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Karahalios DS, Kadiu G, Farooqi A, Singh G, Aggarwal S. Effect of Atrial Septostomy on Left Ventricular Function in Pediatric Dilated Cardiomyopathy Requiring ECMO. Pediatr Cardiol 2024:10.1007/s00246-024-03615-5. [PMID: 39123074 DOI: 10.1007/s00246-024-03615-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 08/02/2024] [Indexed: 08/12/2024]
Abstract
Balloon atrial septostomy (BAS) reduces left ventricular (LV) hypertension during extracorporeal membrane oxygenation (ECMO). However, the acute effect of BAS on LV function as measured by echocardiography is unknown. This was a Retrospective analysis of clinical outcome, LV dimensions, and LV function in dilated cardiomyopathy patients 0-18 years old who underwent BAS on ECMO. In 13 patients with median (IQR) age of 2.3 (0.6-10.9) years, there were no differences in clinical markers of cardiac output at intervals between 12 h before and 6 days after BAS. In addition, BAS was associated with a low rate of periprocedural complications (0.0%), acute kidney injury (7.7%), and worsening radiographic pulmonary vascular congestion (30.7%). There was a significant worsening in LV end systolic diameter (LVIDs; 3.6 [2.9-4.8] cm vs 4.2 [3.2-5.6] cm vs 3.3 [2.6-4.6] cm, p = 0.025), LV end systolic posterior wall thickness (LVPWs; 0.7 [0.5-0.9] cm vs 0.6 [0.5-0.9] cm vs 0.8 [0.6-1.2] cm, p = 0.038), fractional shortening (FS; 17.6% [8.4-20.4%] vs 6.3% [2.0-9.9%] vs 13.2% [3.6-23.4%], p = 0.013), and ejection fraction (EF; 13.1% [8.7-18.9%] vs 5.3% [2.5-11.1%] vs 9.2% [6.0-16.3%], p = 0.039) following BAS that improved in approximately 1 week. There were no differences in LV global longitudinal strain following BAS. We conclude that BAS was associated with low procedural and clinical adverse event rates in our cohort. The worsening LVIDs, LVPWs, FS, and EF seen immediately after the procedure suggests that BAS causes altered loading conditions affecting LV function in pediatric patients with dilated cardiomyopathy requiring ECMO.
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Affiliation(s)
- Dean S Karahalios
- Department of Pediatrics, Division of Pediatric Cardiology, Northwestern University Ann and Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Chicago, IL, 60611, USA.
| | - Gilda Kadiu
- Department of Pediatrics, Division of Pediatric Cardiology, Central Michigan University Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI, 48201, USA
| | - Ahmad Farooqi
- Children's Research Institute, Central Michigan University Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI, 48201, USA
| | - Gautam Singh
- Department of Pediatrics, Division of Pediatric Cardiology, Central Michigan University Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI, 48201, USA
| | - Sanjeev Aggarwal
- Department of Pediatrics, Division of Pediatric Cardiology, Central Michigan University Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI, 48201, USA
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Kobayashi RL, Przybylski R, Gauvreau K, Esteso P, Nathan M, Fynn-Thompson F, Teele SA. Contemporary Outcomes of Children With Acute Fulminant Myocarditis Supported With Peripheral Extracorporeal Membrane Oxygenation. ASAIO J 2024; 70:321-327. [PMID: 38029737 DOI: 10.1097/mat.0000000000002103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
Despite extracorporeal membrane oxygenation (ECMO) utilization in nearly 20% of cases, there are limited data in children with acute fulminant myocarditis (AFM) requiring ECMO. Herein we identify risk factors for death or heart transplant (HT) in children with AFM supported with ECMO, describe our experience with left atrial (LA) decompression, and depict long-term outcomes of survivors. We performed a retrospective cohort of patients <18 years with AFM (≤14 days of symptoms, rapid cardiogenic shock, and normal left ventricular [LV] size on presentation) supported with ECMO admitted to a single intensive care unit from 1997 to 2021. Among 28 patients (median age 9 years), 21 (75%) survived to discharge without HT. Patients were supported on ECMO for a median of 6 days. Three patients were bridged to HT with durable ventricular assist devices (VAD). Four patients died, two of whom were supported with VAD. At presentation, seven (25%) patients had high grade or complete atrioventricular block and eight (29%) had ventricular tachycardia. Before ECMO cannulation, 21 (75%) patients received CPR. The death/HT group had higher peak troponin levels (12.5 vs . 1.0 ng/ml, p = 0.02) and initial mean LA or pulmonary capillary wedge pressure (27 vs . 18 mm Hg, p = 0.03). Left atrial decompression was performed in 22 patients (79%). Twenty-two (79%) had acute myocarditis on endomyocardial biopsy. Among transplant-free survivors, 18 (86%) had normalization in LV function (median 7 days); the remaining three patients had persistent mild LV dysfunction at last follow-up (median 842 days). Transplant-free survival of pediatric patients with AFM supported on ECMO was 75% and associated with lower initial LA pressure and lower peak troponin. Recovery in ventricular function among survivors was rapid and durable.
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Affiliation(s)
- Ryan L Kobayashi
- From the Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Robert Przybylski
- From the Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Kimberlee Gauvreau
- From the Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, Massachusetts
| | - Paul Esteso
- From the Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Francis Fynn-Thompson
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Sarah A Teele
- From the Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Deng MX, Haller C, Moss K, Saha S, Runeckles K, Fan CPS, Langanecha B, Floh A, Guerguerian AM, Honjo O. Early outcomes of moderate-to-high-risk pediatric congenital cardiac surgery and predictors of extracorporeal circulatory life support requirement. Front Pediatr 2024; 12:1282275. [PMID: 38523837 PMCID: PMC10957634 DOI: 10.3389/fped.2024.1282275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 02/23/2024] [Indexed: 03/26/2024] Open
Abstract
Background Cardiopulmonary failure refractory to medical management after moderate-to-high-risk congenital cardiac surgery may necessitate mechanical support with veno-arterial extracorporeal membrane oxygenation (ECMO). On the extreme, ECMO can also be initiated in the setting of cardiac arrest (extracorporeal cardiopulmonary resuscitation, ECPR) unresponsive to conventional resuscitative measures. Methods This was a single-center retrospective cohort study of patients (n = 510) aged <3 years old who underwent cardiac surgery with cardiopulmonary bypass with a RACHS-1 score ≥3 between 2011 and 2014. Perioperative factors were reviewed to identify predictors of ECMO initiation and mortality in the operating room (OR) and the intensive care unit (ICU). Results A total of 510 patients with a mean surgical age of 10.0 ± 13.4 months were included. Among them, 21 (4%) patients received postoperative ECMO-12 were initiated in the OR and 9 in the ICU. ECMO cannulation was associated with cardiopulmonary bypass duration, aortopulmonary shunt, residual severe mitral regurgitation, vaso-inotropic score, and postprocedural lactate (p < 0.001). Of the 32 (6%) total deaths, 7 (22%) were ECMO patients-4 were elective OR cannulations and 3 were ICU ECPR. Prematurity [hazard ratio (HR): 2.61, p < 0.01), Norwood or Damus-Kaye-Stansel procedure (HR: 4.29, p < 0.001), postoperative left ventricular dysfunction (HR: 5.10, p = 0.01), residual severe tricuspid regurgitation (HR: 6.06, p < 0.001), and postoperative ECMO (ECPR: HR: 15.42, p < 0.001 vs. elective: HR: 5.26, p = 0.01) were associated with mortality. The two patients who were electively cannulated in the ICU survived. Discussion Although uncommon, postoperative ECMO in children after congenital cardiac surgery is associated with high mortality, especially in cases of ECPR. Patients with long cardiopulmonary bypass time, residual cardiac lesions, or increased vaso-inotropic requirement are at higher risk of receiving ECMO. Pre-emptive or early ECMO initiation before deterioration into cardiac arrest may improve survival.
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Affiliation(s)
- Mimi Xiaoming Deng
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Christoph Haller
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Kasey Moss
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
- Faculty of Internal Medicine, McMaster University, Hamilton, ON, Canada
| | - Sudipta Saha
- Rogers Computational Program, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Kyle Runeckles
- Rogers Computational Program, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Chun-Po Steve Fan
- Rogers Computational Program, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | | | - Alejandro Floh
- Department of Critical Care Medicine, Labatt Family Heart Centre, Toronto, ON, Canada
| | | | - Osami Honjo
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
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Perry T, Greenberg JW, Cooper DS, Smith R, Benscoter AL, Koh W, Ryan TD, Lehenbauer DG, Brown TN, Zafar F, Thiagarajan RR, Sweberg TM, Morales DL. Balloon atrial septostomy versus left atrial cannulation for left heart decompression in children with dilated cardiomyopathy and myocarditis on extracorporeal membrane oxygenation: An ELSO registry analysis. Perfusion 2023:2676591231220816. [PMID: 38053305 DOI: 10.1177/02676591231220816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
INTRODUCTION In children with myocarditis or dilated cardiomyopathy (DCM) on extracorporeal membrane oxygenation (ECMO) for cardiogenic shock, it is often necessary to decompress the left heart to minimize distension and promote myocardial recovery. We compare outcomes in those who underwent balloon atrial septostomy (BAS) versus direct left atrial (LA) drainage for left heart decompression in this population. METHODS Retrospective study of the Extracorporeal Life Support Organization (ELSO) multicenter registry of patients ≤ 18 years with myocarditis or DCM on ECMO who underwent LA decompression. Descriptive and univariate statistics assessed association of patient factors with decompression type. Multivariable logistic regression sought independent associations with outcomes. RESULTS 369 pediatric ECMO runs were identified. 52% myocarditis, 48% DCM, overall survival 74%. 65% underwent BAS and 35% LA drainage. Patient demographics including age, weight, gender, race/ethnicity, diagnosis, pre-ECMO pH, mean airway pressure, and arrest status were similar. 89% in the BAS group were peripherally cannulated onto ECMO, versus 3% in the LA drainage group (p < .001). On multivariable analysis, LA drainage (OR 3.96; 95% CI, 1.47-10.711; p = .007), renal complication (OR 2.37; 95% CI, 1.41-4.01; p = .001), cardiac complication (OR 3.14; 95% CI, 1.70-5.82; p < .001), and non-white race/ethnicity (OR 1.75; 95% CI, 1.04-2.94; p = .035) were associated with greater odds of mortality. There was a trend toward more episodes of pulmonary hemorrhage in BAS (n = 17) versus LA drainage group (n = 3), p = .08. Comparing only those with central cannulation, LA drainage group was more likely to be discontinued from ECMO due to recovery (72%) versus the BAS group (48%), p = .032. CONCLUSIONS In children with myocarditis or DCM, there was a three times greater likelihood for mortality with LA drainage versus BAS for LA decompression. When adjusted for central cannulation groups only, there was better recovery in the LA drainage group and no difference in mortality. Further prospective evaluation is warranted.
