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Abstract
Despite advances in cardiovascular care, managing cardiogenic shock caused by structural heart disease is challenging. Patients with cardiogenic shock are critically ill upon presentation and require early disease recognition and rapid escalation of care. Temporary mechanical circulatory support provides a higher level of care than current medical therapies such as vasopressors and inotropes. This review article focuses on the role of hemodynamic monitoring, mechanical circulatory support, and device selection in patients who present with cardiogenic shock due to structural heart disease. Early initiation of appropriate mechanical circulatory support may reduce morbidity and mortality.
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Pahuja M, Schrage B, Westermann D, Basir MB, Garan AR, Burkhoff D. Hemodynamic Effects of Mechanical Circulatory Support Devices in Ventricular Septal Defect. Circ Heart Fail 2019; 12:e005981. [DOI: 10.1161/circheartfailure.119.005981] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background:
Ventricular septal defect (VSD) is a lethal complication of acute myocardial infarction (AMI) and is often associated with cardiogenic shock. The optimal form of percutaneous mechanical circulatory support (MCS) for AMI-VSD is unknown.
Methods and Results:
We used a previously validated cardiovascular model to simulate AMI-VSD with parameters adjusted to replicate average hemodynamics reported in the literature, including a pulmonary-to-systemic blood flow ratio of 3.0. We then predicted effects of different types of percutaneous MCS (including intra-aortic balloon pumping, Impella, TandemHeart, and extracorporeal membrane oxygenation) on pressures and flows throughout the cardiovascular system. The simulation replicated all major hemodynamic parameters reported in the literature with AMI-VSD. Inotropes and vasopressors worsened left-to-right shunting, whereas vasodilators decreased shunting at the expense of worsening hypotension. All MCS devices increased forward blood flow and arterial pressure but other effects varied among devices. Impella 5.0 provided the greatest degree of pulmonary capillary wedge pressure reductions and decreased left-to-right shunting. Extracorporeal membrane oxygenation worsened pulmonary capillary wedge pressure and shunting, which could be improved by adding Impella or passive left ventricular vent. Pulmonary-to-systemic blood flow ratio could not be reduced below 2.0, and pulmonary flows remained high with all forms of MCS.
Conclusions:
Although no form of percutaneous MCS normalized hemodynamics in AMI-VSD, pulmonary capillary wedge pressure and shunting were worsened by extracorporeal membrane oxygenation and improved by Impella. Accordingly, based on hemodynamics alone, Impella provides the optimal form of support in AMI-VSD. However, other factors, including team experience, device availability, potential for tissue ingestion, and clinical characteristics, need to be considered when choosing a percutaneous MCS device for AMI-VSD.
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Affiliation(s)
- Mohit Pahuja
- Division of Cardiology, Department of Internal Medicine, Detroit Medical Center/Wayne State University Medical School of Medicine, Detroit, MI (M.P.)
| | - Benedikt Schrage
- Department of Cardiology, University Heart Centre Hamburg Eppendorf, Hamburg, Germany (B.S., D.W.)
| | - Dirk Westermann
- Department of Cardiology, University Heart Centre Hamburg Eppendorf, Hamburg, Germany (B.S., D.W.)
| | - Mir B. Basir
- Division of Cardiology, Department of Medicine, Henry Ford Health System, Detroit, MI (M.B.B.)
| | - Arthur Reshad Garan
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY (A.R.G., D.B.)
| | - Daniel Burkhoff
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY (A.R.G., D.B.)
- Cardiovascular Research Foundation, New York, NY (D.B.)
