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Koziol KJ, Isath A, Rao S, Gregory V, Ohira S, Van Diepen S, Lorusso R, Krittanawong C. Extracorporeal Membrane Oxygenation (VA-ECMO) in Management of Cardiogenic Shock. J Clin Med 2023; 12:5576. [PMID: 37685643 PMCID: PMC10488419 DOI: 10.3390/jcm12175576] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/13/2023] [Accepted: 08/17/2023] [Indexed: 09/10/2023] Open
Abstract
Cardiogenic shock is a critical condition of low cardiac output resulting in insufficient systemic perfusion and end-organ dysfunction. Though significant advances have been achieved in reperfusion therapy and mechanical circulatory support, cardiogenic shock continues to be a life-threatening condition associated with a high rate of complications and excessively high patient mortality, reported to be between 35% and 50%. Extracorporeal membrane oxygenation can provide full cardiopulmonary support, has been increasingly used in the last two decades, and can be used to restore systemic end-organ hypoperfusion. However, a paucity of randomized controlled trials in combination with high complication and mortality rates suggest the need for more research to better define its efficacy, safety, and optimal patient selection. In this review, we provide an updated review on VA-ECMO, with an emphasis on its application in cardiogenic shock, including indications and contraindications, expected hemodynamic and echocardiographic findings, recommendations for weaning, complications, and outcomes. Furthermore, specific emphasis will be devoted to the two published randomized controlled trials recently presented in this setting.
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Affiliation(s)
- Klaudia J. Koziol
- School of Medicine, New York Medical College and Westchester Medical Center, Valhalla, NY 10595, USA
| | - Ameesh Isath
- Department of Cardiology, Westchester Medical Center, Valhalla, NY 10595, USA
| | - Shiavax Rao
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD 21218, USA
| | - Vasiliki Gregory
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD 21218, USA
| | - Suguru Ohira
- Division of Cardiothoracic Surgery, New York Medical College and Westchester Medical Center, Valhalla, NY 10595, USA
| | - Sean Van Diepen
- Division of Cardiology and Critical Care, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, 6202 AZ Maastricht, The Netherlands
| | - Chayakrit Krittanawong
- Cardiology Division, NYU Langone Health and NYU School of Medicine, New York, NY 10016, USA
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Prasad A, Brehm C, Singbartl K. The impact of preservation and recovery of renal function on survival after veno-arterial extracorporeal life support: A retrospective cohort study. Artif Organs 2023; 47:554-565. [PMID: 36325712 DOI: 10.1111/aor.14449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/23/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Veno-arterial extracorporeal life support (V-A ECLS) has become a cornerstone in the management of critical cardiogenic shock, but it can also precipitate organ injury, e.g., acute kidney injury (AKI). Available studies highlight the effect of non-cardiac organ injury on patient outcomes. Only very little is known about the impact of non-cardiac organ recovery on patient survival. AKI occurs frequently during cardiogenic shock and carries a poor prognosis. We have developed descriptive models to hypothesize on the role of AKI severity versus that of recovery of renal function for patient survival. METHODS Retrospective, observational study including 175 patients who were successfully decannulated from V-A ECLS. We assessed AKI severity using the "Kidney Disease: Improving Global Outcomes" (KDIGO) criteria. We defined recovered or preserved renal function (RPRF) prior to decannulation from V-A ECLS as 0 (AKI with no improvement) or 1 (no AKI or AKI with improvement). We classified patient outcomes as alive or dead at hospital discharge. RESULTS 78% (n = 138) of all patients survived hospital discharge of which 38% (n = 67) never developed AKI. After adjusting for shock severity and non-renal organ injury, RPRF emerged as an independent predictor of survival in both the overall cohort [OR (95% CI) - 4.11 (1.72-9.79)] and the AKI-only sub-cohort [OR (95% CI) - 5.18 (1.8-14.92)]. Neither maximum KDIGO stage nor KDIGO stage at the end of V-A ECLS was independently associated with survival. CONCLUSIONS Our model identifies RPRF, but not AKI severity, as an independent predictor of hospital survival in patients undergoing V-A ECLS for cardiogenic shock. We hypothesize that recovered or preserved non-cardiac organ function during V-A ECLS is crucial for patient survival.
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Affiliation(s)
- Amit Prasad
- Heart and Vascular Institute, PennState Health, Hershey, Pennsylvania, USA
| | - Christoph Brehm
- Heart and Vascular Institute, PennState Health, Hershey, Pennsylvania, USA
| | - Kai Singbartl
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, Arizona, USA
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Walsh RW, Smith NJ, Shepherd JF, Turbati MS, Teng BQ, Brazauskas R, Joyce DL, Joyce LD, Durham L, Rossi PJ. Peripherally inserted concomitant surgical right and left ventricular support, the Propella, is associated with low rates of limb ischemia, with mortality comparable with peripheral venoarterial extracorporeal membrane oxygenation. Surgery 2023; 173:855-863. [PMID: 36435648 DOI: 10.1016/j.surg.2022.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 10/02/2022] [Accepted: 10/04/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Mechanical circulatory support effectively treats adult cardiogenic shock. Whereas cardiogenic shock confers high mortality, acute limb ischemia is a known complication of mechanical circulatory support that confers significant morbidity. We compared our novel approach to peripheral mechanical circulatory support with a conventional femoral approach, with a focus on the incidence of acute limb ischemia. METHODS This was a retrospective cohort study of patients treated with mechanical circulatory support between January 1, 2015 and December 5, 2021 at our institution. Patients receiving any femoral peripheral venoarterial extracorporeal membrane oxygenation were compared with those receiving minimally invasive, peripherally inserted, concomitant right and left ventricular assist devices. These included the Impella 5.0 (Abiomed, Danvers, MA) left ventricular assist device and the ProtekDuo (LivaNova, London, UK) right ventricular assist device used concomitantly (Propella) approach. The primary outcome was incidence of acute limb ischemia. The baseline patient characteristics, hemodynamic data, and post-mechanical circulatory support outcomes were collected. Fisher exact test and Wilcoxon rank sum test was used for the categorical and continuous variables, respectively. Kaplan-Meier curves and log-rank test were used to estimate overall survival probabilities and survival experience, respectively. RESULTS Fifty patients were treated with mechanical circulatory support at our institution for cardiogenic shock, with 13 patients supported with the novel Propella strategy and 37 with peripheral venoarterial extracorporeal membrane oxygenation. The baseline characteristics, including patient organ function and medical comorbidities, were similar among the groups. Nine patients suffered mortality in ≤48 hours of mechanical circulatory support initiation and were excluded. Twenty patients (69%) suffered acute limb ischemia in the peripheral venoarterial extracorporeal membrane oxygenation group; 0 patients receiving Propella suffered acute limb ischemia (P < .001). The percentages of patients surviving to discharge in peripheral venoarterial extracorporeal membrane oxygenation and Propella groups were 24% and 69%, respectively (P = .007). CONCLUSION Patients treated with the Propella experienced a lower incidence of acute limb ischemia compared with patients treated with peripheral venoarterial extracorporeal membrane oxygenation.
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Affiliation(s)
- Richard W Walsh
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Nathan J Smith
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - John F Shepherd
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Mia S Turbati
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Bi Qing Teng
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI
| | - Ruta Brazauskas
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI
| | - David L Joyce
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Lyle D Joyce
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Lucian Durham
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Peter J Rossi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.
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Alonso-Fernandez-Gatta M, Merchan-Gomez S, Gonzalez-Cebrian M, Diego-Nieto A, Gonzalez-Martin J, Toranzo-Nieto I, Barrio A, Martin-Herrero F, Sanchez PL. Echocardiographic Prediction of Successful Weaning From Venoarterial Extracorporeal Membrane Oxygenation. Am J Crit Care 2022; 31:483-493. [PMID: 36316178 DOI: 10.4037/ajcc2022588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Weaning from venoarterial extracorporeal membrane oxygenation (VA-ECMO) support fails in 30% to 70% of patients. OBJECTIVE To explore the utility of echocardiographic parameters in predicting successful disconnection from VA-ECMO. METHODS Patients receiving VA-ECMO in a referral hospital were included. The relationships between echocardiographic parameters during the weaning trial and weaning success (survival > 24 hours after VA-ECMO explant and no death from cardiogenic shock, heart failure, or cardiac arrest during the hospital stay) and survival were evaluated. RESULTS Of 85 patients included, 61% had successful weaning. Parameters significantly related to weaning success were higher left ventricular ejection fraction (LVEF; 40% in patients with weaning success vs 30% in patients with weaning failure, P = .01), left ventricular outflow tract velocity time integral (15 cm vs 11 cm, P = .01), aortic valve opening in every cycle (98% vs 91% of patients, P = .01), and normal qualitative right ventricular function (60% vs 42% of patients, P = .02). The LVEF remained as an independent predictor of weaning success (hazard ratio, 0.938; 95% CI, 0.888-0.991; P = .02). An LVEF >33.4% was the optimal cutoff value to discriminate patients with successful weaning (area under the curve, 0.808; sensitivity, 93%; specificity, 72%) and was related to higher survival at discharge (60% vs 20%, P < .001). CONCLUSION Among weaning trial echocardiographic parameters, LVEF was the only independent predictor of successful VA-ECMO weaning. An LVEF >33.4% was the optimal cutoff value to discriminate patients with successful weaning and was related to final survival.
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Affiliation(s)
- Marta Alonso-Fernandez-Gatta
- Marta Alonso-Fernandez-Gatta is a cardiologist at University Hospital of Salamanca-Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain and takes part in the Centro de Investigación en Red de Enfermedades Cardio vasculares (CIBER-CV), Instituto de Salud Carlos III, Madrid, Spain
| | - Soraya Merchan-Gomez
- Soraya Merchan-Gomez is a cardiologist at University Hospital of Salamanca-IBSAL and takes part in CIBER-CV, Instituto de Salud Carlos III
| | - Miryam Gonzalez-Cebrian
- Miryam Gonzalez-Cebrian is a nursing supervisor, Cardiology Department, University Hospital of Salamanca-IBSAL
| | - Alejandro Diego-Nieto
- Alejandro Diego-Nieto is a cardiologist at University Hospital of Salamanca-IBSAL and takes part in CIBER-CV, Instituto de Salud Carlos III
| | | | - Ines Toranzo-Nieto
- Ines Toranzo-Nieto is a cardiologist at University Hospital of Salamanca-IBSAL and takes part in CIBER-CV, Instituto de Salud Carlos III
| | - Alfredo Barrio
- Alfredo Barrio is a cardiologist at University Hospital of Salamanca-IBSAL and takes part in CIBER-CV, Instituto de Salud Carlos III
| | - Francisco Martin-Herrero
- Francisco Martin-Herrero is a cardiologist at University Hospital of Salamanca-IBSAL and takes part in CIBER-CV, Instituto de Salud Carlos III
| | - Pedro L Sanchez
- Pedro L. Sanchez is head of the Cardiology Department, University Hospital of Salamanca-IBSAL, and takes part in CIBER-CV, Instituto de Salud Carlos III
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Al-Kawaz M, Shou B, Prokupets R, Whitman G, Geocadin R, Cho SM. Mild hypothermia and neurologic outcomes in patients undergoing venoarterial extracorporeal membrane oxygenation. J Card Surg 2022; 37:825-830. [PMID: 35152478 PMCID: PMC8891050 DOI: 10.1111/jocs.16308] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/07/2021] [Accepted: 12/24/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND Patients with venoarterial extracorporeal membrane oxygenation (VA-ECMO) are at risk of cerebral reperfusion injury after prolonged hypoperfusion and immediate restoration of systemic blood flow. We aimed to examine the impact of mild hypothermia during the first 24 h post-ECMO on neurological outcomes in VA-ECMO patients. METHODS This was a retrospective study of adult VA-ECMO patients from a tertiary care center. Mild hypothermia was defined as 32-36°C during the first 24 h post-ECMO. The primary outcome was a good neurological function at discharge measured by a modified Rankin Scale ≤3. Multivariable logistic regression analysis was performed for primary outcome adjusting for pre-specified covariates. RESULTS Overall, 128 consecutive patients with VA-ECMO support (median age: 60 years and 63% males) were included. Within the first 24 h of VA-ECMO cannulation, we found a median of 71 readings per patient (interquartile range 45-88). Eighty-eight patients (68.8%) experienced mild hypothermia within the first 24 h while 18 of those 88 patients (14.2%) had a mean temperature <36°C. ECMO indications included post-cardiotomy shock (39.8%), cardiac arrest (29.7%), and cardiogenic shock (26.6%). Duration of mild hypothermia, but not mean temperature, was independently associated with increased odds of good neurological outcome at discharge (odds ratio [OR] = 1.16, 95% confidence interval [CI] = 1.04-1.31, p = .01) after adjusting for age, the severity of illness, post-ECMO systemic hemorrhage, post-cardiotomy shock, acute brain injury, and mean 24-h PaO2 . Neither duration of mild hypothermia (OR = 0.93, CI = 0.84-1.03, p = .17) nor mean temperature (OR = 0.78, CI = 0.29-2.08, p = .62) was significantly associated with mortality. Similarly, duration of mild hypothermia (p = .47) and mean 24-h temperature (p = .76) were not significantly associated with the frequency of systemic hemorrhages. CONCLUSIONS In this single-center study, a longer duration of mild hypothermia during the first 24 h of ECMO support was significantly associated with improved neurological outcomes. Mild hypothermia was not associated with an increased risk of systemic hemorrhage or improved survival.