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Affiliation(s)
- Tanya Perry
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jason W Greenberg
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David S Cooper
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Reanna Smith
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Alexis L Benscoter
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Wonshill Koh
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Thomas D Ryan
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David G Lehenbauer
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Tyler N Brown
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Farhan Zafar
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Todd M Sweberg
- Department of Pediatric Critical Care, Cohen Children's Medical Center of New York, New Hyde Park, NY, USA
| | - David Ls Morales
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Sperotto F, Gearhart A, Hoskote A, Alexander PMA, Barreto JA, Habet V, Valencia E, Thiagarajan RR. Cardiac arrest and cardiopulmonary resuscitation in pediatric patients with cardiac disease: a narrative review. Eur J Pediatr 2023; 182:4289-4308. [PMID: 37336847 PMCID: PMC10909121 DOI: 10.1007/s00431-023-05055-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/27/2023] [Accepted: 06/02/2023] [Indexed: 06/21/2023]
Abstract
Children with cardiac disease are at a higher risk of cardiac arrest as compared to healthy children. Delivering adequate cardiopulmonary resuscitation (CPR) can be challenging due to anatomic characteristics, risk profiles, and physiologies. We aimed to review the physiological aspects of resuscitation in different cardiac physiologies, summarize the current recommendations, provide un update of current literature, and highlight knowledge gaps to guide research efforts. We specifically reviewed current knowledge on resuscitation strategies for high-risk categories of patients including patients with single-ventricle physiology, right-sided lesions, right ventricle restrictive physiology, left-sided lesions, myocarditis, cardiomyopathy, pulmonary arterial hypertension, and arrhythmias. Cardiac arrest occurs in about 1% of hospitalized children with cardiac disease, and in 5% of those admitted to an intensive care unit. Mortality after cardiac arrest in this population remains high, ranging from 30 to 65%. The neurologic outcome varies widely among studies, with a favorable neurologic outcome at discharge observed in 64%-95% of the survivors. Risk factors for cardiac arrest and associated mortality include younger age, lower weight, prematurity, genetic syndrome, single-ventricle physiology, arrhythmias, pulmonary arterial hypertension, comorbidities, mechanical ventilation preceding cardiac arrest, surgical complexity, higher vasoactive-inotropic score, and factors related to resources and institutional characteristics. Recent data suggest that Extracorporeal membrane oxygenation CPR (ECPR) may be a valid strategy in centers with expertise. Overall, knowledge on resuscitation strategies based on physiology remains limited, with a crucial need for further research in this field. Collaborative and interprofessional studies are highly needed to improve care and outcomes for this high-risk population. What is Known: • Children with cardiac disease are at high risk of cardiac arrest, and cardiopulmonary resuscitation may be challenging due to unique characteristics and different physiologies. • Mortality after cardiac arrest remains high and neurologic outcomes suboptimal. What is New: • We reviewed the unique resuscitation challenges, current knowledge, and recommendations for different cardiac physiologies. • We highlighted knowledge gaps to guide research efforts aimed to improve care and outcomes in this high-risk population.
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Affiliation(s)
- Francesca Sperotto
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Addison Gearhart
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Aparna Hoskote
- Cardiac Intensive Care Unit, Heart and Lung Directorate, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Jessica A Barreto
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Victoria Habet
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Eleonore Valencia
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Ravi R Thiagarajan
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Phillip R, Howard J, Hawamdeh H, Tribble T, Gurley J, Saha S. Left Atrial Veno-Arterial Extracorporeal Membrane Oxygenation Case Series: A Single-Center Experience. J Surg Res 2023; 281:238-244. [PMID: 36209682 DOI: 10.1016/j.jss.2022.08.020] [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: 02/28/2022] [Revised: 08/01/2022] [Accepted: 08/20/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION We aimed to review the characteristics and outcomes of left atrial veno-arterial extra corporeal membrane oxygenation (LAVA ECMO) at our institution over a 4-y period from 2017 to 2020. METHODS Among 227 adult patients who received VA ECMO support from January 2017 to December 2020, we reviewed 33 of these who underwent transseptal cannulation and were converted to LAVA ECMO. The timing of transseptal cannulation, either at initiation of VA ECMO (n = 25) or with a later transseptal cannulation to treat complications of left ventricular (LV) distention while on VA ECMO (n = 8), was reviewed. The clinical characteristics, indications, echocardiography data, and outcomes were assessed. RESULTS Duration of LAVA ECMO support ranged from 1 to 13 d, with a median of 5 d. Successful weaning from the LAVA ECMO circuit was achieved for 15 patients (45%). The in-hospital mortality rate was 66%. There were 11 patients (33%) who survived to be discharged from the hospital. CONCLUSIONS LV distention is a known complication of VA ECMO and impedes the recovery of the heart. LAVA ECMO provides a novel approach to treating LV distention. Additionally, our review shows that this modality may be used as a bridge to durable mechanical circulatory support, cardiac transplantation, or recovery.
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Affiliation(s)
- Rebecca Phillip
- Department of Surgery, University of Kentucky, Lexington, Kentucky; Division of Cardiothoracic Surgery, University of Kentucky, Lexington, Kentucky.
| | - Jordan Howard
- UK College of Medicine - 3(rd) Year, University of Kentucky, Lexington, Kentucky
| | - Hussam Hawamdeh
- Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
| | - Thomas Tribble
- UK HealthCare Extracorporeal Life Support (ECLS), University of Kentucky, Lexington, Kentucky
| | - John Gurley
- Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
| | - Sibu Saha
- Department of Surgery, University of Kentucky, Lexington, Kentucky; Division of Cardiothoracic Surgery, University of Kentucky, Lexington, Kentucky
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Sperotto F, Polito A, Amigoni A, Maschietto N, Thiagarajan RR. Left Atrial Decompression in Pediatric Patients Supported With Extracorporeal Membrane Oxygenation for Failure to Wean From Cardiopulmonary Bypass: A Propensity-Weighted Analysis. J Am Heart Assoc 2022; 11:e023963. [PMID: 35535596 PMCID: PMC9851456 DOI: 10.1161/jaha.121.023963] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background Left atrial (LA) decompression on extracorporeal membrane oxygenation (ECMO) can reduce left ventricular distension, allowing myocardial rest and recovery, and protect from lung injury secondary to cardiogenic pulmonary edema. However, clinical benefits remain unknown. We sought to evaluate the association between LA decompression and in-hospital adverse outcome (mortality, transplant on ECMO, or conversion to ventricular assist device) in patients who failed to wean from cardiopulmonary bypass using a propensity score to adjust for baseline differences. Methods and Results Children (aged <18 years) with biventricular physiology supported with ECMO for failure to wean from cardiopulmonary bypass after cardiac surgery from 2000 through 2016, reported to the ELSO (Extracorporeal Life Support Organization) Registry, were included. Inverse probability of treatment weighted logistic regression was used to test the association between LA decompression and in-hospital adverse outcomes. Of the 2915 patients supported with venoarterial ECMO for failure to wean from cardiopulmonary bypass, 1508 had biventricular physiology and 279 (18%) underwent LA decompression (LA+). Genetic and congenital abnormalities (P=0.001) and pulmonary hypertension (P=0.010) were less frequent and baseline arrhythmias (P=0.022) were more frequent in LA+ patients. LA+ patients had longer pre-ECMO mechanical ventilation and CBP time (P<0.001), and used aortic cross-clamp (P=0.001) more frequently. Covariates were well balanced between the propensity-weighted cohorts. In-hospital adverse outcomes occurred in 47% of LA+ patients and 51% of the others. Weighted multivariate logistic regression showed LA decompression to be protective for in-hospital adverse outcomes (adjusted odds ratio, 0.775 [95% CI, 0.644-0.932]). Conclusions LA decompression independently decreased the risk of in-hospital adverse outcome in pediatric venoarterial ECMO patients who failed to wean from cardiopulmonary bypass, suggesting that these patients may benefit from LA decompression.
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Affiliation(s)
- Francesca Sperotto
- Department of Cardiology Boston Children's HospitalHarvard Medical School Boston MA.,Pediatric Intensive Care Unit Department of Women's and Children's Health University of Padova Italy
| | - Angelo Polito
- Pediatric Intensive Care Unit University Hospital of GenevaUniversity of Geneva Switzerland
| | - Angela Amigoni
- Pediatric Intensive Care Unit Department of Women's and Children's Health University of Padova Italy
| | - Nicola Maschietto
- Department of Cardiology Boston Children's HospitalHarvard Medical School Boston MA
| | - Ravi R Thiagarajan
- Department of Cardiology Boston Children's HospitalHarvard Medical School Boston MA
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8
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Welker CC, Huang J, Boswell MR, Spencer PJ, Theoduloz MAV, Ramakrishna H. Left Ventricular Decompression in VA-ECMO: Analysis of Techniques and Outcomes. J Cardiothorac Vasc Anesth 2022; 36:4192-4197. [PMID: 35965232 DOI: 10.1053/j.jvca.2022.07.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 07/18/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Carson C Welker
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Jeffrey Huang
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Michael R Boswell
- Division of Cardiovascular Anesthesi, Mayo Clinic, Rochester, MN, United States
| | - Philip J Spencer
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States
| | | | - Harish Ramakrishna
- Division of Cardiovascular Anesthesia, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55901, United States.
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Abstract
PURPOSE OF REVIEW Right ventricular (RV) failure is increasingly recognized as a major cause of morbidity and mortality. When RV failure is refractory to medical therapy, escalation to right-sided mechanical circulatory support (MCS) should be considered. In this review, we begin by recapitulating the hemodynamics of RV failure, then we delve into current and future right-sided MCS devices and describe their hemodynamic profiles. RECENT FINDINGS The field of temporary right-sided MCS continues to expand, with evolving strategies and new devices actively under development. All right-sided MCS devices bypass the RV, with each bypass configuration conferring a unique hemodynamic profile. Devices that aspirate blood directly from the RV, as opposed to the RA or the IVC, have more favorable hemodynamics and more effective RV unloading. There has been a growing interest in single-access MCS devices which do not restrict patient mobility. Additionally, a first-of-its-kind percutaneous, pulsatile, right-sided MCS device (PERKAT RV) is currently undergoing investigation in humans. Prompt recognition of refractory RV failure and deployment of right-sided MCS can improve outcomes. The field of right-sided MCS is rapidly evolving, with ongoing efforts dedicated towards developing novel temporary devices that are single access, allow for patient mobility, and directly unload the RV, as well as more durable devices.
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Lüsebrink E, Binzenhöfer L, Kellnar A, Müller C, Scherer C, Schrage B, Joskowiak D, Petzold T, Braun D, Brunner S, Peterss S, Hausleiter J, Zimmer S, Born F, Westermann D, Thiele H, Schäfer A, Hagl C, Massberg S, Orban M. Venting during venoarterial extracorporeal membrane oxygenation. Clin Res Cardiol 2022; 112:464-505. [PMID: 35986750 PMCID: PMC10050067 DOI: 10.1007/s00392-022-02069-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 07/12/2022] [Indexed: 11/03/2022]
Abstract
AbstractCardiogenic shock and cardiac arrest contribute pre-dominantly to mortality in acute cardiovascular care. Here, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has emerged as an established therapeutic option for patients suffering from these life-threatening entities. VA-ECMO provides temporary circulatory support until causative treatments are effective and enables recovery or serves as a bridging strategy to surgical ventricular assist devices, heart transplantation or decision-making. However, in-hospital mortality rate in this treatment population is still around 60%. In the recently published ARREST trial, VA-ECMO treatment lowered mortality rate in patients with ongoing cardiac arrest due to therapy refractory ventricular fibrillation compared to standard advanced cardiac life support in selected patients. Whether VA-ECMO can reduce mortality compared to standard of care in cardiogenic shock has to be evaluated in the ongoing prospective randomized studies EURO-SHOCK (NCT03813134) and ECLS-SHOCK (NCT03637205). As an innate drawback of VA-ECMO treatment, the retrograde aortic flow could lead to an elevation of left ventricular (LV) afterload, increase in LV filling pressure, mitral regurgitation, and elevated left atrial pressure. This may compromise myocardial function and recovery, pulmonary hemodynamics—possibly with concomitant pulmonary congestion and even lung failure—and contribute to poor outcomes in a relevant proportion of treated patients. To overcome these detrimental effects, a multitude of venting strategies are currently engaged for both preventive and emergent unloading. This review aims to provide a comprehensive and structured synopsis of existing venting modalities and their specific hemodynamic characteristics. We discuss in detail the available data on outcome categories and complication rates related to the respective venting option.