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Ariza-Solé A, Sánchez-Salado JC, Sbraga F, Ortiz D, González-Costello J, Blasco-Lucas A, Alegre O, Toral D, Lorente V, Santafosta E, Toscano J, Izquierdo A, Miralles A, Cequier Á. The role of perioperative cardiorespiratory support in post infarction ventricular septal rupture-related cardiogenic shock. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 9:128-137. [DOI: 10.1177/2048872618817485] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Current guidelines recommend emergency surgical correction in patients with post infarction ventricular septal rupture (PIVSR), but patients with multiorgan failure are commonly managed conservatively because of high surgical risk. We assessed characteristics and outcomes of operated PIVSR patients with or without the use of short-term ventricular assist devices (ST-VADs). We also assessed the impact of a ST-VAD on the performance of surgery Methods: We retrospectively analysed all consecutive patients with PIVSR between January 2004 and May 2017. Baseline clinical characteristics, use of ST-VAD and performance of surgery during admission were assessed. The main outcome measured was in-hospital mortality. Results: A total of 28 patients were included. Mean age was 69.2 years. Most patients (20/28, 71.4%) underwent surgical repair. ST-VADs were used in 11/28 patients (39.3%). This percentage progressively increased across the study period, from 22.2% (2/9) in 2004–2011 to 58.3% (7/12) in 2015–2017 ( p=0.091). Patients undergoing ST-VAD use had poorer INTERMACS status, higher values of creatinine, lactate and alanine aminotransferase and lower left ventricular ejection fraction as compared with operated patients without support. In-hospital mortality did not differ according to the use of ST-VADs in operated patients (27.3% without ST-VAD vs. 22.2% with ST-VAD, p=0.604). All five patients undergoing early preoperative venoarterial extracorporeal membrane oxygenator support and delayed surgery survived at hospital discharge. Conclusions: ST-VAD use increased in patients with PIVSR. Despite a higher risk profile in operated patients undergoing ST-VAD use, mortality was not significantly different in these patients. Early preoperative venoarterial extracorporeal membrane oxygenation should be considered for very high risk PIVSR patients.
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Affiliation(s)
- Albert Ariza-Solé
- Intensive Cardiac Care Unit, Cardiology Department, Heart Disease Institute, Bellvitge University Hospital, Barcelona, Spain
| | - José C Sánchez-Salado
- Intensive Cardiac Care Unit, Cardiology Department, Heart Disease Institute, Bellvitge University Hospital, Barcelona, Spain
| | - Fabrizio Sbraga
- Heart Surgery Department, Heart Disease Institute, Bellvitge University Hospital, Barcelona, Spain
| | - Daniel Ortiz
- Heart Surgery Department, Heart Disease Institute, Bellvitge University Hospital, Barcelona, Spain
| | - José González-Costello
- Advanced Heart Failure and Heart Transplant Unit, Cardiology Department, Heart Disease Institute, Bellvitge University Hospital, Barcelona, Spain
| | - Arnau Blasco-Lucas
- Heart Surgery Department, Heart Disease Institute, Bellvitge University Hospital, Barcelona, Spain
| | - Oriol Alegre
- Intensive Cardiac Care Unit, Cardiology Department, Heart Disease Institute, Bellvitge University Hospital, Barcelona, Spain
| | - David Toral
- Heart Surgery Department, Heart Disease Institute, Bellvitge University Hospital, Barcelona, Spain
| | - Victòria Lorente
- Intensive Cardiac Care Unit, Cardiology Department, Heart Disease Institute, Bellvitge University Hospital, Barcelona, Spain
| | - Eva Santafosta
- Intensive Care Unit, Bellvitge University Hospital, Barcelona, Spain
| | - Jacobo Toscano
- Heart Surgery Department, Heart Disease Institute, Bellvitge University Hospital, Barcelona, Spain
| | - Andrea Izquierdo
- Intensive Cardiac Care Unit, Cardiology Department, Heart Disease Institute, Bellvitge University Hospital, Barcelona, Spain
| | - Albert Miralles
- Heart Surgery Department, Heart Disease Institute, Bellvitge University Hospital, Barcelona, Spain
| | - Ángel Cequier
- Intensive Cardiac Care Unit, Cardiology Department, Heart Disease Institute, Bellvitge University Hospital, Barcelona, Spain
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ECMO and cytokine removal for bridging to surgery in a patient with ischemic ventricular septal defect - a case report. Int J Artif Organs 2017; 40:526-529. [PMID: 28574104 DOI: 10.5301/ijao.5000600] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2017] [Indexed: 11/20/2022]
Abstract
Even in the modern era of percutaneous coronary intervention, postinfarction ventricular septal defect (VSD) remains a serious and often lethal complication. Whether or not immediate surgical repair or delaying surgery a few days aided by intra-aortic counterpulsation provides the optimal strategy remains a matter of debate. An interdisciplinary approach of intensivists and cardiac surgeons in this setting is mandatory. We report the use of veno-arterial extracorporeal membrane oxygenation and extracorporeal blood purification therapy (CytoSorb®) as bridging to surgical closure in a patient with an ischemic VSD leading to protracted cardiogenic shock after posterior myocardial infarction.