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Affiliation(s)
- Mais Al-Kawaz
- Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Benjamin Shou
- Division of Cardiac Surgery, Heart and Vascular Institute, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rochelle Prokupets
- Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Glenn Whitman
- Division of Cardiac Surgery, Heart and Vascular Institute, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Romergryko Geocadin
- Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sung-Min Cho
- Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Nezami FR, Ramezanpour M, Khodaee F, Goffer E, Edelman ER, Keller SP. Simulation of Fluid-Structure Interaction in Extracorporeal Membrane Oxygenation Circulatory Support Systems. J Cardiovasc Transl Res 2022; 15:249-257. [PMID: 34128180 DOI: 10.1007/s12265-021-10143-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 05/31/2021] [Indexed: 11/25/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a vital mechanical circulatory support modality capable of restoring perfusion for the patient in circulatory failure. Despite increasing adoption of ECMO, there is incomplete understanding of its effects on systemic hemodynamics and how the vasculature responds to varying levels of continuous retrograde perfusion. To gain further insight into the complex ECMO:failing heart circulation, computational fluid dynamics simulations focused on perfusion distribution and hemodynamic flow patterns were conducted using a patient-derived aorta geometry. Three case scenarios were simulated: (1) healthy control; (2) 90% ECMO-derived perfusion to model profound heart failure; and, (3) 50% ECMO-derived perfusion to model the recovering heart. Fluid-structure interface simulations were performed to quantify systemic pressure and vascular deformation throughout the aorta over the cardiac cycle. ECMO support alters pressure distribution while decreasing shear stress. Insights derived from computational modeling may lead to better understanding of ECMO support and improved patient outcomes.
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Affiliation(s)
- Farhad R Nezami
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Surgery (Thoracic and Cardiac Surgery), Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mehdi Ramezanpour
- Department of Mechanical Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Farhan Khodaee
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Efrat Goffer
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Elazer R Edelman
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Medicine (Cardiovascular Medicine), Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven P Keller
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA.
- Department of Medicine (Pulmonary and Critical Care Medicine), Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Pozzi M, Buzzi R, Hayek A, Portran P, Schweizer R, Fellahi JL, Armoiry X, Flagiello M, Grinberg D, Obadia JF. Veno-arterial extracorporeal membrane oxygenation for drug intoxications: A single center, 14-year experience. J Card Surg 2022; 37:1512-1519. [PMID: 35353389 DOI: 10.1111/jocs.16456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/02/2022] [Accepted: 02/17/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIM OF THE STUDY Acute cardiovascular failure remains a leading cause of death in severe poisonings. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been increasingly used as a rescue therapeutic option for those cases refractory to optimal conventional treatment. We sought to evaluate the outcomes after VA-ECMO used for drug intoxications in a single-center experience. METHODS We performed an observational analysis of our prospective institutional database. The primary endpoint was survival to hospital discharge. RESULTS Between January 2007 and December 2020, 32 patients (mean age: 45.4 ± 15.8 years; 62.5% female) received VA-ECMO for drug intoxication-induced refractory cardiogenic shock (n = 25) or cardiac arrest (n = 7). Seven (21.8%) patients developed lower limb ischemia during VA-ECMO support. Twenty-six (81.2%) patients were successfully weaned after a mean VA-ECMO support of 2.9 ± 1.3 days. One (3.1%) patient died after VA-ECMO weaning for multiorgan failure and survival to hospital discharge was 78.1% (n = 25). In-hospital survivors were discharged from hospital with a good neurological status. Survival to hospital discharge was not statistically different according to sex (male = 75.0% vs. female = 80.0%; p = .535), type of intoxication (single drug = 81.8% vs. multiple drugs = 76.1%; p = .544) and location of VA-ECMO implantation (within our center = 75% vs. peripheral hospital using our Mobile Unit of Mechanical Circulatory Support = 100%; p = .352). Survival to hospital discharge was significantly lower in patients receiving VA-ECMO during on-going cardiopulmonary resuscitation (42.8% vs. 88.0%; p = .026). CONCLUSIONS VA-ECMO appears to be a feasible therapeutic option with a satisfactory survival rate and acceptable complications rate in poisonings complicated by refractory cardiogenic shock or cardiac arrest.
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Affiliation(s)
- Matteo Pozzi
- Department of Cardiac Surgery, Louis Pradel Cardiologic Hospital, Claude Bernard University, Lyon, France.,Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
| | - Rémi Buzzi
- Department of Cardiac Surgery, Louis Pradel Cardiologic Hospital, Claude Bernard University, Lyon, France
| | - Ahmad Hayek
- Department of Cardiology, Louis Pradel Cardiologic Hospital, Claude Bernard University, Lyon, France
| | - Philippe Portran
- Department of Anesthesia and ICU, Louis Pradel Cardiologic Hospital, Lyon, France
| | - Rémi Schweizer
- Department of Anesthesia and ICU, Louis Pradel Cardiologic Hospital, Lyon, France
| | - Jean Luc Fellahi
- Department of Anesthesia and ICU, Louis Pradel Cardiologic Hospital, Lyon, France
| | - Xavier Armoiry
- Pharmacy Department, School of Pharmacy (ISPB)/UMR CNRS 5510 MATEIS/Edouard Herriot Hospital, University of Lyon, Lyon, France
| | - Michele Flagiello
- Department of Cardiac Surgery, Louis Pradel Cardiologic Hospital, Claude Bernard University, Lyon, France
| | - Daniel Grinberg
- Department of Cardiac Surgery, Louis Pradel Cardiologic Hospital, Claude Bernard University, Lyon, France
| | - Jean Francois Obadia
- Department of Cardiac Surgery, Louis Pradel Cardiologic Hospital, Claude Bernard University, Lyon, France
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Artemiou P, Gasparovic I, Hudec V, Hulman M. The efficiency of the preoperative extracorporeal membrane oxygenation in the setting of postinfarction ventricular septal defect and how to optimize outcomes: A single center case series. J Card Surg 2022; 37:1416-1421. [PMID: 35182446 DOI: 10.1111/jocs.16333] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/13/2022] [Accepted: 02/01/2022] [Indexed: 11/27/2022]
Abstract
The mortality rate after the development of postinfarction ventricular septal defect remains high despite progress in pharmacologic therapy, invasive cardiology, and surgical techniques. We present a case series of six patients with preoperative venoarterial extracorporeal membrane oxygenation as a bridge to reparative surgical repair. Venoarterial extracorporeal membrane oxygenation allows to hemodynamically stabilize the patient, and safely delay the surgery. Delayed surgery might facilitate successful repair by allowing friable tissue to organize, strengthen, and become well-differentiated from surrounding healthy tissue; thus, definite repair can be performed safely. All patients were in cardiogenic shock and would otherwise require emergent cardiac surgery with associated risk. Three patients were discharged, with one hospital mortality of a patient who had a successful bridge to corrective surgery and died due to pulmonary artery rupture after a right ventricular assist device implantation. Two patients died before surgery while they were supported by venoarterial extracorporeal membrane oxygenation due to vascular complications. We discuss strategies how to optimize the management and function of the venoarterial extracorporeal membrane oxygenation to decrease the rate of adverse effects and optimize the outcomes of these patients.
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Affiliation(s)
- Panagiotis Artemiou
- National Institute of Cardiovascular Diseases, Medical Faculty of the Comenious University, Clinic of Cardiac Surgery, Bratislava, Slovakia
| | - Ivo Gasparovic
- National Institute of Cardiovascular Diseases, Medical Faculty of the Comenious University, Clinic of Cardiac Surgery, Bratislava, Slovakia
| | - Vladan Hudec
- National Institute of Cardiovascular Diseases, Medical Faculty of the Comenious University, Clinic of Cardiac Surgery, Bratislava, Slovakia
| | - Michal Hulman
- National Institute of Cardiovascular Diseases, Medical Faculty of the Comenious University, Clinic of Cardiac Surgery, Bratislava, Slovakia
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9
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Khodaee F, Nezami FR, Zampell BA, Galper E, Edelman ER, Keller SP. Effect of anatomical variation on extracorporeal membrane oxygenation circulatory support: A computational study. Comput Biol Med 2022; 141:105178. [PMID: 34995875 PMCID: PMC10600951 DOI: 10.1016/j.compbiomed.2021.105178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 12/23/2021] [Accepted: 12/24/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) via femoral cannulation is a vital intervention capable of rapidly restoring perfusion for patients in shock. Despite increasing use to provide circulatory support, its hemodynamic effects are poorly understood and the impact of patient-specific anatomical variation on perfusion is unknown. This study investigates the complex failing heart-mechanical circulatory support circulation and analyzes the effect of patient-specific vascular anatomical variations on hemodynamics and end-organ perfusion. METHODS Patient-specific vascular geometries were constructed from segmenting clinical computerized tomography angiography images and quantitatively compared using tortuosity, curvature, torsion, and lumen diameter. Computational fluid dynamic simulations were performed on a subset of geometries selected to represent a range of anatomical variation. Heart failure severity was modeled by varying the relative fraction of total flow provided by the heart and the extracorporeal circuit. A 3-element lumped parameter model was applied to accurately and dynamically model distal perfusion boundary conditions. Hemodynamic parameters and end-organ perfusion were analyzed and compared to assess the effect of anatomical variation. RESULTS Pulsatile antegrade cardiac perfusion and ECMO retrograde perfusion collide in the aorta to form a dynamic watershed region. The size, position, and variation of this region over the cardiac cycle is substantially altered by patient anatomical region. Increased vascular tortuosity reduces the proximal extent of flow from circulatory support and decreases the size of the watershed region. CONCLUSIONS Patient vascular anatomy is a key determinant of the ECMO-failing heart circulation that alters the location and extent of the watershed region and affects the tissues at risk for differential hypoxia and circuit-derived thromboemboli for a given level of support.
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Affiliation(s)
- Farhan Khodaee
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Farhad R Nezami
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA; Department of Surgery (Thoracic and Cardiac Surgery), Brigham and Women's Hospital, Boston, MA, USA
| | - Brooke A Zampell
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA; École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Eitan Galper
- Department of Mechanical Engineering, University of Maryland, College Park, MD, USA
| | - Elazer R Edelman
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA; Department of Medicine (Cardiovascular Medicine), Brigham and Women's Hospital, Boston, MA, USA
| | - Steven P Keller
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA; Department of Medicine (Pulmonary and Critical Care Medicine), Johns Hopkins Hospital, Baltimore, MD, USA.
