scholarly journals Trans-Aortic or Pulmonary Artery-Based Drainage for Left Ventricular Unloading and Veno-Arterial Extracorporeal Life Support Management in a Porcine Cardiogenic Shock Model.

2020 ◽  
Author(s):  
Paolo Meani ◽  
Mikulas Mlcek ◽  
Mariusz Kowalewski ◽  
Giuseppe Maria Raffa ◽  
Federica Jiritano ◽  
...  
Keyword(s):  
Pulmonary Artery ◽  
Cardiogenic Shock ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Blood Stasis ◽  
Left Ventricular ◽  
Circulatory Support ◽  
Stroke Work ◽  
Organ Perfusion ◽  
Suction Device

Abstract Background The use of peripheral veno-arterial extracorporeal life support (V-A ECLS) as a mechanical circulatory support in cardiogenic shock has increased dramatically over the last years. However, increased afterload may jeopardize left ventricle (LV) recovery and cause blood stasis and pulmonary edema. Therefore, several LV unloading techniques have been developed and used with limited understanding of the actual difference among them. The aim of the present study was to compare a trans-aortic suction device (Impella) and pulmonary artery (PA) drainage, for LV unloading and V-A ECLS management as well as efficacy in a porcine cardiogenic shock (CS) model Methods A dedicated CS model compared included twelve female swine (21± 1,8-weeks old and weighing 54,3 ± 4,6 kg) supported with V-A ECLS and randomized to Impella or PA-related LV drainage. LV unloading and end-organ perfusion were evaluated through the pulmonary artery catheter and the LV pressure/volume analysis. All the variables were collected at baseline, profound CS, V-A ECLS support with maximum flow and when Impella or PA cannula run on top. Results CS was successfully induced in all twelve animals. Impella resulted in a marked drop of LVEDV compared to a slight decrease in the PA cannula group, resulting in an overall stroke work (SW) and Pressure-Volume Area (PVA) reductions with both techniques. However, SW reduction was significant in the Impella CP group (VA ECMO 3998.82027.6 mmHg x mL vs VAECMO + Impella 1796.9±1033.9 mmHg x ml, p value 0,016), leading to a more consistent PVA reduction (Impella reduction 34,7% vs PA cannula reduction 9,7%) In terms of end organ perfusion, central and mixed O 2 saturation improved with V-A ECLS, and subsequently, remaining unchanged with either Impella or PA cannula as unloading strategy Conclusions Trans-aortic suction and PA drainage provided effective LV unloading during V-A ECLS while maintaining adequate end-organ perfusion. Trans-aortic suction device provides a greater LV unloading effect and reduces more effectively the total LV stroke work.

scholarly journals Inverted takotsubo syndrome complicated with cardiogenic shock requiring veno-arterial extracorporeal membrane oxygenation in a patient with bilateral pheochromocytoma: a case report

2020 ◽  
Vol 4 (2) ◽  
pp. 1-5
Author(s):  
Bebiana Manuela Monteiro Faria ◽  
João Português ◽  
Roberto Roncon-Albuquerque Jr ◽  
Rodrigo Pimentel
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
Cardiogenic Shock ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Left Ventricular ◽  
Circulatory Support ◽  
Lv Function ◽  
Takotsubo Syndrome ◽  
Membrane Oxygenation ◽  
Lv Dysfunction

Abstract Background Takotsubo syndrome (TS) is characterized by a transient left ventricular (LV) dysfunction and rarely presents with cardiogenic shock (CS). Inverted TS (ITS) is a rare entity associated with the presence of a pheochromocytoma. Case summary We present a case of a young woman was admitted to the emergency department due to intense headache, chest discomfort, palpitations, and breathlessness. An ITS secondary to a pheochromocytoma crisis presenting with CS was diagnosed. The patient was managed with veno-arterial extracorporeal membrane oxygenation, until recovery of LV function. On the 35th day of hospitalization, open bilateral adrenalectomy was performed. Discussion Takotsubo syndrome patients presenting with CS are challenging and clinicians should be aware of underlying causes. Specific triggers such as pheochromocytoma should systematically be considered particularly if ITS was presented. Extracorporeal life support devices could provide temporary mechanical circulatory support in patients with TS on refractory CS and help to manage complex cases with TS due to pheochromocytoma.

scholarly journals Trans-Aortic or Pulmonary Artery-Based Drainage for Left Ventricular Unloading and Veno-Arterial Extracorporeal Life Support Management in a Porcine Cardiogenic Shock Model.

