1
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Raasveld SJ, van den Oord C, Schenk J, van den Bergh WM, Oude Lansink-Hartgring A, van der Velde F, Maas JJ, van de Berg P, Lorusso R, Delnoij TSR, Dos Reis Miranda D, Scholten E, Taccone FS, Dauwe DF, De Troy E, Hermans G, Pappalardo F, Fominskiy E, Ivancan V, Bojčić R, de Metz J, van den Bogaard B, Donker DW, Meuwese CL, De Bakker M, Reddi B, Henriques JPS, Broman LM, Dongelmans DA, Vlaar APJ. The interaction of thrombocytopenia, hemorrhage, and platelet transfusion in venoarterial extracorporeal membrane oxygenation: a multicenter observational study. Crit Care 2023; 27:321. [PMID: 37605277 PMCID: PMC10441744 DOI: 10.1186/s13054-023-04612-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/14/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Thrombocytopenia, hemorrhage and platelet transfusion are common in patients supported with venoarterial extracorporeal membrane oxygenation (VA ECMO). However, current literature is limited to small single-center experiences with high degrees of heterogeneity. Therefore, we aimed to ascertain in a multicenter study the course and occurrence rate of thrombocytopenia, and to assess the association between thrombocytopenia, hemorrhage and platelet transfusion during VA ECMO. METHODS This was a sub-study of a multicenter (N = 16) study on transfusion practices in patients on VA ECMO, in which a retrospective cohort (Jan-2018-Jul-2019) focusing on platelets was selected. The primary outcome was thrombocytopenia during VA ECMO, defined as mild (100-150·109/L), moderate (50-100·109/L) and severe (< 50·109/L). Secondary outcomes included the occurrence rate of platelet transfusion, and the association between thrombocytopenia, hemorrhage and platelet transfusion, assessed through mixed-effect models. RESULTS Of the 419 patients included, median platelet count at admission was 179·109/L. During VA ECMO, almost all (N = 398, 95%) patients developed a thrombocytopenia, of which a significant part severe (N = 179, 45%). One or more platelet transfusions were administered in 226 patients (54%), whereas 207 patients (49%) suffered a hemorrhagic event during VA ECMO. In non-bleeding patients, still one in three patients received a platelet transfusion. The strongest association to receive a platelet transfusion was found in the presence of severe thrombocytopenia (adjusted OR 31.8, 95% CI 17.9-56.5). After including an interaction term of hemorrhage and thrombocytopenia, this even increased up to an OR of 110 (95% CI 34-360). CONCLUSIONS Thrombocytopenia has a higher occurrence than is currently recognized. Severe thrombocytopenia is strongly associated with platelet transfusion. Future studies should focus on the etiology of severe thrombocytopenia during ECMO, as well as identifying indications and platelet thresholds for transfusion in the absence of bleeding. TRIAL REGISTRATION This study was registered at the Netherlands Trial Registry at February 26th, 2020 with number NL8413 and can currently be found at https://trialsearch.who.int/Trial2.aspx?TrialID=NL8413.
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Affiliation(s)
- Senta Jorinde Raasveld
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Centers, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Claudia van den Oord
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Centers, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jimmy Schenk
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Centers, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Epidemiology and Data Science, Amsterdam University Medical Centre, Amsterdam Public Health, University of Amsterdam, Location AMC, Amsterdam, The Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | | | - Jacinta J Maas
- Adult Intensive Care Unit, Leiden University Medical Center, Leiden, The Netherlands
| | - Pablo van de Berg
- Adult Intensive Care Unit, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Roberto Lorusso
- Cardiothoracic Surgery Department, Heart and Vascular Center, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Thijs S R Delnoij
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Intensive Care, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Dinis Dos Reis Miranda
- Adult Intensive Care Unit, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Erik Scholten
- Department of Intensive Care, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Fabio Silvio Taccone
- Department of Intensive Care, Université Libre de Bruxelles, Hôpital Erasme Bruxelles, Brussels, Belgium
| | - Dieter F Dauwe
- Surgical Intensive Care Unit, Department of Intensive Care Medicine, University Hospital Leuven, Leuven, Belgium
| | - Erwin De Troy
- Surgical Intensive Care Unit, Department of Intensive Care Medicine, University Hospital Leuven, Leuven, Belgium
| | - Greet Hermans
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Federico Pappalardo
- Department of CardioThoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Višnja Ivancan
- Department of Anesthesia and Intensive Care, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Robert Bojčić
- Department of Anesthesia and Intensive Care, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Jesse de Metz
- Department of Intensive Care, OLVG, Amsterdam, The Netherlands
| | | | - Dirk W Donker
- Intensive Care Center, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
- Cardiovascular and Respiratory Physiology, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Christiaan L Meuwese
- Adult Intensive Care Unit, Erasmus University Medical Center, Rotterdam, The Netherlands
- Intensive Care Center, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Martin De Bakker
- Department of Critical Care, Royal Adelaide Hospital, Adelaide, Australia
| | - Benjamin Reddi
- Department of Critical Care, Royal Adelaide Hospital, Adelaide, Australia
| | - José P S Henriques
- Department of Cardiology, Amsterdam University Medical Centers, Location Academic Medical Centers, Amsterdam, The Netherlands
| | - Lars Mikael Broman
- ECMO Center Karolinska, Karolinska University Hospital, Stockholm, Sweden
| | - Dave A Dongelmans
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Centers, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Alexander P J Vlaar
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Centers, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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2
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Rychlíčková J, Šrámek V, Suk P. Use of fondaparinux in patients with heparin-induced thrombocytopenia on veno-venous extracorporeal membrane oxygenation: A three-patient case series report. Front Med (Lausanne) 2023; 10:1112770. [PMID: 36910487 PMCID: PMC9996216 DOI: 10.3389/fmed.2023.1112770] [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: 12/05/2022] [Accepted: 02/06/2023] [Indexed: 02/25/2023] Open
Abstract
Heparin-induced thrombocytopenia is a life-threatening immune-mediated complication of unfractionated heparin therapy. Fondaparinux is a therapeutic alternative, but it has limited evidence for its use in patients on extracorporeal membrane oxygenation (ECMO). We present a series of three adult patients with COVID-19 on ECMO who were diagnosed with heparin-induced thrombocytopenia after 7-12 days of unfractionated heparin treatment and were switched to fondaparinux. Fondaparinux was initiated with an intravenous loading dose of 5 mg, followed by a dose of 2.5 mg subcutaneously every 8-12 h. Dosage was adjusted according to daily measured anti-Xa concentration with a target range of 0.4-0.7 mg/L. The total duration of treatment with fondaparinux and ECMO ranged from 13 to 26 days. One major bleeding episode unrelated to fondaparinux therapy was observed, and the transfusions requirement was also low in all patients. The ECMO circuit was changed once in each patient. This series provides a deep insight into the use of fondaparinux over an extended period of time in patients on ECMO. Based on the presented data, fondaparinux can be considered a reasonable and affordable anticoagulant in patients without a high risk of bleeding.
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Affiliation(s)
- Jitka Rychlíčková
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia.,Department of Anesthesiology and Intensive Care, Faculty of Medicine, Masaryk University, St. Anne's University Hospital Brno, Brno, Czechia.,Department of Pharmacology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Vladimír Šrámek
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia.,Department of Anesthesiology and Intensive Care, Faculty of Medicine, Masaryk University, St. Anne's University Hospital Brno, Brno, Czechia
| | - Pavel Suk
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia.,Department of Anesthesiology and Intensive Care, Faculty of Medicine, Masaryk University, St. Anne's University Hospital Brno, Brno, Czechia
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3
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Membranes for extracorporeal membrane oxygenator (ECMO): history, preparation, modification and mass transfer. Chin J Chem Eng 2022. [DOI: 10.1016/j.cjche.2022.05.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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4
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Levine D, Volk L, Vagaonescu T, Soto C, Ikegami H, Ghaly A, Lemaire A. Risk of Stroke with Impella Placement Is Not Associated with Access Vessel. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:25-29. [PMID: 35037774 DOI: 10.1177/15569845211057818] [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] [Indexed: 11/16/2022]
Abstract
Objective: The Impella heart pump is an intravascular microaxial device that provides short-term mechanical circulatory support and can be placed through the femoral, axillary, or central vessels. One of the most feared complications is stroke. It is unclear if patient stroke risk varies based on access vessel. Methods: A retrospective review of consecutive patients who underwent Impella placement at an academic institution from January 1, 2007, through September 15, 2018, was performed. Four groups were compared: (1) minimally invasive Impella (femoral or axillary access), (2) minimally invasive Impella upgraded to another minimally invasive Impella, (3) minimally invasive Impella upgraded to a central Impella (ascending aorta), and (4) central Impella. Patient charts were reviewed to identify baseline characteristics. Outcome measures included length of stay, stroke, and mortality. Results: A total of 349 patients (or 407 Impellas) were identified, and the majority of the devices were inserted through a minimally invasive approach (n = 248, 60.9%), while the remainder were implanted via central access (n = 159, 39.1%). Minimally invasive Impellas were upgraded in 44 patients. The risk of stroke for the entire cohort was 10.3% (n = 36), with no difference observed in any particular group. Overall mortality was 44.4% (n = 155). Of the patients who initially received a minimally invasive Impella, those who were upgraded had higher rates of mortality (56.8% vs 39.4%, P = 0.03), postoperative dialysis (50.0% vs 27.4%, P < 0.01), and sepsis (43.2% vs 20.0%, P < 0.01). Conclusions: This study found no statistically significant difference in rates of postoperative stroke based on initial access vessel.
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Affiliation(s)
- Dov Levine
- 12287Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Lindsay Volk
- 12287Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Tudor Vagaonescu
- 12287Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Cassandra Soto
- 12287Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Hirohisa Ikegami
- 12287Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Aziz Ghaly
- 12287Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Anthony Lemaire
- 12287Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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5
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Behandlung der heparininduzierten Thrombozytopenie unter extrakorporaler Membranoxygenierung. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2021. [DOI: 10.1007/s00398-021-00437-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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6
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A Systematic Literature Review of Packed Red Cell Transfusion Usage in Adult Extracorporeal Membrane Oxygenation. MEMBRANES 2021; 11:membranes11040251. [PMID: 33808419 PMCID: PMC8065680 DOI: 10.3390/membranes11040251] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/19/2021] [Accepted: 03/22/2021] [Indexed: 01/28/2023]
Abstract
Background: Blood product administration plays a major role in the management of patients treated with extracorporeal membrane oxygenation (ECMO) and may be a contributor to morbidity and mortality. Methods: We performed a systematic review of the published literature to determine the current usage of packed red cell transfusions. Predefined search criteria were used to identify journal articles reporting transfusion practice in ECMO by interrogating EMBASE and Medline databases and following the PRISMA statement. Results: Out of 1579 abstracts screened, articles reporting ECMO usage in a minimum of 10 adult patients were included. Full texts of 331 articles were obtained, and 54 were included in the final analysis. All studies were observational (2 were designed prospectively, and two were multicentre). A total of 3808 patients were reported (range 10–517). Mean exposure to ECMO was 8.2 days (95% confidence interval (CI) 7.0–9.4). A median of 5.6% was not transfused (interquartile range (IQR) 0–11.3%, 19 studies). The mean red cell transfusion per ECMO run was 17.7 units (CI 14.2–21.2, from 52 studies) or 2.60 units per day (CI 1.93–3.27, from 49 studies). The median survival to discharge was 50.8% (IQR 40.0–64.9%). Conclusion: Current evidence on transfusion practice in ECMO is mainly drawn from single-centre observational trials and varies widely. The need for transfusions is highly variable. Confounding factors influencing transfusion practice need to be identified in prospective multicentre studies to mitigate potential harmful effects and generate hypotheses for interventional trials.
