Venoarterial extracorporeal membrane oxygenation (VA ECMO) is an established method of short-term mechanical support for patients in cardiogenic shock, but can create left ventricular (LV) distension. This paper analyzes the physiologic basis of this phenomenon and treatment methods. This is a retrospective review of the existing literature on VA ECMO and LV distension. We undertook a PubMed review of all peer-reviewed papers focusing on VA ECMO, LV distension, and LV venting. We reviewed these papers and synthesized our findings. We also will discuss the various methods of LV venting and venting strategies we use at Columbia. LV distension is becoming an increasingly appreciated aspect of caring for patients on VA ECMO support. The literature demonstrates that the consequences of failing to anticipate, recognize, and treat LV distension are grave, and will worsen an already distended and hypocontractile LV. Myocardial recovery will be hindered, and LV thrombus formation more likely. Early recognition and aggressive management of LV distension is paramount in helping care for this critically ill patient population.
Background: Early right ventricular (RV) failure after LVAD increases morbidity and mortality. Percutaneous RVAD (pRVAD) support is an alternative to more invasive surgical RVAD (sRVAD). Methods:We retrospectively reviewed patients receiving isolated pRVAD or sRVAD after durable LVAD at our center between 2007-2018. Hemodynamic parameters before and after implantation and survival outcomes were compared among groups.Results: Nineteen patients received pRVAD and 21 received sRVAD. Hemodynamic parameters improved immediately with pRVAD; central venous pressure decreased (15.9±2.4 to 12.3±3.2 mmHg, p<0.001) and cardiac index increased (2.4±0.5 to 3.5±0.8 L/min/m 2 , p<0.001). These were sustained following device removal and were similar to those with sRVAD. Patients with pRVAD required fewer blood transfusions and mechanically-ventilated days than with sRVAD. Among survivors, ICU and hospital days were fewer with pRVAD [21(16-27) vs. 34(27-46) ICU days, p=0.01; 43.5(30-66) vs. 91(62-111) hospital days, p=0.03]. There was no significant difference in 30-day mortality with pRVAD compared to sRVAD (21.1% vs. 42.9%, p=0.14), but there was a trend toward higher rate of discharge free from hemodialysis (73.7% vs. 47.6%, p=0.09). Conclusions:Novel pRVAD systems for RV failure provide hemodynamic benefits comparable to sRVAD, are associated with less morbidity, and should be considered an alternative to sRVAD.
Background Glucocorticoid treatment remains the cornerstone of therapy for immune checkpoint inhibitor (ICI) myocarditis, but data supporting the use of additional immunotherapy for steroid refractory cases remains limited. We investigate the safety and efficacy of infliximab in patients with ICI myocarditis who are refractory to corticosteroids. Additionally, we highlight the importance of a multi-disciplinary approach in the care for these complex patients. Methods We retrospectively identified consecutive patients who developed ICI myocarditis at our institution between January 2017 and January 2020. Baseline characteristics, laboratory data and clinical outcomes were compared between patients who received infliximab and those who did not. Results Of a total of 11 patients who developed ICI myocarditis, 4 were treated with infliximab. Aside from age, there were no significant differences in baseline patient characteristics between the two groups including total number of ICI doses received and duration from initial ICI dose to onset of symptoms. The time to troponin normalization was 58 vs. 151.5 days (p = 0.25). The duration of prednisone taper was longer in the infliximab group (90 vs. 150 days p = 0.32). All patients survived initial hospital admission. Over a median follow-up period of 287 days, two of the 4 patients died from sepsis 2 and 3 months after initial treatment of their myocarditis; one of these patients was on a steroid taper and the other patient had just completed a steroid taper. Conclusions Infliximab, despite its black box warning in patients with heart failure, may be a safe and effective treatment for ICI myocarditis.
The HeartMate II (HMII) left ventricular assist device can be exchanged to HeartMate 3 (HM3) to reduce the risk of device thrombosis and stroke. However, data of this procedure are still limited. We reviewed early and mid-term outcomes of 9 patients who received a HMII to HM3 exchange at our institution. The median age of the cohort was 58 years [interquartile range (IQR) 53–61], and 7 (78%) patients were men. The median duration of HMII support was 608 days (IQR 493–1116). Indications for device exchange include device thrombosis (n = 8.89%) and driveline injury (n = 1.11%). Procedures were performed through a lateral thoracotomy in all patients. The median cardiopulmonary bypass time was 117 min (IQR 97–133). In-hospital mortality was 0%. One patient required repositioning of the HM3 pump through full sternotomy due to inflow malposition. During 486 days (IQR 235–712) of follow-up, 3 patients (33%) developed late HMII pump pocket infection after discharge. Five patients had a successful heart transplant and 1 patient died due to unknown reason. HMII to HM3 exchange can be performed via lateral thoracotomy. However, there is a risk of inflow malposition and previous pump pocket infection.
Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) can be life-saving in refractory cardiogenic shock but carries a risk of neurologic complications such as stroke and hemorrhage. As little is known about the effects of different peripheral VA-ECMO cannulation sites on cerebral blood flow (CBF), transcranial Doppler (TCD) was used to determine whether the cannulation site affects CBF. Methods: Thirty-seven patients receiving VA-ECMO for cardiogenic shock via axillary or femoral artery cannulation were prospectively enrolled. Measured bilateral middle cerebral artery (MCA), mean flow velocities (MFV), and pulsatility indices (PI) were the primary outcomes and adverse neurologic events were secondary outcomes. Results: The median age was 58 years (IQR 51-66) with 26 (70%) males. Median VA-ECMO flow was 3.8 L/min (IQR 3.2-4.9) with mean arterial pressures of 80 mm Hg (IQR 75-86). Nineteen patients received right axillary artery cannulation while 18 underwent femoral cannulation. Compared with the femoral group, MFV was higher in the axillary group in the right MCA (46 cm/s [IQR 26-57] vs 27 [17-36], P = 0.03) and left (43 [IQR 35-60] vs 29 cm/s [16-48], P = 0.05). Axillary PI was significantly lower compared with the femoral group (right: 0.48 cm/s [0.25-0.65] vs 0.83 [0.66-0.93], P = 0.02; left: 0.41 cm/s [0.29-0.63] vs 1.02 [0.7-1.3], P = 0.004). One axillary patient experienced a stroke with deficits.Conclusions: TCD appears to be an effective tool for indirect monitoring of CBF in patients with ECMO with limited pulsatility. Axillary artery cannulation seems to provide higher cerebral flow rates without any difference in neurologic outcomes. Future studies may incorporate TCD into regulating ECMO flows to achieve physiologic CBF. K E Y W O R D S cardiogenic shock, extracorporeal membrane oxygenation, perfusion J Card Surg. 2019;34:447-452.wileyonlinelibrary.com/journal/jocs
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