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10
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George TJ, Sheasby J, Shih E, Erwin GE, Taylor JE, Curry MW, Lilly JC, Vaquera KA, Harness-Brumley CL, Myers DP, Michael DiMaio J. Intermediate-term survival and functional outcomes of COVID-19 extracorporeal membrane oxygenation patients. J Card Surg 2022; 37:789-794. [PMID: 35099834 DOI: 10.1111/jocs.16284] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/06/2021] [Accepted: 12/24/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has been associated with acceptable short-term survival in patients with refractory respiratory failure secondary to coronavirus disease 2019 (COVID-19) pneumonia. Previous studies have demonstrated acceptable long-term outcomes in patients supported with ECMO for respiratory failure of other etiologies. However, long-term survival and functional outcomes in COVID ECMO patients remain unknown. METHODS We conducted a retrospective review of all COVID patients requiring ECMO at our hospital. The primary outcomes measured were survival to discharge and contemporary survival. Secondary outcomes included two simple functional assessments: the ongoing need for oxygen supplementation and the ability to return to work. Survival was calculated using the Kaplan-Meier method. Hazard ratios were calculated using Cox hazards regression models. RESULTS From 2020 to 2021, 48 COVID patients have been supported with ECMO at our hospital. Four patients remain on support and were excluded from further analysis. The average age was 47 ± 8 years, 34 (77%) were males, and the plurality (19, 43%) were Hispanic. Median duration of support was 23 (12-51) days. Median follow-up was 106 (29-226) days. Survival to discharge was 59%. Kaplan-Meier 180-day survival was 51%. Long-term survival conditioned on survival to discharge was 89%. In evaluating functional outcomes, the overwhelming majority of patients no longer required oxygen supplementation (74%), and most had returned to work (52%). CONCLUSION In conclusion, COVID ECMO patients have acceptable intermediate-term survival with adequate functional recovery.
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Affiliation(s)
| | - Jenelle Sheasby
- Baylor Scott and White, The Heart Hospital, Plano, Texas, USA
| | - Emily Shih
- Baylor Scott and White, The Heart Hospital, Plano, Texas, USA
| | - Gary E Erwin
- Baylor Scott and White, The Heart Hospital, Plano, Texas, USA
| | - Jeff E Taylor
- Baylor Scott and White, The Heart Hospital, Plano, Texas, USA
| | - Matthew W Curry
- Baylor Scott and White, The Heart Hospital, Plano, Texas, USA
| | - Jeffrey C Lilly
- Baylor Scott and White, The Heart Hospital, Plano, Texas, USA
| | - Key A Vaquera
- Baylor Scott and White, The Heart Hospital, Plano, Texas, USA
| | | | - David P Myers
- Baylor Scott and White, The Heart Hospital, Plano, Texas, USA
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11
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Sef D, Verzelloni Sef A, Trkulja V, Raj B, Lees NJ, Walker C, Mitchell J, Petrou M, De Robertis F, Stock U, McGovern I. Midterm outcomes of venovenous extracorporeal membrane oxygenation as a bridge to lung transplantation: Comparison with nonbridged recipients. J Card Surg 2022; 37:747-759. [PMID: 35060184 DOI: 10.1111/jocs.16253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 11/28/2021] [Accepted: 12/24/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Davorin Sef
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Alessandra Verzelloni Sef
- Department of Anesthesia and Critical Care Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Vladimir Trkulja
- Department of Pharmacology Zagreb University School of Medicine Zagreb Croatia
| | - Binu Raj
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Nicholas J. Lees
- Department of Anesthesia and Critical Care Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Christopher Walker
- Department of Anesthesia and Critical Care Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Jerry Mitchell
- Department of Anesthesia and Critical Care Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Mario Petrou
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Fabio De Robertis
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Ulrich Stock
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Ian McGovern
- Department of Anesthesia and Critical Care Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
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12
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Jörg Rustenbach C, Djordjevic I, David L, Ivanov B, Gerfer S, Gaisendrees C, Wendt S, Merkle J, Seo J, Sabashnikov A, Rahmanian P, Kuhn E, Kroener A, Bennink G, Eghbalzadeh K, Wahlers T. Risk factors associated with in-hospital mortality for patients with ECLS due to post cardiotomy cardiogenic shock after isolated coronary surgery. Artif Organs 2022; 46:1158-1164. [PMID: 34985129 DOI: 10.1111/aor.14166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 11/15/2021] [Accepted: 12/13/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Extracorporeal membrane oxygenation (ECMO) or extracorporeal life support (ECLS) in patients after cardiac surgery and post cardiotomy cardiogenic shock (PCS) is known to be associated with high mortality. Especially in patients after coronary artery bypass grafting (CABG) and PCS, ECLS is frequently established. Aim of this analysis was to evaluate factors associated with in-hospital mortality in patients treated with ECLS due to PCS after CABG. METHODS Between August 2006 and January 2017, 92 consecutive patients with V-A ECLS due to PCS after isolated CABG were identified and included in this retrospective analysis. Patients were divided into survivors (S) and non-survivors (NS) and analysed in regard of risk factors of in-hospital mortality. RESULTS In-hospital mortality added up to 61 patients (66 %). Non-survivors were significantly older (60±12 (S) vs. 67±10 (NS); p=0.013). Bilateral internal mammary artery graft was significantly more frequently used in S (23% (S) vs. 2% (NS); p=0.001). After 24 hours of ECLS support, median lactate levels were significantly higher in NS (1.9(1.3;3.5) mmol/L (S) vs. 3.5(2.1;6.3) mmol/L (NS); p=0.001). NS suffered more often acute kidney injury requiring dialysis (42% (S) vs. 74% (NS); p=0.002). CONCLUSION Mortality in patients with refractory PCS after CABG and consecutive ECLS support remains high. Failing end-organ recovery under ECLS despite optimized concomitant medical therapy is an indicator of adverse outcomes in this specific patient cohort. Moreover, total-arterial revascularization might be beneficial for cardiac recovery in patients suffering PCS after CABG and following ECLS.
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Affiliation(s)
| | - Ilija Djordjevic
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
| | - Lara David
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
| | - Borko Ivanov
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
| | - Stephen Gerfer
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
| | | | - Stefanie Wendt
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
| | - Julia Merkle
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
| | - Joon Seo
- Evangelical Hospital Herne, Department of Thoracic Surgery, Herne, Germany
| | - Anton Sabashnikov
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
| | - Parwis Rahmanian
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
| | - Elmar Kuhn
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
| | - Axel Kroener
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
| | - Gerardus Bennink
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
| | - Kaveh Eghbalzadeh
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
| | - Thorsten Wahlers
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
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13
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Ghodsizad A, Salerno TA. Commentary: Should the brain be continuously monitored during extracorporeal membrane oxygenation (ECMO) support? J Thorac Cardiovasc Surg 2021; 165:2111-2112. [PMID: 34702563 DOI: 10.1016/j.jtcvs.2021.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 10/06/2021] [Accepted: 10/07/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Ali Ghodsizad
- Division of Thoracic Transplantation and Mechanical Support, Miami Transplant Institute, Miami, Fla
| | - Tomas A Salerno
- Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine, Miami, Fla; Jackson Memorial Hospital, Miami, Fla.
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14
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Flagiello M, Al Harthy A, Boccalini S, Jacquemet L, Obadia JF, Baudry G, Pozzi M. Veno-arterial extracorporeal membrane oxygenation for COVID-19-associated acute myocardial injury complicated by refractory cardiogenic shock. J Card Surg 2021; 36:4396-4399. [PMID: 34396587 PMCID: PMC8447130 DOI: 10.1111/jocs.15919] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 08/02/2021] [Accepted: 08/08/2021] [Indexed: 12/02/2022]
Abstract
Cardiovascular system involvement and its negative prognostic impact have been increasingly identified in coronavirus disease 2019 (COVID‐19) patients. Optimal medical treatment allows for safe management of most of these cardiovascular presentations while COVID‐19‐associated refractory cardiogenic shock could be rescued by veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO). We present a case of acute myocardial injury related to COVID‐19 complicated by refractory cardiogenic shock and treated by VA‐ECMO implantation.
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Affiliation(s)
- Michele Flagiello
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Ahmed Al Harthy
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Sara Boccalini
- Department of Radiology, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Louis Jacquemet
- Department of Anesthesia and ICU, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Jean F Obadia
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Guillaume Baudry
- Department of Cardiology, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Matteo Pozzi
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France.,Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard, Lyon, France
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15
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Hess NR, Wang Y, Kilic A. Utilization and outcomes of postcardiotomy mechanical circulatory support. J Card Surg 2021; 36:4030-4037. [PMID: 34378836 DOI: 10.1111/jocs.15908] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 08/01/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study evaluated the utilization and outcomes of postcardiotomy mechanical circulatory support (MCS). METHODS This was a retrospective, single institution analysis of adult cardiac surgery cases that required de novo MCS following surgery from 2011 to 2018. Patients that were bridged with MCS to surgery were excluded. The primary outcomes were early operative mortality and longitudinal survival. Secondary outcomes included postoperative complications, and 5-year all-cause readmission. RESULTS Five hundred and thirty-three patients required de novo postcardiotomy MCS, with the most commonly performed procedure being isolated coronary artery bypass grafting (29.8%). Median cardiopulmonary bypass and cross-clamp times were 185 (IQR 123-260) min and 122 (IQR 81-179) min, respectively. A total of 442 (82.9%) of patients were supported with intra-aortic balloon pump counterpulsation, 23 (4.3%) with an Impella device, and 115 (21.6%) with extracorporeal membrane oxygenation. Three (0.6%) patients had an unplanned ventricular assist device placed. Operative mortality was 29.8%. Longitudinal survival was 56.1% and 43.0% at 1 and 5 years, respectively. Survival was lowest in those supported with ECMO and highest with those supported with an Impella (p < 0.001). Freedom from readmission was 61.4% at 5 years. Postoperative ECMO was an independent predictor of mortality (HR 5.1, 95% CI 2.0-12.9, p < 0.001), but none of the MCS types predicted long-term hospital readmission after risk adjustment. CONCLUSIONS Postcardiotomy MCS is associated with high operative mortality. Even patients that survive to discharge have compromised longitudinal survival, with nearly only half surviving to 1 year. Close follow-up and early referral to advanced heart failure specialists may be prudent in improving these outcomes.
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Affiliation(s)
- Nicholas R Hess
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yisi Wang
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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16
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Ketenciler S, Gemalmaz H, Yücel C, Kayalar N. Successful treatment of massive pulmonary embolism in a pregnant woman complicated with atypical hemolytic uremic syndrome. J Card Surg 2021; 36:3924-3928. [PMID: 34309878 DOI: 10.1111/jocs.15829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/08/2021] [Accepted: 07/10/2021] [Indexed: 11/30/2022]
Abstract
The treatment of the massive pulmonary embolism concomitant hemodynamic instability in pregnancy is difficult and controversial and carries a high risk for both the baby and the mother. The catheter-directed thrombectomy with or without extracorporeal membrane oxygenation support may be a suitable management strategy in suitable cases but pregnancy-related complications may follow the treatment of pulmonary embolism and atypical hemolytic uremic syndrome should be considered in the differential diagnosis. We present a case of a 32-year-old patient who had a pulmonary embolism with shock in the 8th week of pregnancy complicated by atypical hemolytic uremic syndrome.
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Affiliation(s)
- Serkan Ketenciler
- Prof. Dr. Cemil Taşçıoğlu City Hospital, Cardiovascular Surgery Clinic, Istanbul, Turkey
| | - Hüseyin Gemalmaz
- Prof. Dr. Cemil Taşçıoğlu City Hospital, Cardiovascular Surgery Clinic, Istanbul, Turkey
| | - Cihan Yücel
- Prof. Dr. Cemil Taşçıoğlu City Hospital, Cardiovascular Surgery Clinic, Istanbul, Turkey
| | - Nihan Kayalar
- Çam and Sakura City Hospital, Cardiovascular Surgery Clinic, Istanbul, Turkey
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17
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Hlaváček D, Pokorný M, Ivák P, Netuka I, Szárszoi O. Implantation of durable left ventricular assist device in patient with postmyocardial infarction ventricular septal defect. J Card Surg 2021; 36:3944-3947. [PMID: 34296475 DOI: 10.1111/jocs.15839] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 06/30/2021] [Accepted: 07/10/2021] [Indexed: 12/01/2022]
Abstract
Ventricular septal defect (VSD) is a severe complication of myocardial infarction (MI) with a high mortality rate. We report a case of a large post-MI VSD treated with percutaneous venoarterial extracorporeal membrane oxygenation (VA-ECMO) to restore hemodynamic stability and to avoid surgery in the acute setting. VSD closure with endoventricular patch and implantation of biventricular assist device (BiVAD) was arranged sixteen days after MI. Because of no signs of myocardial recovery, implantation of durable left ventricular assist device (LVAD) as a bridge to transplant was provided, leaving right ventricular assist device (RVAD) to right ventricle recovery. RVAD was explanted 18 days after durable LVAD placement and the patient was discharged home two months after MI. The use of durable LVAD is a unique solution that can be applied in selected patients with MI-VSD and heart failure.