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Rob D, Špunda R, Lindner J, Rohn V, Kunstýř J, Balík M, Rulíšek J, Kopecký P, Lipš M, Šmíd O, Kovárník T, Mlejnský F, Linhart A, Bělohlávek J. A rationale for early extracorporeal membrane oxygenation in patients with postinfarction ventricular septal rupture complicated by cardiogenic shock. Eur J Heart Fail 2017; 19 Suppl 2:97-103. [DOI: 10.1002/ejhf.852] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Daniel Rob
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine; Charles University and General University Hospital; Prague Czech Republic
| | - Rudolf Špunda
- 2nd Surgery Department - Department of Cardiovascular Surgery, First Faculty of Medicine; Charles University and General University Hospital; Prague Czech Republic
| | - Jaroslav Lindner
- 2nd Surgery Department - Department of Cardiovascular Surgery, First Faculty of Medicine; Charles University and General University Hospital; Prague Czech Republic
| | - Vilém Rohn
- Cardiovascular Surgery Department, Second Faculty of Medicine; Charles University and Motol University Hospital; Prague Czech Republic
| | - Jan Kunstýř
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine; Charles University and General University Hospital; Prague Czech Republic
| | - Martin Balík
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine; Charles University and General University Hospital; Prague Czech Republic
| | - Jan Rulíšek
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine; Charles University and General University Hospital; Prague Czech Republic
| | - Petr Kopecký
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine; Charles University and General University Hospital; Prague Czech Republic
| | - Michal Lipš
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine; Charles University and General University Hospital; Prague Czech Republic
| | - Ondřej Šmíd
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine; Charles University and General University Hospital; Prague Czech Republic
| | - Tomáš Kovárník
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine; Charles University and General University Hospital; Prague Czech Republic
| | - František Mlejnský
- 2nd Surgery Department - Department of Cardiovascular Surgery, First Faculty of Medicine; Charles University and General University Hospital; Prague Czech Republic
| | - Aleš Linhart
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine; Charles University and General University Hospital; Prague Czech Republic
| | - Jan Bělohlávek
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine; Charles University and General University Hospital; Prague Czech Republic
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Jacob S, Patel MJ, Lima B, Felius J, Malyala RS, Chamogeorgakis T, MacHannaford JC, Gonzalez-Stawinski GV, Rafael AE. Using extracorporeal membrane oxygenation support preoperatively and postoperatively as a successful bridge to recovery in a patient with a large infarct-induced ventricular septal defect. Proc (Bayl Univ Med Cent) 2016; 29:301-4. [PMID: 27365878 DOI: 10.1080/08998280.2016.11929443] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Rupture of the ventricular septum during acute myocardial infarction usually occurs within the first week. The event is usually followed by low cardiac output, heart failure, and multiorgan failure. Despite the many advances in the nonoperative treatment of heart failure and cardiogenic shock, including the intra-aortic balloon pump and a multitude of new inotropic agents and vasodilators, these do not supplant the need for operative intervention in these critically ill patients. This article describes the successful use of extracorporeal membrane oxygenation support as a bridge to recovery postoperatively in a patient with a large infarct-produced ventricular septal defect.
