scholarly journals Protracted aortic valve closure during peripheral veno-arterial extracorporeal life support: is intra-aortic balloon pump an effective solution?

Perfusion ◽  
2018 ◽  
Vol 34 (1) ◽  
pp. 35-41 ◽  
Author(s):  
Paolo Meani ◽  
Thijs Delnoij ◽  
Giuseppe M. Raffa ◽  
Nuccia Morici ◽  
Giovanna Viola ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Left Ventricular ◽  
Ecmo Support ◽  
Effective Solution ◽  
Intra Aortic Balloon Pump ◽  
University Center ◽  
Aortic Valve Closure ◽  
The Impact

Background: Left ventricular (LV) afterload increase with protracted aortic valve (AV) closure may represent a complication of veno-arterial extracorporeal membrane oxygenation (V-A ECMO). The aim of the present study was to assess the effects of an intra-aortic balloon pump (IABP) to overcome such a hemodynamic shortcoming in patients submitted to peripheral V-A ECMO. Methods: Among 184 adult patients who were treated with peripheral V-A ECMO support at Medical University Center Maastricht Hospital between 2007 and 2018, patients submitted to IABP implant for protracted AV closure after V-A ECMO implant were retrospectively identified. All clinical and hemodynamic data, including echocardiographic monitoring, were collected and analyzed. Results: During the study period, 10 subjects (mean age 60 years old, 80% males) underwent IABP implant after peripheral V-A ECMO positioning due to the diagnosis of protracted AV closure and inefficient LV unloading as assessed by echocardiography and an absence of pulsation in the arterial pressure wave. Recovery of blood pressure pulsatility and enhanced LV unloading were observed in 8 patients after IABP placement, with no significant differences in the main hemodynamic parameters, inotropic therapy or in the ECMO flow (p=0.48). The weaning rate in this patient subgroup (mean ECMO duration 8 days), however, was only 10%, with another patient finally transplanted, leading to a 20% survival-to-hospital discharge. Conclusion: IABP placement was an effective solution in order to reverse the protracted AV closure and impaired LV unloading observed during peripheral V-A ECMO support. However, the impact on the weaning rate and survival needs further investigations.

scholarly journals Extracorporeal Life Support to Left Ventricular Assist Device Bridge to Heart Transplant

Circulation ◽  
1999 ◽  
Vol 100 (suppl_2) ◽  
Author(s):  
Francis D. Pagani ◽  
William Lynch ◽  
Fresca Swaniker ◽  
David B. Dyke ◽  
Robert Bartlett ◽  
...  
Keyword(s):  
High Risk ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Multiorgan Failure ◽  
Hemodynamic Instability ◽  
Left Ventricular ◽  
Ecmo Support ◽  
Circulatory Support ◽  
Group I ◽  
Group Ii