Graphical abstract
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11
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Meani P, Lorusso R, Kowalewski M, Isgrò G, Cazzaniga A, Satriano A, Ascari A, Bernardinetti M, Cotza M, Marchese G, Ciotti E, Kandil H, Di Dedda U, Aloisio T, Varrica A, Giamberti A, Ranucci M. Influence of left ventricular unloading on pediatric post-cardiotomy veno-arterial extracorporeal life support outcomes. Front Cardiovasc Med 2022; 9:970334. [PMID: 36035925 PMCID: PMC9399613 DOI: 10.3389/fcvm.2022.970334] [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: 06/15/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe effectiveness of veno-arterial extracorporeal life support (V-A ECLS) in treating neonatal and pediatric patients with complex congenital heart disease (CHD) and requiring cardio-circulatory assistance is well-known. Nevertheless, the influence of left ventricle (LV) distension and its countermeasure, namely LV unloading, on survival and clinical outcomes in neonates and children treated with V-A ECLS needs still to be addressed. Therefore, the aim of this study was to determine the effects of LV unloading on in-hospital survival and complications in neonates and children treated with V-A ECLS.MethodsThe clinical outcomes of 90 pediatric patients with CHD under 16 years of age supported with V-A ECLS for post-cardiotomy cardiogenic shock (CS) were retrospectively reviewed in relationship with the presence or absence of an active LV unloading strategy.ResultsThe patient cohort included 90 patients (age 19.6 ± 31.54 months, 64.4% males), 42 of whom were vented with different techniques (38 with atrial septostomy (AS) or left atria cannula, two with cannula from LV apex, 1 with intra-aortic balloon pump (IABP), and one with pigtail across the aortic valve). The LV unloading strategy significantly increased the in-hospital survival (odds ratio [OR] = 2.74, 95% CI 1.06–7.08; p = 0.037). On the contrary, extracorporeal cardiopulmonary resuscitation decreased the related survival (OR = 0.32, 95% CI 1.09–0.96; p = 0.041). The most common complications were infections (28.8%), neurological injury (26%), and bleeding (25.6%). However, these did not differently occur in venting and no-venting groups.ConclusionIn pediatric patients with CHD supported with V-A ECLS for post-cardiotomy CS, the LV unloading strategy was associated with increased survival.
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Affiliation(s)
- Paolo Meani
- Cardio-Thoracic Surgery Department, ECLS Centrum, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, Netherlands
- *Correspondence: Paolo Meani
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, ECLS Centrum, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Mariusz Kowalewski
- Cardio-Thoracic Surgery Department, ECLS Centrum, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, Netherlands
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Giuseppe Isgrò
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Anna Cazzaniga
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Angela Satriano
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Alice Ascari
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Mattia Bernardinetti
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Mauro Cotza
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Giuseppe Marchese
- Department of Anesthesiology and Intensive Care, Ospedale Civile Legnano, Legnano, Italy
| | - Erika Ciotti
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Hassan Kandil
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Umberto Di Dedda
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Tommaso Aloisio
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Alessandro Varrica
- Department of Congenital Cardiac Surgery, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Alessandro Giamberti
- Department of Congenital Cardiac Surgery, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Marco Ranucci
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
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Suzuki H, Kuroko Y, Kotani Y, Sakoda N, Kasahara S. A Ruptured Coronary Artery Aneurysm Secondary to Kawasaki Disease. JACC Case Rep 2022; 4:790-793. [PMID: 35818603 PMCID: PMC9270623 DOI: 10.1016/j.jaccas.2022.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/29/2022] [Accepted: 05/11/2022] [Indexed: 06/15/2023]
Abstract
Coronary artery aneurysm occurs in 0.3%-0.8% of patients with Kawasaki disease, and cases of rupture are extremely rare. Only 2 cases have been reported in which the patients survived. We report a case of ruptured coronary artery aneurysm that was treated with coronary artery bypass grafting and extracorporeal membrane oxygenation. (Level of Difficulty: Advanced.).
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Affiliation(s)
| | - Yosuke Kuroko
- Address for correspondence: Dr Yosuke Kuroko, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama City, Okayama 700-8558, Japan.
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Extracorporeal Membrane Oxygenation in Congenital Heart Disease. CHILDREN 2022; 9:children9030380. [PMID: 35327752 PMCID: PMC8947570 DOI: 10.3390/children9030380] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 11/24/2022]
Abstract
Mechanical circulatory support (MCS) is a key therapy in the management of patients with severe cardiac disease or respiratory failure. There are two major forms of MCS commonly employed in the pediatric population—extracorporeal membrane oxygenation (ECMO) and ventricular assist device (VAD). These modalities have overlapping but distinct roles in the management of pediatric patients with severe cardiopulmonary compromise. The use of ECMO to provide circulatory support arose from the development of the first membrane oxygenator by George Clowes in 1957, and subsequent incorporation into pediatric cardiopulmonary bypass (CPB) by Dorson and colleagues. The first successful application of ECMO in children with congenital heart disease undergoing cardiac surgery was reported by Baffes et al. in 1970. For the ensuing nearly two decades, ECMO was performed sparingly and only in specialized centers with varying degrees of success. The formation of the Extracorporeal Life Support Organization (ELSO) in 1989 allowed for the collation of ECMO-related data across multiple centers for the first time. This facilitated development of consensus guidelines for the use of ECMO in various populations. Coupled with improving ECMO technology, these advances resulted in significant improvements in ECMO utilization, morbidity, and mortality. This article will review the use of ECMO in children with congenital heart disease.
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14
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Hemodynamic Effects of Left-Atrial Venous Arterial Extra-Corporeal Membrane Oxygenation (LAVA-ECMO). ASAIO J 2021; 68:e148-e151. [PMID: 34967778 DOI: 10.1097/mat.0000000000001628] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We report a case of a 59-year-old male in post-myocardial infarction cardiogenic shock undergoing left atrial venous arterial extracorporeal membrane oxygenation (LAVA-ECMO) as a bridge to transplantation. The unique feature of this ECMO configuration is use of a single trans-septal cannula to provide biventricular unloading and use of a single arterial access.
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15
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Choudhury TA, Ofori-Amanfo G, Choi J, Eisenberg RE, Rycus P, Medar SS, Aydin SI. Left Heart Decompression on Veno-Arterial Extracorporeal Membrane Oxygenation in Children With Dilated Cardiomyopathy and Myocarditis: An Extracorporeal Life Support Organization Registry Review. Pediatr Crit Care Med 2021; 22:1026-1032. [PMID: 34054118 DOI: 10.1097/pcc.0000000000002775] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe the association between left heart decompression on veno-arterial extracorporeal membrane oxygenation and survival in patients with myocarditis and dilated cardiomyopathy. The secondary outcome is to study association of left heart decompression with survival in children with myocarditis compared with those with dilated cardiomyopathy. DESIGN Retrospective study of a multicenter registry database. SETTING Data reported to Extracorporeal Life Support Organization from international extracorporeal membrane oxygenation centers. PATIENTS Patients less than or equal to 18 years old with a diagnosis of myocarditis or dilated cardiomyopathy receiving extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 1,438 pediatric extracorporeal membrane oxygenation runs were identified. Thirty-seven percent of the patients had myocarditis (n = 532), whereas the rest had dilated cardiomyopathy. Survival to hospital discharge was 63%. Median extracorporeal membrane oxygenation duration was 148 hours with interquartile range (84-248 hr). Nineteen percent of patients (n = 274) had left heart decompression. Multivariable analysis revealed using left heart decompression (adjusted odds ratio, 1.42; 95% CI, 1.06-1.89; p = 0.02), e-cardiopulmonary resuscitation (adjusted odds ratio, 0.63; 95% CI, 0.51-0.79; p < 0.001), higher pH (adjusted odds ratio, 3.69; 95% CI, 1.80-7.53; p < 0.001), and diagnosis of myocarditis (adjusted odds ratio, 1.69; 95% CI, 1.35-2.08; p < 0.001) were associated with greater odds of survival. In the multivariable analysis for patients with dilated cardiomyopathy, left heart decompression failed to reveal a significant association with survival (20% among survivors vs 17% among nonsurvivors, 95% CI, -2.2% to 8.0%). Meanwhile in patients with myocarditis, the multivariable analysis failed to exclude the possibility that left heart decompression was associated with up to a three-fold greater odds of survival (adjusted odds ratio, 1.77; 95% CI, 0.99-.15). CONCLUSIONS Retrospective review of the Extracorporeal Life Support Organization registry revealed an association between left heart decompression and greater odds of survival in children with myocarditis and dilated cardiomyopathy on extracorporeal membrane oxygenation. When comparing patients with dilated cardiomyopathy against those with myocarditis, we could not exclude a three-fold greater odds of survival associated with the use of left heart decompression. This finding warrants further prospective evaluation.
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Affiliation(s)
- Tarif A Choudhury
- Divisions of Pediatric Critical Care Medicine and Pediatric Cardiology, Morgan Stanley Children's Hospital of New York, Columbia University Medical Center, New York, NY
| | - George Ofori-Amanfo
- Division of Critical Care Medicine, Kravis Children's Hospital, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jaeun Choi
- Division of Critical Care Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY
| | - Ruth E Eisenberg
- Division of Critical Care Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY
| | - Peter Rycus
- Extracorporeal Life Support Organization, Ann Arbor, MI
| | - Shivanand S Medar
- Division of Critical Care Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY
| | - Scott I Aydin
- Division of Critical Care Medicine, Kravis Children's Hospital, Icahn School of Medicine at Mount Sinai, New York, NY
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16
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Puri K, Adachi I. Left Heart Decompression on Extracorporeal Membrane Oxygenation Support and Cardiopulmonary Bypass. Pediatr Crit Care Med 2021; 22:e599-e604. [PMID: 34657072 DOI: 10.1097/pcc.0000000000002846] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Kriti Puri
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Iki Adachi
- Department of Surgery, Section of Congenital Cardiac Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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17
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Shimizu T, Kanazawa T, Sakura T, Shimizu K, Iwasaki T. Intact survival from severe cardiogenic shock caused by the first attack of atrial tachycardia treated with extracorporeal membrane oxygenation and surgical left atrium appendage resection: a case report. JA Clin Rep 2021; 7:81. [PMID: 34731340 PMCID: PMC8563818 DOI: 10.1186/s40981-021-00481-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/07/2021] [Accepted: 10/10/2021] [Indexed: 11/21/2022] Open
Abstract
Background Atrial tachycardia (AT) is rare in children and can usually be reversed to sinus rhythm with pharmacotherapy and cardioversion. We report a rare case of severe left-sided heart failure due to refractory AT. Case presentation A 12-year-old boy had AT with a heart rate of 180 beats/minute, which was refractory to any medication and defibrillation despite the first attack. Due to rapid cardiorespiratory collapse shortly after arriving at our hospital, central extracorporeal membrane oxygenation (ECMO) with left arterial venting was started immediately. Although AT persisted after that, it stopped on the 3rd day after admission following surgical resection of the left atrial appendage thought to be the source of AT. He was weaned off ECMO on the 7th day and ventilator on the 14th day. Conclusions The appropriate timing of central ECMO and surgical ablation were effective in saving this child from a life-threatening situation caused by refractory AT.
