Clinical use and outcome of extracorporeal membrane oxygenation in patients with pulmonary embolism

AIM OF THE STUDY Extracorporeal membrane oxygenation (ECMO) is considered a life-saving treatment option for patients in cardiogenic shock or cardiac arrest undergoing cardiopulmonary resuscitation (CPR) due to acute pulmonary embolism (PE). We sought to analyze use and outcome of ECMO with or without adjunctive treatment strategies in patients with acute PE. METHODS We retrospectively analyzed data on patient characteristics, treatments, and in-hospital outcomes for all PE patients (ICD-code I26) undergoing ECMO in Germany between 2005 and 2018. RESULTS At total of 1,172,354 patients were hospitalized with PE; of those, 2,197 (0.2%) were treated with ECMO support. Cardiac arrest requiring cardiopulmonary resuscitation was present in 77,196 (6.5%) patients. While more than one fourth of those patients were treated with systemic thrombolysis alone (n = 20,839 patients; 27.0%), a minority of patients received thrombolysis and VA-ECMO (n = 165; 0.2%), embolectomy and VA-ECMO (n = 385; 0.5%) or VA-ECMOalone (n = 588; 0.8%). A multivariable logistic regression analysis indicated the lowest risk for in-hospital death in patients who received embolectomy in combination with VA-ECMO (OR, 0.50 [95% CI, 0.41-0.61], p < 0.001), thrombolysis and VA-ECMO (0.60 [0.43-0.85], p = 0.003) or VA-ECMO alone (0.68 [0.57-0.82], p < 0.001) compared to thrombolysis alone (1.04 [0.99-1.01], p = 0.116). CONCLUSION Our findings suggest that the use of VA-ECMO alone or as part of a multi-pronged reperfusion approach including embolectomy or thrombolysis might offer survival advantages compared to thrombolysis alone in patients with PE deteriorating to cardiac arrest

Rodent Orthotopic Left Single Lung Transplantation and Experimental Translational Applications