2020 ◽  
Author(s):  
Paolo Meani ◽  
Mikulas Mlcek ◽  
Mariusz Kowalewski ◽  
Giuseppe Maria Raffa ◽  
Federica Jiritano ◽  
...  
Keyword(s):  
Pulmonary Artery ◽  
Cardiogenic Shock ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Left Ventricular ◽  
Shock Model

Abstract The authors have requested that this preprint be withdrawn due to author disagreement.

scholarly journals Hemodynamic Adaptation of Heart Failure to Percutaneous Venoarterial Extracorporeal Circulatory Supports

2020 ◽  
pp. 739-757
Author(s):  
P Hála ◽  
O Kittnar
Keyword(s):  
Heart Failure ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
High Volume ◽  
Left Ventricular ◽  
Circulatory Support ◽  
Stroke Work ◽  
Atrial Septostomy ◽  
Active Venting ◽  
Myocardial Oxygen Supply

Extracorporeal life support (ECLS) is a treatment modality that provides prolonged blood circulation, gas exchange and can partially support or fully substitute functions of heart and lungs in patients with severe but potentially reversible cardiopulmonary failure refractory to conventional therapy. Due to high-volume bypass, the extracorporeal flow is interacting with native cardiac output. The pathophysiology of circulation and ECLS support reveals significant effects on arterial pressure waveforms, cardiac hemodynamics, and myocardial perfusion. Moreover, it is still subject of research, whether increasing stroke work caused by the extracorporeal flow is accompanied by adequate myocardial oxygen supply. The left ventricular (LV) pressure-volume mechanics are reflecting perfusion and loading conditions and these changes are dependent on the degree of the extracorporeal blood flow. By increasing the afterload, artificial circulation puts higher demands on heart work with increasing myocardial oxygen consumption. Further, this can lead to LV distention, pulmonary edema, and progression of heart failure. Multiple methods of LV decompression (atrial septostomy, active venting, intra-aortic balloon pump, pulsatility of flow) have been suggested to relieve LV overload but the main risk factors still remain unclear. In this context, it has been recommended to keep the rate of circulatory support as low as possible. Also, utilization of detailed hemodynamic monitoring has been suggested in order to avoid possible harm from excessive extracorporeal flow.

Single arterial access ECMELLA: A new concept and step-by-step procedure

2021 ◽  
Keyword(s):  
Cardiogenic Shock ◽  
New Technologies ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Left Ventricular ◽  
Circulatory Support ◽  
Ventricular Assist ◽  
Arterial Access ◽  
Severe Cardiogenic Shock ◽  
Step Procedure

Therapy for cardiogenic shock using temporary mechanical circulatory support has improved significantly in the last decades, providing patients with new technologies for both acute phase stabilization and bridging to long-term therapies. A combination of a venoarterial extracorporeal life support system and the Impella left ventricular assist device (known as the ECMELLA approach) represents an effective therapy for severe cardiogenic shock that achieves high-flow circulatory support with simultaneous left-ventricular unloading. We present the new ECMELLA 2.0 concept, whereby a single arterial access technique is used to treat severe cardiogenic shock. The goal of this technique is to reduce access-related complications and make a bedside staged weaning from mechanical support possible.

Abstract 19380: Synchronized Pulsatile Extracorporeal Life Support Preserves Left Ventricular Functions in Comparison With Continuous Extracorporeal Flow in Porcine Model of Cardiogenic Shock

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Petr Ostadal ◽  
Mikulas Mlcek ◽  
Svitlana Strunina ◽  
Matej Hrachovina ◽  
Andreas Kruger ◽  
...  
Keyword(s):  
Cardiogenic Shock ◽  
Pulsatile Flow ◽  
Continuous Flow ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Systolic Pressure ◽  
Left Ventricular ◽  
Circulatory Support ◽  
Lv Function ◽  
Myocardial Hypoxia