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7
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Park C, Ko UW, Ko RE, Na SJ, Yang JH, Jeon K, Suh GY, Sung K, Cho YH. Outcomes of extracorporeal membrane oxygenation in adults with active hematologic and nonhematologic malignancy. Artif Organs 2021; 45:E236-E246. [PMID: 33507563 DOI: 10.1111/aor.13922] [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: 10/25/2020] [Revised: 01/08/2021] [Accepted: 01/20/2021] [Indexed: 12/27/2022]
Abstract
Although the number of cancer patients admitted to the intensive care unit is increasing, the data on the use of extracorporeal membrane oxygenation in patients with malignancy are limited. We applied extracorporeal membrane oxygenation to carefully selected patients with active hematologic malignancy or nonhematologic malignancy who experienced respiratory or cardiac failure despite maximal conventional therapy. Patients with active malignancy who underwent extracorporeal membrane oxygenation in our institution between January 2012 and December 2016 were included in this study. The primary outcome of this study was defined as survival to hospital discharge. We also investigated the factors associated with survival to hospital discharge. There were 30 (30.6%) and 68 (69.4%) patients in the hematologic malignancy group and the nonhematologic malignancy group, respectively. Patients in the hematologic malignancy group were younger, more neutropenic, more hypotensive, had a lower Charlson Comorbidity Index, higher sequential organ failure assessment score, and lower platelet count than those in the nonhematologic malignancy group. Forty-six (46.9%) patients were successfully weaned off extracorporeal membrane oxygenation, and 30 (30.6%) patients survived until hospital discharge. Hospital survival rate and survival status 6 months after hospital discharge were significantly lower in patients with hematologic malignancy than in those with nonhematologic malignancy (13.3% vs. 38.2%, P = .026 and 3.3% vs. 26.5%, P = .017, respectively). Multivariate analysis identified an active hematologic malignancy, older age, acidosis, thrombocytopenia, high vasoactive-inotrope score, and respiratory failure as the risk factors for in-hospital death. Patients with hematologic malignancy requiring extracorporeal membrane oxygenation support had significantly lower rates of hospital survival and 6-month survival after discharge than patients with nonhematologic malignancy. Therefore, extracorporeal membrane oxygenation for treating cardiac or respiratory failure should only be considered in highly selected patients with hematologic malignancy.
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Affiliation(s)
- Chul Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Division of Pulmonology, Department of Medicine, Wonkwang University Hospital, Iksan, Republic of Korea
| | - Ui Won Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Division of Pulmonology, Department of Medicine, Gachon University Gil Medical Center, Incheon, Republic of Korea
| | - Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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8
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Kim AR, Park H, Lee SE, Ahn JM, Park DW, Lee SW, Kim JJ, Park SJ, Hong JA, Kang PJ, Jung SH, Kim MS. Outcomes of left ventricular unloading with a transseptal cannula during extracorporeal membrane oxygenation in adults. Artif Organs 2020; 45:390-398. [PMID: 33001468 DOI: 10.1111/aor.13838] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/16/2020] [Accepted: 09/24/2020] [Indexed: 12/20/2022]
Abstract
We evaluated the benefit of left ventricular (LV) unloading using a percutaneous transseptal left atrial (LA) drain catheter via femoral vein incorporated into the ECMO venous circuit. This single-center retrospective observational study analyzed clinical outcomes of the LA venting group (N = 62) who underwent percutaneous transseptal LA drain placement comparing with the conventionally treated control group (N = 62) with an arterial pulse pressure below 10 mm Hg for at least 24 hours from December 2012 to August 2018. The ECMO weaning rate (61.3% vs. 38.7%, P = .012) and cardiac transplantation rate (29.0% vs. 11.3%, P = .014) were higher in the LA venting group than in the control group. Inhospital mortality was not significantly different (56.5% vs. 69.4%, P = .191). Pulmonary congestion mostly improved after LA decompression (61.3%, P = .003). A serum lactate level at 24 hours after LA venting of more than 2.2 mmol/L was associated with poor outcomes. LA venting via transseptal cannula reduced pulmonary venous congestion and achieved higher rates of successful ECMO weaning and cardiac transplantation. Placement of a transseptal venous drain cannula should be considered in patients with uncontrolled pulmonary edema secondary to severe LV loading undergoing VA-ECMO.
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Affiliation(s)
- Ah-Ram Kim
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hanbit Park
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Eun Lee
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Min Ahn
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duk-Woo Park
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Whan Lee
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Joong Kim
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jung Park
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Ae Hong
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Pil-Je Kang
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min-Seok Kim
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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9
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Kapur NK, Whitehead EH, Thayer KL, Pahuja M. The science of safety: complications associated with the use of mechanical circulatory support in cardiogenic shock and best practices to maximize safety. F1000Res 2020; 9. [PMID: 32765837 PMCID: PMC7391013 DOI: 10.12688/f1000research.25518.1] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/20/2020] [Indexed: 12/16/2022] Open
Abstract
Acute mechanical circulatory support (MCS) devices are widely used in cardiogenic shock (CS) despite a lack of high-quality clinical evidence to guide their use. Multiple devices exist across a spectrum from modest to complete support, and each is associated with unique risks. In this review, we summarize existing data on complications associated with the three most widely used acute MCS platforms: the intra-aortic balloon pump (IABP), Impella systems, and veno-arterial extracorporeal membrane oxygenation (VA-ECMO). We review evidence from available randomized trials and highlight challenges comparing complication rates from case series and comparative observational studies where a lack of granular data precludes appropriate matching of patients by CS severity. We further offer a series of best practices to help shock practitioners minimize the risk of MCS-associated complications and ensure the best possible outcomes for patients.
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Affiliation(s)
- Navin K Kapur
- The Cardiovascular Center for Research and Innovation, Tufts Medical Center, Boston, MA, USA
| | - Evan H Whitehead
- The Cardiovascular Center for Research and Innovation, Tufts Medical Center, Boston, MA, USA
| | - Katherine L Thayer
- The Cardiovascular Center for Research and Innovation, Tufts Medical Center, Boston, MA, USA
| | - Mohit Pahuja
- Division of Cardiology, Detroit Medical Center/Wayne State University School of Medicine, Detroit, MI, USA
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10
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Jiritano F, Serraino GF, Ten Cate H, Fina D, Matteucci M, Mastroroberto P, Lorusso R. Platelets and extra-corporeal membrane oxygenation in adult patients: a systematic review and meta-analysis. Intensive Care Med 2020; 46:1154-1169. [PMID: 32328725 PMCID: PMC7292815 DOI: 10.1007/s00134-020-06031-4] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 03/28/2020] [Indexed: 12/24/2022]
Abstract
Despite increasing improvement in extracorporeal membrane oxygenation (ECMO) technology and knowledge, thrombocytopenia and impaired platelet function are usual findings in ECMO patients and the underlying mechanisms are only partially elucidated. The purpose of this meta-analysis and systematic review was to thoroughly summarize and discuss the existing knowledge of platelet profile in adult ECMO population. All studies meeting the inclusion criteria (detailed data about platelet count and function) were selected, after screening literature from July 1975 to August 2019. Twenty-one studies from 1.742 abstracts were selected. The pooled prevalence of thrombocytopenia in ECMO patients was 21% (95% CI 12.9-29.0; 14 studies). Thrombocytopenia prevalence was 25.4% (95% CI 10.6-61.4; 4 studies) in veno-venous ECMO, whereas it was 23.2% (95% CI 11.8-34.5; 6 studies) in veno-arterial ECMO. Heparin-induced thrombocytopenia prevalence was 3.7% (95% CI 1.8-5.5; 12 studies). Meta-regression revealed no significant association between ECMO duration and thrombocytopenia. Platelet function impairment was described in 7 studies. Impaired aggregation was shown in 5 studies, whereas loss of platelet receptors was found in one trial, and platelet activation was described in 2 studies. Platelet transfusions were needed in up to 50% of the patients. Red blood cell transfusions were administered from 46 to 100% of the ECMO patients. Bleeding events varied from 16.6 to 50.7%, although the cause and type of haemorrhage was not consistently reported. Thrombocytopenia and platelet dysfunction are common in ECMO patients, regardless the type of ECMO mode. The underlying mechanisms are multifactorial, and understanding and management are still limited. Further research to design appropriate strategies and protocols for its monitoring, management, or prevention should be matter of thorough investigations.
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Affiliation(s)
- Federica Jiritano
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC), P. Debeylaan, 26, 6220 AZ, Maastricht, The Netherlands.
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy.
| | - Giuseppe Filiberto Serraino
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Hugo Ten Cate
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Dario Fina
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC), P. Debeylaan, 26, 6220 AZ, Maastricht, The Netherlands
- IRCCS San Donato, University of Milan, Milan, Italy
| | - Matteo Matteucci
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC), P. Debeylaan, 26, 6220 AZ, Maastricht, The Netherlands
- Department of Cardiac Surgery, Circolo Hospital, University of Insubria, Varese, Italy
| | - Pasquale Mastroroberto
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC), P. Debeylaan, 26, 6220 AZ, Maastricht, The Netherlands
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11
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Al-Fares AA, Randhawa VK, Englesakis M, McDonald MA, Nagpal AD, Estep JD, Soltesz EG, Fan E. Optimal Strategy and Timing of Left Ventricular Venting During Veno-Arterial Extracorporeal Life Support for Adults in Cardiogenic Shock. Circ Heart Fail 2019; 12:e006486. [DOI: 10.1161/circheartfailure.119.006486] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background:
Veno-arterial extracorporeal life support (VA-ECLS) is widely used to treat refractory cardiogenic shock. However, increased left ventricular (LV) afterload in VA-ECLS can worsen pulmonary congestion and compromise myocardial recovery. Our objectives were to explore the efficacy, safety, and optimal timing of adjunctive LV venting strategies.