Background —The use of extracorporeal life support (extracorporeal membrane oxygenation [ECMO]) as a direct bridge to heart transplant in adult patients is associated with poor survival. Similarly, the use of an implantable left ventricular assist device (LVAD) to salvage patients with cardiac arrest, severe hemodynamic instability, and multiorgan failure results in poor outcome. The use of LVAD implant in patients who present with cardiogenic shock who have not been evaluated for transplantation or who have sustained a recent myocardial infarction also raises concerns. ECMO may provide reasonable short-term support to patients with severe hemodynamic instability, permit recovery of multiorgan injury, and allow time to complete a transplant evaluation before long-term circulatory support with an implantable LVAD is instituted. After acquisition of the HeartMate LVAD (Thermo Cardiosystems, Inc), we began using ECMO as a bridge to an implantable LVAD and, subsequently, to transplantation in selected high-risk patients. Methods and Results —From October 1, 1996, through September 30, 1998, 32 adult patients who presented with refractory cardiogenic shock (cardiac index <2.0 L · min −1 · m −2 , with systolic blood pressure <100 mm Hg and pulmonary capillary wedge pressure ≥24 mm Hg and dependent on ≥2 inotropes with or without intra-aortic balloon pump) were evaluated and accepted as candidates for mechanical assistance as a bridge to transplant. Of the 32 patients, 14 (group I) had a cardiac arrest or severe hemodynamic instability (systolic blood pressure ≤75 mm Hg) with evidence of multiorgan failure (defined as serum creatinine level >3 mg/dL or oliguria; international normalized ratio >1.5 or transaminases >5 times normal or total bilirubin >3 mg/dL; and needing mechanical ventilation). Group I patients were placed on ECMO support; 7 underwent subsequent LVAD implant and 1 was bridged directly to transplant. Six patients in group I survived to transplant hospitalization discharge. The remaining 18 patients (group II) underwent LVAD implant without ECMO support; 12 survived to transplant hospitalization discharge and 2 remained alive with ongoing LVAD support and awaited transplant. One-year actuarial survival from the initiation of circulatory support was 43% in group I and 75% in group II. One-year actuarial survival from the time of LVAD implant in group I, conditional on surviving ECMO, was 71% ( P =NS compared with group II). Conclusions —In appropriately selected high-risk patients, the rate of LVAD survival after initial ECMO support was not significantly different from the survival rate after LVAD support alone. An initial period of resuscitation with ECMO is an effective strategy to salvage patients with extreme hemodynamic instability and multiorgan injury. Use of LVAD resources is improved by avoiding LVAD implant in a very-high-risk cohort of patients who do not survive ECMO.

Abstract 15696: Outcomes With Intra-Aortic Balloon Pump versus Percutaneous Ventricular Assist Device for Left Ventricular Venting in Adults Receiving Venoarterial Extracorporeal Life Support: An ELSO Registry Analysis

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Brooks Willar ◽  
Jose Nunez ◽  
Kennedy Kevin ◽  
Peter Rycus ◽  
Joseph Tonna ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Ventricular Assist Device ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Left Ventricular ◽  
Published Data ◽  
Assist Device ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Ventricular Assist ◽  
Intra Aortic Balloon Pump

Background: Insufficient left ventricular (LV) unloading during venoarterial extracorporeal life support (VA-ECLS) can result in poor LV recovery and inability to wean from support. Published data suggest a survival benefit with LV mechanical venting (MV), but there is limited data comparing modalities. Methods: We queried the ELSO registry from 2010-2019 for adults undergoing VA-ECLS with MV and stratified them by intra-aortic balloon pump (IABP) or percutaneous ventricular assist device (pVAD). We excluded patients with pulmonary embolism, heart transplant, congenital and valvular heart disease, aortic disease, and central cannulation. We performed a subgroup analysis excluding extracorporeal cardiopulmonary resuscitation (ECPR). The primary outcome was in-hospital mortality. Secondary outcomes were on-support mortality, medical and cannula site bleeding, hemolysis, ischemic stroke, limb ischemia, and renal injury. We used multivariable logistic regression modeling to adjust for clinical covariates. Results: Among 3353 adults with MV on VA-ECLS, 2782 (83%) were vented with IABP and 571 (17%) with pVAD. IABP patients were less likely to be supported for ventricular arrhythmia (9.6% vs 14.3%) and had lower rates of pre-ECLS arrest (49% vs 66%) and concomitant renal (13.5% vs 34.5%), liver (3.4% vs 9.3%), and respiratory (17.6% vs 37.0%) failure, p<0.001 for all. On-support (40.8% vs 45.5%, p=0.037) and in-hospital (55.9% vs 60.6%, p=0.038) mortality were lower with IABP vs pVAD. In multivariate modeling, IABP was associated with a significantly lower odds of medical bleeding with a trend towards lower in-hospital mortality that was significant after excluding ECPR patients (Figure). Conclusion: In adults with MV on VA-ECLS, IABP compared to pVAD is associated with a significantly lower risk of bleeding and a strong signal of improved survival. We cannot exclude residual unmeasured confounding, so prospective studies are needed to compare MV devices.

scholarly journals IMPULSE: the impact of gender on the presentation and management of aortic stenosis across Europe