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Affiliation(s)
- Daniel Hlaváček
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic.,Department of Physiology, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Martin Pokorný
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Peter Ivák
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic.,Department of Physiology, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Ivan Netuka
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic.,Second Department of Surgery, Department of Cardiovascular Surgery, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Ondrej Szárszoi
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic.,Department of Pathophysiology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
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18
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Djordjevic I, Merkle J, Eghbalzadeh K, Sabashnikov A, Ivanov B, Gummert J, Potapov E, Schoenrath F, Meyns B, Özbaran M, de By TMMH, Wahlers T, Zeriouh M, Rahmanian PB. The outcome of patients with peripartum cardiomyopathy and consecutive implantation of a left ventricular assist device. J Card Surg 2021; 36:2651-2657. [PMID: 33960521 DOI: 10.1111/jocs.15598] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/03/2021] [Accepted: 04/18/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Peripartum cardiomyopathy (PPCM) is a form of systolic heart failure occurring toward the end of pregnancy or in the period after delivery. Lack of myocardial recovery or therapy-refractory cardiogenic shock are rare complications and left ventricular assist device (LVAD) systems might be used as a life-saving option. The aim of this study was to investigate outcomes of PPCM patients supported with LVAD, registered in the European Registry for Patients with Mechanical Circulatory Support (EUROMACS). METHODS All patients registered in EUROMACS with a primary diagnosis of PPCM were included in this study. Demographic, preoperative, intraoperative, postoperative, and follow-up data were collected and patients analysed concerning their outcome after initiation of LVAD therapy. RESULTS Between May 2011 and September 2018, 16 patients with PPCM and consecutive LVAD implantation were enrolled into EUROMACS. The median age of the patient population was 31 (26;41) years with a mean left ventricular ejection fraction (LV-EF) of 15% ± 6%. In-hospital mortality after LVAD implantation was 6% (n = 1). One-year mortality accounted for 13% (n = 2). Six patients (40%) were transplanted with a median support time of 769 (193;1529) days. Weaning of LVAD support due to ventricular recovery was feasible in 3 (20%) patients. CONCLUSION In patients with severe PPCM, LVAD therapy is associated with considerably low in-hospital mortality, potentially allowing bridging to heart transplantation, or left ventricular recovery. Therefore, durable mechanical support should be considered as a treatment option in this, by nature, young and often otherwise healthy patient population.
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Affiliation(s)
- Ilija Djordjevic
- Department of Cardiothoracic Surgery, Heart Centre Cologne, University Hospital Cologne, Cologne, Germany
| | - Julia Merkle
- Department of Cardiothoracic Surgery, Heart Centre Cologne, University Hospital Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, Heart Centre Cologne, University Hospital Cologne, Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, Heart Centre Cologne, University Hospital Cologne, Cologne, Germany
| | - Borko Ivanov
- Department of Cardiothoracic Surgery, Heart Centre Cologne, University Hospital Cologne, Cologne, Germany
| | - Jan Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre NRW, Bad Oeynhausen, Germany
| | - Evgenij Potapov
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre, Berlin, Germany
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre, Berlin, Germany
| | - Bart Meyns
- Department of Cardiac Surgery, KU Leuven, Leuven, Belgium
| | - Mustafa Özbaran
- Department of Cardiovascular Surgery, Ege University, Izmir, Turkey
| | - Theo M M H de By
- European Registry for Patients with Mechanical Circulatory Support (EUROMACS), European Association of Cardiothoracic Surgery (EACTS), Windsor, UK
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Centre Cologne, University Hospital Cologne, Cologne, Germany
| | - Mohamed Zeriouh
- Department of Cardiac Surgery, Kerckhoff Klinik, Bad Nauheim, Germany
| | - Parwis B Rahmanian
- Department of Cardiothoracic Surgery, Heart Centre Cologne, University Hospital Cologne, Cologne, Germany
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19
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Concomitant ECMO And IABP Support in Postcardiotomy Cardiogenic Shock Patients. Heart Lung Circ 2021; 30:1533-1539. [PMID: 33903028 DOI: 10.1016/j.hlc.2021.03.276] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/27/2021] [Accepted: 03/11/2021] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Simultaneous mechanical circulatory support (MCS) with intra-aortic balloon pump (IABP) to extracorporeal membrane oxygenation (ECMO) is common in postcardiotomy cardiogenic shock (PCS). This study aimed to analyse the effect of concomitant ECMO and IABP therapy on the short-term outcomes of patients with PCS. METHODS Between March 2006 and March 2017, 172 consecutive patients with central (c) or peripheral (p) veno-arterial ECMO therapy due to PCS were identified at the current institution and included in this retrospective analysis. Patients were divided into ECMO+IABP and ECMO alone groups. Further, the impact of ECMO flow direction was analysed for the groups. RESULTS A total of 129 patients received ECMO+IABP support and 43 patients were treated with ECMO alone. Median ECMO duration did not differ between the groups (68 [34; 95] hours ECMO+IABP vs 44 [20; 103] hours ECMO; p=0.151). However, a trend toward a higher weaning rate was evident in ECMO+IABP patients (75 [58%] ECMO+IABP vs 18 [42%] ECMO; p=0.078). Concomitant IABP support with either cECMO (73% [n=24] cECMO+IABP vs 50% [n=11] ECMO; p=0.098) or pECMO (57% [n=55] ECMO+IABP vs 33% [n=7] ECMO; p=0.056) was also associated with a trend toward a higher weaning rate off ECMO. In-hospital mortality did not differ between the groups. CONCLUSION This analysis found that, independent of ECMO type, additional IABP support might increase ECMO weaning; however, it did not influence survival in PCS patients. Larger studies are necessary to further analyse the impact of this concomitant MSC therapy on clinical outcomes.
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20
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Gerfer S, Gaisendrees C, Djordjevic I, Ivanov B, Merkle J, Eghbalzadeh K, Schlachtenberger G, Rustenbach C, Sabashnikov A, Kuhn-Régnier F, Mader N, Wahlers T. Gender-related propensity score match analysis of ECMO therapy in postcardiotomy cardiogenic shock in patients after myocardial revascularization. Perfusion 2021; 37:470-476. [PMID: 33779391 DOI: 10.1177/02676591211004363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Gender is known to influence the pathophysiology and pathogenesis of the coronary vascular disease. Data on gender-related differences in patients with veno-arterial extracorporeal membrane oxygenation due to postcardiotomy cardiogenic shock is lacking in current literature. We aimed to analyze the impact of gender on intraoperative and short-term outcomes of vaECMO patients after coronary surgery and postcardiotomy cardiogenic shock. METHODS Between 2006 and 2017, a total of 92 patients with PCS after CABG underwent vaECMO-implantation at our institution. After a 1:1 propensity score match (PSM) for relevant preoperative data, we identified a cohort of 32 patients, 16 males, and 16 females. Periprocedural and short-term outcome data were analyzed with respect to sex differences. RESULTS The mean age was 64 ± 11 years, and 79% (n = 73) were male patients. Clinical outcomes showed a 30-day all-cause mortality of 64% (n = 59). After PSM, male patients showed a significantly smaller number of arterial grafts (0.4 ± 0.53 male vs 1.1 ± 0.7 female; p = 0.037). Thirty-day all-cause mortality did not differ between the groups (56% male vs 75% female; p = 0.262). In general, short-term outcome data were comparable without significant differences for the matched groups. CONCLUSION Gender has no impact on patients with vaECMO therapy due to PCS in isolated coronary surgery.
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Affiliation(s)
- Stephen Gerfer
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Christopher Gaisendrees
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Borko Ivanov
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Julia Merkle
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Georg Schlachtenberger
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Christian Rustenbach
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Ferdinand Kuhn-Régnier
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Navid Mader
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
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21
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Yin K, March RJ, Hoopes CW, Balk RA, Raman J, Lateef OB, Tiwari A, Bak E, Karlson KJ, Edwards NM, Dobrilovic N. Extracorporeal membrane oxygenation in the management of granulomatosis with polyangiitis. J Card Surg 2020; 36:743-747. [PMID: 33350513 DOI: 10.1111/jocs.15252] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 10/14/2020] [Accepted: 11/22/2020] [Indexed: 11/28/2022]
Abstract
Granulomatosis with polyangiitis (GPA, also known as Wegener's granulomatosis) is a type of systematic vasculitis that primarily involves the lung and kidney. Diffuse alveolar hemorrhage (DAH) and associated acute respiratory failure are uncommon but devastating complications of GPA. Experience in using extracorporeal membrane oxygenation (ECMO) to manage DAH caused by GPA is limited. We report two GPA patients with DAH that were successfully managed using ECMO support. Examining 13 cases identified in the literature and two of our own, we observed that most patients experienced rapid deterioration in respiratory function in conjunction with a precedent respiratory infection. All 15 patients received veno-venous ECMO support. The median duration of ECMO support was 11 days (interquartile range: 7.5-20.75 days). Bleeding was the most common complication, seen in four (26.7%) cases. All patients were successfully weaned off ECMO after a median length of hospital stay of 42 days (interquartile range: 30-78 days). We demonstrated that the use of ECMO is a reasonable and effective support option in the management of GPA patients with DAH. The risk of bleeding is high but maybe reduced using a lower anticoagulation goal.
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Affiliation(s)
- Kanhua Yin
- Division of Cardiac Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Robert J March
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Charles W Hoopes
- Division of Cardiothoracic Surgery, University of Alabama School of Medicine, Birmingham, Alabama, USA
| | - Robert A Balk
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Jaishankar Raman
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Omar B Lateef
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Ankur Tiwari
- Division of Cardiac Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Erica Bak
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Karl J Karlson
- Division of Cardiac Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Niloo M Edwards
- Division of Cardiac Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Nikola Dobrilovic
- Division of Cardiac Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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22
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Artemiou P, Gasparovic I, Bezak B, Hudec V, Glonek I, Hulman M. Preoperative extracorporeal membrane oxygenation for postinfarction ventricular septal defect: Case series of three patients with a literature review. J Card Surg 2020; 35:3626-3630. [DOI: 10.1111/jocs.15086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/02/2020] [Accepted: 09/21/2020] [Indexed: 12/29/2022]
Affiliation(s)
- Panagiotis Artemiou
- Department of Cardiac Surgery, Clinic of Cardiac Surgery, National Institute of Cardiovascular Diseases Medical Faculty of the Comenius University Bratislava Slovakia
| | - Ivo Gasparovic
- Department of Cardiac Surgery, Clinic of Cardiac Surgery, National Institute of Cardiovascular Diseases Medical Faculty of the Comenius University Bratislava Slovakia
| | - Branislav Bezak
- Department of Cardiac Surgery, Clinic of Cardiac Surgery, National Institute of Cardiovascular Diseases Medical Faculty of the Comenius University Bratislava Slovakia
| | - Vladan Hudec
- Department of Cardiac Surgery, Clinic of Cardiac Surgery, National Institute of Cardiovascular Diseases Medical Faculty of the Comenius University Bratislava Slovakia
| | - Ivan Glonek
- Department of Cardiac Surgery, Clinic of Cardiac Surgery, National Institute of Cardiovascular Diseases Medical Faculty of the Comenius University Bratislava Slovakia
| | - Michal Hulman
- Department of Cardiac Surgery, Clinic of Cardiac Surgery, National Institute of Cardiovascular Diseases Medical Faculty of the Comenius University Bratislava Slovakia
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23
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Orozco-Hernandez EJ, Ahmed MI, Von Meering G, Mcelwee SK, Prejean SP, Gongora E, Hoopes CW. Femoral venoarterial extracorporeal membrane oxygenation using a novel biatrial cannula for venous drainage and left ventricular venting. J Card Surg 2020; 35:3631-3633. [PMID: 33001516 DOI: 10.1111/jocs.15087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/29/2020] [Accepted: 09/21/2020] [Indexed: 12/01/2022]
Abstract
Extracorporeal life support (ECLS) is an expanding technology for patients in cardiogenic shock. The majority of patients requiring ECLS can be managed with percutaneous venoarterial (VA) femoral cannulation. Despite sufficient extracorporeal circulatory support, a unclear number of patients develop left ventricular distension which can result in increased wall tension and stress as well as worsening pulmonary edema. Indications to vent the left ventricle can be controversial. When venting is indicated, a number of additional procedures may be considered including inotropic support, intra-aortic balloon pump, impella, balloon atrial septostomy, or placement of a transseptal cannula. We present a unique case of a femoral VA extracorporeal membrane oxygenation as a bridge to transplant with left-sided venting using a Bio-Medicus NextGen cannula (Medtronic) with a transseptal approach.
