Extracorporeal Membrane Oxygenation in Massive Pulmonary Embolism

BACKGROUND

Extracorporeal Membrane Oxygenation (ECMO) has been suggested for cardiopulmonary support in patients with massive pulmonary embolism (PE) refractory to other treatment or as bridging to embolectomy. The survival benefit from ECMO in patients with massive PE remains unclear.

METHODS

Here, we describe 5 cases in which ECMO was used as cardiopulmonary support following massive near-fatal pulmonary embolism.

RESULTS

The overall mortality in patients with massive PE that received ECMO support was 40%. Death occurred secondary to ECMO-related complication in one case and due to inability to maintain adequate cerebral perfusion despite ECMO support in the second case.

CONCLUSIONS

ECMO can be considered as a treatment modality for patients with massive PE.

Left Ventricular Mechanical Support with the Impella during Extracorporeal Membrane Oxygenation

Background: Venoarterial extracorporeal membrane oxygenation (ECMO) provides systemic arterial support without directly unloading the left heart, which causes an elevated left ventricular (LV) pressure. The aim of the present study was to investigate the adjunctive application of the Impella device for LV unloading in patients during ECMO. Methods: This retrospective cohort study included patients who received Impella support in addition to venoarterial ECMO between April 2012 and December 2015. ECMO cannulation was performed peripherally or centrally, while the Impella device was surgically inserted into the femoral artery or the right axillary artery. Results: Among 62 patients, 10 (16.1%) received an Impella device during ECMO support. Following Impella support, right atrial pressure improved from a median of 18 (IQR, 14-24) mmHg to 13 (IQR, 10-15) mmHg and pulmonary wedge pressure improved from 30 (IQR, 26-35) mmHg to 16 (IQR, 12-19) mmHg in all the patients (p value < 0.001). Follow-up transthoracic echocardiograms (n = 6) showed a median decrease of 0.8 cm in LV end-diastolic volume (p value = 0.021). There were 5 (50%) in-hospital deaths due to sustained brain injury (n = 3) and refractory cardiogenic shock (n = 2). The remaining 5 patients were discharged and successfully bridged to more permanent LV assist device (n = 2) or heart transplantation (n = 3). Conclusion: The findings of the present study indicate that the application of the Impella device during ECMO support is effective in LV unloading and confers optimal hemodynamic support.

Extracorporeal membrane oxygenation in transcatheter aortic valve replacement

Background

Patients undergoing transcatheter aortic valve replacement can experience severe perioperative complications leading to hemodynamic instability and death. Venoarterial extracorporeal membrane oxygenation can be used to provide cardiorespiratory support during this time.

Methods

From 2012 to 2015, of 247 patients who underwent transcatheter aortic valve replacement, 6 (2.42%) required extracorporeal membrane oxygenation support. Their mean age was 82 ± 7.4 years, mean Society of Thoracic Surgeons score was 9.4 ± 6.6, and mean aortic gradient was 28.3 ± 12 mm Hg. Rescue extracorporeal membrane oxygenation was required for hemodynamic instability due to ventricular fibrillation ( n = 1), respiratory failure ( n = 1), left ventricular wall rupture ( n = 2), and aortic annulus rupture ( n = 1). In one patient, prophylactic extracorporeal membrane oxygenation was required due to advanced heart failure. Additional procedures included valve-in-valve implantation ( n = 1), conversion to an open procedure ( n = 3), and intraaortic balloon pump insertion ( n = 1).

Results

The median hospital stay was 20 days. There were 2 hospital deaths in patients whose hospital course was complicated by left ventricular wall rupture or aortic annulus rupture with resulting tamponade. Among the 4 survivors, one required continuous ventilator support following discharge, and 3 experienced no major complications during the first month after discharge.

Conclusions

Extracorporeal membrane oxygenation can be considered a viable option for high-risk patients undergoing transcatheter aortic valve replacement and those who develop cardiac complications following this procedure and require cardiorespiratory support.

Transseptal biopsy of a left atrial mass with 3-dimensional transesophageal echocardiographic guidance

A 31-year-old man presented with a large cardiac mass that originated from the basal posterior left atrial wall and occupied most of the dilated atrium. Minimally invasive studies yielded inconclusive results, but the patient was considered at high risk for an open cardiac biopsy due to the size of the mass. To establish a tissue diagnosis for definitive treatment, we performed a transseptal cardiac biopsy guided by 3-dimensional transesophageal echocardiography. We thereby determined that the mass was a primary left atrial sarcoma. To the best of our knowledge, this is the first report concerning the use of 3-dimensional transesophageal echocardiography for biopsy of a left atrial mass.

