure despite conventional therapy, mechanical circulatory support may be the only option to ensure adequate organ perfusion and to save the life of the patient. In recent years, several conceptionally different methods of circulatory support have been developed for percutaneous application in interventional cardiology and intensive care. Indications range from elective use in complex cardiac interventions to long-term support as a bridge to recovery. As intra-aortic balloon pump support can no longer be considered for routine use in ischemic cardiogenic shock, micro-axial pumps for extracorporeal membrane oxygenation and extracorporeal life support systems (ECMO/ECLS) gain attractiveness due to a more convincing impact on the hemodynamics. However, an increasing level of support is paralleled by greater invasiveness and complexity of the systems. Due to a lack of larger comparative trials, the benefits and risks of adverse events must be balanced against those of conventional therapy with inotropes and largely on an individual basis. This review summarizes the options for percutaneous circulatory support with special consideration to applications in the catheter laboratory and intensive care units in internal medicine.
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Affiliation(s)
- T Seidler
- Abteilung Kardiologie und Pneumologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland,
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Park TK, Yang JH, Choi SH, Song YB, Hahn JY, Choi JH, Sung K, Lee YT, Gwon HC. Clinical impact of intra-aortic balloon pump during extracorporeal life support in patients with acute myocardial infarction complicated by cardiogenic shock. BMC Anesthesiol 2014; 14:27. [PMID: 24725532 PMCID: PMC4003289 DOI: 10.1186/1471-2253-14-27] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 04/02/2014] [Indexed: 12/13/2022] Open
Abstract
Background There is no available data on clinical outcome in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock who are supported by an intra-aortic balloon pump (IABP) in combination with extracorporeal life support (ECLS). Methods We analysed 96 consecutive patients with AMI and complicating cardiogenic shock who were assisted by an ECLS system between January 2004 and December 2011. The primary outcome was in-hospital mortality. The secondary outcomes were the success rate of weaning from ECLS and the lactate clearance for 48 hours (%). Results A combination of IABP and ECLS was used in 41 (42.7%) patients. In-hospital mortality occurred for 51 patients (ECLS with IABP versus ECLS alone; 51.2% vs. 54.5%, p = 0.747). The success rate of weaning from ECLS was similar between the two groups (63.4% vs. 58.2%, p = 0.604). Complications such as ischemia of a lower extremity or bleeding at the ECLS insertion site (p = 0.521 and p = 0.667, respectively) did not increase when ECLS was combined with IABP. Among patients who survived for 24 hours after intervention, lactate clearance was not significantly different between patients who received ECLS alone and those who received ECLS with IABP (p = 0.918). Conclusions The combined use of ECLS and IABP did not improve in-hospital survival in patients with AMI complicated by cardiogenic shock.
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Affiliation(s)
- Taek Kyu Park
- Department of Medicine, Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea
| | - Jeong Hoon Yang
- Department of Medicine, Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea ; Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung-Hyuk Choi
- Department of Medicine, Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea
| | - Young Bin Song
- Department of Medicine, Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea
| | - Joo-Yong Hahn
- Department of Medicine, Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea
| | - Jin-Ho Choi
- Department of Medicine, Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Tak Lee
- Department of Thoracic and Cardiovascular Surgery, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyeon-Cheol Gwon
- Department of Medicine, Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea
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Brugts JJ, Manintveld O, Constantinescu A, Donker DW, van Thiel RJ, Nieman K, Jewbali LSD, Zijlstra F, Caliskan K. Preventing LVAD implantation by early short-term mechanical support and prolonged inodilator therapy : A case series with acute refractory cardiogenic shock treated with veno-arterial extracorporeal membrane oxygenation and optimised medical strategy. Neth Heart J 2014; 22:176-81. [PMID: 24424723 PMCID: PMC3954922 DOI: 10.1007/s12471-013-0509-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Cardiogenic shock continues to be a life-threatening condition carrying a high mortality and morbidity, where the prognosis remains poor despite intensive modern treatment modalities. In recent years, mainly technical improvements have led to a more widespread use of short- and long-term mechanical circulatory support, such as veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and left ventricular assist devices (LVADs). Currently, LVADs are indispensable as 'bridge' to cardiac recovery, heart transplantation (HTX), and/or as destination therapy Importantly, both LVADs and HTX put a vast burden on financial resources, besides significant short- and long-term risks of morbidity and mortality. These considerations underscore the importance of optimal timing and appropriate patient selection for LVAD therapy, avoiding as much as possible an unfortunate and costly clinical path. In this report, we present a series of three cases with acute refractory cardiogenic shock ('crash and burn', INTERMACS profile 1) successfully treated by ECMO and early optimal medical therapy preventing a certain path towards LVAD and/or HTX, for which they were initially referred. This conservative approach in INTERMACS profile one patients warrants very early introduction of adequate medical heart failure therapy under the umbrella of a combination of short-term mechanical circulatory and inotropic support by phosphodiesterase inhibitors. Therefore, this novel combined medical-mechanical approach could have important clinical implications for this extremely challenging patient category, as it may avoid an unnecessary and costly clinical path towards LVAD and/or heart transplantation.