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Affiliation(s)
- Erik J Orozco-Hernandez
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Mustafa I Ahmed
- Section of Interventional Cardiology, Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Greg Von Meering
- Section of Interventional Cardiology, Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Samuel K Mcelwee
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Shane P Prejean
- Section of Interventional Cardiology, Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Enrique Gongora
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Charles W Hoopes
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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24
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Franzese I, Cetera V, Pesarini G, Onorati F, Ribichini FL, Faggian G, Milano AD. Transapical mitral valve-in-valve procedure with elective venoarterial ECMO in a patient with severe kyphoscoliosis. J Card Surg 2020; 35:3217-3219. [PMID: 32790016 DOI: 10.1111/jocs.14949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/03/2020] [Accepted: 08/03/2020] [Indexed: 11/27/2022]
Abstract
Transcatheter mitral valve-in-valve replacement (TMVR) is a feasible alternative in high-risk patients requiring reoperation for failing mitral bioprosthesis. Such patients may present with hemodynamic instability or sudden complications, which may jeopardize the outcomes. We report a successful transapical TMVR in a patient, with severe kyphoscoliosis and on prolonged mechanical ventilation, with prophylactic extracorporeal membrane oxygenator support. This combined procedure may be helpful to reduce the complications of TMVR in critically ill subjects.
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Affiliation(s)
- Ilaria Franzese
- Division of Cardiac Surgery, Department of Surgery, University of Verona, Verona, Italy
| | - Vera Cetera
- Division of Cardiac Surgery, Department of Surgery, University of Verona, Verona, Italy
| | - Gabriele Pesarini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Francesco Onorati
- Division of Cardiac Surgery, Department of Surgery, University of Verona, Verona, Italy
| | - Flavio L Ribichini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Giuseppe Faggian
- Division of Cardiac Surgery, Department of Surgery, University of Verona, Verona, Italy
| | - Aldo D Milano
- Department of Emergency and Organ Transplants, Cardiac Surgery Unit, University of Bari Medical School, Bari, Italy
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25
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Popov AF, Berger R, Schlensak C, Bongers MN, Haeberle H, Acharya M, Lausberg HF. Mechanical circulatory support for cardiovascular complications in a young COVID-19 patient. J Card Surg 2020; 35:3173-3175. [PMID: 32740953 PMCID: PMC7436693 DOI: 10.1111/jocs.14916] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/06/2020] [Accepted: 07/22/2020] [Indexed: 12/28/2022]
Abstract
Background: The current coronavirus (COVID‐19) pandemic is associated with severe pulmonary and cardiovascular complications. Case presentation: This report describes a young patient with COVID‐19 without any comorbidity presenting with severe cardiovascular complications, manifesting with pulmonary embolism, embolic stroke, and right heart failure. Conclusion: Management with short‐term mechanical circulatory support, including different cannulation strategies, resulted in a successful outcome despite his critical cardiovascular status.
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Affiliation(s)
- Aron Frederik Popov
- Department of Cardiothoracic and Vascular Surgery, University of Tuebingen, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - R Berger
- Department of Cardiothoracic and Vascular Surgery, University of Tuebingen, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Christian Schlensak
- Department of Cardiothoracic and Vascular Surgery, University of Tuebingen, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Malte N Bongers
- Department of Diagnostic and Interventional Radiology, University of Tuebingen, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Helene Haeberle
- Department of Anaesthesiology and Intensive Care Medicine, University of Tübingen, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Metesh Acharya
- Department of Cardiac Surgery, Glenfield Hospital, Leicester, UK
| | - Henning F Lausberg
- Department of Cardiothoracic and Vascular Surgery, University of Tuebingen, Eberhard-Karls-University Tübingen, Tübingen, Germany
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26
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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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27
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Lang H, Milanuk M, Brady J, Trujillo K, Lyden E, Merritt-Genore H. Outcomes of noncardiotomy patients requiring postoperative extracorporeal membrane oxygenation. J Card Surg 2020; 35:1444-1451. [PMID: 32383223 DOI: 10.1111/jocs.14598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The use of extracorporeal membrane oxygenation (ECMO) in the postoperative period has expanded to include a variety of noncardiotomy procedures. It is important to investigate outcomes for this uniquely ill subset of patients as currently published data on this subject is limited. METHODS All ECMO events at our institution from 2006 to 2017 were retrospectively considered. Patients were grouped into a postoperative noncardiotomy (PNC) cohort (n = 20) and a larger control cohort (n = 220). For additional analysis, the PNC cohort was further split into a liver transplant group (n = 4) and thoracic surgery group (n = 10). Basic demographics, medical history, type of operation performed, indication for support, and survival data were collected on all patients. Appropriate statistical analyses were performed and a P < .05 was considered statistically significant. RESULTS Twenty PNC-ECMO patients were identified. The indications for support were respiratory failure, cardiac arrest, and cardiogenic shock. PNC patient survival was similar to our control cohort, as well as extracorporeal life support organization (ELSO) published data with 55% weaning off ECMO and 50% surviving to discharge. Twelve-month predicted survival was 40%. Post thoracic surgical patients were reviewed, and their survival rates were similar to the larger control cohort as well. There were no survivors in the liver transplant group. CONCLUSIONS Despite recent noncardiotomy surgery, patients who required ECMO for salvage in the postoperative period showed similar outcomes compared to our larger cohort and to published ELSO data, and reasonable long-term survival outcomes. This suggests that ECMO may be applied to a variety of postoperative settings with outcomes on par with nationally published results.
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Affiliation(s)
- Harrison Lang
- Division of Cardiothoracic Surgery, School of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Mitchell Milanuk
- Division of Cardiothoracic Surgery, School of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - John Brady
- Division of Cardiothoracic Surgery, School of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Karin Trujillo
- Division of Cardiothoracic Surgery, School of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Elizabeth Lyden
- School of Public Health, University of Nebraska Medical Center, Omaha, Nebraska
| | - HelenMari Merritt-Genore
- Division of Cardiothoracic Surgery, School of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
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28
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Ayers B, Wood K, Melvin A, Prasad S, Gosev I. MELD-XI is predictive of mortality in venoarterial extracorporeal membrane oxygenation. J Card Surg 2020; 35:1275-1282. [PMID: 32340073 DOI: 10.1111/jocs.14578] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a life-saving method of supporting critically ill patients. However, it is expensive and associated with high morbidity and mortality, making early predictive outcome modeling extremely valuable. The model for end-stage liver disease-excluding international normalized ratio (MELD-XI) scoring system has been shown to have prognostic value in other critically ill patient populations. MATERIALS AND METHODS A single-center retrospective review was performed for all adult patients managed on VA-ECMO from May 2011 to January 2018 (n = 247). Patients were included in the study if MELD-XI scores could be calculated during the first 48 hours on ECMO (n = 187). Receiver operating characteristic curve analysis was performed for MELD-XI in regard to in-hospital mortality. RESULTS Of the 187 patients, 74 (40%) patients had MELD-XI less than 14 (low-risk) and 113 (60%) had a MELD-XI of 14 or greater (high-risk). The cohorts did not differ significantly in terms of patient characteristics or indication for ECMO. The high-risk MELD-XI group had significantly greater mortality during index hospitalization compared to the low-risk group (74% vs 39%; P < .0001). Quartile stratification demonstrated progressively worse prognosis associated with higher MELD-XI scores; the fourth quartile showed a ninefold increased risk of mortality compared to the first quartile (P < .001). The AUC for predicting index hospitalization mortality was 0.69 (95% CI, 0.62-0.77) with a Youden index (J) of 0.36 and optimized cutoff of 12.98. CONCLUSIONS These findings suggest that the MELD-XI scoring system can be applied to the VA-ECMO patient population early in their course of ECMO as a prognostic tool to aid in complex clinical decision making.
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Affiliation(s)
- Brian Ayers
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York
| | - Katherine Wood
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York
| | - Amber Melvin
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York
| | - Sunil Prasad
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York
| | - Igor Gosev
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York
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29
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Djordjevic I, Eghbalzadeh K, Sabashnikov A, Deppe AC, Kuhn E, Merkle J, Weber C, Ivanov B, Ghodsizad A, Rustenbach C, Adler C, Rahmanian P, Mader N, Kuhn-Regnier F, Zeriouh M, Wahlers T. Central vs peripheral venoarterial ECMO in postcardiotomy cardiogenic shock. J Card Surg 2020; 35:1037-1042. [PMID: 32227395 DOI: 10.1111/jocs.14526] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 03/03/2020] [Accepted: 03/13/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Central or peripheral venoarterial extracorporeal membrane oxygenation (va ECMO) is widely used in postcardiotomy cardiogenic shock (PCS). Available data suggest controversial results for both types. Our aim was to investigate PCS patients treated with either peripheral (pECMO) or central ECMO (cECMO) concerning their outcome. METHODS Between April 2006 and October 2016, 156 consecutive patients with va ECMO therapy due to PCS were identified and included in this retrospective analysis. Patients were divided into cECMO and pECMO groups. Statistical analysis of risk factors concerning 30-day mortality of the mentioned patient cohort was performed using IBM SPSS Statistics. RESULTS Fifty-six patients received cECMO and 100 patients were treated with pECMO due to PCS. In the group of cECMO peripheral vascular disease was significantly more present (cECMO 19 [34%] vs pECMO 14 [14%]; P < .01). On-site ECMO complications occurred significantly more frequent in patients treated with cECMO (cECMO 44 [79%] vs pECMO 54 [54%] g/dL; P < 0.01). More often cECMO patients required a second look operation due to mediastinal bleeding (cECMO 52 [93%] vs pECMO 61 [61%] g/dL; P < .01). Thirty-day mortality was comparable with nearly 70% in both cohorts (cECMO 39 [70%] vs pECMO 69 [69%]; P = .93). CONCLUSION Patients supported by cECMO or pECMO due to refractory PCS did not show significant differences in 30-day mortality, despite a lower incidence of on-site ECMO complications and re-exploration in pECMO patients. PCS itself is associated with high mortality and peripheral cannulation might help to save resources compared with central cannulation.