Methods:
A systematic search was performed on Medline, EMBASE, PubMed, CDSR, CCRCT, CINAHL, ClinicalTrials.Gov, and WHO ICTRP from inception until January 2019 for all relevant studies, including LV venting. Data were analyzed for mortality and weaning from VA-ECLS on the basis of timing of LV venting, along with adverse complications.
Results:
A total of 7995 patients were included from 62 observational studies, wherein 3458 patients had LV venting during VA-ECLS. LV venting significantly improved weaning from VA-ECLS (odds ratio, 0.62 [95% CI, 0.47–0.83];
P
=0.001) and reduced short-term (30 day; risk ratio [RR], 0.86 [95% CI, 0.77–0.96];
P
=0.008) but not in-hospital (RR, 0.92 [95% CI, 0.83–1.01]
P
=0.09) or long-term (6 months; RR, 0.96 [95% CI, 0.90–1.03];
P
=0.27) mortality. Early (<12 hours; RR, 0.86 [95% CI, 0.75–0.99];
P
=0.03) but not late (≥12 hours; RR, 0.99 [95% CI, 0.71–1.38];
P
=0.93) LV venting significantly reduced short-term mortality. Patients with LV venting spent more time on VA-ECLS (3.6 versus 2.8 days,
P
<0.001), and mechanical ventilation (7.1 versus 4.6 days,
P
=0.013). With the exception of hemolysis (RR, 2.18 [95% CI, 1.58–3.01];
P
<0.00001), overall adverse events did not differ.
Conclusions:
LV venting, especially if done early (<12 hours), appears to be associated with an increased success of weaning and reduced short-term mortality. Future studies are required to delineate the importance of any or early LV venting adjuncts on mortality and morbidity outcomes.
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Affiliation(s)
- Abdulrahman A. Al-Fares
- Interdepartmental Division of Critical Care Medicine (A.A.A.-F., E.F.), Toronto General Hospital, University of Toronto, ON, Canada
- Extracorporeal Life Support Program (A.A.A.-F., E.F.), Toronto General Hospital, University of Toronto, ON, Canada
- Al-Amiri Hospital, Ministry of Health, Kuwait (A.A.A.-F.)
| | - Varinder K. Randhawa
- Departments of Cardiovascular Medicine (V.K.R., J.D.E.), Kaufman Center for Heart Failure, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Marina Englesakis
- Library and Information Services (M.E.), Toronto General Hospital, University of Toronto, ON, Canada
| | - Michael A. McDonald
- Division of Cardiology, Peter Munk Cardiac Centre (M.A.M.), Toronto General Hospital, University of Toronto, ON, Canada
| | - A. Dave Nagpal
- Divisions of Cardiac Surgery and Critical Care, London Health Sciences Center, ON, Canada (A.D.N.)
| | - Jerry D. Estep
- Departments of Cardiovascular Medicine (V.K.R., J.D.E.), Kaufman Center for Heart Failure, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Edward G. Soltesz
- Thoracic and Cardiovascular Surgery (E.G.S.), Kaufman Center for Heart Failure, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine (A.A.A.-F., E.F.), Toronto General Hospital, University of Toronto, ON, Canada
- Extracorporeal Life Support Program (A.A.A.-F., E.F.), Toronto General Hospital, University of Toronto, ON, Canada
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12
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Wang CH, Chang RW, Wu ET, Hsiao YJ, Wu MS, Yu HY, Chen YS, Lai LC, Yu SL. Extracorporeal Life Support Enhances the Forward Pressure Wave to Cause a Mismatch between Cardiac Oxygen Demand and Supply. Sci Rep 2019; 9:13882. [PMID: 31554923 PMCID: PMC6761175 DOI: 10.1038/s41598-019-50428-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 09/11/2019] [Indexed: 11/17/2022] Open
Abstract
Extracorporeal life support (ECLS) is a world-famous life-saving method. Until now, changes in arterial wave properties due to ECLS have remained unexamined. In this study, we determined the effects of ECLS on arterial wave properties and ventricular/arterial coupling in male Wistar rats with the measured aortic pressure alone. Ascending aortic pressure signals were measured before ECLS and at 30, 60, and 90 min after weaned off. The aortic pressure signal then calculated by fourth-order derivative to obtain an assumed triangular flow wave. The ratio of mean systolic pressure to mean diastolic pressure (Pms/Pmd), a parameter for evaluating the matching condition between myocardial oxygen demand and supply, was significantly higher after ECLS. The magnitude of forward pressure (|Pf|) augmented by ECLS prevailed over the backward pressure (|Pb|), leading to a decline in wave reflection factor. Pms/Pmd was positively linearly correlated with |Pf| (Pms/Pmd = 0.9177 + 0.0078 × |Pf|, r = 0.8677; P < 0.0001). These findings suggest that |Pf| was a predominant factor responsible for the mismatch between the myocardial oxygen demand and supply in rats after ECLS phase of experiment.
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Affiliation(s)
- Chih-Hsien Wang
- Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.
| | - Ru-Wen Chang
- Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - En- Ting Wu
- Department of Pediatrics, College of Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Jing Hsiao
- Department of Clinical and Laboratory Sciences and Medical Biotechnology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ming-Shiou Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsi-Yu Yu
- Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Yih-Sharng Chen
- Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Liang-Chuan Lai
- Department of Physiology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Sung-Liang Yu
- Department of Clinical and Laboratory Sciences and Medical Biotechnology, National Taiwan University College of Medicine, Taipei, Taiwan
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13
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Thongprayoon C, Cheungpasitporn W, Lertjitbanjong P, Aeddula NR, Bathini T, Watthanasuntorn K, Srivali N, Mao MA, Kashani K. Incidence and Impact of Acute Kidney Injury in Patients Receiving Extracorporeal Membrane Oxygenation: A Meta-Analysis. J Clin Med 2019; 8:jcm8070981. [PMID: 31284451 PMCID: PMC6678289 DOI: 10.3390/jcm8070981] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/23/2019] [Accepted: 07/02/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Although acute kidney injury (AKI) is a frequent complication in patients receiving extracorporeal membrane oxygenation (ECMO), the incidence and impact of AKI on mortality among patients on ECMO remain unclear. We conducted this systematic review to summarize the incidence and impact of AKI on mortality risk among adult patients on ECMO. METHODS A literature search was performed using EMBASE, Ovid MEDLINE, and Cochrane Databases from inception until March 2019 to identify studies assessing the incidence of AKI (using a standard AKI definition), severe AKI requiring renal replacement therapy (RRT), and the impact of AKI among adult patients on ECMO. Effect estimates from the individual studies were obtained and combined utilizing random-effects, generic inverse variance method of DerSimonian-Laird. The protocol for this systematic review is registered with PROSPERO (no. CRD42018103527). RESULTS 41 cohort studies with a total of 10,282 adult patients receiving ECMO were enrolled. Overall, the pooled estimated incidence of AKI and severe AKI requiring RRT were 62.8% (95%CI: 52.1%-72.4%) and 44.9% (95%CI: 40.8%-49.0%), respectively. Meta-regression showed that the year of study did not significantly affect the incidence of AKI (p = 0.67) or AKI requiring RRT (p = 0.83). The pooled odds ratio (OR) of hospital mortality among patients receiving ECMO with AKI on RRT was 3.73 (95% CI, 2.87-4.85). When the analysis was limited to studies with confounder-adjusted analysis, increased hospital mortality remained significant among patients receiving ECMO with AKI requiring RRT with pooled OR of 3.32 (95% CI, 2.21-4.99). There was no publication bias as evaluated by the funnel plot and Egger's regression asymmetry test with p = 0.62 and p = 0.17 for the incidence of AKI and severe AKI requiring RRT, respectively. CONCLUSION Among patients receiving ECMO, the incidence rates of AKI and severe AKI requiring RRT are high, which has not changed over time. Patients who develop AKI requiring RRT while on ECMO carry 3.7-fold higher hospital mortality.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | | | - Narothama Reddy Aeddula
- Division of Nephrology, Department of Medicine, Deaconess Health System, Evansville, IN 47747, USA
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, AZ 85721, USA
| | | | - Narat Srivali
- Division of Pulmonary and Critical Care Medicine, St. Agnes Hospital, Baltimore, MD 21229, USA
| | - Michael A Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA.
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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14
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Ng WT, Ling L, Joynt GM, Chan KM. An audit of mortality by using ECMO specific scores and APACHE II scoring system in patients receiving extracorporeal membrane oxygenation in a tertiary intensive care unit in Hong Kong. J Thorac Dis 2019; 11:445-455. [PMID: 30962988 DOI: 10.21037/jtd.2018.12.121] [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] [Indexed: 11/06/2022]
Abstract
Background Outcomes of patients receiving extracorporeal membrane oxygenation (ECMO) therapies risk-adjusted by ECMO specific scores have rarely been reported. Our primary aim was to determine the risk adjusted outcome of these patients by the use of Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP), Survival After Veno-Arterial-ECMO (SAVE) and APACHE II scores. The differences in predicted mortality between these scoring systems were analyzed. Methods This is a single-center retrospective study reviewing 62 patients who received venous-venous ECMO (VV-ECMO) and venous-arterial ECMO (VA-ECMO) between 2009 and 2017 in a tertiary ICU. Demographic, clinical, laboratory, imaging data were analyzed. Primary outcome measures were the crude mortality and standardized mortality ratio (SMR), expressed as observed mortality divided by expected mortality predicted from RESP, SAVE and APACHE II scores, respectively. We also examined the difference in predicted mortality derived from RESP, SAVE, and APACHE II by using Bland Altman plots. Results Twenty and Forty-two patients received VV-ECMO (20 runs) and VA-ECMO (43 runs) respectively. For VV-ECMO, the mean RESP was 0.6 [standard deviation (SD) 4.86] with RESP-SMR of 1.16 [95% confidence interval (95% CI) =0.44-1.88]. For VA-ECMO, the mean SAVE score was -7.8 (SD 5.6), with SAVE-SMR of 0.69 (95% CI =0.39-0.98). In the Bland Altman plot for VA-ECMO, mean difference in predicted mortality between SAVE and APACHE II was 17.6% (95% CI: 7.6% to 27.6%, P<0.0001), with 95% limit of agreement of -30.2% to 65.5% and beta coefficient of -1.04. APACHE II predicted mortality for VA-ECMO was lower than that for SAVE until it crossed SAVE prediction at about 80% mortality. After this point, it becomes progressively higher than that for SAVE. Conclusions The mortality outcome of our patients on VV-ECMO and VA-ECMO compares favorably with predicted mortality based on RESP and SAVE, respectively. In our cohort of patients receiving VA-ECMO, APACHE II tends to underestimate mortality in lower risk patients, and overestimate the mortality in patients at high risk of death.
