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Akazawa Y, Higashi H, Miyoshi T, Inaba S, Yamaguchi O. Utility of Adjunctive Impella Support to Venoarterial Extracorporeal Membrane Oxygenation for a Refractory Electrical Storm. Cureus 2024; 16:e64382. [PMID: 39130934 PMCID: PMC11316968 DOI: 10.7759/cureus.64382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2024] [Indexed: 08/13/2024] Open
Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) stabilizes hemodynamics in an electrical storm leading to cardiogenic shock. However, adverse effects of VA-ECMO are increased left ventricular (LV) afterload and LV end-diastolic pressure due to retrograde blood return. These adverse effects could be ameliorated by LV unloading with Impella insertion. This case illustrates the possible efficacy of adjunctive Impella insertion for a refractory electrical storm that is resistant to defibrillation under mechanical support with VA-ECMO for cardiogenic shock.
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Affiliation(s)
- Yusuke Akazawa
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University, Toon, JPN
| | - Haruhiko Higashi
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, JPN
| | - Toru Miyoshi
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, JPN
| | - Shinji Inaba
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, JPN
| | - Osamu Yamaguchi
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, JPN
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De Potter T, Valeriano C, Buytaert D, Bouchez S, Ector J. Noninvasive neurological monitoring to enhance pLVAD-assisted ventricular tachycardia ablation - a Mini review. Front Cardiovasc Med 2023; 10:1140153. [PMID: 36970357 PMCID: PMC10031079 DOI: 10.3389/fcvm.2023.1140153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 02/16/2023] [Indexed: 03/29/2023] Open
Abstract
For critically ill patients, hemodynamic fluctuations can be life-threatening; this is particularly true for patients experiencing cardiac comorbidities. Patients may suffer from problems with heart contractility and rate, vascular tone, and intravascular volume, resulting in hemodynamic instability. Unsurprisingly, hemodynamic support provides a crucial and specific benefit during percutaneous ablation of ventricular tachycardia (VT). Mapping, understanding, and treating the arrhythmia during sustained VT without hemodynamic support is often infeasible due to patient hemodynamic collapse. Substrate mapping in sinus rhythm can be successful for VT ablation, but there are limitations to this approach. Patients with nonischemic cardiomyopathy may present for ablation without exhibiting useful endocardial and/or epicardial substrate-based ablation targets, either due to diffuse extent or a lack of identifiable substrate. This leaves activation mapping during ongoing VT as the only viable diagnostic strategy. By enhancing cardiac output, percutaneous left ventricular assist devices (pLVAD) may facilitate conditions for mapping that would otherwise be incompatible with survival. However, the optimal mean arterial pressure to maintain end-organ perfusion in presence of nonpulsatile flow remains unknown. Near infrared oxygenation monitoring during pLVAD support provides assessment of critical end-organ perfusion during VT, enabling successful mapping and ablation with the continual assurance of adequate brain oxygenation. This focused review provides practical use case scenarios for such an approach, which aims to allow mapping and ablation of ongoing VT while drastically reducing the risk of ischemic brain injury.
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Affiliation(s)
- Tom De Potter
- Cardiovascular Center Aalst, Arrhythmia Unit, OLV Hospital, Aalst, Belgium
- Correspondence: Tom De Potter
| | - Chiara Valeriano
- Cardiovascular Center Aalst, Arrhythmia Unit, OLV Hospital, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Dimitri Buytaert
- Cardiovascular Center Aalst, Arrhythmia Unit, OLV Hospital, Aalst, Belgium
| | | | - Joris Ector
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
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Dhir N, Haneke T, Mixon T. Mechanical circulatory support for thyrotoxicosis-induced cardiomyopathy. Proc AMIA Symp 2023; 36:211-212. [PMID: 36876277 PMCID: PMC9980612 DOI: 10.1080/08998280.2022.2139956] [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: 11/11/2022] Open
Abstract
Thyroid storm is a life-threatening condition which, in rare cases, may lead to cardiogenic shock and dysrhythmias. Mechanical circulatory support with an Impella device or extracorporeal membrane oxygenation may be used as a bridge to recovery in these cases. This case involves a patient with thyrotoxicosis and reduced ejection fraction and hemodynamic instability requiring Impella device placement. After treatment with methimazole, Lugol's iodine, and hydrocortisone, he was weaned off mechanical circulatory support and made a full recovery. Mechanical circulatory support devices can be a useful bridging tool in reversible causes of cardiogenic shock, such as thyroid storm.