Determinants of right ventricular failure in patients admitted with acute left heart failure

Pulmonary hypertension, which may lead to right ventricular (RV) failure, increases with left ventricular (LV) diastolic dysfunction severity. The prevalence and determinants of RV failure were analyzed in 120 patients admitted with acute left heart (LH) failure. Patients were divided into RV failure (n=50) and non-RV failure (n=70) groups. The prevalence of RV failure was found to be 42%. In both groups, two thirds of the patients had isolated LV diastolic dysfunction and the rest had combined LV systolic and diastolic dysfunction. Patients in the RV failure group were characterized by higher LV diastolic grade (2.2 ± 0.6 vs 1.84 ± 0.7; P=.0070), pulmonary artery systolic pressure (PASP; 57.8 ± 15.3 vs 50.14 ± 12.1 mm Hg; P=.0028), right atrial enlargement (92% vs 25.7%; P=.000001), and more-than-moderate tricuspid regurgitation (58% vs 27.1%; P=.0006). RV failure is a frequent finding in patients with advanced LH failure. It is strongly associated with the severity of LV diastolic dysfunction and the severity of PASP.

Role of steroids on the clinical course and outcome of meconium aspiration syndrome-a randomized controlled trial

BACKGROUND

Meconium aspiration syndrome (MAS) is one of the major causes of severe respiratory distress in the newborn and there is no uniform protocol of management after the development of MAS.

OBJECTIVE

The objective of the study was to determine whether systemic and inhalational steroid therapy can alter the clinical course of MAS and improve the outcome without causing any serious adverse effects.

METHODS

A randomized controlled trial was conducted in three groups of MAS over a period of 1 year. Group A (n = 33) served as controls, Group B (n = 34) received systemic methyl prednisolone and Group C (n = 32) received nebulized budesonide both for a period of 7 days starting after 24 h of age. Details of clinical progress were noted during the hospital stay. Follow up for a minimum period of 3 months was done in all. Data were analysed by SPSS 10 software. Student's t and ANOVA were used to assess statistical significance.

RESULTS

Patient profile was similar in all the three groups. Period of oxygen dependency and duration of hospital stay was significantly less in the steroid treated groups. Similarly full enteral feeding and radiological clearance of chest could be achieved earlier in groups B and C. No difference between the steroid treated groups could be appreciated by Student's Newman Kuel (SNK) test. Development of sepsis was similar in all the groups and no serious adverse effects were noted in steroid treated groups.

CONCLUSION

Steroids are effective in the management of MAS and route of administration does not have a bearing on the efficacy.

Injectable midazolam as oral premedicant in pediatric neurosurgery

In a randomized, double blind, placebo controlled study; the acceptability, efficacy and safety of injectable midazolam as oral premedicant in children was evaluated. One hundred children (ASA 1,2) aged 6 months to 6 years, undergoing elective neurosurgical operations, like meningomyelocele, meningo-encephalocele, ventriculo peritoneal and other shunts and craniotomies for tumour decompression etc., were included in the study. The patients were randomly assigned to one of four groups (A, B, C, D) receiving respectively saline or 0.50, 0.75 and 1.0 mg/kg midazolam in honey, 45 min before separation from parents. All received identical general anesthesia (GA). Age, sex, weight, heart rate, blood pressure, respiratory rate, saturation (SaO2), reaction to parent's separation, sedation score and duration of anesthesia, recovery conditions and side effects were noted. We found no difference in age, sex, weight, patient acceptability vomiting after ingestion and duration of anesthesia between groups. Even though many children resisted the placement of premedicant in the mouth, only three children spat it out and none vomited after swallowing. The reaction to separation from parents was better after midazolam premedication. However, on reaching the operating room, 24% children (placebo-60%) were found anxious after 0.50 mg/kg, but 12% were deeply sedated after a dose of 1.0 mg/kg. Recovery was similar in groups A, B and C except that more (48%) patients were anxious in group A. Recovery, however was delayed in 16% patients of group D. Though, fewer complications were reported during recovery after midazolam than placebo premedication, they were minimal in the 0.75 mg/kg group. We concluded that giving injectable midazolam orally as premedication in pediatric age group scheduled for neurosurgical operations is acceptable, effective and safe in 0.75 mg/kg dose. While 0.50 mg/kg is less effective, 1.0 mg/kg does not offer any additional benefit over 0.75 mg/kg but does delay recovery and may compromise safety.

Pregnancy wastage in rural Varanasi: relationship with maternal nutrition and sociodemographic characteristics

OBJECTIVE

To study the relationship between pregnancy wastage and matrnal undernutrition and other sociodemographic factors in rural Indian women.