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Affiliation(s)
- Ilija Djordjevic
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,ECMO Centre, University Hospital Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,ECMO Centre, University Hospital Cologne, Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,ECMO Centre, University Hospital Cologne, Cologne, Germany
| | - Antje-Christin Deppe
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,ECMO Centre, University Hospital Cologne, Cologne, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,ECMO Centre, University Hospital Cologne, Cologne, Germany
| | - Julia Merkle
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,ECMO Centre, University Hospital Cologne, Cologne, Germany
| | - Carolyn Weber
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,ECMO Centre, University Hospital Cologne, Cologne, Germany
| | - Borko Ivanov
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Ali Ghodsizad
- Division of Thoracic Transplantation and Mechanical Support, Miami Transplant Institute, Jackson Health System, Miami, Florida
| | - Christian Rustenbach
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Christoph Adler
- Department of Cardiology, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Parwis Rahmanian
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Navid Mader
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Ferdinand Kuhn-Regnier
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Mohamed Zeriouh
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,ECMO Centre, University Hospital Cologne, Cologne, Germany
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30
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Prasad A, Brehm CE, Goldenberg M, Ghodsizad A, Koerner MM, El-Banayosy A, Singbartl K. Early prediction of transition to durable mechanical circulatory support in patients undergoing peripheral veno-arterial extracorporeal membrane oxygenation for critical cardiogenic shock. Artif Organs 2019; 44:402-410. [PMID: 31660618 DOI: 10.1111/aor.13590] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 10/22/2019] [Accepted: 10/24/2019] [Indexed: 01/02/2023]
Abstract
Peripheral veno-arterial extracorporeal membrane oxygenation (pVA-ECMO) has gained increasing value in the management of patients with critical cardiogenic shock (cCS), allowing time for myocardial recovery. Failure of myocardial recovery has life-altering consequences: transition to durable mechanical circulatory support (dMCS), urgent heart transplantation, or withdrawal of support. Clinical factors controlling myocardial recovery under these circumstances remain largely unknown. Using a retrospective cohort, we developed a model for early prediction of transition to dMCS in patients undergoing pVA-ECMO for cCS. To promote myocardial recovery, our clinical management centered around left ventricular pressure unloading, that is, targeting pulmonary capillary wedge pressures (PCWP) ≤18 mm Hg. We collected demographic data, laboratory findings, inotrope use, and two-dimensional transthoracic echocardiography measurements, all limited to the first 72h of pVA-ECMO (D1-3). Out of 70 patients who were alive after pVA-ECMO, 27 patients underwent implantation of dMCS. There was no significant difference in survival to hospital discharge between patients with or without transition to dMCS. Ejection fractionD1-3 (per 10% increase, OR 0.37 [0.17-0.79]) and amount of inotropic supportD1-3 (OR 4.77 [1.6-14.18]) but neither myocardial wall tension nor PCWP emerged as significant predictors of transition to dMCS. Optimism-corrected c-index (0.90 [0.89-0.90]) revealed an excellent discriminative ability of our model. In summary, our model for early prediction of transition to dMCS in patients with cCS undergoing pVA-ECMO identifies indicators of inotropic state as relevant factors. Absence of markers for myocardial oxygen consumption or left ventricular pressure loading allows us to hypothesize sufficient cardiac unloading in our cohort with PCWP-targeted management.
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Affiliation(s)
- Amit Prasad
- Heart and Vascular Institute, Penn State Health, Hershey, PA, USA
| | | | | | - Ali Ghodsizad
- Miami Transplant Institute, University of Miami, Miami, FL, USA
| | - Michael M Koerner
- Advanced Cardiac Care and Transplant Institute, INTEGRIS Baptist Medical Center, Oklahoma City, OK, USA
| | - Aly El-Banayosy
- Advanced Cardiac Care and Transplant Institute, INTEGRIS Baptist Medical Center, Oklahoma City, OK, USA
| | - Kai Singbartl
- Critical Care Medicine, Mayo Clinic, Phoenix, AZ, USA
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31
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Djordjevic I, Rahmanian P, Zeriouh M, Eghbalzadeh K, Sangsari S, Merkle J, Kuhn E, Deppe A, Weber C, Sabashnikov A, Liakopoulos O, Wahlers T. Treatment of cardiogenic shock in peripartum cardiomyopathy: Case series from a tertiary ECMO center. J Card Surg 2019; 35:254-257. [DOI: 10.1111/jocs.14324] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Ilija Djordjevic
- Department of Cardiothoracic Surgery, ECMO Centre Cologne, Heart Centre University Hospital Cologne Cologne Germany
| | - Parwis Rahmanian
- Department of Cardiothoracic Surgery, ECMO Centre Cologne, Heart Centre University Hospital Cologne Cologne Germany
| | - Mohamed Zeriouh
- Department of Cardiothoracic Surgery, ECMO Centre Cologne, Heart Centre University Hospital Cologne Cologne Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, ECMO Centre Cologne, Heart Centre University Hospital Cologne Cologne Germany
| | - Sassan Sangsari
- Department of Cardiothoracic Surgery, ECMO Centre Cologne, Heart Centre University Hospital Cologne Cologne Germany
| | - Julia Merkle
- Department of Cardiothoracic Surgery, ECMO Centre Cologne, Heart Centre University Hospital Cologne Cologne Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, ECMO Centre Cologne, Heart Centre University Hospital Cologne Cologne Germany
| | - Antje‐Christin Deppe
- Department of Cardiothoracic Surgery, ECMO Centre Cologne, Heart Centre University Hospital Cologne Cologne Germany
| | - Carolyn Weber
- Department of Cardiothoracic Surgery, ECMO Centre Cologne, Heart Centre University Hospital Cologne Cologne Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, ECMO Centre Cologne, Heart Centre University Hospital Cologne Cologne Germany
| | - Oliver Liakopoulos
- Department of Cardiothoracic Surgery, ECMO Centre Cologne, Heart Centre University Hospital Cologne Cologne Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, ECMO Centre Cologne, Heart Centre University Hospital Cologne Cologne Germany
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Djordjevic I, Eghbalzadeh K, Sabashnikov A, Deppe AC, Kuhn EW, Seo J, Weber C, Merkle J, Adler C, Rahmanian PB, Liakopoulos OJ, Mader N, Kuhn-Regnier F, Zeriouh M, Wahlers T. Single center experience with patients on veno arterial ECMO due to postcardiotomy right ventricular failure. J Card Surg 2019; 35:83-88. [PMID: 31692108 DOI: 10.1111/jocs.14332] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Right ventricular (RV) failure is associated with poor outcome and increased mortality in cardiac surgery. Aim of our study was to analyze the outcome of veno arterial extracorporeal membrane oxygenation (va ECMO) therapy in patients with isolated RV failure in postcardiotomy cardiogenic shock (PCS) and to evaluate risk factors associated with 30-day-mortality. METHODS Between August 2006 until August 2016, 64 consecutive patients with va ECMO therapy due to fulminant RV failure in PCS were identified and included in this retrospective observation. Further, outcome data and a comparison of va ECMO survivors and nonsurvivors was conducted. RESULTS The mean age of the patient cohort was 63 ± 14 years. Patients were treated with va ECMO for 79 ± 61 hours. Twenty-eight patients (44%) were successfully weaned off ECMO support. Overall 30-day-mortality was 88% (56/64). Hemoglobin concentration before ECMO implantation, maximum rise of muscle-brain type creatine kinase during ECMO therapy, as well as lactic acid concentration 24 hours after initiation of va ECMO therapy were predictive for 30-day mortality. CONCLUSION ECMO therapy in RV failure due to PCS is shown to be associated with an excessive mortality. Regarding our data, va ECMO might only be an appropriate short-term mechanical assist device separating patients form cardiopulmonary bypass with an acceptable weaning rate. Particularly, in case of failed hemodynamic recovery of the right heart on va ECMO, direct RV bypass systems might function as a bailout option. Additionally, cardiac enzymes and lactic acid might provide valuable information in meeting therapy-related decisions.
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Affiliation(s)
- Ilija Djordjevic
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,Heart Centre, ECMO Centre Cologne, University Hospital Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,Heart Centre, ECMO Centre Cologne, University Hospital Cologne, Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,Heart Centre, ECMO Centre Cologne, University Hospital Cologne, Cologne, Germany
| | - Antje C Deppe
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,Heart Centre, ECMO Centre Cologne, University Hospital Cologne, Cologne, Germany
| | - Elmar W Kuhn
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,Heart Centre, ECMO Centre Cologne, University Hospital Cologne, Cologne, Germany
| | - Joon Seo
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Carolyn Weber
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,Heart Centre, ECMO Centre Cologne, University Hospital Cologne, Cologne, Germany
| | - Julia Merkle
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Christoph Adler
- Department of Cardiology, University Hospital Cologne, Cologne, Germany
| | - Parwis B Rahmanian
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Oliver J Liakopoulos
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Navid Mader
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Ferdinand Kuhn-Regnier
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Mohamed Zeriouh
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,Heart Centre, ECMO Centre Cologne, University Hospital Cologne, Cologne, Germany
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33
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Hassan MF, Lawrence M, Lee D, Velazco J, Martin C, Reddy R. Simplified percutaneous VA ECMO decannulation using the MANTA vascular closure device: Initial US experience. J Card Surg 2019; 35:217-221. [PMID: 31899831 DOI: 10.1111/jocs.14308] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Mohammed F Hassan
- Division of Cardiothoracic Surgery, Baylor Scott & White Medical Center, Temple, Texas
| | - Mark Lawrence
- Division of Cardiology, Baylor Scott & White Medical Center, Temple, Texas
| | - Daniel Lee
- Division of Cardiothoracic Surgery, Baylor Scott & White Medical Center, Temple, Texas
| | - Jorge Velazco
- Division of Critical Care, Baylor Scott & White Medical Center, Temple, Texas
| | | | - Ramachandra Reddy
- Division of Cardiothoracic Surgery, Baylor Scott & White Medical Center, Temple, Texas
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Quader M, Hawkins RB, Mehaffey JH, Mazimba S, Ailawadi G, Yarboro L, Rich J, Speir A, Fonner C, Wolfe L, Kasirajan V. Primary graft dysfunction after heart transplantation: Outcomes and resource utilization. J Card Surg 2019; 34:1519-1525. [PMID: 31609510 DOI: 10.1111/jocs.14274] [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: 10/25/2022]
Abstract
BACKGROUND A unified definition of primary graft dysfunction (PGD) after heart transplantation was adopted in 2014, with moderate and severe PGD defined as a need for mechanical circulatory support. While risk factors for PGD are well identified, outcomes and resource utilization have not been well-studied. We examined the resource utilization and associated costs with PGD. METHODS All adult heart transplantations (2001-2016) from a statewide Society of Thoracic Surgery database were analyzed by dividing them into two groups-with PGD (requiring mechanical circulatory support) and without PGD. RESULTS Of the 718 heart transplants, 110 (15.3%) patients developed PGD. Prevalence of PGD for the study duration ranged from 3.7% to 22.7% with no significant trend. The most frequently used mechanical circulatory support device was intra-aortic balloon pump (88%), followed by extracorporeal membrane oxygenation (17%), and catheter-based circulatory support devices (3%). There were no significant differences in demographics or preoperative variables between the two groups. Resource utilization such as total intensive care unit hours, ventilation hours, reoperation for bleeding, blood product transfusions, and length of stay were significantly higher in the PGD group. Postoperative complications were also higher in PGD group including operative mortality (31.8% vs 3.8%, P < .0001). The median cost of heart transplantation was significantly higher in the PGD group $229 482 ($126 044-$388 889) vs $101 788 ($72 638-$181 180) P < .0001. CONCLUSION Primary graft dysfunction following heart transplantation developed in 15% of patients. Patients with PGD had significantly higher complications, resource utilization, and mortality. Preventive measures to address the development of PGD would reduce resource utilization and improve outcomes.
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Affiliation(s)
- Mohammed Quader
- Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Robert B Hawkins
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - J Hunter Mehaffey
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Sula Mazimba
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Leora Yarboro
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Jeffrey Rich
- Virginia Cardiac Services Quality Initiative, Virginia Beach, Virginia
| | - Alan Speir
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Clifford Fonner
- Virginia Cardiac Services Quality Initiative, Virginia Beach, Virginia
| | - Luke Wolfe
- Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Vigneshwar Kasirajan
- Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, Virginia
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35
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Rinewalt D, Shudo Y, Kawana M, Woo YJ. Physical therapy in successful venoarterial extracorporeal membrane oxygenation bridge to orthotopic heart transplantation. J Card Surg 2019; 34:1390-1392. [PMID: 31441558 DOI: 10.1111/jocs.14220] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a temporary mechanical circulatory support system that may be used as a lifesaving therapy for patients in acute heart failure and as a bridge to definitive management. Physical therapy in these patients remains challenging, with limited protocols to guide practitioners. METHODS We describe a case of a 37-year-old gentleman who presented with familial cardiomyopathy and cardiogenic shock. RESULTS Our patient underwent urgent peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) followed by successful heart transplantation. While on ECMO support he was enrolled in a physical therapy program that included the VitalGo Tilt Bed to improve lower body weight bearing while avoiding hip flexion and damage to the peripheral ECMO cannulae. The patient was discharged home expeditiously after heart transplant due to aggressive physical rehabilitation while on full VA-ECMO support. CONCLUSIONS Early intensive physical rehabilitation is feasible and safe and may result in improved outcomes and expeditious discharge in VA ECMO patients. Protocol driven multidisciplinary physical therapy with a patient on femorally cannulated VA-ECMO retains the advantages of lower extremity peripheral cannulation while eliminating the risks of immobility. The new UNOS allocation system may result in a successful bridge to transplantation in patients on VA-ECMO due to the increased prioritization of this population to receive donor organs.