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Affiliation(s)
- J J Brugts
- Department of Cardiology, Erasmus MC Thoraxcenter, 's Gravendijkwal 230, 3015CE, Rotterdam, the Netherlands,
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Tehrani S, Malik A, Hausenloy DJ. Cardiogenic Shock and the ICU Patient. J Intensive Care Soc 2013. [DOI: 10.1177/175114371301400312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Cardiogenic shock is one of the most important complications of acute myocardial infarction (MI) and acute left ventricular failure (LVF). It threatens the life of 5–10% of patients with ST-segment elevation myocardial infarction (STEMI) particularly in the presence of inappropriately low peripheral vascular resistance. Cardiogenic shock results in poor tissue perfusion, end-organ damage and carries a high mortality risk. The goal of therapy is to prevent end-organ dysfunction and severe metabolic derangement by raising mean arterial blood pressure, which is achieved with the use of inotropes and vasopressors, often at the expense of tachycardia, elevated myocardial oxygen consumption and extended myocardial ischaemia. Current therapeutic approaches include early coronary artery revascularisation (which has significantly improved the survival rate), fluid resuscitation, inotropic support and mechanical circulatory support using intra-aortic balloon pumps or ventricular assist devices. In this article, we review the pathophysiology, diagnosis and management of cardiogenic shock.
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Affiliation(s)
- Shana Tehrani
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Medicine, University College London
| | - Abdul Malik
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Medicine, University College London
| | - Derek J Hausenloy
- Reader in Cardiovascular Medicine
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Medicine, University College London
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Tharmaratnam D, Nolan J, Jain A. Management of cardiogenic shock complicating acute coronary syndromes. Heart 2013; 99:1614-23. [PMID: 23468511 DOI: 10.1136/heartjnl-2012-302028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Subramaniam K, Boisen M, Shah PR, Ramesh V, Pete A. Mechanical circulatory support for cardiogenic shock. Best Pract Res Clin Anaesthesiol 2013; 26:131-46. [PMID: 22910086 DOI: 10.1016/j.bpa.2012.05.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 05/18/2012] [Indexed: 02/08/2023]
Abstract
Cardiogenic shock (CS) is a syndrome of progressive depression of myocardial function with systemic hypoperfusion. It occurs due to various aetiologies such as acute myocardial infarction, myocarditis, acute decompensated heart failure and postcardiotomy. Cardiogenic shock carries poor prognosis, and medical therapy alone is not effective. Mechanical circulatory support is required to unload the ventricles, decrease the myocardial demand, prevent further injury, improve the coronary perfusion, stabilise the haemodynamics and maintain the end-organ perfusion before definitive interventions such as coronary reperfusion can take place. Currently, there are several methods of mechanical circulatory support. These include extracorporeal life support, paracorporeal or extracorporeal ventricular-assist devices, percutaneous ventricular assist devices, intra-aortic balloon counterpulsation and total artificial heart. In this review, we discuss the role of each of these circulatory support devices in the management of acute cardiac failure.
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Affiliation(s)
- Kathirvel Subramaniam
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
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24
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Cardiac transplant or rotary blood pump: Contemporary evidence. J Thorac Cardiovasc Surg 2013; 145:24-31. [DOI: 10.1016/j.jtcvs.2012.08.048] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 07/23/2012] [Accepted: 08/21/2012] [Indexed: 11/19/2022]
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Somasundaram K, Ball J. Medical emergencies: atrial fibrillation and myocardial infarction. Anaesthesia 2012; 68 Suppl 1:84-101. [DOI: 10.1111/anae.12050] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Abstract
With a stable frequency (about 5% of acute coronary syndromes) and a mortality of nearly 45%, cardiogenic shock (CS), especially when it occurs in the immediate waning of myocardial infarction, still represents a therapeutic challenge. In this review, will be detailed the actual epidemiologic data of CS, its physiopathology and the different modalities of treatments available to the interventional cardiologist, especially the coronary revascularisation and the percutaneous left ventricular assistance, whether by intra-aortic balloon counterpulsation or by more complex systems.
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Affiliation(s)
- G Leurent
- Service de cardiologie et maladies vasculaires, CHU de Rennes, 35000 Rennes, France.
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Affiliation(s)
- Alia Noorani
- Department of Cardiothoracic Transplantation, Papworth Hospital, Papworth Everard, Cambridgeshire, UK.
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Westaby S, Kharbanda R, Banning AP. Cardiogenic shock in ACS. Part 1: prediction, presentation and medical therapy. Nat Rev Cardiol 2011; 9:158-71. [PMID: 22182955 DOI: 10.1038/nrcardio.2011.194] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Ischemic cardiogenic shock is a complex, self-perpetuating pathological process that frequently causes death irrespective of medical therapy. Early definition of coronary anatomy is a pivotal step towards survival. Those destined to develop shock are likely to have three-vessel or left main stem disease with previously impaired left ventricular function. Early reperfusion of the occluded artery can limit infarct size, but ischemia-reperfusion injury or the 'no-reflow' phenomenon can preclude improvement in myocardial contractility. Emergence of shock depends upon the volume of ischemic myocardium, stroke volume, and peripheral vascular resistance. If cytokine release triggers the systemic inflammatory response, systemic vascular resistance falls and inadequate coronary perfusion pressure heralds the downward spiral. Survival depends on early recognition of shock, followed by aggressive targeted treatment of left, right, or biventricular failure. The goal is to prevent end-organ dysfunction and severe metabolic derangement by raising mean arterial pressure, which is achieved with inotropes and vasopressors, often at the expense of tachycardia, elevated myocardial oxygen consumption, and extended ischemia. The value of intra-aortic balloon counter-pulsation is now questioned in patients with advanced shock. When mean arterial pressure is <55 mmHg with serum lactate >11 mmol/l, death is likely and mechanical circulatory support becomes the only chance for survival.
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Affiliation(s)
- Stephen Westaby
- Departments of Cardiothoracic Surgery, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, UK.
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