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Affiliation(s)
- Wai Tsan Ng
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Hong Kong, China
| | - Lowell Ling
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Hong Kong, China
| | - Gavin M Joynt
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Hong Kong, China
| | - Kai Man Chan
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Hong Kong, China
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15
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Wilson-Smith AR, Bogdanova Y, Roydhouse S, Phan K, Tian DH, Yan TD, Loforte A. Outcomes of venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock: systematic review and meta-analysis. Ann Cardiothorac Surg 2019; 8:1-8. [PMID: 30854307 DOI: 10.21037/acs.2018.11.09] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Despite advances in management techniques and medical therapy, refractory cardiogenic shock remains a life-threatening condition with high mortality rates. The present systematic review and meta-analysis aims to explore the outcomes associated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) use in the setting of refractory cardiogenic shock, stratified per survivorship. Methods A literature search was performed using three electronic databases from the date of their inception up to June 2018. The literature search and subsequent data extraction were performed by two independent reviewers. Digitized survival data were extracted from Kaplan-Meier curves in order to re-create the original patient data using an iterative algorithm and were subsequently aggregated for analysis. Results Fifty-two studies were included, with 44 undergoing quantitative analysis. A total of 17,515 patients were identified, with a mean age of 58.4±9.4 years and a mean duration of ECMO support of 5.1±2.6 days; 68.7% of the patients were male. Aggregated survival rates at 1, 2, 3 and 5 years were 36.7%, 34.8%, 33.8% and 29.9%, respectively. Conclusions The present systematic review illustrates the expected survival results for VA-ECMO in the intermediate- to long-term. Extended follow-up and standardized reporting measures are urgently needed in order to carry out more definitive subgroup analyses.
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Affiliation(s)
- Ashley R Wilson-Smith
- The Collaborative Research Group (CORE), Macquarie University, Sydney, Australia.,The University of New South Wales, Faculty of Medicine, Sydney, Australia
| | - Yulia Bogdanova
- The University of New South Wales, Faculty of Medicine, Sydney, Australia
| | | | - Kevin Phan
- The Collaborative Research Group (CORE), Macquarie University, Sydney, Australia
| | - David H Tian
- The Collaborative Research Group (CORE), Macquarie University, Sydney, Australia.,Royal North Shore Hospital, Sydney, Australia
| | - Tristan D Yan
- The Collaborative Research Group (CORE), Macquarie University, Sydney, Australia.,Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital (RPA), Camperdown, Australia
| | - Antonio Loforte
- Department of Cardiovascular Surgery and Transplantation, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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16
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Lo Coco V, Lorusso R, Raffa GM, Malvindi PG, Pilato M, Martucci G, Arcadipane A, Zieliński K, Suwalski P, Kowalewski M. Clinical complications during veno-arterial extracorporeal membrane oxigenation in post-cardiotomy and non post-cardiotomy shock: still the achille's heel. J Thorac Dis 2018; 10:6993-7004. [PMID: 30746245 DOI: 10.21037/jtd.2018.11.103] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is life-saving for potentially reversible heart failure and respiratory injuries not responsive to conventional therapies. Technological innovations have produced over the years significant improvements in ECMO devices (pump, cannula design and oxygenator) and have allowed a better risk/benefit profile. Alongside with recognized advantages in the treatment of very sick patients, ECMO remains an invasive procedure for mechanical circulatory support (MCS) and it is associated with complications that strongly influence the prognosis. Current review was designed to provide a comprehensive outline on ECMO complications, analyzing risk factors and strategies of management, focusing on adult population undergoing veno-arterial ECMO (VA-ECMO) therapy.
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Affiliation(s)
- Valeria Lo Coco
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Giuseppe M Raffa
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | | | - Michele Pilato
- Department of the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Gennaro Martucci
- Department of Anaesthesia and Intensive Care, IRCCS-ISMETT, Palermo, Italy
| | - Antonio Arcadipane
- Department of Anaesthesia and Intensive Care, IRCCS-ISMETT, Palermo, Italy
| | | | - Piotr Suwalski
- Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior in Warsaw, Poland.,Clinical Department of Cardiac Surgery, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Mariusz Kowalewski
- Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior in Warsaw, Poland.,Cardiothoracic Research Centre, Innovative Medical Forum, Bydgoszcz, Poland
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17
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Meani P, Delnoij T, Raffa GM, Morici N, Viola G, Sacco A, Oliva F, Heuts S, Sels JW, Driessen R, Roekaerts P, Gilbers M, Bidar E, Schreurs R, Natour E, Veenstra L, Kats S, Maessen J, Lorusso R. Protracted aortic valve closure during peripheral veno-arterial extracorporeal life support: is intra-aortic balloon pump an effective solution? Perfusion 2018; 34:35-41. [PMID: 30024298 PMCID: PMC6304680 DOI: 10.1177/0267659118787426] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Left ventricular (LV) afterload increase with protracted aortic valve (AV)
closure may represent a complication of veno-arterial extracorporeal
membrane oxygenation (V-A ECMO). The aim of the present study was to assess
the effects of an intra-aortic balloon pump (IABP) to overcome such a
hemodynamic shortcoming in patients submitted to peripheral V-A ECMO. Methods: Among 184 adult patients who were treated with peripheral V-A ECMO support at
Medical University Center Maastricht Hospital between 2007 and 2018,
patients submitted to IABP implant for protracted AV closure after V-A ECMO
implant were retrospectively identified. All clinical and hemodynamic data,
including echocardiographic monitoring, were collected and analyzed. Results: During the study period, 10 subjects (mean age 60 years old, 80% males)
underwent IABP implant after peripheral V-A ECMO positioning due to the
diagnosis of protracted AV closure and inefficient LV unloading as assessed
by echocardiography and an absence of pulsation in the arterial pressure
wave. Recovery of blood pressure pulsatility and enhanced LV unloading were
observed in 8 patients after IABP placement, with no significant differences
in the main hemodynamic parameters, inotropic therapy or in the ECMO flow
(p=0.48). The weaning rate in this patient subgroup (mean ECMO duration 8
days), however, was only 10%, with another patient finally transplanted,
leading to a 20% survival-to-hospital discharge. Conclusion: IABP placement was an effective solution in order to reverse the protracted
AV closure and impaired LV unloading observed during peripheral V-A ECMO
support. However, the impact on the weaning rate and survival needs further
investigations.
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Affiliation(s)
- Paolo Meani
- 1 Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,2 Cardiology, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Thijs Delnoij
- 2 Cardiology, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,3 Intensive Care Unit, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Giuseppe M Raffa
- 1 Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,4 Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation and Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Nuccia Morici
- 5 De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda Ca' Granda, Milan, Italy.,6 Department of Clinical Sciences and Community Health, Università degli Studi, Milan, Italy
| | - Giovanna Viola
- 5 De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda Ca' Granda, Milan, Italy
| | - Alice Sacco
- 5 De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda Ca' Granda, Milan, Italy
| | - Fabrizio Oliva
- 5 De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda Ca' Granda, Milan, Italy
| | - Sam Heuts
- 1 Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Jan-Willem Sels
- 2 Cardiology, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,3 Intensive Care Unit, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Rob Driessen
- 2 Cardiology, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,3 Intensive Care Unit, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Paul Roekaerts
- 3 Intensive Care Unit, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Martijn Gilbers
- 1 Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Elham Bidar
- 1 Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Rick Schreurs
- 1 Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Ehsan Natour
- 1 Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Leo Veenstra
- 2 Cardiology, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Suzanne Kats
- 1 Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Jos Maessen
- 1 Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Roberto Lorusso
- 1 Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
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18
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Tepper S, Masood MF, Baltazar Garcia M, Pisani M, Ewald GA, Lasala JM, Bach RG, Singh J, Balsara KR, Itoh A. Left Ventricular Unloading by Impella Device Versus Surgical Vent During Extracorporeal Life Support. Ann Thorac Surg 2017; 104:861-867. [DOI: 10.1016/j.athoracsur.2016.12.049] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 12/18/2016] [Accepted: 12/23/2016] [Indexed: 01/12/2023]
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19
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Cheng Z, Zhang D, Gong B, Wang P, Liu F. CD163 as a novel target gene of STAT3 is a potential therapeutic target for gastric cancer. Oncotarget 2017; 8:87244-87262. [PMID: 29152078 PMCID: PMC5675630 DOI: 10.18632/oncotarget.20244] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 07/18/2017] [Indexed: 12/15/2022] Open
Abstract
CD163 is a member of the scavenger receptor cysteine-rich superfamily, and has been widely used to identify M2 type macrophage. However, the expression of CD163 in gastric cancer and its regulatory mechanism are still unclear. Here we show that CD163 is elevated in gastric cancer tissues. High expression of CD163 is a potential indicator to evaluate the status of tumor associated macrophages (TAMs), regulatory T cells (Tregs), myeloid-derived suppressor cells (MDSCs) and cancer associated fibroblasts (Cafs). Besides, more CD163 positive macrophages and CD163 expressing gastric cancer cells are associated with tumor invasion and poor prognosis. Knocking-down CD163 in cancer cells could inhibit tumor growth in vivo. We also find various immune molecules which are correlated with CD163 in gastric cancer tissues and cell lines have positive staining in the cancer cells of clinical sample. Finally, we confirm CD163 is a novel target gene of STAT3 (signal transducer and activator of transcription 3) in gastric cancer. Our data indicate that CD163 may be a potential poor prognostic marker and therapeutic target for gastric cancer.
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Affiliation(s)
- Zhenguo Cheng
- National Center for The International Research in Cell and Gene Therapy, Sino-British Research Centre for Molecular Oncology, School of Basic Medical Sciences, Academy of Medical Sciences, Zhengzhou University, Zhengzhou 450052, China
| | - Danhua Zhang
- Department of General Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Baocheng Gong
- Department of Surgical Oncology, The First Affiliated Hospital of China Medical University, Shenyang 110001, China
| | - Pengliang Wang
- Department of Surgical Oncology, The First Affiliated Hospital of China Medical University, Shenyang 110001, China
| | - Funan Liu
- Department of Surgical Oncology, The First Affiliated Hospital of China Medical University, Shenyang 110001, China
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20
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Mansouri Majd S, Salimi A, Astinchap B. Label-free attomolar detection of lactate based on radio frequency sputtered of nickel oxide thin film field effect transistor. Biosens Bioelectron 2017; 92:733-740. [DOI: 10.1016/j.bios.2016.09.097] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 09/16/2016] [Accepted: 09/27/2016] [Indexed: 10/20/2022]
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21
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Advanced Age as a Predictor of Survival and Weaning in Venoarterial Extracorporeal Oxygenation: A Retrospective Observational Study. BIOMED RESEARCH INTERNATIONAL 2017; 2017:3505784. [PMID: 28484710 PMCID: PMC5397620 DOI: 10.1155/2017/3505784] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 01/16/2017] [Accepted: 03/07/2017] [Indexed: 02/07/2023]
Abstract
Background. In most reports on ECMO treatment, advanced age is classified as a contraindication to VA ECMO. We attempted to investigate whether advanced age would be a main risk factor deciding VA ECMO application and performing VA ECMO support. We determined whether advanced age should be regarded as an absolute or relative contraindication to VA ECMO and could affect weaning and survival rates of VA ECMO patients. Methods. VA ECMO was performed on 135 adult patients with primary cardiogenic shock between January 2010 and December 2014. Successful weaning was defined as weaning from ECMO followed by survival for more than 48 hours. Results. Among the 135 patients, 35 survived and were discharged uneventfully, and the remaining 100 did not survive. There were significant differences in survival between age groups, and older age showed a lower survival rate with statistical significance (P = .01). By multivariate logistic regression analysis, age was not significantly associated with in-hospital mortality (P = .83) and was not significantly associated with VA ECMO weaning (P = .11). Conclusions. Advanced age is an undeniable risk factor for VA ECMO; however, patients of advanced age should not be excluded from the chance of recovery after VA ECMO treatment.