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Affiliation(s)
- Daniel Rinewalt
- Department of Cardiothoracic Surgery, Stanford University, Palo Alto, California
| | - Yasuhiro Shudo
- Department of Cardiothoracic Surgery, Stanford University, Palo Alto, California
| | - Masataka Kawana
- Cardiovascular Institute, Stanford University, Palo Alto, California
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Palo Alto, California
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36
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Ayaon Albarrán A, Pérez Chulia N, Meca Aguirrezabalaga J, Blázquez González JA. Thrombus straddling a patent foramen ovale and massive pulmonary embolism: Venous arterial extracorporeal membrane oxygenation as a valuable support tool. J Card Surg 2019; 34:867-870. [PMID: 31233236 DOI: 10.1111/jocs.14123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 05/15/2019] [Accepted: 05/27/2019] [Indexed: 12/19/2022]
Abstract
Thrombus straddling a patent foramen ovale and massive pulmonary embolism is a very rare and life-threatening condition. Optimal management can be controversial because different therapeutic options are available and individual approach based in individual risk is needed. We present a case of a thrombus straddling the patent foramen ovale with massive pulmonary embolism, hemodynamic instability, and upper extremity embolism. We performed surgical pulmonary embolectomy, and venous arterial extracorporeal membrane oxygenation was needed to successfully overcome severe right ventricular impairment and pulmonary injury.
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Affiliation(s)
- Ali Ayaon Albarrán
- Adult Cardiac Surgery Department, La Paz University Hospital, Madrid, Spain
| | - Nuria Pérez Chulia
- Anesthesiology Department, Division of Cardiothoracic Anesthesia, La Paz University Hospital, Madrid, Spain
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37
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Sugiyama K, Suzuki S, Fujiyoshi T, Koizumi N, Sato M, Ogino H. Extracorporeal membrane oxygenation after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. J Card Surg 2019; 34:428-434. [PMID: 31017313 DOI: 10.1111/jocs.14052] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 03/04/2019] [Accepted: 04/02/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Pulmonary endarterectomy (PEA) is the treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH) but can result in respiratory and cardiac complications that may require extracorporeal membrane oxygenation (ECMO). We reviewed our experience with ECMO in patients undergoing PEA. METHODS AND RESULTS Between January 2012 and August 2015, 35 patients underwent PEA for CTEPH. In all, four patients (11%) required veno-arterial (V-A) ECMO support due to severe cardiac and respiratory failure, including severe reperfusion pulmonary edema and persistent pulmonary hypertension. No significant differences in preoperative characteristics were found between patients who required ECMO and those who did not require ECMO. ECMO support was associated with a significantly higher incidence of postoperative respiratory complications, a longer intensive care unit stay, increased in-hospital mortality, residual pulmonary hypertension, and postoperative balloon pulmonary angioplasty (BPA). The postoperative mean pulmonary artery pressure and pulmonary vascular resistance were significantly higher in patients requiring ECMO. All patients requiring ECMO were successfully weaned off ECMO support (100%), and three of them were discharged from the hospital alive (75%). CONCLUSIONS Patients with CTEPH may benefit from ECMO after PEA for cardiac and respiratory complications. A prompt decision to use V-A ECMO is critical for a successful outcome in these patients.
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Affiliation(s)
- Kayo Sugiyama
- Department of Cardiac Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Shun Suzuki
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Toshiki Fujiyoshi
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Nobusato Koizumi
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masato Sato
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
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38
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Koerner MM, Harper MD, Gordon CK, Horstmanshof D, Long JW, Sasevich MJ, Neel JD, El Banayosy A. Adult cardiac veno-arterial extracorporeal life support (VA-ECMO): prevention and management of acute complications. Ann Cardiothorac Surg 2019; 8:66-75. [PMID: 30854314 DOI: 10.21037/acs.2018.12.09] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been shown to be a viable and effective treatment for patients suffering from refractory cardiogenic shock (rCS), which is associated with high mortality rates. Although ECMO therapy used as short-term mechanical circulatory support (MCS) has shown tremendous growth in its application over the past decade, the complication and mortality rates remain high. This retrospective study analyzes complications associated with VA-ECMO support, evaluates the use of defined protocols at a single center, and examines factors that may contribute to patient complication and mortality. Methods This retrospective analysis included 184 patients who were supported with ECMO from September 2014 through March 2018 at Integris Baptist Medical Center (IBMC). Descriptive statistics were generated to analyze baseline characteristics, demographics, complications, and outcomes. Results Acute myocardial infarct (AMI) was the primary etiology of this cohort (N=40; 22%). The mean age was 55±15 (median 56, range 15-84) years. All patients were inotrope and/or vasopressor dependent prior to ECMO initiation. Mean time on ECMO support was 7.8±7.9 days with median time of 6 days. Total patient days on support were 1,430. Most ECMO cannulations, 97 (52%) were performed within Integris Baptist Medical Center, with 48% done outside the hospital; 38% were performed outside of the hospital by the IBMC ECMO team, and 10.5% were performed by an outside team. Bleeding was noted to be the most common VA ECMO complication [N=41; 22.3%; 0.028 events per patient day (EPPD)]. Conclusions A dedicated 24/7 ECMO service using a multidisciplinary team (MDT) and defined protocols in a single center is able to effectively reduce complications due to VA-ECMO support in the sickest of the sick VA-ECMO patients.
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Affiliation(s)
- Michael M Koerner
- Advanced Cardiac Care and Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, USA
| | - Michael D Harper
- Advanced Cardiac Care and Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, USA
| | - Christopher K Gordon
- Advanced Cardiac Care and Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, USA
| | - Douglas Horstmanshof
- Advanced Cardiac Care and Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, USA
| | - James W Long
- Advanced Cardiac Care and Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, USA
| | - Michael J Sasevich
- Advanced Cardiac Care and Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, USA
| | - James D Neel
- Advanced Cardiac Care and Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, USA
| | - Aly El Banayosy
- Advanced Cardiac Care and Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, USA
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39
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Grant AA, Hart VJ, Lineen EB, Forsberg BC, Klima A, Mirsaeidi M, Schulman IH, Badiye A, Vianna RM, Patel A, Loebe M, Ghodsizad A. Rescue therapy for hypercapnia due to high PEEP mechanical ventilation in patients with ARDS and renal failure. Artif Organs 2018; 43:599-604. [PMID: 30431163 DOI: 10.1111/aor.13393] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 11/02/2018] [Accepted: 11/06/2018] [Indexed: 11/30/2022]
Abstract
Extracorporeal removal of carbon dioxide in patients experiencing severe hypercapnia due to lung protective mechanical ventilation was first described over four decades ago. There have been many devices developed and described in the interim, many of which require additional training, resources, and staff. This manuscript describes a readily available and relatively simple adjunct that can provide partial lung support in patients with acute respiratory distress syndrome complicated by severe hypercapnia and acute kidney injury requiring dialysis.
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Affiliation(s)
- April A Grant
- Dewitt Daughtry Family Department of Surgery, Division of Trauma, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida.,Jackson Health System & Ryder Trauma Center, Miami, Florida
| | - Valerie J Hart
- Dewitt Daughtry Family Department of Surgery, Division of Trauma, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida.,Jackson Health System & Ryder Trauma Center, Miami, Florida
| | - Edward B Lineen
- Dewitt Daughtry Family Department of Surgery, Division of Trauma, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida.,Jackson Health System & Ryder Trauma Center, Miami, Florida
| | | | - Alan Klima
- Comprehensive Care Services, Inc, Livonia, Michigan
| | - Mehdi Mirsaeidi
- Department of Medicine, Division of Pulmonology and Sleep Medicine, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida
| | - Ivonne H Schulman
- Department of Medicine, Division of Nephrology, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida
| | - Amit Badiye
- Department of Medicine, Division of Cardiology, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida
| | - Rodrigo M Vianna
- Miami Transplant Institute, Miami, Florida.,Dewitt Daughtry Family Department of Surgery, Liver, Intestinal and Multivisceral Transplant, University of Miami, Leonard M Miller School of Medicine, Miami, Florida
| | - Amit Patel
- Dewitt Daughtry Family Department of Surgery, Division of Cardiothoracic Surgery, University of Miami, Leonard M Miller School of Medicine, Miami, Florida
| | - Matthias Loebe
- Miami Transplant Institute, Miami, Florida.,Dewitt Daughtry Family Department of Surgery, Division of Cardiothoracic Surgery, University of Miami, Leonard M Miller School of Medicine, Miami, Florida
| | - Ali Ghodsizad
- Miami Transplant Institute, Miami, Florida.,Dewitt Daughtry Family Department of Surgery, Division of Cardiothoracic Surgery, University of Miami, Leonard M Miller School of Medicine, Miami, Florida
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40
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Eleuteri K, Koerner MM, Horstmanshof D, El Banayosy A. Temporary Circulatory Support and Extracorporeal Membrane Oxygenation. Cardiol Clin 2018; 36:473-485. [PMID: 30297065 DOI: 10.1016/j.ccl.2018.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Cardiogenic shock (CS) refractory to conventional therapies continues to be a challenging medical syndrome, with poor prognosis and high complication and mortality rates. The application and use of temporary mechanical circulatory support (MCS) is a component in the treatment of CS patients and should be applied early in the presentation. Crucial to the success of their application, temporary MCS devices should be chosen based on degree of patient acuity and etiology of CS. Not all temporary MCS devices deliver the same degree of hemodynamic support and range from minimal support to systemic support via veno-arterial extracorporeal membrane oxygenation.
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Affiliation(s)
- Kimber Eleuteri
- Mechanical Circulatory Support, Medtronic, 500 Old Connecticut Path, Framingham, MA 01701, USA.
| | - Michael Mathias Koerner
- Cardiovascular Intensive Care, Integris Baptist Medical Center, 3300 Northwest Expressway, Oklahoma City, OK 73112, USA
| | - Douglas Horstmanshof
- Department of Heart Failure Cardiology, Integris Baptist Medical Center, 3300 Northwest Expressway, Oklahoma City, OK 73112, USA
| | - Aly El Banayosy
- Department of Heart Failure Cardiology, Integris Baptist Medical Center, 3300 Northwest Expressway, Oklahoma City, OK 73112, USA
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41
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Bautista-Rodriguez C, Sanchez-de-Toledo J, Da Cruz EM. The Role of Echocardiography in Neonates and Pediatric Patients on Extracorporeal Membrane Oxygenation. Front Pediatr 2018; 6:297. [PMID: 30416991 PMCID: PMC6212474 DOI: 10.3389/fped.2018.00297] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 09/21/2018] [Indexed: 11/13/2022] Open
Abstract
Indications for extracorporeal membrane oxygenation (ECMO) and extracorporeal cardiopulmonary resuscitation (ECPR) are expanding, and echocardiography is a tool of utmost importance to assess safety, effectiveness and readiness for circuit initiation and separation. Echocardiography is key to anticipating complications and improving outcomes. Understanding the patient's as well as the ECMO circuit's anatomy and physiology is crucial prior to any ECMO echocardiographic evaluation. It is also vital to acknowledge that the utility of echocardiography in ECMO patients is not limited to the evaluation of cardiac function, and that clinical decisions should not be made exclusively upon echocardiographic findings. Though echocardiography has specific indications and applications, it also has limitations, characterized as: prior to and during cannulation, throughout the ECMO run, upon separation and after separation from the circuit. The use of specific and consistent echocardiographic protocols for patients on ECMO is recommended.