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Affiliation(s)
- Tatsuhiko Shimizu
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Tomoyuki Kanazawa
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.
| | - Takanobu Sakura
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Kazuyoshi Shimizu
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Tatsuo Iwasaki
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
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18
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Boeken U, Assmann A, Beckmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan A, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Groesdonk H, Ferrari M, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel L, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Fischer S, Wiebe K, Hartog CS, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Kelm M, Ensminger S. S3 Guideline of Extracorporeal Circulation (ECLS/ECMO) for Cardiocirculatory Failure. Thorac Cardiovasc Surg 2021; 69:S121-S212. [PMID: 34655070 DOI: 10.1055/s-0041-1735490] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Udo Boeken
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Alexander Assmann
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Andreas Beckmann
- German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Karl Werdan
- Clinic for Internal Medicine III, University Hospital Halle (Saale), Martin-Luther University Halle-Wittenberg, Germany
| | - Guido Michels
- Department of Acute and Emergency Care, St Antonius Hospital Eschweiler, Eschweiler, Germany
| | - Oliver Miera
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Florian Schmidt
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Germany
| | - Stefan Klotz
- Department of Cardiac Surgery, Segeberger Kliniken, Bad Segeberg, Germany
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre, Berlin, German
| | - Kevin Pilarczyk
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Ardawan Rastan
- Department of Cardiac and Vascular Thoracic Surgery, Philipps-University Hospital Marburg, Marburg, Germany
| | - Marion Burckhardt
- Department of Health Sciences and Management; Baden-Wuerttemberg Cooperative State University (DHBW), Stuttgart, Germany
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies (AWMF), Universität Marburg, Marburg, Germany
| | - Ralf Muellenbach
- Department of Anaesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - York Zausig
- Department of Anesthesiology and Operative Intensive Care Medicine, Aschaffenburg-Alzenau Hospital, Aschaffenburg, Bavaria, Germany
| | - Nils Haake
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Heinrich Groesdonk
- Department of Intensive Care Medicine, Helios Clinic Erfurt, Erfurt, Germany
| | - Markus Ferrari
- HSK, Clinic of Internal Medicine I, Helios-Kliniken, Wiesbaden, Germany
| | - Michael Buerke
- Department of Cardiology, Angiology and Intensive Care Medicine, St. Marienkrankenhaus Siegen, Siegen, Germany
| | - Marcus Hennersdorf
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, SLK-Kliniken Heilbronn, Heilbronn, Germany
| | - Mark Rosenberg
- Klinikum Aschaffenburg-Alzenau, Medizinische Klinik 1, Aschaffenburg, Germany
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Harald Köditz
- Medical University Children's Hospital, Hannover, Germany
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St Antonius Hospital, Eschweiler, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Flemmer
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Munich, Germany
| | - Susanne Herber-Jonat
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Germany
| | - Lucas Wessel
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Dirk Buchwald
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | - Lars Krüger
- Division of Thoracic and Cardiovascular Surgery, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | - Andreas Fründ
- Department of Physiotherapy, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | | | - Stefan Fischer
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Karsten Wiebe
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Christiane S Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, and Klinik Bavaria, Kreischa
| | - Omer Dzemali
- Department of Cardiac Surgery, Triemli City hospital Zurich, Zurich, Switzerland
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Christian Schlensak
- Department of Cardio-Thoracic and Vascular Surgery, University of Tübingen, Tübingen, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig-Holstein, Lübeck, Germany
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Ye LF, Shu Q, Zhang C, Fan Y, Ying L, Yang L, Lin R. Surgical minimal invasive left atrial decompression during venoarterial extracorporeal membrane oxygenation for pediatric acute fulminant myocarditis. WORLD JOURNAL OF PEDIATRIC SURGERY 2021; 4:e000291. [DOI: 10.1136/wjps-2021-000291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2021] [Indexed: 11/04/2022] Open
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20
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Sperotto F, Saengsin K, Danehy A, Godsay M, Geisser DL, Rivkin M, Amigoni A, Thiagarajan RR, Kheir JN. Modeling severe functional impairment or death following ECPR in pediatric cardiac patients: Planning for an interventional trial. Resuscitation 2021; 167:12-21. [PMID: 34389452 DOI: 10.1016/j.resuscitation.2021.07.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/16/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
AIM We aimed to characterize extracorporeal CPR (ECPR) outcomes in our center and to model prediction of severe functional impairment or death at discharge. METHODS All ECPR events between 2011 and 2019 were reviewed. The primary outcome measure was severe functional impairment or death at discharge (Functional Status Score [FSS] ≥ 16). Organ dysfunction was graded using the Pediatric Logistic Organ Dysfunction Score-2, neuroimaging using the modified Alberta Stroke Program Early Computed Tomography Score. Multivariable logistic regression was used to model FSS ≥ 16 at discharge. RESULTS Of the 214 patients who underwent ECPR, 182 (median age 148 days, IQR 14-827) had an in-hospital cardiac arrest and congenital heart disease and were included in the analysis. Of the 110 patients who underwent neuroimaging, 52 (47%) had hypoxic-ischemic injury and 45 (41%) had hemorrhage. In-hospital mortality was 52% at discharge. Of these, 87% died from the withdrawal of life-sustaining therapies; severe neurologic injury was a contributing factor in the decision to withdraw life-sustaining therapies in 50%. The median FSS among survivors was 8 (IQR 6-8), and only one survivor had severe functional impairment. At 6 months, mortality was 57%, and the median FSS among survivors was 6 (IQR 6-8, n = 79). Predictive models identified FSS at admission, single ventricle physiology, extracorporeal membrane oxygenation (ECMO) duration, mean PELOD-2, and worst mASPECTS (or DWI-ASPECTS) as independent predictors of FSS ≥ 16 (AUC = 0.931) and at 6 months (AUC = 0.924). CONCLUSION Mortality and functional impairment following ECPR in children remain high. It is possible to model severe functional impairment or death at discharge with high accuracy using daily post-ECPR data up to 28 days. This represents a prognostically valuable tool and may identify endpoints for future interventional trials.
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Affiliation(s)
- Francesca Sperotto
- Departments of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Pediatrics, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA; Pediatric Intensive Care Unit, Department of Women's and Children's Health, University of Padova, Via Giustiniani 2, Padova 35128, Italy
| | - Kwannapas Saengsin
- Departments of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Pediatrics, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
| | - Amy Danehy
- Radiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Pediatrics, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
| | - Manasee Godsay
- Departments of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Diana L Geisser
- Departments of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Pediatrics, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
| | - Michael Rivkin
- Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Pediatrics, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University of Padova, Via Giustiniani 2, Padova 35128, Italy
| | - Ravi R Thiagarajan
- Departments of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Pediatrics, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
| | - John N Kheir
- Departments of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Pediatrics, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA.
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Heinsar S, Raman S, Suen JY, Cho HJ, Fraser JF. The use of extracorporeal membrane oxygenation in children with acute fulminant myocarditis. Clin Exp Pediatr 2021; 64:188-195. [PMID: 32777915 PMCID: PMC8103038 DOI: 10.3345/cep.2020.00836] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/02/2020] [Indexed: 12/28/2022] Open
Abstract
Acute fulminant myocarditis (AFM) occurs as an inflammatory response to an initial myocardial insult. Its rapid and deadly progression calls for prompt diagnosis with aggressive treatment measures. The demonstration of its excellent recovery potential has led to increasing use of mechanical circulatory support, especially extracorporeal membrane oxygenation (ECMO). Arrhythmias, organ failure, elevated cardiac biomarkers, and decreased ventricular function at presentation predict requirement for ECMO. In these patients, ECMO should be considered earlier as the clinical course of AFM can be unpredictable and can lead to rapid haemodynamic collapse. Key uncertainties that clinicians face when managing children with AFM such as timing of initiation of ECMO and left ventricular decompression need further investigation.
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Affiliation(s)
- Silver Heinsar
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia
| | - Sainath Raman
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia.,Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Queensland, Australia.,Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia
| | - Jacky Y Suen
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia
| | - Hwa Jin Cho
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia.,Department of Pediatrics, Chonnam National University Children's Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - John F Fraser
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia
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22
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Hasde Aİ, Sarıcaoğlu MC, Dikmen Yaman N, Baran Ç, Özçınar E, Çakıcı M, İnan MB, Akar AR. Comparison of left ventricular unloading strategies on venoarterial extracorporeal life support. Interact Cardiovasc Thorac Surg 2021; 32:467-475. [PMID: 33249443 PMCID: PMC8906780 DOI: 10.1093/icvts/ivaa284] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/16/2020] [Accepted: 09/20/2020] [Indexed: 01/22/2024] Open
Abstract
OBJECTIVES Our goal was to compare the haemodynamic effects of different mechanical left ventricular (LV) unloading strategies and clinical outcomes in patients with refractory cardiogenic shock supported with venoarterial extracorporeal membrane oxygenation (VA-ECMO). METHODS A total of 448 patients supported with VA-ECMO for refractory cardiogenic shock between 1 March 2015 and 31 January 2020 were included and analysed in a single-centre, retrospective case-control study. Fifty-three patients (11.8%) on VA-ECMO required LV unloading. Percutaneous balloon atrial septostomy (PBAS), intra-aortic balloon pump (IABP) and transapical LV vent (TALVV) strategies were compared with regards to the composite rate of death, procedure-related complications and neurological complications. The secondary outcomes were reduced pulmonary capillary wedge pressure, pulmonary artery pressure, central venous pressure, left atrial diameter and resolution of pulmonary oedema on a chest X-ray within 48 h. RESULTS No death related to the LV unloading procedure was detected. Reduction in pulmonary capillary wedge pressure was highest with the TALVV technique (17.2 ± 2.1 mmHg; P < 0.001) and was higher in the PBAS than in the IABP group; the difference was significant (9.6 ± 2.5 and 3.9 ± 1.3, respectively; P = 0.001). Reduction in central venous pressure with TALVV was highest with the other procedures (7.4 ± 1.1 mmHg; P < 0.001). However, procedure-related complications were significantly higher with TALVV compared to the PBAS and IABP groups (50% vs 17.6% and 10%, respectively; P = 0.015). We observed no significant differences in mortality or neurological complications between the groups. CONCLUSIONS Our results suggest that TALVV was the most effective method for LV unloading compared with PBAS and IABP for VA-ECMO support but was associated with complications. Efficient LV unloading may not improve survival.
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Affiliation(s)
- Ali İhsan Hasde
- Department of Cardiovascular Surgery, Heart Center, Ankara University School of Medicine, Ankara, Turkey
| | - Mehmet Cahit Sarıcaoğlu
- Department of Cardiovascular Surgery, Heart Center, Ankara University School of Medicine, Ankara, Turkey
| | - Nur Dikmen Yaman
- Department of Pediatric Cardiovascular Surgery, Sami Ulus Maternity and Children Research and Training Hospital, Ankara, Turkey
| | - Çağdaş Baran
- Department of Cardiovascular Surgery, Heart Center, Ankara University School of Medicine, Ankara, Turkey
| | - Evren Özçınar
- Department of Cardiovascular Surgery, Heart Center, Ankara University School of Medicine, Ankara, Turkey
| | - Mehmet Çakıcı
- Department of Cardiovascular Surgery, Heart Center, Ankara University School of Medicine, Ankara, Turkey
| | - Mustafa Bahadır İnan
- Department of Cardiovascular Surgery, Heart Center, Ankara University School of Medicine, Ankara, Turkey
| | - Ahmet Ruchan Akar
- Department of Cardiovascular Surgery, Heart Center, Ankara University School of Medicine, Ankara, Turkey
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23
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Deshpande SR, Kennedy KF, Vincent RN, Maher KO. Atrial septostomy in patients supported with venoarterial extracorporeal membrane oxygenation: Analysis of the IMPACT registry data. Int J Artif Organs 2021; 44:262-268. [DOI: 10.1177/0391398820953860] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Background: Patients with severe cardiac dysfunction, supported on extra-corporeal membrane oxygenation (ECMO), develop left atrial hypertension and often warrant atrial decompression. The procedural risks and outcomes, however, are not well established. Objective of this study is to understand the utilization, safety, and outcomes of atrial septostomy in children supported on venoarterial ECMO utilizing the IMPACT registry database. Methods: Data from 55 independent sites reporting to the registry was used for this descriptive study. Patients supported with cardiac ECMO that underwent percutaneous atrial septostomy (PAS) were included and data analyzed. Results: Between 2011 and 2018, 223 patients underwent atrial septostomy and were reported to the registry. Mean age was 4.65 years with 52% being males. Diagnoses of heart failure, sepsis, arrhythmia, and renal insufficiency were commonly noted prior to ECMO. The procedure was performed urgently or emergently in most cases (80%). PAS was associated with significant procedural complications such as arrhythmia (6.8%), tamponade (5.4%), and unplanned surgery (3.6%) but no procedural mortality. Overall hospital mortality was 46% (103/223) with 46 of these deaths occurring within 7 days of procedure. Regression analysis showed that African American race (vs Caucasian), race other than Caucasian, chronic lung disease and emergent procedure need were significantly associated with early post-procedural mortality (all p < 0.05). Conclusion: Using a large multicenter cardiac catheterization registry, we found that left atrial decompression can be performed without procedural mortality but is associated with significant morbidity. Impact of race, chronic lung disease and procedural urgency on early mortality warrant further studies.