Introduction: Veno-arterial extracorporeal life support (ECLS) is increasingly used for the therapy of rapidly progressing or severe cardiogenic shock. However, it has been repeatedly shown that increased afterload associated with ECLS significantly deteriorates left ventricular (LV) performance. Recently, new ECG-synchronized pulsatile cardiac assist system was introduced that offers full circulatory support with increased diastolic and decreased systolic extracorporeal flow. The aim of the present study was to compare the parameters of LV function during standard continuous flow ECLS support and ECG-synchronized pulsatile flow ECLS in cardiogenic shock. Methods: Ten female swine (body weight 45 kg) underwent ECLS implantation under general anesthesia and artificial ventilation. Subsequently, acute cardiogenic shock with signs of tissue hypoperfusion was induced by global myocardial hypoxia. Hemodynamic and cardiac performance parameters were then measured at different levels of continuous or pulsatile ECLS flow (ranging from 1 L/min to 4 L/min) using arterial and venous catheters, a pulmonary artery catheter and a LV pressure-volume loop catheter. Results: Myocardial hypoxia resulted in a decline in mean (±SD) cardiac output to 2.3±1.2 L/min, systolic blood pressure to 61±7 mmHg and LV ejection fraction (EF) to 21±7%. Synchronized pulsatile flow was associated with significant reduction of LV end-systolic volume (ESV), increase in LV stroke volume (SV), and higher EF at all ECLS flow levels in comparison with continuous ECLS flow (Figure 1). At selected ECLS flow levels, pulsatile flow reduced also LV end-diastolic pressure (EDP), end-diastolic volume (EDV), and systolic pressure (SP) (Figure 1). Conclusion: Our results indicate that ECG-synchronized pulsatile ECLS flow preserves LV function in comparison with standard continuous-flow ECLS in cardiogenic shock.

scholarly journals The “TIDE”-Algorithm for the Weaning of Patients With Cardiogenic Shock and Temporarily Mechanical Left Ventricular Support With Impella Devices. A Cardiovascular Physiology-Based Approach

2021 ◽  
Vol 8 ◽  
Author(s):  
Carsten Tschöpe ◽  
Frank Spillmann ◽  
Evgenij Potapov ◽  
Alessandro Faragli ◽  
Konstantinos Rapis ◽  
...  
Keyword(s):  
Cardiogenic Shock ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Left Ventricular ◽  
Fulminant Myocarditis ◽  
Circulatory Support ◽  
Heart Catheterization ◽  
Cardiovascular Physiology ◽  
Weaning Failure ◽  
Ventricular Support

Objectives: Mechanical circulatory support (MCS) is often required to stabilize therapy-refractory cardiogenic shock patients. Left ventricular (LV) unloading by mechanical ventricular support (MVS) via percutaneous devices, such as with Impella® axial pumps, alone or in combination with extracorporeal life support (ECLS, ECMELLA approach), has emerged as a potential clinical breakthrough in the field. While the weaning from MCS is essentially based on the evaluation of circulatory stability of patients, weaning from MVS holds a higher complexity, being dependent on bi-ventricular function and its adaption to load. As a result of this, weaning from MVS is mostly performed in the absence of established algorithms. MVS via Impella is applied in several cardiogenic shock etiologies, such as acute myocardial infarction (support over days) or acute fulminant myocarditis (prolonged support over weeks, PROPELLA). The time point of weaning from Impella in these cohorts of patients remains unclear. We here propose a novel cardiovascular physiology-based weaning algorithm for MVS.Methods: The proposed algorithm is based on the experience gathered at our center undergoing an Impella weaning between 2017 and 2020. Before undertaking a weaning process, patients must had been ECMO-free, afebrile, and euvolemic, with hemodynamic stability guaranteed in the absence of any inotropic support. The algorithm consists of 4 steps according to the acronym TIDE: (i) Transthoracic echocardiography under full Impella-unloading; (ii) Impella rate reduction in single 8–24 h-steps according to patients hemodynamics (blood pressure, heart rate, and ScVO2), including a daily echocardiographic assessment at minimal flow (P2); (iii) Dobutamine stress-echocardiography; (iv) Right heart catheterization at rest and during Exercise-testing via handgrip. We here present clinical and hemodynamic data (including LV conductance data) from paradigmatic weaning protocols of awake patients admitted to our intensive care unit with cardiogenic shock. We discuss the clinical consequences of the TIDE algorithm, leading to either a bridge-to-recovery, or to a bridge-to-permanent LV assist device (LVAD) and/or transplantation. With this protocol we were able to wean 74.2% of the investigated patients successfully. 25.8% showed a permanent weaning failure and became LVAD candidates.Conclusions: The proposed novel cardiovascular physiology-based weaning algorithm is based on the characterization of the extent and sustainment of LV unloading reached during hospitalization in patients with cardiogenic shock undergoing MVS with Impella in our center. Prospective studies are needed to validate the algorithm.