SETTING

Rural community of Varanasi.

DESIGN

Longitudinal observation.

METHOD

In 49 villages during 1988-92, 8111 pregnancies were registered to observe for wastage. The pregnancy outcome was correlated with various factors.

RESULTS

There were 1321 abortions and 141 still births. Women's income < Rs. 250 per month, education < 10th class and protein intake < 50 g/day had significantly higher relative risks (RR) (4.1, 2.9 and 2.8, respectively) for abortions. Poor maternal nutrition was in additional important risk factor, for still births (RR 5.1 and 4.2 for maternal weight and height, respectively). A pregnancy interval over 2 years reduced both.

CONCLUSION

Low socioeconomic status, chronic undernutrition and illiteracy in rural India are associated with high pregnancy wastage.

Weight gain during pregnancy--a key factor in perinatal and infant mortality

OBJECTIVE

To identify risk factors for high perinatal (PMR) and infant (IMR) mortality in a rural area.

DESIGN

In 49 randomly selected villages from two adjoining blocks of rural Varanasi, all pregnant women and live births were followed for perinatal and infant mortality, during the years 1988-1992.

SUBJECTS

6790 births and their 6649 live births.

RESULTS

The PMR was 90.7 per thousand births and IMR was 98.6/1000 live births. These mortalities were significantly higher if weight gain during pregnancy was less than 7.0 kg. Low weight gain during pregnancy was also associated with significantly higher low birth weight deliveries and to some extent increased still birth rate. PMR and IMR decreased with higher levels of hemoglobin in third trimester and socioeconomic index; however, the calculated RR were not significant.

CONCLUSION

Low weight gain during pregnancy is an important risk factor for PMR and IMR.

Motor nerve conduction velocity & Hoffman's reflex latency in newborns

A total of 72 newborns and their mothers were studied to assess the influence of various variables on the motor nerve conduction velocity (MNCV) and Hoffman's reflex latency (H-RL) of the babies with a view to differentiate fullterm and preterm low birth weight babies. MNCV were significantly lower and H-RL significantly higher in preterm appropriate for gestational (PT-AGA) age babies compared to fullterm appropriate for gestational age (FT-AGA) and fullterm intrauterine growth retarded babies (FT-IUGR). In FT-IUGR babies, only MNCV was significantly reduced as compared to FT-AGA babies.

Cellular immunity status in anaemia in pregnancy

Fifty pregnant women (25 anaemic and 25 non-anaemic) and 20 non pregnant women (10 anaemic and 10 non-anaemic) were studied. All pregnant women delivered full term (37-41 wk) singleton babies. Maternal blood lymphocyte stimulation indices (SI) at 0 and 24 h were lower in anaemic and non-anaemic pregnant women, compared to anaemic and non-anaemic non-pregnant women. This difference was more marked in anaemic pregnant women, as compared to non pregnant anaemic women at 0 and 24 h respectively. The SI of maternal and cord blood lymphocytes were significantly lower in severely anaemic mothers both at 0 and 24 h and in those with maternal serum iron levels below 50 micrograms/dl or maternal per cent transferrin saturation was below 15 per cent. The anaemic mothers and their offspring were found to have significantly lower blastogenic response to PHA added at 24 h indicating depression of T-suppressor cell function.

Electrophysiological studies in newborns with reference to gestation and anthropometry

Fourteen full term appropriate for gestational age (FT-AGA) and 11 preterm appropriate for gestational age (PT-AGA) newborns and their mothers constituted study subjects. The mothers were subjected to hemoglobin and serum albumin estimations. Offsprings were subjected to measurements of weight, crown heel length and head circumference along with motor nerve conduction velocity (MNCV) and H-reflex latency (H-RL) at right median nerve. The MNCV was found to be significantly lower and H-RL significantly higher in PT-AGA babies compared to FT-AGA babies. The gestation, crown heel length of baby and maternal serum albumin status were found to be significant independent variables. Multiple regression equations have been derived using these parameters as determinative variables. These equations explained much higher per cent variation than explained by simple regression equations.

Comparative evaluation of two maternal weight-height indices during pregnancy

Three hundred forty one primiparous women and their offsprings were the subjects of the study. Mothers were subjected to weight and height measurement as well as hemoglobin estimation. The weight for height ratio index (WHRI) and weight-height product index (WHPI) were calculated. Both WHRI and WHPI were studied in relation to birth weight (BW). WHPI was found to be superior over WHRI as it explained greater per cent variation in birth weight. The means for BW increased and incidence of low birth weight babies decreased significantly with increase of WHPI in each WHRI group.