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Affiliation(s)
- Shriprasad R Deshpande
- Pediatric Cardiology Division, Children’s National Heart Institute, George Washington University, Washington, DC, USA
| | - Kevin F Kennedy
- Department of Cardiovascular Research, Saint Luke’s Hospital, Kansas City, MO, USA
| | - Robert N Vincent
- Sibley Heart Center Cardiology, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - Kevin O Maher
- Sibley Heart Center Cardiology, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, USA
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24
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Ricarte Bratti JP, Cavayas YA, Noly PE, Serri K, Lamarche Y. Modalities of Left Ventricle Decompression during VA-ECMO Therapy. MEMBRANES 2021; 11:membranes11030209. [PMID: 33809568 PMCID: PMC8002319 DOI: 10.3390/membranes11030209] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/04/2021] [Accepted: 03/12/2021] [Indexed: 12/22/2022]
Abstract
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used to sustain circulatory and respiratory support in patients with severe cardiogenic shock or refractory cardiac arrest. Although VA-ECMO allows adequate perfusion of end-organs, it may have detrimental effects on myocardial recovery. Hemodynamic consequences on the left ventricle, such as the increase of afterload, end-diastolic pressure and volume, can lead to left ventricular (LV) distention, increase of myocardial oxygen consumption and delayed LV function recovery. LV distention occurs in almost 50% of patients supported with VA-ECMO and is associated with an increase in morbidity and mortality. Thus, recognizing, preventing and treating LV distention is key in the management of these patients. In this review, we aim to discuss the pathophysiology of LV distention and to describe the strategies to unload the LV in patients supported with VA-ECMO.
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Affiliation(s)
- Juan Pablo Ricarte Bratti
- Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC H1T 1C8, Canada; (J.P.R.B.); (Y.A.C.); (P.E.N.); (K.S.)
| | - Yiorgos Alexandros Cavayas
- Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC H1T 1C8, Canada; (J.P.R.B.); (Y.A.C.); (P.E.N.); (K.S.)
- Hôpital Sacré-Coeur de Montréal, 5400. Gouin Blvd. West, Montreal, QC H4J 1C5, Canada
| | - Pierre Emmanuel Noly
- Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC H1T 1C8, Canada; (J.P.R.B.); (Y.A.C.); (P.E.N.); (K.S.)
| | - Karim Serri
- Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC H1T 1C8, Canada; (J.P.R.B.); (Y.A.C.); (P.E.N.); (K.S.)
- Hôpital Sacré-Coeur de Montréal, 5400. Gouin Blvd. West, Montreal, QC H4J 1C5, Canada
| | - Yoan Lamarche
- Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC H1T 1C8, Canada; (J.P.R.B.); (Y.A.C.); (P.E.N.); (K.S.)
- Hôpital Sacré-Coeur de Montréal, 5400. Gouin Blvd. West, Montreal, QC H4J 1C5, Canada
- Correspondence: ; Tel.: +1-514-376-3330
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25
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Dolader P, Betrián Blasco P, Balcells J, Izquierdo-Blasco J, Gran F, Martí Aguasca G. Percutaneous atrioseptostomy for left ventricular unloading in pediatric patients in cardiogenic shock on venoarterial ECMO support. ACTA ACUST UNITED AC 2021; 74:710-712. [PMID: 33632636 DOI: 10.1016/j.rec.2021.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 01/04/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Paola Dolader
- Unidad de Insuficiencia Cardiaca y Trasplante Pediátricos, Hospital Universitario Infantil Vall d'Hebron, Universidad Autónoma, Barcelona, Spain
| | - Pedro Betrián Blasco
- Unidad de Hemodinámica Pediátrica, Hospital Universitario Infantil Vall d'Hebron, Universidad Autónoma, Barcelona, Spain.
| | - Joan Balcells
- Unidad de Cuidados Intensivos Pediátricos, Hospital Universitario Infantil Vall d'Hebron, Universidad Autónoma, Barcelona, Spain
| | - Jaume Izquierdo-Blasco
- Unidad de Cuidados Intensivos Pediátricos, Hospital Universitario Infantil Vall d'Hebron, Universidad Autónoma, Barcelona, Spain
| | - Ferran Gran
- Unidad de Insuficiencia Cardiaca y Trasplante Pediátricos, Hospital Universitario Infantil Vall d'Hebron, Universidad Autónoma, Barcelona, Spain
| | - Gerard Martí Aguasca
- Unidad de Hemodinámica Pediátrica, Hospital Universitario Infantil Vall d'Hebron, Universidad Autónoma, Barcelona, Spain
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26
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Dolader P, Betrián Blasco P, Balcells J, Izquierdo-Blasco J, Gran F, Martí Aguasca G. Septostomía auricular percutánea de descarga ventricular izquierda en pacientes pediátricos en shock cardiogénico asistidos con ECMO venoarterial. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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27
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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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28
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Extracorporeal Membrane Oxygenation Support for Failure to Wean From Cardiopulmonary Bypass After Pediatric Cardiac Surgery: Analysis of Extracorporeal Life Support Organization Registry Data. Crit Care Explor 2020; 2:e0183. [PMID: 32984825 PMCID: PMC7498130 DOI: 10.1097/cce.0000000000000183] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. Objectives: Extracorporeal membrane oxygenation has been used to support children who fail to wean from cardiopulmonary bypass after pediatric cardiac surgery, but little is known about outcomes. We aimed to describe epidemiology and extracorporeal membrane oxygenation factors associated with inhospital mortality in these patients. Design: Retrospective multicenter registry-based cohort study. Setting: International pediatric extracorporeal membrane oxygenation centers. Patients: Children less than 18 years old supported with extracorporeal membrane oxygenation for failure to wean from cardiopulmonary bypass after cardiac surgery during 2000–2016 and reported to Extracorporeal Life Support Organization’s registry. Intervention: None. Measurements and Main Results: The primary outcome measure was inhospital mortality. Cardiac surgical procedural complexity was assigned using risk adjustment in congenital heart surgery-1. Multivariable logistic regression was used to identify factors independently associated with the primary outcome. We included 2,322 patients, with a median age of 26 days (interquartile range, 7–159); 47% underwent complex surgical procedures (risk adjustment in congenital heart surgery 4–6 categories). Inhospital mortality was 55%. The multivariable model evaluating associations with inhospital mortality showed noncardiac congenital anomalies (odds ratio, 1.78; CI, 1.36–2.32), comorbidities (odds ratio, 1.59; CI, 1.30–1.94), preoperative cardiac arrest (odds ratio, 1.67; CI, 1.20–2.34), preoperative mechanical ventilation greater than 24 hours (odds ratio, 1.49; CI, 1.21–1.84), preoperative bicarbonate administration (odds ratio, 1.42; CI, 1.08–1.86), longer cardiopulmonary bypass time (> 251 min; odds ratio, 1.50; CI, 1.13–1.99), complex surgical procedures (odds ratio, 1.43; CI, 1.13–1.81), longer extracorporeal membrane oxygenation duration (> 104 hr, odds ratio, 1.54; CI, 1.17–2.02), and extracorporeal membrane oxygenation complications increased the odds of inhospital mortality. Age greater than 26 days (odds ratio, 0.56; CI, 0.42–0.75) reduced the odds of mortality. Conclusions: Children supported with extracorporeal membrane oxygenation for failure to wean from cardiopulmonary bypass after cardiac surgery are at high risk of mortality (55%). Younger patients, those with congenital abnormalities and comorbidities, undergoing complex procedures, requiring longer cardiopulmonary bypass, and experiencing extracorporeal membrane oxygenation complications and longer extracorporeal membrane oxygenation duration have higher mortality risk. These data can help assessing prognosis in this high-risk population.
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29
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Das BB. Patent Foramen Ovale in Fetal Life, Infancy and Childhood. Med Sci (Basel) 2020; 8:medsci8030025. [PMID: 32630193 PMCID: PMC7565039 DOI: 10.3390/medsci8030025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 06/25/2020] [Accepted: 06/28/2020] [Indexed: 01/16/2023] Open
Abstract
A patent foramen ovale (PFO) is a common, incidental echocardiographic finding in otherwise healthy and asymptomatic infants and children. However, a variety of clinical conditions have been ascribed to the presence of a PFO in childhood, such as cryptogenic stroke, platypnea-orthodeoxia syndrome, decompression sickness and migraine, although the data on these are controversial and sometimes contradictory. This review discusses embryology and correlation with post-natal anatomy, anatomical variations of the atrial septum, diagnostic modalities in special circumstances of PFO associated clinical syndromes, and the role of PFO in congenital heart disease, pulmonary hypertension, dilated cardiomyopathy and heart failure in children who require an extracorporeal membrane oxygenator or ventricular assist device as life support.
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Affiliation(s)
- Bibhuti B Das
- Department of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital Specialty Care Austin, Austin, TX 78759, USA
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30
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Guimaraes L, Del Val D, Bergeron S, O'Connor K, Bernier M, Rodés-Cabau J. Interatrial Shunting for Treating Acute and Chronic Left Heart Failure. Eur Cardiol 2020; 15:e18. [PMID: 32419849 PMCID: PMC7215499 DOI: 10.15420/ecr.2019.04] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 08/09/2019] [Indexed: 12/19/2022] Open
Abstract
The creation of an interatrial shunt has emerged as a new therapy to decompress the left atrium in patients with acute and chronic left heart failure (HF). Current data support the safety of this therapy, and promising preliminary efficacy results have been reported in patients who are refractory to optimal medical/device therapy. This article aims to provide an updated overview and clinical perspective on interatrial shunting for treating different HF conditions, and highlights the potential challenges and future directions of this therapy.
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Affiliation(s)
- Leonardo Guimaraes
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University Quebec City, Quebec, Canada
| | - David Del Val
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University Quebec City, Quebec, Canada
| | - Sebastien Bergeron
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University Quebec City, Quebec, Canada
| | - Kim O'Connor
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University Quebec City, Quebec, Canada
| | - Mathieu Bernier
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University Quebec City, Quebec, Canada
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31
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Saini A, Maher KO, Deshpande SR. Nonopioid analgesics for perioperative and cardiac surgery pain in children: Current evidence and knowledge gaps. Ann Pediatr Cardiol 2019; 13:46-55. [PMID: 32030035 PMCID: PMC6979012 DOI: 10.4103/apc.apc_190_18] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 06/05/2019] [Accepted: 10/08/2019] [Indexed: 11/23/2022] Open
Abstract
Objective: The purpose of this review is to present the available literature on the use of nonopioid analgesics such as nonsteroidal anti-inflammatory drugs in postcardiac surgery pediatric patients, mainly to focus on patients <1 year of age, and to provide the foundation for future research. Materials and Methods: Published studies that address the use on nonopioid medications for postoperative sedation and analgesia in infants and children undergoing cardiac surgery were identified from online sources. Studies were reviewed by two authors independently to assess the quality of the data as well as the evidence. Due to limited availability of such studies, the review was then expanded to include use in noncardiac procedures as well as to expanded age groups. All studies that met the primary objective were included. Results/Data Synthesis: Majority of the studies in the population of interest were related to use of ketorolac. Five studies specifically addressed ketorolac use in cardiac patients. In addition, studies were reviewed for nonopioid analgesia in noncardiac patients and included as a part of the available evidence as in the case of acetaminophen use. Newer agents as well as agents with very limited information were also acknowledged. Conclusion: Nonopioid medications appear to show promise for analgesia in infants undergoing cardiac surgery, with ketorolac being the most potent agent as a potential substitute for opioids. These agents demonstrate a reasonable safety profile even in the very young. There continue to be significant gaps in knowledge before their adoption becomes routine. However, gives the awareness regarding short-term and long-term impact of opioid use in this vulnerable population, and studies of such agents are an urgent need.