Open Heart ◽  
2021 ◽  
Vol 8 (1) ◽  
pp. e001443
Author(s):  
Richard Paul Steeds ◽  
David Messika-Zeitoun ◽  
Jeetendra Thambyrajah ◽  
Antonio Serra ◽  
Eberhard Schulz ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Severe Aortic Stenosis ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Surgical Aortic Valve Replacement ◽  
Ventricular Ejection Fraction ◽  
Patient Profile ◽  
Transcatheter Aortic Valve ◽  
The Impact

AimsThere is an increasing awareness of gender-related differences in patients with severe aortic stenosis and their outcomes after surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI).MethodsData from the IMPULSE registry were analysed. Patients with severe aortic stenosis (AS) were enrolled between March 2015 and April 2017 and stratified by gender. A subgroup analysis was performed to assess the impact of age.ResultsOverall, 2171 patients were enrolled, and 48.0% were female. Women were characterised by a higher rate of renal impairment (31.7 vs 23.3%; p<0.001), were at higher surgical risk (EuroSCORE II: 4.5 vs 3.6%; p=0.001) and more often in a critical preoperative state (7.0vs 4.2%; p=0.003). Men had an increased rate of previous cardiac surgery (9.4 vs 4.7%; p<0.001) and a reduced left ventricular ejection fraction (4.9 vs 1.3%; p<0.001). Concomitant mitral and tricuspid valve disease was substantially more common among women. Symptoms were highly prevalent in both women and men (83.6 vs 77.3%; p<0.001). AVR was planned in 1379 cases. Women were more frequently scheduled to undergo TAVI (49.3 vs 41.0%; p<0.001) and less frequently for SAVR (20.3 vs 27.5%; p<0.001).ConclusionsThe present data show that female patients with severe AS have a distinct patient profile and are managed in a different way to males. Gender-based differences in the management of patients with severe AS need to be taken into account more systematically to improve outcomes, especially for women.

scholarly journals Flow manipulation and the association with myocardial contractility during extracorporeal life support (FLAME)

2021 ◽  
Vol 10 (Supplement_1) ◽  
Author(s):  
SKT Ma ◽  
WC Sin ◽  
CW Ngai ◽  
ASK Wong ◽  
WM Chan ◽  
...  
Keyword(s):  
Blood Flow ◽  
Cardiogenic Shock ◽  
Myocardial Contractility ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Ventricular Contractility ◽  
Left Ventricular Contractility ◽  
Extracorporeal Blood

Abstract Funding Acknowledgements Type of funding sources: None. Background Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is an advanced technique in extracorporeal life support (ECLS) used to support extreme circulatory failure including patients with cardiac arrest and cardiogenic shock refractory to conventional support. It is a long-standing belief that peripheral V-A ECMO poses increased afterload to the inured heart, but conventional echocardiographic measurements are often insensitive in detecting subtle changes in loading conditions. Purpose This study aimed to evaluate the effects of varying blood flow during peripheral V-A ECMO on intrinsic myocardial contractility, using detailed echocardiographic assessment including speckle tracking echocardiography (STE). Methods Adult patients with acute cardiogenic shock who were supported by peripheral V-A ECMO from April 2019 to September 2020 were recruited. Serial hemodynamic and cardiac performance parameters were measured by transthoracic echocardiogram (TTE) within 48 hours after implementation of V-A ECMO, at different levels of extracorporeal blood flow – 100%, 120% and 50% of target blood flow (TBF). Results A total of 30 patients were included. 22 (71%) were male, and the mean (SD) age was 54 (13) years. The major indications for V-A ECMO were myocardial infarction (19, 63% patients), and myocarditis (5, 17%). With a decrease in extracorporeal blood flow from 100% to 50% of TBF, mean arterial pressure (MAP) dropped from 76+/-3 to 64+/-3mmHg (p &lt;0.001), and cardiac index (CI) increased from 0.89+/-0.13 to 1.27+/-0.18L/min/m2 (p &lt; 0.001). All indices of left ventricular contractility improved at a lower extracorporeal blood flow: the myocardial contractility measured by global longitudinal peak systolic strain (GLPSS) improved from -3+/-0.7% to -5+/-0.8% (p &lt; 0.001); left ventricular ejection fraction (LVEF) increased from 21.5+/-2.6% to 30.9+/-2.7% (p &lt; 0.001) and 19.7+/-3.1% to 28.4+/-3.2% (p &lt; 0.001) by biplane and linear methods, respectively; left ventricular index of myocardial performance (LIMP) improved from 1.51+/-0.12 to 1.03+/-0.09 (p &lt; 0.001). Similar findings were reproduced when comparing left ventricular contractility at extracorporeal blood flows of 120% and 50% of TBF. Conclusions The ECMO blood flow rate in peripheral V-A ECMO is inversely related to myocardial contractility, and is quantifiable by myocardial strain measured by STE.