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22
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Loforte A, Murana G, Cefarelli M, Jafrancesco G, Sabatino M, Martin Suarez S, Pilato E, Pacini D, Grigioni F, Bartolomeo RD, Marinelli G. Role of Intra-Aortic Balloon Pump and Extracorporeal Membrane Oxygenation in Early Graft Failure After Cardiac Transplantation. Artif Organs 2017; 40:E136-45. [PMID: 27530673 DOI: 10.1111/aor.12793] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 05/06/2016] [Accepted: 05/31/2016] [Indexed: 11/28/2022]
Abstract
Early graft failure (EGF) is a major risk factor for death after heart transplantation (Htx). We investigated the predictive risk factors for moderate-to-severe EGF requiring an intra-aortic balloon pump (IABP) or extracorporeal membrane oxygenation (ECMO) circulatory support as treatment after Htx. Between January 2000 and December 2014, 412 consecutive adult patients underwent isolated Htx at our institution. Moderate and severe EGF were defined as the need for IABP and ECMO support, respectively, within 24 h after Htx. All available recipient and donor variables were analyzed to assess the risk of EGF occurrence. Overall, moderate-to-severe EGF occurred in 46 (11.1%) patients. Twenty-nine (63.04%) patients required peripheral or central ECMO support in the treatment of severe EGF and 17 (36.9%) patients required IABP support for the treatment of moderate EGF. The predictive risk factors for moderate-to-severe EGF in recipients, as assessed by logistic regression analysis, were a preoperative transpulmonary gradient > 12 mm Hg (odds ratio [OR] 5.2; P = 0.023), a preoperative inotropic score > 10 (OR 8.5; P = 0.0001), and preoperative ECMO support (OR 4.2; P = 0.012). For donors, the predictive risk factor was a donor score ≥ 17 (OR 8.3; P = 0.006). The absence of EGF was correlated with improved long-term survival: 94% at 1 year and 81% at 5 years without EGF versus 76% and 36% at 1 year (P < 0.001), and 70% and 28% at 5 years (P < 0.001) with EGF requiring IABP and ECMO support, respectively. In-hospital weaned and survived patients after IABP or ECMO treatment for moderate-to-severe EGF had a similar 5-year conditional survival rate as transplant patients who had not suffered EGF: 88% without EGF versus 84% with EGF treated with mechanical circulatory support devices (P = 0.08). The occurrence of EGF is a multifactorial deleterious event that depends on donor and recipient profiles. IABP and ECMO support are reliable treatment strategies, depending on the grade of EGF. Furthermore, surviving patients treated with IABP or ECMO have the same long-term conditional survival rate as patients who have not suffered EGF.
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Affiliation(s)
| | - Giacomo Murana
- Departments of Cardiovascular Surgery and Transplantation
| | | | | | - Mario Sabatino
- Cardiology and Transplantation, S. Orsola-Malpighi Hospital, Bologna University, Bologna, Italy
| | | | | | - Davide Pacini
- Departments of Cardiovascular Surgery and Transplantation
| | - Francesco Grigioni
- Cardiology and Transplantation, S. Orsola-Malpighi Hospital, Bologna University, Bologna, Italy
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Rigamonti F, Montecucco F, Boroli F, Rey F, Gencer B, Cikirikcioglu M, Reverdin S, Carbone F, Noble S, Roffi M, Banfi C, Giraud R. The peak of blood lactate during the first 24h predicts mortality in acute coronary syndrome patients under extracorporeal membrane oxygenation. Int J Cardiol 2016; 221:741-5. [PMID: 27428314 DOI: 10.1016/j.ijcard.2016.07.065] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 07/04/2016] [Indexed: 11/17/2022]
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Blumenstein J, Leick J, Liebetrau C, Kempfert J, Gaede L, Groß S, Krug M, Berkowitsch A, Nef H, Rolf A, Arlt M, Walther T, Hamm CW, Möllmann H. Extracorporeal life support in cardiovascular patients with observed refractory in-hospital cardiac arrest is associated with favourable short and long-term outcomes: A propensity-matched analysis. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 5:13-22. [DOI: 10.1177/2048872615612454] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Jürgen Leick
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Germany
| | | | - Joerg Kempfert
- Department of Cardiac Surgery, Kerckhoff Heart and Thorax Center, Germany
| | - Luise Gaede
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Germany
| | - Sebastian Groß
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Germany
| | - Marcel Krug
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Germany
| | | | - Holger Nef
- Justus Liebig University of Giessen, Department of Internal Medicine I, Germany
| | - Andreas Rolf
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Germany
- Justus Liebig University of Giessen, Department of Internal Medicine I, Germany
| | - Matthias Arlt
- Department of Anesthesiology, Kerckhoff Heart and Thorax Center, Germany
| | - Thomas Walther
- Department of Cardiac Surgery, Kerckhoff Heart and Thorax Center, Germany
| | - Christian W Hamm
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Germany
- Justus Liebig University of Giessen, Department of Internal Medicine I, Germany
| | - Helge Möllmann
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Germany
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Contemporary Outcomes of Venoarterial Extracorporeal Membrane Oxygenation for Refractory Cardiogenic Shock at a Large Tertiary Care Center. ASAIO J 2016; 61:403-9. [PMID: 26125665 DOI: 10.1097/mat.0000000000000225] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Refractory cardiogenic shock (RCS) is associated with significant morbidity and mortality, and current mainstays of medical therapy appear inadequate. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) represents an increasingly accepted therapy for RCS. Demographics, past medical history, preoperative characteristics, outcomes, and adverse events were collected for consecutive patients who received VA-ECMO support for RCS at our institution from March 2007 to December 2013. One hundred and seventy-nine patients with a mean age of 56.9 ± 16.1 years were included. Etiologies of RCS included postcardiotomy shock in 70 patients (39%), acute myocardial infarction in 46 patients (26%), primary graft failure in 17 patients (10%), and acute decompensated heart failure in 24 patients (13%). Mean arterial pressure before VA-ECMO support was 59.4 ± 22.8 mm Hg and 30.7% (n = 55) were undergoing active cardiopulmonary resuscitation at the time of cannulation. Overall, 38.6% of patients (n = 69) survived to discharge and 44.7% of patients (n = 80) survived to 30 days. Myocardial recovery was achieved in 79.7% of survivors (n = 55) and 39.1% were transitioned to a more durable device. Univariate analysis identified age (p = 0.002) and etiology of RCS (p = 0.041) as the most significant predictors of in-hospital mortality. Venoarterial extracorporeal membrane oxygenation for RCS appears successful as salvage therapy. Age and etiology should be considered when evaluating patients for VA-ECMO.
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26
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Carroll BJ, Shah RV, Murthy V, McCullough SA, Reza N, Thomas SS, Song TH, Newton-Cheh CH, Camuso JM, MacGillivray T, Sundt TM, Semigran MJ, Lewis GD, Baker JN, Garcia JP. Clinical Features and outcomes in adults with cardiogenic shock supported by extracorporeal membrane oxygenation. Am J Cardiol 2015; 116:1624-30. [PMID: 26443560 DOI: 10.1016/j.amjcard.2015.08.030] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 08/18/2015] [Accepted: 08/18/2015] [Indexed: 10/23/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is an increasingly used supportive measure for patients with refractory cardiogenic shock (CS). Despite its increasing use, there remain minimal data regarding which patients with refractory CS are most likely to benefit from ECMO. We retrospectively studied all patients (n = 123) who underwent initiation of ECMO for CS from February 2009 to September 2014 at a single center. Baseline patient characteristics, including demographics, co-morbid illness, cause of CS, available laboratory values, and patient outcomes were analyzed. Overall, 69 patients (56%) were weaned from ECMO, with 48 patients (39%) surviving to discharge. Survivors were younger (50 vs 60 years; p ≤0.0001), had a lower rate of previous smoking (27 vs 56%; p = 0.01) and chronic kidney disease (2% vs 13%; p = 0.03), and had lower lactate measured soon after ECMO initiation (3.1 vs 10.2 mmol/l; p = 0.01). Patients with pulmonary embolism (odds ratio 8.0, 95% confidence interval 2.00 to 31.99; p = 0.01) and acute cardiomyopathy (odds ratio 7.5, 95% confidence interval 1.69 to 33.27; p = 0.01) had a higher rate of survival than acute myocardial infarction, chronic cardiomyopathy, and miscellaneous etiologies compared to postcardiotomy CS as a referent. In conclusion, survival after ECMO initiation differs based on underlying cause of CS. Survival may be lower in older patients and those with early evidence of persistent hypoperfusion after initiation of ECMO for CS.