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Affiliation(s)
- Ashish Saini
- Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kevin O Maher
- Division of Pediatric Cardiology, Sibley Heart Center Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Shriprasad R Deshpande
- Heart Transplant and Advanced Cardiac Therapies Program, Children's National Health Institute, Washington, DC, USA
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32
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Kim S, Kim JS, Shin JS, Shin HJ. How small is enough for the left heart decompression cannula during extracorporeal membrane oxygenation? Acute Crit Care 2019; 34:263-268. [PMID: 31795624 PMCID: PMC6895469 DOI: 10.4266/acc.2019.00577] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 11/04/2019] [Indexed: 11/30/2022] Open
Abstract
Background Left ventricular (LV) distension is a recognizable problem accompanied by subsequent complications during venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, no gold standard for LV decompression has been established, and no minimal flow requirement has been designated. Thus, we evaluated the efficacy of the 8-Fr Mullins sheath for left heart decompression during VA-ECMO in adult patients. Methods Left heart decompression was performed when severe pulmonary edema was detected on chest radiography or when no generation of pulse pressure followed severe LV dysfunction in patients receiving VA-ECMO. We punctured the interatrial septum and inserted an 8-Fr Mullins sheath into the left atrium via the femoral vein. The sheath was connected to the venous catheter used for ECMO. The catheter was maintained during VA-ECMO. Results The left heart decompression procedure was performed in seven of 35 patients who received VA-ECMO between February 2017 and June 2018. Three patients had acute myocardial infarction; three, fulminant myocarditis; and one, dilated cardiomyopathy. Four patients showed noticeable improvement of pulmonary edema within 3 days, and three patients with a pulse pressure of <10 mm Hg showed an increase in pulse pressure of >20 mm Hg within 24 hours from the left heart decompression procedure. All seven patients were successfully weaned from VA-ECMO. No complications related to the left heart decompression procedure occurred. Conclusions An 8-Fr sheath may be a possible option for left heart decompression in adult patients with LV distension under VA-ECMO who are expecting recovery of LV function.
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Affiliation(s)
- Sua Kim
- Department of Critical Care Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea.,Division of Cardiology, Department of Internal Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Jin Seok Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Jae Seung Shin
- Department of Thoracic and Cardiovascular Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Hong Ju Shin
- Department of Thoracic and Cardiovascular Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
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33
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Singh G, Hudson D, Shaw A. Medical Optimization and Liberation of Adult Patients From VA-ECMO. Can J Cardiol 2019; 36:280-290. [PMID: 32036869 DOI: 10.1016/j.cjca.2019.10.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 10/31/2019] [Accepted: 10/31/2019] [Indexed: 12/30/2022] Open
Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) can be an efficacious cardiopulmonary support for adults as rescue from refractory cardiogenic shock. It is best employed as a bridging strategy to recovery or alternative support rather than sustained, long-term mechanical circulatory support. The purpose of this paper is to discuss strategies to optimize patient management on VA-ECMO and approaches to promote successful separation from support. Rapid medical optimization will assist in reducing the time on VA-ECMO, thereby improving the likelihood of patient salvage. Suitably trained physicians and personnel, guided by structured protocols, can promote excellence in team care and provision of consistent management. Focusing on anticoagulation, careful neurologic monitoring, prevention of leg ischemia, awareness of differential hypoxemia, optimizing mechanical ventilation, identifying and timely intervention for left-ventricular distension (LVD), along with a strategic weaning algorithm, can prevent significant morbidity and mortality. LVD physiology, diagnosis, and risk factors are reviewed. Indications for LV decompression, along with medical and mechanical management options, are elucidated.
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Affiliation(s)
- Gurmeet Singh
- Critical Care Medicine, Edmonton, Alberta, Canada; Cardiac Surgery, Edmonton, Alberta, Canada; Adult ECMO Program, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada; University of Alberta, Edmonton, Alberta, Canada.
| | - Darren Hudson
- Critical Care Medicine, Edmonton, Alberta, Canada; University of Alberta, Edmonton, Alberta, Canada
| | - Andrew Shaw
- Department of Anesthesiology and Pain Medicine, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada; University of Alberta, Edmonton, Alberta, Canada
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Valencia E, Nasr VG. Updates in Pediatric Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2019; 34:1309-1323. [PMID: 31607521 DOI: 10.1053/j.jvca.2019.09.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 08/30/2019] [Accepted: 09/05/2019] [Indexed: 01/28/2023]
Abstract
Extracorporeal membrane oxygenation is an increasingly used mode of life support for patients with cardiac and/or respiratory failure refractory to conventional therapy. This review provides a synopsis of the evolution of extracorporeal life support in neonates, infants, and children and offers a framework for areas in need of research. Specific aspects addressed are the changing epidemiology; technologic advancements in extracorporeal membrane oxygenation circuitry; the current status and future direction of anticoagulation management; sedative and analgesic strategies; and outcomes, with special attention to the lessons learned from neonatal survivors.
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Affiliation(s)
- Eleonore Valencia
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA.
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Na SJ, Yang JH, Yang JH, Sung K, Choi JO, Hahn JY, Jeon ES, Cho YH. Left heart decompression at venoarterial extracorporeal membrane oxygenation initiation in cardiogenic shock: prophylactic versus therapeutic strategy. J Thorac Dis 2019; 11:3746-3756. [PMID: 31656647 DOI: 10.21037/jtd.2019.09.35] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background We aimed to investigate the effects and proper timing of left heart decompression (LHD) on the clinical outcomes of patients on venoarterial extracorporeal membrane oxygenation (VA ECMO). Methods Among 335 adult patients who underwent VA ECMO from January 2013 to December 2016, 50 who underwent LHD were analyzed. The patients were divided into two groups according to the timing of LHD: those in whom percutaneous LHD was performed at ECMO initiation (prophylactic LHD group, n=18) and those who required LHD to treat complications of impaired left ventricle (LV) unloading (therapeutic LHD group, n=32). Results Thirty-day mortality rates were 34.4% and 5.6% in the therapeutic and prophylactic LHD groups, respectively (P=0.036). The rate of successful weaning from ECMO (62.5% vs. 83.3%, P=0.123) and duration of ECMO support (10.5 vs. 15.4 days, P=0.332) were not significantly different between the groups. However, the rate of bridging to cardiac replacement therapy, such as heart transplantation or left ventricular assist device, was significantly higher in the prophylactic LHD group (66.7%) than in the therapeutic LHD group (37.5%) (P=0.048). Conclusions Prophylactic percutaneous transseptal left atrial (LA) drainage at ECMO initiation appeared to be associated with a lower early mortality rate and a higher likelihood of successful bridging to cardiac replacement therapy than therapeutic LHD to treat complications of left ventricular distension.
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Affiliation(s)
- Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ji-Hyuk Yang
- Department of Thoracic and Cardiovascular Surgery, 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
| | - Jin-Oh Choi
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Eun-Seok Jeon
- Division of Cardiology, Department of Medicine, 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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36
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Relationship Between Time to Left Atrial Decompression and Outcomes in Patients Receiving Venoarterial Extracorporeal Membrane Oxygenation Support: A Multicenter Pediatric Interventional Cardiology Early-Career Society Study. Pediatr Crit Care Med 2019; 20:728-736. [PMID: 30985609 DOI: 10.1097/pcc.0000000000001936] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess the variation in timing of left atrial decompression and its association with clinical outcomes in pediatric patients supported with venoarterial extracorporeal membrane oxygenation across a multicenter cohort. DESIGN Multicenter retrospective study. SETTING Eleven pediatric hospitals within the United States. PATIENTS Patients less than 18 years on venoarterial extracorporeal membrane oxygenation who underwent left atrial decompression from 2004 to 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 137 patients (median age, 4.7 yr) were included. Cardiomyopathy was the most common diagnosis (47%). Cardiac arrest (39%) and low cardiac output (50%) were the most common extracorporeal membrane oxygenation indications. Median time to left atrial decompression was 6.2 hours (interquartile range, 3.8-17.2 hr) with the optimal cut-point of greater than or equal to 18 hours for late decompression determined by receiver operating characteristic curve. In univariate analysis, late decompression was associated with longer extracorporeal membrane oxygenation duration (median 8.5 vs 5 d; p = 0.02). In multivariable analysis taking into account clinical confounder and center effects, late decompression remained significantly associated with prolonged extracorporeal membrane oxygenation duration (adjusted odds ratio, 4.4; p = 0.002). Late decompression was also associated with longer duration of mechanical ventilation (adjusted odds ratio, 4.8; p = 0.002). Timing of decompression was not associated with in-hospital survival (p = 0.36) or overall survival (p = 0.42) with median follow-up of 3.2 years. CONCLUSIONS In this multicenter study of pediatric patients receiving venoarterial extracorporeal membrane oxygenation, late left atrial decompression (≥ 18 hr) was associated with longer duration of extracorporeal membrane oxygenation support and mechanical ventilation. Although no survival benefit was demonstrated, the known morbidities associated with prolonged extracorporeal membrane oxygenation use may justify a recommendation for early left atrial decompression.
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Impact of Left Atrial Decompression on Patient Outcomes During Pediatric Venoarterial Extracorporeal Membrane Oxygenation: A Case-Control Study. Pediatr Cardiol 2019; 40:1266-1274. [PMID: 31250046 DOI: 10.1007/s00246-019-02147-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 06/22/2019] [Indexed: 10/26/2022]
Abstract
Left heart distension during venoarterial extracorporeal membrane oxygenation (VA ECMO) often necessitates decompression to facilitate myocardial recovery and prevent life-threatening complications. The objectives of this study were to compare clinical outcomes between patients who did and did not undergo left atrial (LA) decompression, quantify decompression efficacy, and identify risk factors for development of left heart distension. This was a single-center retrospective case-control study. Pediatric VA ECMO patients who underwent LA decompression from June 2004 to March 2016 were identified, and a control cohort of VA ECMO patients who did not undergo LA decompression were matched based on diagnosis, extracorporeal cardiopulmonary resuscitation, and age. Among 194 VA ECMO cases, 21 (11%) underwent LA decompression. Compared to the control cohort, patients with decompression had longer hospital length of stay (60 ± 55 vs. 27 ± 23 days, p = 0.012), but similar in-hospital mortality (29% vs. 38%, p = 0.513). Decompression successfully decreased mean LA pressure (24 ± 11 to 14 ± 4 mmHg, p = 0.022) and LA:RA pressure gradient (10 ± 7 to 0 ± 1 mmHg, p = 0.011). No significant differences in early quantitative measures of cardiac function were observed between cases and controls to identify risk factors for left heart distension. Despite higher qualitative risk for impaired cardiac recovery, patients who underwent LA decompression had comparable outcomes to those who did not. Given that traditional quantitative measures of cardiac function are insufficient to predict development of eventual left heart distension, a combination of clinical history, radiographic findings, hemodynamic monitoring, and laboratory markers should be used during the evaluation and management of these patients.
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Chioncel O, Collins SP, Ambrosy AP, Pang PS, Radu RI, Ahmed A, Antohi EL, Masip J, Butler J, Iliescu VA. Therapeutic Advances in the Management of Cardiogenic Shock. Am J Ther 2019; 26:e234-e247. [PMID: 30839372 PMCID: PMC6404765 DOI: 10.1097/mjt.0000000000000920] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Cardiogenic shock (CS) is a life-threatening state of tissue hypoperfusion, associated with a very high risk of mortality, despite intensive monitoring and modern treatment modalities. The present review aimed at describing the therapeutic advances in the management of CS. AREAS OF UNCERTAINTY Many uncertainties about CS management remain in clinical practice, and these relate to the intensity of invasive monitoring, the type and timing of vasoactive therapies, the risk-benefit ratio of mechanical circulatory support (MCS) therapy, and optimal ventilation mode. Furthermore, most of the data are obtained from CS in the setting of acute myocardial infarction (AMI), although for non-AMI-CS patients, there are very few evidences for etiological or MCS therapies. DATA SOURCES The prospective multicentric acute heart failure registries that specifically presented characteristics of patients with CS, distinct to other phenotypes, were included in the present review. Relevant clinical trials investigating therapeutic strategies in post-AMI-CS patients were added as source information. Several trials investigating vasoactive medications and meta-analysis providing information about benefits and risks of MCS devices were reviewed in this study. THERAPEUTIC ADVANCES Early revascularization remains the most important intervention for CS in settings of AMI, and in patients with multivessel disease, recent trial data recommend revascularization on a "culprit-lesion-only" strategy. Although diverse types of MCS devices improve hemodynamics and organ perfusion in patients with CS, results from almost all randomized trials incorporating clinical end points were inconclusive. However, development of new algorithms for utilization of MCS devices and progresses in technology showed benefit in selected patients. A major advance in the management of CS is development of concept of regional CS centers based on the level of facilities and expertise. The modern systems of care with CS centers used as hubs integrated with emergency medical systems and other referee hospitals have the potential to improve patient outcomes. CONCLUSIONS Additional research is needed to establish new triage algorithms and to clarify intensity and timing of pharmacological and mechanical therapies.