Rescue extracorporeal life support as a bridge to durable left ventricular assist device

2021 ◽  
pp. 039139882110538
Author(s):  
Alina Zubarevich ◽  
Konstantin Zhigalov ◽  
Marcin Szczechowicz ◽  
Arian Arjomandi Rad ◽  
Robert Vardanyan ◽  
...  
Keyword(s):  
Heart Failure ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Left Ventricular ◽  
Organ Function ◽  
Assist Device ◽  
Ventricular Assist ◽  
Left Ventricular Assist ◽  
End Stage Heart Failure ◽  
End Stage

Background: The ideal timing of a durable assist device implantation in patients with end-stage heart failure presenting with INTERMACS profile I is still controversial. The data on extracorporeal life support (ECLS) bridge to durable left ventricular assist device (LVAD) in these patients is limited. Materials and methods: We retrospectively analyzed the outcomes of 35 patients in acute cardiogenic shock (CS) who, between December 2013 and September 2020, were bridged with ECLS to durable LVAD. The mean age was 52.3 ± 12.0 years. The primary endpoints of this study were in-hospital, 30-day, 6-month, and 1-year mortality. The secondary endpoint was the development of any postoperative adverse events and other characteristics during the follow-up period. We also assessed the impact of the rescue ECLS on the recovery of the end-organ function. Results: In-hospital, 30-day, 6-month, and 1-year survival was 65.6%, 75.9%, 69.2%, and 62.7% respectively. The median time on ECLS was 7 days (IQR 5.0–13.0). We observed a high incidence of a severe right heart failure (22.9%), acute kidney injury on dialysis (68.6%), and respiratory failure (77.1%). Bridge with ECLS provided a significant recovery of liver and kidney function prior to durable LVAD implantation. Conclusion: The concept of bridging patients presenting in end-stage heart failure and cardiogenic shock with ECLS prior to durable LVAD implantation is a feasible method to ensure acceptable survival rates and significant recovery of the end-organ function.

scholarly journals Organization and Application of ECLS Therapy—A Nationwide Survey in German Cardiosurgical Departments

2018 ◽  
Vol 67 (03) ◽  
pp. 164-169
Author(s):  
Alexander Assmann ◽  
Udo Boeken ◽  
Stefan Klotz ◽  
Wolfgang Harringer ◽  
Andreas Beckmann
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
Extracorporeal Circulation ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Nationwide Survey ◽  
Left Ventricular ◽  
Local Application ◽  
Circulatory Support ◽  
Anticoagulation Management ◽  
The Status

Background In context of the multidisciplinary German scientific guideline “Use of extracorporeal circulation (extracorporeal life support [ECLS]/extracorporeal membrane oxygenation) for cardiac and circulatory failure,” a nationwide survey should depict the status of organization and application of ECLS therapy in Germany. Methods Between June and October 2017, a standardized questionnaire consisting of 30 items related to ECLS therapy was sent to all German cardiosurgical departments, and all returned results were analyzed and evaluated. Results The return rate amounted to 92.9% (78 out of 84 departments). In the participating departments, ECLS therapy is subject to different responsibilities, and exhibits divergent processes and various ways for specialization of the involved personnel. This also concerns local application standards, such as cannulation strategies, anticoagulation management, left ventricular unloading, antiwatershed treatment, and weaning from circulatory support. Conclusion This nationwide survey underlines the necessity of a multidisciplinary guideline concerning ECLS therapy.

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