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Pieri M, Contri R, Winterton D, Montorfano M, Colombo A, Zangrillo A, De Bonis M, Pappalardo F. The contemporary role of Impella in a comprehensive mechanical circulatory support program: a single institutional experience. BMC Cardiovasc Disord 2015; 15:126. [PMID: 26466899 PMCID: PMC4606842 DOI: 10.1186/s12872-015-0119-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 09/30/2015] [Indexed: 11/28/2022] Open
Abstract
Background The treatment of cardiogenic shock with percutaneous mechanical circulatory support (MCS) is attractive: however, at present it is not clear which is the best strategy, as no survival benefit has been demonstrated for any device as single therapy. Aim of this study is to describe the role of percutaneous Impella in a comprehensive MCS program. Methods Observational study on 22 patients supported with the Impella device in our hospital from May 2013 to June 2014. Results Four patients (18 %) were treated with Impella alone, 8 patients (36 %) were treated with Impella and IABP, 6 patients (27 %) with Impella and VA ECMO, and 4 patients (18 %) with Impella, IABP and VA ECMO. The cause of cardiogenic shock was myocardial infarction (CSMI) in 9 patients (41 %), postcardiotomic cardiogenic shock in 5 (23 %), and a miscellaneous of other causes in the remaining 8 (36 %). Eight Impella devices (36 %) were placed under transesophageal echocardiographic guidance, while 14 (64 %) under fluoroscopy. The device was removed with manual compression at bedside and no vascular complications were observed. Duration of Impella support was 107 (54–141) hours and duration of ventilation was 48 (14–92) hours. Hemolysis occurred in 6 patients (27 %), while major bleeding in 4 patients (18 %). Survival was 73 %: 13 patients (58 %) showed recovery of cardiac function; 1 patient (5 %) was bridged to left ventricular assist device (LVAD) implantation, 1 patient (5 %) to heart transplantation (HTx) and 1 patient (5 %) received a BiVAD and was eventually bridged to HTx. Conclusions Our data suggest that a multi-device approach, encompassing active LV support with Impella, is safe and can significantly improve survival in patients with cardiogenic shock.
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Affiliation(s)
- Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
| | - Rachele Contri
- Department of Interventional Cardiology, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
| | - Dario Winterton
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
| | - Matteo Montorfano
- Department of Interventional Cardiology, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
| | - Antonio Colombo
- Department of Interventional Cardiology, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
| | - Michele De Bonis
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
| | - Federico Pappalardo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
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Gaudard P, Mourad M, Eliet J, Zeroual N, Culas G, Rouvière P, Albat B, Colson P. Management and outcome of patients supported with Impella 5.0 for refractory cardiogenic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:363. [PMID: 26453047 PMCID: PMC4600310 DOI: 10.1186/s13054-015-1073-8] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 09/20/2015] [Indexed: 12/20/2022]
Abstract
Introduction Cardiogenic shock refractory to standard therapy with inotropes and/or intra-aortic balloon pump is accompanied with an unacceptable high mortality. Percutaneous left ventricular assist devices may provide a survival benefit for these very sick patients. In this study, we describe our experience with the Impella 5.0 device used in the setting of refractory cardiogenic shock. Methods In this observational, retrospective, single-center study we included all the consecutive patients supported with Impella 5.0, between May 2008 and December 2013, for refractory cardiogenic shock. Patients’ baseline and procedural characteristics, hemodynamics and outcome to the first 48 h of support, to ICU discharge and day-28 visit were collected. Results A total of 40 patients were included in the study. Median age was 57 years and 87.5 % were male. Cardiogenic shock resulted from acute myocardial infarction in 17 patients (43 %), dilated cardiomyopathy in 12 (30 %) and postcardiotomy cardiac failure in 7 (18 %). In 15 patients Impella 5.0 was added to an ECMO to unload the left ventricle. The median SOFA score for the entire cohort prior to circulatory support was 12 [10–14] and the duration of Impella support was 7 [5–10] days. We observed a significant decrease of the inotrope score (10 [1–17] vs. 1 [0–9]; p = 0.04) and the lactate values (3.8 [1.7–5.9] mmol/L vs. 2.5 [1.5–3.4] mmol/L; p = 0.01) after 6 h of support with Impella 5.0. Furthermore, at Impella removal the patients’ left ventricular ejection fraction improved significantly (p < 0.001) when compared to baseline. Cardiac recovery, bridge to left ventricular assist device or heart transplantation was possible in 28 patients (70 %). Twenty-six patients (65 %) survived at day 28. A multivariate analysis showed a higher risk of mortality for patients with acute myocardial infarction (hazard ratio = 4.1 (1.2–14.2); p = 0.02). Conclusions Impella 5.0 allowed fast weaning of inotropes and might facilitate myocardial recovery. Despite high severity scores at admission, day-28 mortality rate was better than predicated.
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Affiliation(s)
- Philippe Gaudard
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHRU Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France. .,PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR9214, 371 avenue du Doyen G. Giraud, 34295, Montpellier, France.
| | - Marc Mourad
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHRU Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France.
| | - Jacob Eliet
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHRU Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France.
| | - Norddine Zeroual
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHRU Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France.
| | - Geraldine Culas
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHRU Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France.
| | - Philippe Rouvière
- Department of Cardiac Surgery, Arnaud de Villeneuve Hospital, CHRU Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France.
| | - Bernard Albat
- Department of Cardiac Surgery, Arnaud de Villeneuve Hospital, CHRU Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France.
| | - Pascal Colson
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHRU Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France.
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Peigh G, Cavarocchi N, Keith SW, Hirose H. Simple new risk score model for adult cardiac extracorporeal membrane oxygenation: simple cardiac ECMO score. J Surg Res 2015; 198:273-9. [DOI: 10.1016/j.jss.2015.04.044] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Revised: 04/07/2015] [Accepted: 04/14/2015] [Indexed: 11/24/2022]
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Abstract
PURPOSE OF REVIEW To examine the utility and technical challenges of applying veno-arterial extracorporeal membrane oxygenation for acute cardiovascular failure in adults with acute and chronic causes of heart failure. RECENT FINDINGS The role of mechanical circulatory support in acute cardiovascular continues to evolve as technology and clinical experience develop. There is increasing interest in the role of veno-arterial extracorporeal membrane oxygenation as a bridging therapy and as an adjunct to conventional cardiopulmonary resuscitation. SUMMARY Veno-arterial extracorporeal membrane oxygenation is an expensive, complex, resource intensive support. It is essential that its future use be guided by evidence obtained from centres that have demonstrated timely, safe support.
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Abstract
PURPOSE OF REVIEW To discuss the role of extracorporeal membrane oxygenation (ECMO) in patients with cardiac arrest. RECENT FINDINGS Return to spontaneous circulation dramatically decreases with the duration of cardiopulmonary resuscitation (CPR). In this context, it has been proposed to implement venoarterial ECMO in order to assist CPR (ECPR) both in inhospital cardiac arrest (IHCA) and in out-of-hospital cardiac arrest (OHCA). SUMMARY This review highlights that ECPR is feasible for both IHCA and OHCA. In the recent series, the outcome of ECPR in IHCA is satisfactory, with survival rates good with neurologic outcome reaching the 40-50% range. All series converge in highlighting that time from cardiac arrest to ECMO flow is a critical determinant of outcome, with survival rates of 50% when initiated within 30 min of IHCA, 30% between 30 and 60 min, and 18% after 60 min. Results of ECPR in OHCA are more challenging. Recent series suggest that good outcome can be obtained in 15-20% of the patients, provided that time from arrest to ECMO is shorter than 60 min. Duration of cardiac arrest seems to be more important than location of cardiac arrest. ECPR thus seems to be a valuable option in selected cases.
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Loforte A, Pilato E, Martin Suarez S, Folesani G, Jafrancesco G, Castrovinci S, Grigioni F, Marinelli G. RotaFlow and CentriMag Extracorporeal Membrane Oxygenation Support Systems as Treatment Strategies for Refractory Cardiogenic Shock. J Card Surg 2014; 30:201-8. [DOI: 10.1111/jocs.12480] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Antonio Loforte
- Department of Cardiovascular Surgery and Transplantation; S. Orsola-Malpighi Hospital; Bologna University; Bologna Italy
| | - Emanuele Pilato
- Department of Cardiovascular Surgery and Transplantation; S. Orsola-Malpighi Hospital; Bologna University; Bologna Italy
| | - Sofia Martin Suarez
- Department of Cardiovascular Surgery and Transplantation; S. Orsola-Malpighi Hospital; Bologna University; Bologna Italy
| | - Gianluca Folesani
- Department of Cardiovascular Surgery and Transplantation; S. Orsola-Malpighi Hospital; Bologna University; Bologna Italy
| | - Giuliano Jafrancesco
- Department of Cardiovascular Surgery and Transplantation; S. Orsola-Malpighi Hospital; Bologna University; Bologna Italy
| | - Sebastiano Castrovinci
- Department of Cardiovascular Surgery and Transplantation; S. Orsola-Malpighi Hospital; Bologna University; Bologna Italy
| | - Francesco Grigioni
- Department of Cardiology and Transplantation; S. Orsola-Malpighi Hospital; Bologna University; Bologna Italy
| | - Giuseppe Marinelli
- Department of Cardiovascular Surgery and Transplantation; S. Orsola-Malpighi Hospital; Bologna University; Bologna Italy
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Chen H, Tan X, Zhang J, Lu Q, Ou X, Ruo Y, Chen S. An electrogenerated chemiluminescent biosensor based on a g-C3N4–hemin nanocomposite and hollow gold nanoparticles for the detection of lactate. RSC Adv 2014. [DOI: 10.1039/c4ra09616a] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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34
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Alozie A, Kische S, Birken T, Kaminski A, Westphal B, Nöldge-Schomburg G, Ince H, Steinhoff G. Awake Extracorporeal Membrane Oxygenation (ECMO) as Bridge to Recovery After Left Main Coronary Artery Occlusion: A Promising Concept of Haemodynamic Support in Cardiogenic Shock. Heart Lung Circ 2014; 23:e217-21. [DOI: 10.1016/j.hlc.2014.06.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 04/28/2014] [Accepted: 06/10/2014] [Indexed: 11/28/2022]
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Loforte A, Montalto A, Lilla della Monica P, Lappa A, Contento C, Menichetti A, Musumeci F. Mechanical circulatory support in advanced heart failure: single-center experience. Transplant Proc 2014; 46:1476-80. [PMID: 24935316 DOI: 10.1016/j.transproceed.2014.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 01/08/2014] [Accepted: 01/15/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Currently, ventricular assist device (VAD) or total artificial heart (TAH) mechanical support provides an effective treatment of unstable patients with advanced heart failure. We report our single-center experience with mechanical circulatory support therapy. METHODS From March 2002 to December 2012, 107 adult patients (mean age, 56.8 ± 9.9 y; range, 31-76 y) were primarly supported on temporary or long-term VAD or TAH support as treatment for refractory heart failure at our institution. Temporary extracorporeal radial VAD support (group A) was established in 49 patients (45.7%), and long-term paracorporeal and intracorporeal VAD or TAH (group B) in 58 patients (54.2%). Left ventricular (LVAD) support was established in 55 patients (51.4%; n = 33, Heartmate II; n = 6, Heartmate I XVE; n = 4, Heartware HVAD; and n = 12, Centrimag) and biventricular (BVAD/TAH) support (group B) in 28 patients (26.1%; n = 10, Thoratec paracorporeal; n = 2, Heartware HVAD, n = 1, Thoratec implantable; n = 1, Syncardia TAH; and n = 14, Centrimag). The temporary Centrimag was the only device adopted as isolated right ventricular (RVAD) support, and it was inserted in 24 patients (22.4%). RESULTS In group A, overall mean support time was 10.2 ± 6.6 days (range, 3-43 d). In group B, LVAD mean support time was 357 ± 352.3 days (range, 1-902 d) and BVAD/TAH support time was 98 ± 82.6 days (range, 8-832 d). In group A, the overall success rate was 55.1% (27 patients). In group B, LVAD overall success rate was 74.4% (32 patients) and BVAD/TAH success rate was 50% (7 patients). Overall heart transplantation rate for both groups was 27.1% (n = 2, group A; n = 27, group B). Overall 1-year and 5-year survivals after heart transplantation were 72.4% (n = 21) and 58.6% (n = 17), respectively. CONCLUSIONS Mechanical circulatory support is an effective strategy even in cases of end-stage heart failure according to our experience. Further improvement of VAD and TAH technologies may support their adoption as an encouraging alternative to heart transplantation in the near future.