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Affiliation(s)
- Ovidiu Chioncel
- University of Medicine Carol Davila, Bucharest; Emergency Institute for Cardiovascular Diseases-“Prof. C.C.Iliescu”, Bucharest, Romania
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Andrew P Ambrosy
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | - Peter S Pang
- Department of Emergency Medicine and Indianapolis EMS, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Razvan I Radu
- University of Medicine Carol Davila, Bucharest; Emergency Institute for Cardiovascular Diseases-“Prof. C.C.Iliescu”, Bucharest, Romania
| | - Ali Ahmed
- Veteran Affairs Medical Center and George Washington University, Washington DC, USA
| | - Elena-Laura Antohi
- University of Medicine Carol Davila, Bucharest; Emergency Institute for Cardiovascular Diseases-“Prof. C.C.Iliescu”, Bucharest, Romania
| | - Josep Masip
- Cardiology Department, Hospital Sanitas CIMA, Barcelona, Spain; Department of Intensive Care, Consorci Sanitari Integral, Barcelona, Spain
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MI, USA
| | - Vlad Anton Iliescu
- University of Medicine Carol Davila, Bucharest; Emergency Institute for Cardiovascular Diseases-“Prof. C.C.Iliescu”, Bucharest, Romania
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Curran J, Burkhoff D, Kloner RA. Beyond Reperfusion: Acute Ventricular Unloading and Cardioprotection During Myocardial Infarction. J Cardiovasc Transl Res 2019; 12:95-106. [PMID: 30671717 PMCID: PMC6497619 DOI: 10.1007/s12265-019-9863-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 01/02/2019] [Indexed: 12/21/2022]
Abstract
Heart failure is a major cause of morbidity and mortality around the world, and myocardial infarction is its leading cause. Myocardial infarction destroys viable myocardium, and this dead tissue is replaced by a non-contractile scar that results in impaired cardiac function and a significantly increased likelihood of the patient developing heart failure. Limiting infarct scar size has been the target of pre-clinical and clinical investigations for decades. However, beyond reperfusion, few therapies have translated into the clinic that limit its formation. New approaches are needed. This review will focus on new clinical and pre-clinical data demonstrating that acute ventricular unloading prior to reperfusion by means of percutaneous left ventricular support devices reduces ischemia-reperfusion injury and limits infarct scar size. Emphasis will be given to summarizing our current mechanistic understanding of this new therapeutic approach to treating myocardial infarction.
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Affiliation(s)
| | | | - Robert A Kloner
- Huntington Medical Research Institutes, Pasadena, CA, USA
- University of Southern California, Los Angeles, CA, USA
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40
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Eliet J, Gaudard P, Zeroual N, Rouvière P, Albat B, Mourad M, Colson PH. Effect of Impella During Veno-Arterial Extracorporeal Membrane Oxygenation on Pulmonary Artery Flow as Assessed by End-Tidal Carbon Dioxide. ASAIO J 2019; 64:502-507. [PMID: 28953197 DOI: 10.1097/mat.0000000000000662] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Peripheral veno-arterial extracorporeal membrane oxygenation (VA ECMO) exposes the patient to a pulmonary blood flow bypass and a left ventricle afterload increase. Impella, a catheter-mounted microaxial rotary pump, has been proposed for left ventricle (LV) unloading in combination with VA ECMO. In order to assess the effect of Impella on pulmonary flow and LV preload, we checked Doppler pulmonary artery velocity-time integral (pVTI) and LV diastolic diameter (LVED) by transesophageal echocardiography and end-tidal carbon dioxide (EtCO2) during a step-by-step increase in Impella flow (Impella ramp test). From 134 patients on VA ECMO retrieved from our database, 27 (20%) have benefited secondary Impella implantation, out of which 11 patients had available EtCO2, pVTI, and LVED measurements at various levels of Impella speeds. We observed a proportional increases in pVTI and EtCO2 and decrease in LVED (p ≤ 0.001) during Impella flow increase. There was a significant correlation between EtCO2 and pVTI (Pearson correlation coefficient 0.64; p = 0.006). The study shows that Impella improves pulmonary flow, an effect that can be easily measured by EtCO2 monitoring, and ensures LV discharge, allowing adapting Impella flow adequately to patient's individual needs.
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Affiliation(s)
- Jacob Eliet
- From the Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Academic Hospital, F-34295 Montpellier, France
| | - Philippe Gaudard
- From the Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Academic Hospital, F-34295 Montpellier, France.,PhyMedExp, University of Montpellier, INSERM U1046, Montpellier, France
| | - Norddine Zeroual
- From the Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Academic Hospital, F-34295 Montpellier, France
| | - Philippe Rouvière
- Department of Cardiac Surgery, Arnaud de Villeneuve Academic Hospital, F-34295 Montpellier, France
| | - Bernard Albat
- Department of Cardiac Surgery, Arnaud de Villeneuve Academic Hospital, F-34295 Montpellier, France
| | - Marc Mourad
- From the Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Academic Hospital, F-34295 Montpellier, France
| | - Pascal H Colson
- From the Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Academic Hospital, F-34295 Montpellier, France.,Institut de Génomique Fonctionnelle, Department of Endocrinology, CNRS UMR 5203, INSERM U1191, University of Montpellier, Montpellier, France
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41
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Ok YJ, Jung SH, Lee SW, Ahn JM, Lim JY. Efficacy of left heart decompression during extracorporeal membrane oxygenation: a case-control study. J Thorac Dis 2019; 11:865-872. [PMID: 31019775 DOI: 10.21037/jtd.2019.01.110] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) is used in various cardiogenic shocks. In severe myocardial dysfunction, left heart (LH) distension may occur and aggravate pulmonary edema. Despite the recent case reports on various venting catheter insertion methods for LH decompression, the necessity and efficacy of LH venting procedure are still controversial. Therefore, we focused on evaluating efficacy of LH venting catheter insertion for LH decompression. Methods In total, 373 patients received VA ECMO at our institution from May 2012 to January 2016. Of these, 25 patients underwent LH venting catheter insertion. Indication for the procedure included pulmonary congestion observed on chest radiogram, with arterial pulse pressure ≤10 mmHg. The control group comprised of 45 patients with peripheral VA ECMO having arterial pulse pressure ≤ for ≥24 hours during the same study period who did not undergo LH venting procedure. Finally, 70 patients were compared and analyzed. Results Mean age of the patients was 52.6±17.1 years. The ECMO running time in each group was 7.2±7.1 days in the vent (-) group and 9.2±8.5 days in the vent (+) group. Successful weaning rate was higher in the LH vent (+) group (P=0.08). Moreover, LH venting catheter insertion was identified as a predictor of weaning success with marginal significance (OR =2.47; 95% CI: 0.90-6.72; P=0.07). Conclusions LH decompression by venting catheter insertion in patients on VA ECMO may be more effective and helpful for successful ECMO weaning than conventional medical management without survival benefit.
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Affiliation(s)
- You Jung Ok
- 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
| | - Seung-Whan Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Min Ahn
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ju Yong Lim
- Departments of Thoracic and Cardiovascular Surgery, Anam Hospital, University of Korea College of Medicine, Seoul, Korea
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Transcatheter left atrial decompression in patients with dilated cardiomyopathy: bridging to cardiac transplantation or recovery. Cardiol Young 2019; 29:355-362. [PMID: 30806346 DOI: 10.1017/s1047951118002433] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Left atrial congestion results from backward failure in dilated cardiomyopathy. We aimed to evaluate feasibility and efficacy of percutaneous atrioseptostomy to create a restrictive atrial septum defect in management of dilated cardiomyopathy.Methods and resultsFrom June 2009 to December 2016, 27 interventions comprised left atria decompressions in 22 dilated cardiomyopathy patients; 9 females; age: 24 days to 36.9 years; weight: 3-50 kg; NYHA-/Ross class IV (n=16). Mean left ventricular ejection fraction was 21.5±9.7% and brain natriuretic peptide was 2291±1992 pg/ml. Dilated cardiomyopathy was classified as chronic (n=9); acute (n=1) myocarditis; idiopathic (n=5); left ventricular non-compaction (n=4); mitochondriopathy, pacemaker induced, and arrhythmogenic (n=3). Atrioseptostomy was concomitantly performed with myocardial biopsies 6.5 days (±11.7) after admission (n=11). Trans-septal puncture was used in 18 patients; foramen ovale dilatation was done in four patients. Mean balloon size was 11 mm (range 7-14 mm); total procedure time was 133±38 minutes. No procedural complications were observed. Mean left atrial pressure decreased from 15.8±6.8 to 12.2±4.8 mmHg (p=0.005), left/right atrial pressure gradient from 9.6±5.6 to 5±3.5 mmHg; brain natriuretic peptide (n=18) decreased from 1968±1606 to 830±1083 pg/ml (p=0.01). One patient unsuitable for heart transplantation died at home despite additionally performed pulmonary artery banding and three further left atrial decompressions; five patients were bridged to transplantation, two died afterwards. Functional recovery occurred in the remaining 14 patients and in six after additional pulmonary artery banding. No patient required assist device. CONCLUSIONS Percutaneous left atrial decompression is an age-independent, effective palliation treating patients with dilated cardiomyopathy.
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43
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Yamamoto M, Oshima Y, Matsuhisa H, Higuma T, Iwaki R, Matsushima S, Murakami Y. Left Atrial Decompression by Minithoracotomy During Extracorporeal Life Support. Ann Thorac Surg 2019; 107:e227-e228. [DOI: 10.1016/j.athoracsur.2018.07.084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/17/2018] [Accepted: 07/23/2018] [Indexed: 11/29/2022]
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Chong SZ, Fang CY, Fang HY, Chen HC, Chen CJ, Yang CH, Hang CL, Yip HK, Wu CJ, Lee WC. Associations with the In-Hospital Survival Following Extracorporeal Membrane Oxygenation in Adult Acute Fulminant Myocarditis. J Clin Med 2018; 7:jcm7110452. [PMID: 30463365 PMCID: PMC6262600 DOI: 10.3390/jcm7110452] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 11/03/2018] [Accepted: 11/16/2018] [Indexed: 12/13/2022] Open
Abstract
Background: Acute fulminant myocarditis (AFM) is a serious disease that progresses rapidly, and leads to failing respiratory and circulatory systems. When medications fail to reverse the patient’s clinical course, extracorporeal membrane oxygenation (ECMO) is considered the most effective, supportive and adjunct strategy. In this paper we analyzed our experience in managing AFM with ECMO support. Methods: During October 2003 and February 2017, a total of 35 patients (≥18 years) were enrolled in the study. Twenty patients survived, and another 15 patients expired. General demographics, the hemodynamic condition, timing of ECMO intervention, and laboratory data were compared for the survival and non-survival groups. Univariate and multivariate Cox regression analyses were performed to identify the associations with in-hospital mortality following ECMO use in this situation. Results: The survival rate was 57.1% during the in-hospital period. The average age, gender, severity of the hemodynamic condition, and cardiac rhythm were similar between the survival and non-survival groups. Higher serum lactic acid (initial and 24 h later), higher peak cardiac biomarkers, higher incidence of acute kidney injury and the need for hemodialysis were noted in the non-survival group. Higher 24-h lactic acid levels and higher peak troponin-I levels were associated with in-hospital mortality. Conclusions: When ECMO was used for AFM, related cardiogenic shock and decompensated heart failure, higher peak serum troponin-I levels and 24-h serum lactic acid levels following ECMO use were independently associated with in-hospital mortality.
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Affiliation(s)
- Shaur-Zheng Chong
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.
| | - Chih-Yuan Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.
| | - Hsiu-Yu Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.
| | - Huang-Chung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.
| | - Chien-Jen Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.
| | - Cheng-Hsu Yang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.
| | - Chi-Ling Hang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.
| | - Hon-Kan Yip
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.
| | - Chiung-Jen Wu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.
| | - Wei-Chieh Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan.
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung 123, Ta Pei Road, Niao Sung District, Kaohsiung City 83301, Taiwan.