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Affiliation(s)
- Samuel Jacob
- Department of Cardiac and Thoracic Surgery (Jacob, Patel, Lima, Malyala, Chamogeorgakis, MacHannaford, Gonzalez-Stawinski, Rafael) and the Annette C. and Harold C. Simmons Transplant Institute (Lima, Felius, Chamogeorgakis, Gonzalez-Stawinski), Baylor University Medical Center at Dallas
| | - Mitesh J Patel
- Department of Cardiac and Thoracic Surgery (Jacob, Patel, Lima, Malyala, Chamogeorgakis, MacHannaford, Gonzalez-Stawinski, Rafael) and the Annette C. and Harold C. Simmons Transplant Institute (Lima, Felius, Chamogeorgakis, Gonzalez-Stawinski), Baylor University Medical Center at Dallas
| | - Brian Lima
- Department of Cardiac and Thoracic Surgery (Jacob, Patel, Lima, Malyala, Chamogeorgakis, MacHannaford, Gonzalez-Stawinski, Rafael) and the Annette C. and Harold C. Simmons Transplant Institute (Lima, Felius, Chamogeorgakis, Gonzalez-Stawinski), Baylor University Medical Center at Dallas
| | - Joost Felius
- Department of Cardiac and Thoracic Surgery (Jacob, Patel, Lima, Malyala, Chamogeorgakis, MacHannaford, Gonzalez-Stawinski, Rafael) and the Annette C. and Harold C. Simmons Transplant Institute (Lima, Felius, Chamogeorgakis, Gonzalez-Stawinski), Baylor University Medical Center at Dallas
| | - Rajasekhar S Malyala
- Department of Cardiac and Thoracic Surgery (Jacob, Patel, Lima, Malyala, Chamogeorgakis, MacHannaford, Gonzalez-Stawinski, Rafael) and the Annette C. and Harold C. Simmons Transplant Institute (Lima, Felius, Chamogeorgakis, Gonzalez-Stawinski), Baylor University Medical Center at Dallas
| | - Themistokles Chamogeorgakis
- Department of Cardiac and Thoracic Surgery (Jacob, Patel, Lima, Malyala, Chamogeorgakis, MacHannaford, Gonzalez-Stawinski, Rafael) and the Annette C. and Harold C. Simmons Transplant Institute (Lima, Felius, Chamogeorgakis, Gonzalez-Stawinski), Baylor University Medical Center at Dallas
| | - Juan C MacHannaford
- Department of Cardiac and Thoracic Surgery (Jacob, Patel, Lima, Malyala, Chamogeorgakis, MacHannaford, Gonzalez-Stawinski, Rafael) and the Annette C. and Harold C. Simmons Transplant Institute (Lima, Felius, Chamogeorgakis, Gonzalez-Stawinski), Baylor University Medical Center at Dallas
| | - Gonzalo V Gonzalez-Stawinski
- Department of Cardiac and Thoracic Surgery (Jacob, Patel, Lima, Malyala, Chamogeorgakis, MacHannaford, Gonzalez-Stawinski, Rafael) and the Annette C. and Harold C. Simmons Transplant Institute (Lima, Felius, Chamogeorgakis, Gonzalez-Stawinski), Baylor University Medical Center at Dallas
| | - Aldo E Rafael
- Department of Cardiac and Thoracic Surgery (Jacob, Patel, Lima, Malyala, Chamogeorgakis, MacHannaford, Gonzalez-Stawinski, Rafael) and the Annette C. and Harold C. Simmons Transplant Institute (Lima, Felius, Chamogeorgakis, Gonzalez-Stawinski), Baylor University Medical Center at Dallas
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Fazekas L, Sax B, Hartyánszky I, Pólos M, Horkay F, Varga T, Rácz K, Németh E, Székely A, Paulovich E, Heltai K, Zima E, Szabolcs Z, Merkely B. [Mechanical circulatory support saves lives -- three years' experience of the newly established assist device program at Semmelweis University, Budapest, Hungary]. Orv Hetil 2015; 156:521-7. [PMID: 25796280 DOI: 10.1556/oh.2015.30115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Since the celebration of the 20th anniversary of the first heart transplantation in Hungary in 2012 the emerging need for modern heart failure management via mechanical circulatory support has evolved. In May 2012 the opening of a new heart failure and transplant unit with 9 beds together with the procurement of necessary devices at Semmelweis University accomplished this need. AIM The aim of the authors was to report their initial experience obtained in this new cardiac assist device program. METHOD Since May, 2012, mechanical circulatory support system was applied in 89 cases in 72 patients. Indication for support were end stage heart failure refractory to medical treatment and acute left or right heart failure. RESULTS Treatment was initiated for acute graft failure after heart transplantation in 27 cases, for end stage heart failure in 24 cases, for acute myocardial infarction in 21 cases, for acute postcardiotomy heart failure in 14 cases, for severe respiratory insufficiency in 2 cases and for drug intoxication in one case. Among the 30 survivor of the whole program 13 patients were successfully transplanted. CONCLUSIONS The available devices can cover all modalities of current bridge therapy from short term support through medium support to heart transplantation or long term support and destination therapy. These conditions made possible the successful start of a new cardiac assist device program.