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Affiliation(s)
- A Loforte
- Department of Cardiac Surgery and Transplantation, S Camillo Hospital, Rome, Italy.
| | - A Montalto
- Department of Cardiac Surgery and Transplantation, S Camillo Hospital, Rome, Italy
| | - P Lilla della Monica
- Department of Cardiac Surgery and Transplantation, S Camillo Hospital, Rome, Italy
| | - A Lappa
- Department of Cardiac Surgery and Transplantation, S Camillo Hospital, Rome, Italy
| | - C Contento
- Department of Cardiac Surgery and Transplantation, S Camillo Hospital, Rome, Italy
| | - A Menichetti
- Department of Cardiac Surgery and Transplantation, S Camillo Hospital, Rome, Italy
| | - F Musumeci
- Department of Cardiac Surgery and Transplantation, S Camillo Hospital, Rome, Italy
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Loforte A, Marinelli G, Musumeci F, Folesani G, Pilato E, Martin Suarez S, Montalto A, Lilla Della Monica P, Grigioni F, Frascaroli G, Menichetti A, Di Bartolomeo R, Arpesella G. Extracorporeal Membrane Oxygenation Support in Refractory Cardiogenic Shock: Treatment Strategies and Analysis of Risk Factors. Artif Organs 2014; 38:E129-41. [DOI: 10.1111/aor.12317] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Antonio Loforte
- Department of Cardiovascular Surgery and Transplantation; S. Orsola-Malpighi Hospital; Bologna University; Bologna Italy
| | - Giuseppe Marinelli
- Department of Cardiovascular Surgery and Transplantation; S. Orsola-Malpighi Hospital; Bologna University; Bologna Italy
| | - Francesco Musumeci
- Department of Cardiac Surgery and Transplantation; S. Camillo Hospital; Rome Italy
| | - Gianluca Folesani
- Department of Cardiovascular Surgery and Transplantation; S. Orsola-Malpighi Hospital; Bologna University; Bologna Italy
| | - Emanuele Pilato
- Department of Cardiovascular Surgery and Transplantation; S. Orsola-Malpighi Hospital; Bologna University; Bologna Italy
| | - Sofia Martin Suarez
- Department of Cardiovascular Surgery and Transplantation; S. Orsola-Malpighi Hospital; Bologna University; Bologna Italy
| | - Andrea Montalto
- Department of Cardiac Surgery and Transplantation; S. Camillo Hospital; Rome Italy
| | | | - Francesco Grigioni
- Department of Cardiovascular Surgery and Transplantation; S. Orsola-Malpighi Hospital; Bologna University; Bologna Italy
| | - Guido Frascaroli
- Department of Cardiovascular Surgery and Transplantation; S. Orsola-Malpighi Hospital; Bologna University; Bologna Italy
| | - Antonio Menichetti
- Department of Cardiac Surgery and Transplantation; S. Camillo Hospital; Rome Italy
| | - Roberto Di Bartolomeo
- Department of Cardiovascular Surgery and Transplantation; S. Orsola-Malpighi Hospital; Bologna University; Bologna Italy
| | - Giorgio Arpesella
- Department of Cardiovascular Surgery and Transplantation; S. Orsola-Malpighi Hospital; Bologna University; Bologna Italy
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Park TK, Yang JH, Choi SH, Song YB, Hahn JY, Choi JH, Sung K, Lee YT, Gwon HC. Clinical impact of intra-aortic balloon pump during extracorporeal life support in patients with acute myocardial infarction complicated by cardiogenic shock. BMC Anesthesiol 2014; 14:27. [PMID: 24725532 PMCID: PMC4003289 DOI: 10.1186/1471-2253-14-27] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 04/02/2014] [Indexed: 12/13/2022] Open
Abstract
Background There is no available data on clinical outcome in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock who are supported by an intra-aortic balloon pump (IABP) in combination with extracorporeal life support (ECLS). Methods We analysed 96 consecutive patients with AMI and complicating cardiogenic shock who were assisted by an ECLS system between January 2004 and December 2011. The primary outcome was in-hospital mortality. The secondary outcomes were the success rate of weaning from ECLS and the lactate clearance for 48 hours (%). Results A combination of IABP and ECLS was used in 41 (42.7%) patients. In-hospital mortality occurred for 51 patients (ECLS with IABP versus ECLS alone; 51.2% vs. 54.5%, p = 0.747). The success rate of weaning from ECLS was similar between the two groups (63.4% vs. 58.2%, p = 0.604). Complications such as ischemia of a lower extremity or bleeding at the ECLS insertion site (p = 0.521 and p = 0.667, respectively) did not increase when ECLS was combined with IABP. Among patients who survived for 24 hours after intervention, lactate clearance was not significantly different between patients who received ECLS alone and those who received ECLS with IABP (p = 0.918). Conclusions The combined use of ECLS and IABP did not improve in-hospital survival in patients with AMI complicated by cardiogenic shock.
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Affiliation(s)
- Taek Kyu Park
- Department of Medicine, Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea
| | - Jeong Hoon Yang
- Department of Medicine, Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea ; Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung-Hyuk Choi
- Department of Medicine, Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea
| | - Young Bin Song
- Department of Medicine, Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea
| | - Joo-Yong Hahn
- Department of Medicine, Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea
| | - Jin-Ho Choi
- Department of Medicine, Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Tak Lee
- Department of Thoracic and Cardiovascular Surgery, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyeon-Cheol Gwon
- Department of Medicine, Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea
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Cheng R, Hachamovitch R, Kittleson M, Patel J, Arabia F, Moriguchi J, Esmailian F, Azarbal B. Complications of Extracorporeal Membrane Oxygenation for Treatment of Cardiogenic Shock and Cardiac Arrest: A Meta-Analysis of 1,866 Adult Patients. Ann Thorac Surg 2014; 97:610-6. [DOI: 10.1016/j.athoracsur.2013.09.008] [Citation(s) in RCA: 547] [Impact Index Per Article: 54.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 08/28/2013] [Accepted: 09/04/2013] [Indexed: 11/26/2022]
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Maini B, Gregory D, Scotti DJ, Buyantseva L. Percutaneous cardiac assist devices compared with surgical hemodynamic support alternatives. Catheter Cardiovasc Interv 2014; 83:E183-92. [DOI: 10.1002/ccd.25247] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Accepted: 10/10/2013] [Indexed: 11/09/2022]
Affiliation(s)
| | - David Gregory
- Presscott Associates-A Division of ParenteBeard LLC; Avon Connecticut
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Kim YH, Lee KY, Hwang SY. Intracranial Hemorrhage Identified in the Early Stage after Applying Extracorporeal Membrane Oxygenation to Support Cardiopulmonary Resuscitation. Korean J Crit Care Med 2014. [DOI: 10.4266/kjccm.2014.29.3.197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Yong Hwan Kim
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Kyoung Yul Lee
- Department of Physical Education, Kyungnam University, Changwon, Korea
| | - Seong Youn Hwang
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
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Lemaire A, Anderson MB, Lee LY, Scholz P, Prendergast T, Goodman A, Lozano AM, Spotnitz A, Batsides G. The Impella device for acute mechanical circulatory support in patients in cardiogenic shock. Ann Thorac Surg 2013; 97:133-8. [PMID: 24090575 DOI: 10.1016/j.athoracsur.2013.07.053] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 07/02/2013] [Accepted: 07/16/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Acute cardiogenic shock is associated with high mortality rates. Mechanical circulatory devices have been increasingly used in this setting for hemodynamic support. The Impella device (Abiomed Inc, Danvers, MA) is a microaxial left ventricular assist device that can be inserted using a less invasive technique. This study was conducted to determine the outcome of patients who have undergone placement of the Impella device for acute cardiogenic shock in our institution. METHODS A retrospective record review of 47 patients who underwent placement of the Impella device was performed from January 1, 2006, to December 31, 2011. Records were evaluated for demographics, operative details, and postoperative outcomes. Operative mortality was defined as death within 30 days of the operation. RESULTS The patients (33 male) were an average age of 60.23 ± 13 years. The indication for placement of the Impella device included cardiogenic shock in 15 patients (32%) and postcardiotomy cardiogenic shock in 32 (68%). Of the 47 patients, 38 (80%) received the Impella 5.0 and the rest the 2.5 device. Ventricular function recovered in 34 of 47 patients (72%), and the device was removed, with 4 patients (8%) transitioned to long-term ventricular assist devices. The 30-day mortality was 25% (12 of 47 patients). Complications occurred in 14 patients (30%), consisting of device malfunction, high purge pressures, tube fracture, and groin hematoma. CONCLUSIONS This is one of the largest series of patients undergoing placement of the Impella device for acute cardiogenic shock. Our outcomes showed improved results compared with historical data. Myocardial recovery was accomplished in most patients. Finally, the 30-day mortality and complication rate was acceptable in these critical patients. These benefits were all achieved with the Impella device in a less invasive method.