scholarly journals A Long Way Home. Biventricular Impella®, VA-ECMO and Extracorporeal LVAD as Bridge to a Permanent LVAD in Severe Ischemic Cardiogenic Shock: A Case Report

2020 ◽  
Author(s):  
Monika Sadlonova ◽  
Birgit Gerecke ◽  
Aschraf El-Essawi ◽  
Lars-Olav Harnisch ◽  
Onnen Moerer ◽  
...  
Keyword(s):  
Heart Failure ◽  
Coronary Artery ◽  
Cardiogenic Shock ◽  
Mechanical Circulatory Support ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Left Ventricular ◽  
Circulatory Support ◽  
Team Approach ◽  
Va Ecmo

Abstract Background: A severe cardiogenic shock can present with clinical complications such as arrhythmias, ischemia and organ failure and even today is associated with a high mortality. Extracorporeal life support (ECLS) by veno-arterial extracorporeal membrane oxygenation (VA-ECMO), Impella® and other mechanical circulatory support systems can reduce the acute circulatory failure. Case presentation: We present the case of a 38-year-old woman with an acute heart failure due to a coronary artery disease who underwent emergency coronary artery bypass grafting and intraoperative implantation of a VA-ECMO. Over the next 4 months, a multidisciplinary team-approach bridged the patient using first a left ventricular (LV) support system (Impella), then additionally a right ventricular (RV) Impella and finally a temporary paracorporeal continuous flow left ventricular support (Rotaflow). Following a promising neurological recovery, a long-term left ventricular assist device (LVAD) was implanted in a bride to transplant (BTT) concept. Conclusions: The addition of LV Impella and RV support by Impella (BiPELLA) on top of VA-ECMO may support survival of patients with refractory cardiogenic shock. In complex biventricular heart failure, an expert center must be able to provide an early multi-modular intervention with elaborated mechanical circulatory support due to a multidisciplinary expertise.

scholarly journals Extracorporeal life support for phaeochromocytoma-induced cardiogenic shock: a systematic review

Perfusion ◽  
2020 ◽  
Vol 35 (1_suppl) ◽  
pp. 20-28 ◽  
Author(s):  
Matteo Matteucci ◽  
Mariusz Kowalewski ◽  
Dario Fina ◽  
Federica Jiritano ◽  
Paolo Meani ◽  
...  
Keyword(s):  
Systematic Review ◽  
Cardiogenic Shock ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Meta Analysis ◽  
Specific Treatment ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Circulatory Support ◽  
Ventricular Ejection Fraction

Introduction: Phaeochromocytoma is a catecholamine-secreting tumour associated with clinical presentation ranging from paroxysmal hypertension to intractable cardiogenic shock. Extracorporeal life support, in veno-arterial mode, application in refractory acute heart dysfunction is sharply increasing worldwide. However, its clinical utility in phaeochromocytoma-induced cardiogenic shock remains still unclear. Methods: A systematic review of published reports was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Statement. Searches were accomplished on PubMed, Embase and Google Scholar to identify articles describing the use of extracorporeal life support in the setting of phaeochromocytoma-induced cardiogenic shock (PROSPERO: CRD42019125225). Results: Thirty-five reports, including 62 patients supported with extracorporeal life support because of intractable phaeochromocytoma crisis, were included for the analysis. Almost all the subjects underwent peripheral cannulation for extracorporeal life support. The median duration of the mechanical circulatory support was 5 days, and most of the patients recovered normal myocardial function (left ventricular ejection fraction ⩾50%). In-hospital survival was 87%. Phaeochromocytoma was removed surgically during extracorporeal life support in 10 patients (16%), while in the remaining after haemodynamic stabilization and weaning from the mechanical support. Conclusion: Successful management of phaeochromocytoma-induced cardiogenic shock depends on prompt recognition and immediate treatment of shock. In this scenario, extracorporeal life support may play a significant role allowing cardiac and end-organ recovery and giving time for accurate diagnosis and specific treatment.

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 <0.001), and cardiac index (CI) increased from 0.89+/-0.13 to 1.27+/-0.18L/min/m2 (p < 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 < 0.001); left ventricular ejection fraction (LVEF) increased from 21.5+/-2.6% to 30.9+/-2.7% (p < 0.001) and 19.7+/-3.1% to 28.4+/-3.2% (p < 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 < 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.

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