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Affiliation(s)
- Levente Fazekas
- Semmelweis Egyetem, Általános Orvostudományi Kar Városmajori Szív- és Érgyógyászati Klinika Budapest Városmajor u. 68. 1122
| | - Balázs Sax
- Semmelweis Egyetem, Általános Orvostudományi Kar Városmajori Szív- és Érgyógyászati Klinika Budapest Városmajor u. 68. 1122
| | - István Hartyánszky
- Semmelweis Egyetem, Általános Orvostudományi Kar Városmajori Szív- és Érgyógyászati Klinika Budapest Városmajor u. 68. 1122
| | - Miklós Pólos
- Semmelweis Egyetem, Általános Orvostudományi Kar Városmajori Szív- és Érgyógyászati Klinika Budapest Városmajor u. 68. 1122
| | - Ferenc Horkay
- Semmelweis Egyetem, Általános Orvostudományi Kar Városmajori Szív- és Érgyógyászati Klinika Budapest Városmajor u. 68. 1122
| | - Tamás Varga
- Semmelweis Egyetem, Általános Orvostudományi Kar Aneszteziológiai és Intenzív Terápiás Klinika Budapest
| | - Kristóf Rácz
- Semmelweis Egyetem, Általános Orvostudományi Kar Aneszteziológiai és Intenzív Terápiás Klinika Budapest
| | - Endre Németh
- Semmelweis Egyetem, Általános Orvostudományi Kar Aneszteziológiai és Intenzív Terápiás Klinika Budapest
| | - Andrea Székely
- Semmelweis Egyetem, Általános Orvostudományi Kar Aneszteziológiai és Intenzív Terápiás Klinika Budapest
| | - Erzsébet Paulovich
- Semmelweis Egyetem, Általános Orvostudományi Kar Aneszteziológiai és Intenzív Terápiás Klinika Budapest
| | - Krisztina Heltai
- Semmelweis Egyetem, Általános Orvostudományi Kar Városmajori Szív- és Érgyógyászati Klinika Budapest Városmajor u. 68. 1122
| | - Endre Zima
- Semmelweis Egyetem, Általános Orvostudományi Kar Városmajori Szív- és Érgyógyászati Klinika Budapest Városmajor u. 68. 1122
| | - Zoltán Szabolcs
- Semmelweis Egyetem, Általános Orvostudományi Kar Városmajori Szív- és Érgyógyászati Klinika Budapest Városmajor u. 68. 1122
| | - Béla Merkely
- Semmelweis Egyetem, Általános Orvostudományi Kar Városmajori Szív- és Érgyógyászati Klinika Budapest Városmajor u. 68. 1122
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Bates ER. Reperfusion therapy reduces the risk of myocardial rupture complicating ST-elevation myocardial infarction. J Am Heart Assoc 2014; 3:e001368. [PMID: 25332182 PMCID: PMC4323812 DOI: 10.1161/jaha.114.001368] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Eric R Bates
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
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