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Affiliation(s)
- Anthony Lemaire
- Department of Cardiothoracic Surgery, Robert Wood Johnson University Hospital, The University of Medicine and Dentistry of New Jersey, New Brunswick, New Jersey; and Abiomed, Inc, Danvers, Massachusetts.
| | - Mark B Anderson
- Department of Cardiothoracic Surgery, Robert Wood Johnson University Hospital, The University of Medicine and Dentistry of New Jersey, New Brunswick, New Jersey; and Abiomed, Inc, Danvers, Massachusetts
| | - Leonard Y Lee
- Department of Cardiothoracic Surgery, Robert Wood Johnson University Hospital, The University of Medicine and Dentistry of New Jersey, New Brunswick, New Jersey; and Abiomed, Inc, Danvers, Massachusetts
| | - Peter Scholz
- Department of Cardiothoracic Surgery, Robert Wood Johnson University Hospital, The University of Medicine and Dentistry of New Jersey, New Brunswick, New Jersey; and Abiomed, Inc, Danvers, Massachusetts
| | - Thomas Prendergast
- Department of Cardiothoracic Surgery, Robert Wood Johnson University Hospital, The University of Medicine and Dentistry of New Jersey, New Brunswick, New Jersey; and Abiomed, Inc, Danvers, Massachusetts
| | - Andrew Goodman
- Department of Cardiothoracic Surgery, Robert Wood Johnson University Hospital, The University of Medicine and Dentistry of New Jersey, New Brunswick, New Jersey; and Abiomed, Inc, Danvers, Massachusetts
| | - Ann Marie Lozano
- Department of Cardiothoracic Surgery, Robert Wood Johnson University Hospital, The University of Medicine and Dentistry of New Jersey, New Brunswick, New Jersey; and Abiomed, Inc, Danvers, Massachusetts
| | - Alan Spotnitz
- Department of Cardiothoracic Surgery, Robert Wood Johnson University Hospital, The University of Medicine and Dentistry of New Jersey, New Brunswick, New Jersey; and Abiomed, Inc, Danvers, Massachusetts
| | - George Batsides
- Department of Cardiothoracic Surgery, Robert Wood Johnson University Hospital, The University of Medicine and Dentistry of New Jersey, New Brunswick, New Jersey; and Abiomed, Inc, Danvers, Massachusetts
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Floerchinger B, Philipp A, Foltan M, Keyser A, Camboni D, Lubnow M, Lunz D, Hilker M, Schmid C. Neuron-specific enolase serum levels predict severe neuronal injury after extracorporeal life support in resuscitation. Eur J Cardiothorac Surg 2013; 45:496-501. [PMID: 23878016 DOI: 10.1093/ejcts/ezt370] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Extracorporeal life support (ECLS) is a rescue option in critically ill patients. Since fast available and appropriate for respiratory and circulatory failure, it is frequently applied in resuscitation scenarios. Neurological injury is a complication common in ECLS patients limiting outcome, particularly after resuscitation. In this study, the institutional ECLS database was used to correlate neuron-specific enolase (NSE) serum peak values with outcome of patients supported with venoarterial (VA) ECLS during cardiopulmonary resuscitation (CPR). METHODS From January 2011 to August 2012, 31 patients were provided with a VA ECLS during CPR (external cardiac massage). Serum NSE peaks were monitored and correlated with neurological outcome and hospital mortality. Patients were divided into two groups with mild-to-moderate and high NSE levels (cut-off value 100 μg/l). RESULTS High NSE levels were seen in 7 patients (mean 218 ± 155 μg/l) and mild-to-moderate levels in 24 patients (50 ± 23 μg/l, P = 0.0001). Duration of extracoporeal support was comparable in both groups (6.3 ± 7.5 vs 5.0 ± 4.5 days, P = n.s.). Patients with mild-to-moderate NSE levels were significantly older than those with high NSE levels (58 ± 16 vs 44 ± 15 years, P = 0.02). Six patients with high NSE levels (86%) developed severe neurological complications. Though 4 patients could be weaned from extracorporeal support, hospital mortality was 86% (6 patients). In contrast, patients with mild-to-moderate NSE levels had a hospital mortality of 46% (11 patients). Eighteen patients (75%) could be weaned from the device, and incidence of major neurological events was 29% (6 patients) only. Serum pH and lactate levels before ECLS implantation were significantly lower in patients with mild-to-moderate NSE values (pH: 7.23 ± 0.04 vs 6.93 ± 0.12, P = 0.039; lactate: 106 ± 11 vs 161 ± 16 mg/l, P = 0.023). CONCLUSIONS High NSE serum levels after ECLS correspond to poor neurological outcome and considerable mortality. Therefore, early neuroimaging is reasonable for determining therapeutic strategies in patients with high NSE peaks after resuscitation and extracorporeal support.
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Affiliation(s)
- Bernhard Floerchinger
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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Tehrani S, Malik A, Hausenloy DJ. Cardiogenic Shock and the ICU Patient. J Intensive Care Soc 2013. [DOI: 10.1177/175114371301400312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Cardiogenic shock is one of the most important complications of acute myocardial infarction (MI) and acute left ventricular failure (LVF). It threatens the life of 5–10% of patients with ST-segment elevation myocardial infarction (STEMI) particularly in the presence of inappropriately low peripheral vascular resistance. Cardiogenic shock results in poor tissue perfusion, end-organ damage and carries a high mortality risk. The goal of therapy is to prevent end-organ dysfunction and severe metabolic derangement by raising mean arterial blood pressure, which is achieved with the use of inotropes and vasopressors, often at the expense of tachycardia, elevated myocardial oxygen consumption and extended myocardial ischaemia. Current therapeutic approaches include early coronary artery revascularisation (which has significantly improved the survival rate), fluid resuscitation, inotropic support and mechanical circulatory support using intra-aortic balloon pumps or ventricular assist devices. In this article, we review the pathophysiology, diagnosis and management of cardiogenic shock.
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Affiliation(s)
- Shana Tehrani
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Medicine, University College London
| | - Abdul Malik
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Medicine, University College London
| | - Derek J Hausenloy
- Reader in Cardiovascular Medicine
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Medicine, University College London
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Door-to-implantation time of extracorporeal life support systems predicts mortality in patients with out-of-hospital cardiac arrest. Clin Res Cardiol 2013; 102:661-9. [DOI: 10.1007/s00392-013-0580-3] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 04/30/2013] [Indexed: 01/05/2023]
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Boulate D, Luyt CE, Pozzi M, Niculescu M, Combes A, Leprince P, Kirsch M. Acute lung injury after mechanical circulatory support implantation in patients on extracorporeal life support: an unrecognized problem†. Eur J Cardiothorac Surg 2013; 44:544-9; discussion 549-50. [DOI: 10.1093/ejcts/ezt125] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Labroo P, Cui Y. Flexible graphene bio-nanosensor for lactate. Biosens Bioelectron 2013; 41:852-6. [DOI: 10.1016/j.bios.2012.08.024] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2012] [Revised: 08/09/2012] [Accepted: 08/09/2012] [Indexed: 01/08/2023]
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Subramaniam K, Boisen M, Shah PR, Ramesh V, Pete A. Mechanical circulatory support for cardiogenic shock. Best Pract Res Clin Anaesthesiol 2013; 26:131-46. [PMID: 22910086 DOI: 10.1016/j.bpa.2012.05.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 05/18/2012] [Indexed: 02/08/2023]
Abstract
Cardiogenic shock (CS) is a syndrome of progressive depression of myocardial function with systemic hypoperfusion. It occurs due to various aetiologies such as acute myocardial infarction, myocarditis, acute decompensated heart failure and postcardiotomy. Cardiogenic shock carries poor prognosis, and medical therapy alone is not effective. Mechanical circulatory support is required to unload the ventricles, decrease the myocardial demand, prevent further injury, improve the coronary perfusion, stabilise the haemodynamics and maintain the end-organ perfusion before definitive interventions such as coronary reperfusion can take place. Currently, there are several methods of mechanical circulatory support. These include extracorporeal life support, paracorporeal or extracorporeal ventricular-assist devices, percutaneous ventricular assist devices, intra-aortic balloon counterpulsation and total artificial heart. In this review, we discuss the role of each of these circulatory support devices in the management of acute cardiac failure.
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Affiliation(s)
- Kathirvel Subramaniam
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
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Lemaire A, Anderson MB, Prendergast T, Stockmaster N, Goodman A, Lozane AM, Batsides G. Outcome of the Impella Device for Acute Mechanical Circulatory Support. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2013. [DOI: 10.1177/155698451300800103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Anthony Lemaire
- Department of Cardiothoracic Surgery, Robert Wood Johnson University Hospital, New Brunswick, NJ USA; and Abiomed, Inc, Danvers, MA USA
| | - Mark B. Anderson
- Department of Cardiothoracic Surgery, Robert Wood Johnson University Hospital, New Brunswick, NJ USA; and Abiomed, Inc, Danvers, MA USA
| | - Thomas Prendergast
- Department of Cardiothoracic Surgery, Robert Wood Johnson University Hospital, New Brunswick, NJ USA; and Abiomed, Inc, Danvers, MA USA
| | - Neil Stockmaster
- Department of Cardiothoracic Surgery, Robert Wood Johnson University Hospital, New Brunswick, NJ USA; and Abiomed, Inc, Danvers, MA USA
| | - Andrew Goodman
- Department of Cardiothoracic Surgery, Robert Wood Johnson University Hospital, New Brunswick, NJ USA; and Abiomed, Inc, Danvers, MA USA
| | - Ann Marie Lozane
- Department of Cardiothoracic Surgery, Robert Wood Johnson University Hospital, New Brunswick, NJ USA; and Abiomed, Inc, Danvers, MA USA
| | - George Batsides
- Department of Cardiothoracic Surgery, Robert Wood Johnson University Hospital, New Brunswick, NJ USA; and Abiomed, Inc, Danvers, MA USA
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50
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Outcome of the Impella Device for Acute Mechanical Circulatory Support. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2013; 8:12-6. [DOI: 10.1097/imi.0b013e31828e0a8a] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective The contribution of cardiogenic shock to in-hospital mortality has not decreased significantly despite prompt revascularization, advances in medical therapy, and mechanical circulatory support. For patients in cardiogenic shock, mechanical circulatory support has been provided by a variety of devices. We report the outcome of the Impella device for acute mechanical circulatory support in cardiogenic shock in a setting of a large-volume single institution. The primary end points include survival to 30 days and recovery of native heart function and survival to 90 days and 1 year. The secondary end points include device complications. Methods We performed a retrospective chart review of 36 consecutive patients who underwent placement of the Impella device from February 6, 2006, to December 31, 2010. The charts were evaluated for data relative to the patients’ demographics, hemodynamics, operative details, 30-day outcome including the patients’ native heart function recovery, and 90-day and 1-year survival. Results Thirty-six consecutive patients were included in our study. The mean ± SD age was 60.3 ± 13 years, and 69% were men. The indication for placement of the Impella device included postcardiotomy cardiogenic shock in 23 patients (64%), acute myocardial infarction complicated with cardiogenic shock in 10 patients (28%), acute decompensated ischemic cardiomyopathy in 2 patients (6%), and myocarditis with cardiogenic shock in 1 patient (3%). The mean ± SD duration of the Impella support was 4.5 ± 3.9 days (range, 1–18). The 30-day survival rate was 72% (26/36), and, of those, 96% (25/26) recovered their native heart function and one (4%) was bridged to long-term left ventricular assist device (HeartMate II; Thoratec, Inc, Pleasanton, CA USA). The 90-day and 1-year survival was 64% and 61%, respectively. Conclusions The Impella devices yielded a very favorable outcome in patients with cardiogenic shock.
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