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Ise H, Kitahara H, Aubin H, Saeed D, Westenfeld R, Akhyari P, Boeken U, Walz R, Albert A, Lichtenberg A, Kamiya H. Additional unloading of the left ventricle using the Impella LP 2.5 during extracorporeal life support in cases of pulmonary congestion. J Surg Case Rep 2018; 2018:rjy302. [PMID: 30443318 PMCID: PMC6232276 DOI: 10.1093/jscr/rjy302] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 10/15/2018] [Accepted: 10/24/2018] [Indexed: 11/24/2022] Open
Abstract
Extracorporeal life support (ECLS) is used for the treatment of severe cardiogenic shock. However, pulmonary congestion can progress to a severe problem with ECLS therapy. We report our experience with the Impella system for severe pulmonary congestion with ECLS therapy. We used the Impella system for two patients, which led to successful unloading of the left ventricle. Impella implantation during ECLS support appears to be a promising concept. However, more evidence is required for further evaluation.
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Affiliation(s)
- Hayato Ise
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Hiroto Kitahara
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan.,Section of Cardiac and Thoracic Surgery, Department of Surgery, the University of Chicago, Chicago, IL, USA
| | - Hug Aubin
- Department of Cardiovascular Surgery, University Hospital Dusseldorf, Dusseldorf, Germany
| | - Diyar Saeed
- Department of Cardiovascular Surgery, University Hospital Dusseldorf, Dusseldorf, Germany
| | - Ralf Westenfeld
- Department of Cardiology, Angiology and Pneumology, University Hospital Dusseldorf, Dusselfdorf, Germany
| | - Payam Akhyari
- Department of Cardiovascular Surgery, University Hospital Dusseldorf, Dusseldorf, Germany
| | - Udo Boeken
- Department of Cardiovascular Surgery, University Hospital Dusseldorf, Dusseldorf, Germany
| | - Roland Walz
- Department of Anaesthesiology, University Hospital Dusseldorf, Dusseldorf, Germany
| | - Alexander Albert
- Department of Cardiovascular Surgery, University Hospital Dusseldorf, Dusseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiovascular Surgery, University Hospital Dusseldorf, Dusseldorf, Germany
| | - Hiroyuki Kamiya
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
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Bautista-Rodriguez C, Sanchez-de-Toledo J, Da Cruz EM. The Role of Echocardiography in Neonates and Pediatric Patients on Extracorporeal Membrane Oxygenation. Front Pediatr 2018; 6:297. [PMID: 30416991 PMCID: PMC6212474 DOI: 10.3389/fped.2018.00297] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 09/21/2018] [Indexed: 11/13/2022] Open
Abstract
Indications for extracorporeal membrane oxygenation (ECMO) and extracorporeal cardiopulmonary resuscitation (ECPR) are expanding, and echocardiography is a tool of utmost importance to assess safety, effectiveness and readiness for circuit initiation and separation. Echocardiography is key to anticipating complications and improving outcomes. Understanding the patient's as well as the ECMO circuit's anatomy and physiology is crucial prior to any ECMO echocardiographic evaluation. It is also vital to acknowledge that the utility of echocardiography in ECMO patients is not limited to the evaluation of cardiac function, and that clinical decisions should not be made exclusively upon echocardiographic findings. Though echocardiography has specific indications and applications, it also has limitations, characterized as: prior to and during cannulation, throughout the ECMO run, upon separation and after separation from the circuit. The use of specific and consistent echocardiographic protocols for patients on ECMO is recommended.
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Affiliation(s)
- Carles Bautista-Rodriguez
- Pediatric Cardiology Department, Hospital Sant Joan de Deu Barcelona, Universitat de Barcelona, Barcelona, Spain
- Department of Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Joan Sanchez-de-Toledo
- Pediatric Cardiology Department, Hospital Sant Joan de Deu Barcelona, Universitat de Barcelona, Barcelona, Spain
- Division of Cardiac Intensive Care, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Eduardo M. Da Cruz
- Department of Pediatrics, Heart Institute, Children's Hospital Colorado, School of Medicine, University of Colorado Denver, Aurora, CO, United States
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Donker DW, Brodie D, Henriques JPS, Broomé M. Left ventricular unloading during veno-arterial ECMO: a review of percutaneous and surgical unloading interventions. Perfusion 2018; 34:98-105. [PMID: 30112975 PMCID: PMC6378398 DOI: 10.1177/0267659118794112] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Short-term mechanical support by veno-arterial extracorporeal membrane oxygenation (VA ECMO) is more and more applied in patients with severe cardiogenic shock. A major shortcoming of VA ECMO is its variable, but inherent increase of left ventricular (LV) mechanical load, which may aggravate pulmonary edema and hamper cardiac recovery. In order to mitigate these negative sequelae of VA ECMO, different adjunct LV unloading interventions have gained a broad interest in recent years. Here, we review the whole spectrum of percutaneous and surgical techniques combined with VA ECMO reported to date.
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Affiliation(s)
- Dirk W Donker
- 1 Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Daniel Brodie
- 2 Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA
| | - José P S Henriques
- 3 Department of Cardiology, Academic Medical Center, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Michael Broomé
- 4 ECMO Department, Karolinska University Hospital, Stockholm, Sweden.,5 Anaesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden.,6 School of Technology and Health, Royal Institute of Technology, Stockholm, Sweden
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Abstract
PURPOSE OF REVIEW An increasing number of patients are placed on extracorporeal membrane oxygenation (ECMO) for respiratory or cardiac failure. Sound understanding of physiology and configuration of ECMO is essential for proper management. This review covers different monitoring parameters and tools for patients supported with different types of ECMO. RECENT FINDINGS Emphasis is placed on monitoring saturations at different sites depending on type of ECMO support. The main monitoring tools detailed in this review are echocardiography and pulmonary artery catheters. SUMMARY The review will help physicians better assess adequate ECMO support by using the appropriate parameters for each type of configuration.
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Mistry MS, Trucco SM, Maul T, Sharma MS, Wang L, West S. Predictors of Poor Outcomes in Pediatric Venoarterial Extracorporeal Membrane Oxygenation. World J Pediatr Congenit Heart Surg 2018; 9:297-304. [PMID: 29552945 DOI: 10.1177/2150135118762391] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides respiratory and hemodynamic support to pediatric patients in severe cardiac failure. We aim to identify risk factors associated with poorer outcomes in this population. METHODS A retrospective chart review was conducted of pediatric patients requiring VA-ECMO support for cardiac indications at our institution from 2004 to 2015. Data were collected on demographics, indication, markers of cardiac output, ventricular assist device (VAD) insertion, heart transplantation, or left atrial (LA) decompression. Univariate Cox proportional hazards models were used to calculate hazard ratios (HRs) for variables associated with the composite primary outcome of transplant-free survival (TFS). RESULTS Of the 68 reviewed patients, 65% were male, 84% were white, 38% had a prior surgery, 13% had a prior transplant, 10% had a prior ECMO support, and 87.5% required vasoactive support within six hours of cannulation. The ECMO indications included congenital heart disease repaired >30 days prior (12%), cardiomyopathy (41%), posttransplant rejection (7%), and cardiorespiratory failure (40%). The TFS was 54.5% at discharge and 47.7% at one year. Predictors of transplant and/or death include epinephrine use (hazard ratio [HR] = 2.269, P = .041), elevated lactate (HR = 1.081, P = 0005), and elevated creatinine (HR = 1.081, P = .005) within six hours prior to cannulation. Sixteen (23.6%) patients underwent LA decompression. Placement of VAD occurred in 16 (23.5%) patients, for which nonwhite race (HR = 2.94, P = .034) and prior ECMO (HR = 3.42, P = .053) were the only identified risk factors. CONCLUSIONS Need for VA-ECMO for cardiac support carries high inpatient morbidity and mortality. Epinephrine use and elevated lactate and creatinine were associated with especially poor outcomes. Patients who survived to discharge had good short-term follow-up results.
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Affiliation(s)
- Maanasi S Mistry
- 1 Pediatric Cardiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Sara M Trucco
- 1 Pediatric Cardiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Timothy Maul
- 2 Biomedical Engineering, University of Pittsburgh, Pittsburgh, PA, USA.,3 Nemours Children's Hospital, Orlando, FL, USA
| | - Mahesh S Sharma
- 4 Pediatric Cardiothoracic Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Li Wang
- 5 Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Shawn West
- 1 Pediatric Cardiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
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Meani P, Gelsomino S, Natour E, Johnson DM, Rocca HPBL, Pappalardo F, Bidar E, Makhoul M, Raffa G, Heuts S, Lozekoot P, Kats S, Sluijpers N, Schreurs R, Delnoij T, Montalti A, Sels JW, van de Poll M, Roekaerts P, Poels T, Korver E, Babar Z, Maessen J, Lorusso R. Modalities and Effects of Left Ventricle Unloading on Extracorporeal Life support: a Review of the Current Literature. Eur J Heart Fail 2018; 19 Suppl 2:84-91. [PMID: 28470925 DOI: 10.1002/ejhf.850] [Citation(s) in RCA: 158] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION/AIM Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support is increasingly used in refractory cardiogenic shock and cardiac arrest, but is characterized by a rise in afterload of the left ventricle (LV) which may ultimately either further impair or delay cardiac contractility improvement. The aim of this study was to provide a comprehensive overview regarding the different LV venting techniques and results currently available in the literature. METHODS A systematic literature search was performed in the PubMed database: 207 articles published between 1993 and 2016 were included. Papers dealing with pre-clinical studies, overlapping series, and association with other assist devices were excluded from the review, with 45 published papers finally selected. Heterogeneous indications for LV unloading were reported. The selected literature was divided into subgroups, according to the location or the performed procedure for LV venting. RESULTS Case reports or case series accounted for 60% of the papers, while retrospective study represented 29% of them. Adult series were present in 67%, paediatric patients in 29%, and a mixed population in 4%. LV unloading was performed percutaneously in 84% of the cases. The most common locations of unloading was the left atrium (31%), followed by indirect unloading (intra-aortic balloon pump) (27%), trans-aortic (27%), LV (11%), and pulmonary artery (4%). Percutaneous trans-septal approach was reported in 22%. Finally, the unloading was conducted surgically in 16%,with open chest surgery in 71%, and minimally invasive surgery in 29% of surgical cases. CONCLUSION Nowadays, only a few data are available about left heart unloading in V-A ECMO support. Despite the well-known controversy, IABP remains widely used in combination with V-A ECMO. Percutaneous approaches utilizing unloading devices is becoming an increasingly used option. However, further studies are required to establish the optimal LV unloading method.
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Affiliation(s)
- Paolo Meani
- Cardiology Department Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Sandro Gelsomino
- Department of Cardiothoracic Surgery, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Eshan Natour
- Department of Cardiothoracic Surgery, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Daniel M Johnson
- Department of Cardiothoracic Surgery, Maastricht University Medical Center +, Maastricht, The Netherlands
| | | | | | - Elham Bidar
- Department of Cardiothoracic Surgery, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Maged Makhoul
- Department of Cardiothoracic Surgery, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Giuseppe Raffa
- Cardiac Surgery and Heart Transplantation Unit; Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Pieter Lozekoot
- Department of Cardiothoracic Surgery, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Suzanne Kats
- Department of Cardiothoracic Surgery, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Niels Sluijpers
- Department of Cardiothoracic Surgery, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Rick Schreurs
- Department of Cardiothoracic Surgery, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Thijs Delnoij
- Cardiology Department Maastricht University Medical Center +, Maastricht, The Netherlands.,Intensive Care Department, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Alice Montalti
- Intensive Care Department, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Jan Willem Sels
- Cardiology Department Maastricht University Medical Center +, Maastricht, The Netherlands.,Intensive Care Department, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Marcel van de Poll
- Intensive Care Department, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Paul Roekaerts
- Intensive Care Department, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Thomas Poels
- Department of Cardiothoracic Surgery, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Eric Korver
- Department of Cardiothoracic Surgery, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Zaheer Babar
- Department of Cardiothoracic Surgery, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Jos Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Roberto Lorusso
- Department of Cardiothoracic Surgery, Maastricht University Medical Center +, Maastricht, The Netherlands
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