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Affiliation(s)
- Nikita Dhir
- Department of Internal Medicine, Baylor Scott and White Medical Center - Temple, Temple, Texas
| | - Travis Haneke
- Division of Cardiology, Baylor Scott and White Medical Center - Temple, Temple, Texas
| | - Timothy Mixon
- Division of Cardiology, Baylor Scott and White Medical Center - Temple, Temple, Texas
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Tavazzi G, Dammassa V, Colombo CNJ, Arbustini E, Castelein T, Balik M, Vandenbriele C. Mechanical circulatory support in ventricular arrhythmias. Front Cardiovasc Med 2022; 9:987008. [PMID: 36304552 PMCID: PMC9593033 DOI: 10.3389/fcvm.2022.987008] [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: 07/05/2022] [Accepted: 09/15/2022] [Indexed: 11/27/2022] Open
Abstract
In atrial and ventricular tachyarrhythmias, reduced time for ventricular filling and loss of atrial contribution lead to a significant reduction in cardiac output, resulting in cardiogenic shock. This may also occur during catheter ablation in 11% of overall procedures and is associated with increased mortality. Managing cardiogenic shock and (supra) ventricular arrhythmias is particularly challenging. Inotropic support may exacerbate tachyarrhythmias or accelerate heart rate; antiarrhythmic drugs often come with negative inotropic effects, and electrical reconversions may risk worsening circulatory failure or even cardiac arrest. The drop in native cardiac output during an arrhythmic storm can be partly covered by the insertion of percutaneous mechanical circulatory support (MCS) devices guaranteeing end-organ perfusion. This provides physicians a time window of stability to investigate the underlying cause of arrhythmia and allow proper therapeutic interventions (e.g., percutaneous coronary intervention and catheter ablation). Temporary MCS can be used in the case of overt hemodynamic decompensation or as a “preemptive strategy” to avoid circulatory instability during interventional cardiology procedures in high-risk patients. Despite the increasing use of MCS in cardiogenic shock and during catheter ablation procedures, the recommendation level is still low, considering the lack of large observational studies and randomized clinical trials. Therefore, the evidence on the timing and the kinds of MCS devices has also scarcely been investigated. In the current review, we discuss the available evidence in the literature and gaps in knowledge on the use of MCS devices in the setting of ventricular arrhythmias and arrhythmic storms, including a specific focus on pathophysiology and related therapies.
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Affiliation(s)
- Guido Tavazzi
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy,Department of Anaesthesia, Intensive Care and Pain Therapy, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy,*Correspondence: Guido Tavazzi
| | - Valentino Dammassa
- PhD in Experimental Medicine, University of Pavia, Pavia, Italy,Adult Intensive Care Unit, Royal Brompton Hospital, London, United Kingdom
| | | | - Eloisa Arbustini
- Centre for Inherited Cardiovascular Diseases, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Thomas Castelein
- Cardiovascular Center, Onze-Lieve-Vrouwziekenhuis Hospital, Aalst, Belgium
| | - Martin Balik
- Department of Anesthesiology and Intensive Care, First Medical Faculty and General University Hospital, Charles University in Prague, Prague, Czechia
| | - Christophe Vandenbriele
- Adult Intensive Care Unit, Royal Brompton Hospital, London, United Kingdom,Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium,Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
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Le Ruz R, Lande G, Lepoivre T, David CH, Michel M, Gourraud JB. Electrical Storm Ablation in a Patient in Cardiogenic Shock Supported by Impella 5.0. JACC Case Rep 2021; 3:486-490. [PMID: 34317564 PMCID: PMC8311017 DOI: 10.1016/j.jaccas.2020.12.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 12/03/2020] [Accepted: 12/14/2020] [Indexed: 11/27/2022]
Abstract
Intra-axial pumps are increasingly used to support cardiogenic shock. The occurrence of electrical storms in this setting is a rising issue, and data remain scarce about optimal management. We report the feasibility of ventricular tachycardia ablation in the presence of a recent surgically inserted Impella 5.0 device (Abiomed, Danvers, Massachusetts). (Level of Difficulty: Intermediate.)
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Affiliation(s)
- Robin Le Ruz
- Department of Cardiology, Nantes University Hospital Center, Saint-Herblain, France
- Address for correspondence: Robin Le Ruz, Department of Cardiology, Centre Hospitalo-Universitaire de Nantes, Boulevard Professeur Jacques Monod, 44800 Saint-Herblain, France. @CHUnantes
| | - Gilles Lande
- Department of Cardiology, Nantes University Hospital Center, Saint-Herblain, France
| | - Thierry Lepoivre
- Department of Cardiac Anesthesiology and Intensive Care, Nantes University Hospital Center, Saint-Herblain, France
| | - Charles-Henri David
- Department of Cardiac Surgery, Nantes University Hospital Center, Saint-Herblain, France
| | - Magali Michel
- Department of Cardiology, Nantes University Hospital Center, Saint-Herblain, France
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