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Affiliation(s)
- Carles Bautista-Rodriguez
- Pediatric Cardiology Department, Hospital Sant Joan de Deu Barcelona, Universitat de Barcelona, Barcelona, Spain
- Department of Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Joan Sanchez-de-Toledo
- Pediatric Cardiology Department, Hospital Sant Joan de Deu Barcelona, Universitat de Barcelona, Barcelona, Spain
- Division of Cardiac Intensive Care, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Eduardo M. Da Cruz
- Department of Pediatrics, Heart Institute, Children's Hospital Colorado, School of Medicine, University of Colorado Denver, Aurora, CO, United States
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42
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Comparing Percutaneous to Open Access for Extracorporeal Membrane Oxygenation in Pediatric Respiratory Failure. Pediatr Crit Care Med 2018; 19:981-991. [PMID: 30080776 PMCID: PMC6173194 DOI: 10.1097/pcc.0000000000001691] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Evaluate trends in method of access (percutaneous cannulation vs open cannulation) for pediatric extracorporeal membrane oxygenation and determine the effects of cannulation method on morbidity and mortality. DESIGN Retrospective cohort study. SETTING AND SUBJECTS The Extracorporeal Life Support Organization's registry was queried for pediatric patients on extracorporeal membrane oxygenation for respiratory failure from 2007 to 2015. INVERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 3,501 patients identified, 77.2% underwent open cannulation, with the frequency of open cannulation decreasing over the study period from approximately 80% to 70% (p < 0.001). Percutaneous cannulation patients were more commonly male (24.2% vs 21.5%; p = 0.01), older (average 7.6 vs 4.5 yr; p < 0.001), and heavier (average 33.0 vs 20.2 kg; p < 0.001). Subset analysis of patients on venovenous extracorporeal membrane oxygenation revealed higher rates of mechanical complications due to blood clots (28.9% vs 22.6%; p = 0.003) or cannula problems (18.9% vs 12.7%; p < 0.001), cannula site bleeding (25.3% vs 20.2%; p = 0.01) and increased rates of cannula site repair in the open cannulation cohort. Limb related complications were not significantly different on subset analysis for venovenous extracorporeal membrane oxygenation patients stratified by access site. Logistic regression analysis revealed that method of access was not associated with a difference in mortality. CONCLUSIONS The proportion of pediatric patients undergoing percutaneous extracorporeal membrane oxygenation cannulation is increasing. Mechanical and physiologic complications occur with both methods of cannulation, but percutaneous cannulation appears safe in this cohort. Further analysis is needed to evaluate long-term outcomes with this technique.
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43
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Grant AA, Badiye A, Vianna RM, Patel A, Namias N, Loebe M, Ghodsizad A. Extracorporeal membrane oxygenation: Establishing a robust, tertiary extracorporeal membrane oxygenation referral center in South Florida. Int J Artif Organs 2018; 41:185-189. [PMID: 29637831 DOI: 10.1177/0391398817753341] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- April A Grant
- 1 Division of Trauma, The Dewitt Daughtry Family Department of Surgery, University of Miami, Leonard M. Miller School of Medicine, Miami, FL, USA.,2 Ryder Trauma Center, Jackson Health System, Miami, FL, USA
| | - Amit Badiye
- 3 Division of Cardiology, Department of Medicine, University of Miami, Leonard M. Miller School of Medicine, Miami, FL, USA
| | - Rodrigo M Vianna
- 4 Division of Liver, Intestinal and Multivisceral Transplant, The Dewitt Daughtry Family Department of Surgery, University of Miami, Leonard M Miller School of Medicine, Miami, FL, USA
| | - Amit Patel
- 5 Division of Cardiothoracic Surgery, The Dewitt Daughtry Family Department of Surgery, University of Miami, Leonard M Miller School of Medicine, Miami, FL, USA
| | - Nicholas Namias
- 1 Division of Trauma, The Dewitt Daughtry Family Department of Surgery, University of Miami, Leonard M. Miller School of Medicine, Miami, FL, USA.,2 Ryder Trauma Center, Jackson Health System, Miami, FL, USA
| | - Matthias Loebe
- 5 Division of Cardiothoracic Surgery, The Dewitt Daughtry Family Department of Surgery, University of Miami, Leonard M Miller School of Medicine, Miami, FL, USA
| | - Ali Ghodsizad
- 5 Division of Cardiothoracic Surgery, The Dewitt Daughtry Family Department of Surgery, University of Miami, Leonard M Miller School of Medicine, Miami, FL, USA
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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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Abstract
Veno-arterial extracorporeal life support (VA-ECLS) provides circulatory and respiratory stabilisation in patients with severe refractory cardiogenic shock. Although randomised controlled trials are lacking, the use of VA-ECLS is increasing and observational studies repeatedly have shown treatment benefits in well-selected patients. Current clinical challenges in VA-ECLS relate to optimal management of the individual patient on extracorporeal support given its inherent complexity. In this review article we will discuss indications, daily clinical management and complications of VA-ECLS in cardiogenic shock refractory to conventional treatment strategies.
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Grant AA, Hart VJ, Lineen EB, Badiye A, Byers PM, Patel A, Vianna R, Koerner MM, El Banayosy A, Loebe M, Ghodsizad A. A Weaning Protocol for Venovenous Extracorporeal Membrane Oxygenation With a Review of the Literature. Artif Organs 2018; 42:605-610. [DOI: 10.1111/aor.13087] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 09/14/2017] [Accepted: 10/27/2017] [Indexed: 11/28/2022]
Affiliation(s)
- April A. Grant
- Dewitt Daughtry Family Department of Surgery, Division of Trauma and Surgical Critical Care; University of Miami, Leonard M. Miller School of Medicine; Miami FL USA
- Jackson Health System & Ryder Trauma Center; Miami FL USA
| | - Valerie J. Hart
- Dewitt Daughtry Family Department of Surgery, Division of Trauma and Surgical Critical Care; University of Miami, Leonard M. Miller School of Medicine; Miami FL USA
- Jackson Health System & Ryder Trauma Center; Miami FL USA
| | - Edward B. Lineen
- Dewitt Daughtry Family Department of Surgery, Division of Trauma and Surgical Critical Care; University of Miami, Leonard M. Miller School of Medicine; Miami FL USA
- Jackson Health System & Ryder Trauma Center; Miami FL USA
| | - Amit Badiye
- Department of Medicine, Division of Cardiology; University of Miami, Leonard M. Miller School of Medicine; Miami FL USA
| | - Patricia M. Byers
- Dewitt Daughtry Family Department of Surgery, Division of Trauma and Surgical Critical Care; University of Miami, Leonard M. Miller School of Medicine; Miami FL USA
- Jackson Health System & Ryder Trauma Center; Miami FL USA
| | - Amit Patel
- Dewitt Daughtry Family Department of Surgery, Division of Cardiothoracic Surgery; University of Miami, Leonard M Miller School of Medicine; Miami FL USA
| | - Rodrigo Vianna
- Miami Transplant Institute, Division of Liver, Intestinal and Multivisceral Transplant; Miami FL USA
- Dewitt Daughtry Family Department of Surgery, Division of Liver and Intestinal Transplant; University of Miami, Leonard M Miller School of Medicine; Miami FL USA
| | - Michael M. Koerner
- Department of Critical Care; Integris Baptist Medical Center; Oklahoma City OK USA
| | - Aly El Banayosy
- Department of Critical Care; Integris Baptist Medical Center; Oklahoma City OK USA
| | - Matthias Loebe
- Dewitt Daughtry Family Department of Surgery, Division of Cardiothoracic Surgery; University of Miami, Leonard M Miller School of Medicine; Miami FL USA
- Miami Transplant Institute, Division of Liver, Intestinal and Multivisceral Transplant; Miami FL USA
| | - Ali Ghodsizad
- Dewitt Daughtry Family Department of Surgery, Division of Cardiothoracic Surgery; University of Miami, Leonard M Miller School of Medicine; Miami FL USA
- Miami Transplant Institute, Division of Liver, Intestinal and Multivisceral Transplant; Miami FL USA
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47
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Ghodsizad A, Lai CM, Grant AA, Mendoza C, Loebe M, Koerner MM, Badiye A. Endovascular crossover perfusion of lower limb in patients supported on venoarterial extracorporeal membrane oxygenation: Rescue therapy or thoughtful approach? J Thorac Cardiovasc Surg 2018; 156:168-170. [PMID: 29921093 DOI: 10.1016/j.jtcvs.2018.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 12/05/2017] [Accepted: 01/06/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Ali Ghodsizad
- Miami Transplant Institute, Miami, Fla; Division of Cardiothoracic Surgery, Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Fla.
| | - Cynthia M Lai
- Miami Transplant Institute, Miami, Fla; Division of Cardiothoracic Surgery, Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Fla
| | - April A Grant
- Division of Trauma and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Fla
| | - Cesar Mendoza
- Division of Cardiology, Department of Medicine, Leonard M. Miller School of Medicine, Miami, Fla
| | - Matthias Loebe
- Miami Transplant Institute, Miami, Fla; Division of Cardiothoracic Surgery, Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Fla
| | | | - Amit Badiye
- Division of Cardiology, Department of Medicine, Leonard M. Miller School of Medicine, Miami, Fla
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48
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Abstract
Major advances have been made in mechanical circulatory support in recent years. Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) provides both pulmonary and circulatory support for critically ill patients with hemodynamic compromise, serving as a bridge to recovery or definitive therapy in the form of transplant or a durable ventricular assist device. In the past, VA ECMO support was used in cases of cardiogenic shock or failure to wean from cardiopulmonary bypass; however, the technology is now being applied to an ever-expanding list of conditions, including massive pulmonary embolism, cardiac arrest, drug overdose, and hypothermia.
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Affiliation(s)
- Christopher S King
- Department of Medicine, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA.
| | - Aviral Roy
- Department of Critical Care, Cooper University Hospital, 427C Dorrance, 1 Cooper Plaza, Camden, NJ 08103, USA
| | - Liam Ryan
- Department of Cardiothoracic Surgery, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Ramesh Singh
- Department of Cardiothoracic Surgery, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA
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49
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Baran DA. Extracorporeal Membrane Oxygenation (ECMO) and the Critical Cardiac Patient. CURRENT TRANSPLANTATION REPORTS 2017; 4:218-225. [PMID: 28932651 PMCID: PMC5577059 DOI: 10.1007/s40472-017-0158-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW This review is to summarize the basics of veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) as it is utilized for critically ill cardiac patients. RECENT FINDINGS ECMO may be instituted in a variety of health care settings, from the emergency room to the operating room. The types of patients who may benefit from ECMO are reviewed in detail. The complications of ECMO are reviewed, including access-related issues and hematologic and neurologic problems. The principles of weaning of ECMO are described. CONCLUSION Due to its versatility and relatively low cost, VA ECMO use is sharply increasing worldwide. It is important to select patients carefully for this mode of therapy as it can keep patients alive even in states of severe neurologic impairment or multiorgan failure. Short courses of ECMO may allow critically ill patients to be salvaged, but ultimately survival depends on resolution of the underlying problem or ability to transition to another more durable mode of cardiac support.
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Affiliation(s)
- David A. Baran
- Advanced Heart Failure, Transplantation and MCS, Sentara Heart Hospital, 600 Gresham Drive, Norfolk, VA 23507 USA
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50
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den Uil CA, Jewbali LS, Heeren MJ, Constantinescu AA, Van Mieghem NM, Reis Miranda DD. Isolated left ventricular failure is a predictor of poor outcome in patients receiving veno-arterial extracorporeal membrane oxygenation. Eur J Heart Fail 2017; 19 Suppl 2:104-109. [DOI: 10.1002/ejhf.853] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Corstiaan A. den Uil
- Department of Cardiology, Thoraxcenter; Erasmus Medical Center; Rotterdam the Netherlands
- Department of Intensive Care Medicine; Erasmus Medical Center; Rotterdam the Netherlands
| | - Lucia S. Jewbali
- Department of Cardiology, Thoraxcenter; Erasmus Medical Center; Rotterdam the Netherlands
- Department of Intensive Care Medicine; Erasmus Medical Center; Rotterdam the Netherlands
| | - Martijn J. Heeren
- Department of Cardiothoracic Surgery, Thoraxcenter; Erasmus Medical Center; Rotterdam the Netherlands
| | | | - Nicolas M. Van Mieghem
- Department of Cardiology, Thoraxcenter; Erasmus Medical Center; Rotterdam the Netherlands
| | - Dinis dos Reis Miranda
- Department of Intensive Care Medicine; Erasmus Medical Center; Rotterdam the Netherlands
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