Die moderne Transplantationsmedizin stellt die letzte kurative Therapieoption für schwerst erkrankte Patienten dar, bei denen sich andere Therapieansätze als insuffizient oder unwirksam erwiesen haben. Beachtliche Fortschritte in der Organprotektion, den chirurgischen Transplantationstechniken sowie der periooperativen Versorgung haben das Gesamtüberleben der Patienten verbessert, jedoch ist die primäre Organdysfunktion (POD) nach wie vor ein essentielles Problem der gesamten Transplantationsmedizin im allgemeinen, sowie der klinischen Lungentransplantation im Speziellen. POD wird in rezenten wissenschaftlichen Arbeiten mit dem Ischämie Reperfusionsschaden als kausalem Faktor in Zusammenhang gebracht, welcher sich aus komplexen, teilweise konfluierenden molekularen Pathways ergibt. Die Schädigung der Mikrozirkulation begünstigt die Entstehung des Lungenödems mit in weiterer Folge reduzierter Sättigungskapazität, reduzierter Compliance der Lunge sowie erhöhtem maschinellem Beatmungsaufwand. Überdies hinaus wird die Entstehung von POD in Zusammenhang mit akuten und chronischen Abstoßungsreaktionen gebracht. Aktuell existiert kein effektiver kausaler Therapieansatz. Dies unterstreicht die Wichtigkeit von experimentellen Transplantationsverfahren am Kleintier als Plattform zur Untersuchung des markoskopischen/ histologischen Gewebeschadens der sich aus Entzündung und immunologischer Abstoßungsreaktion zusammensetzt. Solch experimentelle Ansätze ermöglichen hohe Variabilität von kalter Ischämie Dauer und verschiedene major histocompatibility complex (MHC) Kombinationen. Daher haben wir ein mikrochirurgisches Verfahren zur orthotopen Lungentransplantation an der Ratte entwickelt und optimiert, welches sich durch eine hohe Reproduzierbarkeit und exzellentem Langzeitüberleben auszeichnet. Dieser experimentelle Ansatz diente uns als Basis für die Untersuchung der Therapieeffekte eines cingulin-basiernden Peptides (XIB13) in einem allogenen mismatch Setting (Fischer in Wistar Kyoto Ratte). Endpunkte dabei waren die Verbesserung des IR Schaden und der chronischer Abstoßung. Die Erkenntnisse dienten als Basis für eine weitere in-vitro Studie in der das tight junction assoziierte Protein Cingulin als wichtiges Schlüsselmolekül in der Kontrolle der vaskulären Barrierefunktion identifiziert werden konnte. Weiters konnte die Langzeitfunktion der transplantieren Lungen mittels funktionellem MRT bestätigt werden. Damit stellt die experimentelle Lungentransplantation am Kleintier ein wertvolles Werkzeug in der Transplantationsbiologie dar, mit dem Ziel Therapieansätze zu entwickeln die sowohl das Kurzzeit-Überleben als auch das Langzeit-Überleben lungentransplantierter Patienten verbessern sollen.Organ transplantation represents the treatment option of last resort for terminal organ failure when other strategies have demonstrated insufficient effect or even failed. Significant advances in both surgical technique and perioperative care have increased survival rates, yet primary graft dysfunction (PGD) represents a serious medical problem accompanying lung transplantation medicine resulting in significant morbidity and mortality. PGD is identified as the clinical correlate of ischemia reperfusion (IR) injury, representing the confluence of complex biological pathways. Microvascular incompetence with a dysfunctional endothelial cell barrier results in lung edema formation with reduced tissue oxygenation capacity and increased requirements for mechanical ventilatory support. PGD has additionally been associated with both acute and chronic rejection events. No effective treatment approach exists to date. In order to evolve novel treatment options for this unsolved issue, accurate, time sensitive animal models displaying both macroscopic/ histologic processes and molecular changes associated with inflammation and rejection under settings of various ischemia times and major histocompatibility complex (MHC) combinations are needed. We have successfully established and mastered a rodent model of orthotopic left single lung transplantation and tested experimental translational applications in vivo, studying effects of the Cingulin-derived peptide sequence XIB13 on IR injury and chronic rejection and identifying the tight junction (TJ) associated protein Cingulin as a key regulator of endothelial cell barrier function in a later study. Additionally, for the first time graft function over both short term and long term follow-up could be confirmed by functional radiographic means both validating the concept of lung transplantation in rats and highlighting its importance in transplantation biology.submitted by Dr. med. univ. Andreas HabertheuerZusammenfassung in deutscher SpracheAbweichender Titel laut Übersetzung der Verfasserin/des VerfassersMedizinische Universität Wien, Dissertation, 2016OeBB(VLID)192338

How to Perfuse: Concepts of Cerebral Protection during Arch Replacement

Arch surgery remains undoubtedly among the most technically and strategically challenging endeavors in cardiovascular surgery. Surgical interventions of thoracic aneurysms involving the aortic arch require complete circulatory arrest in deep hypothermia (DHCA) or elaborate cerebral perfusion strategies with varying degrees of hypothermia to achieve satisfactory protection of the brain from ischemic insults, that is, unilateral/bilateral antegrade cerebral perfusion (ACP) and retrograde cerebral perfusion (RCP). Despite sophisticated and increasingly individualized surgical approaches for complex aortic pathologies, there remains a lack of consensus regarding the optimal method of cerebral protection and circulatory management during the time of arch exclusion. Many recent studies argue in favor of ACP with various degrees of hypothermic arrest during arch reconstruction and its advantages have been widely demonstrated. In fact ACP with more moderate degrees of hypothermia represents a paradigm shift in the cardiac surgery community and is widely adopted as an emergent strategy; however, many centers continue to report good results using other perfusion strategies. Amidst this important discussion we review currently available surgical strategies of cerebral protection management and compare the results of recent European multicenter and single-center data

Journal of Cardiothoracic Surgery / Left ventricular thrombus in a patient with cutaneous T-cell lymphoma, hypereosinophilia and Mycoplasma pneumoniae infection a challenging diagnosis : a case report

Differential diagnoses of cardiac masses include primary benign and malignant neoplasms, secondary neoplasms, and non-neoplastic masses, such as thrombi. Owing to different therapeutic approaches and the way these affect the prognosis, the early and correct diagnostic determination of the etiology of a cardiac mass is of utmost importance and essential for the appropriate management of patients. We report a case of a 52-year-old woman with a left ventricular mass in the setting of a recent Mycoplasma pneumoniae infection and a medical history of cutaneous T-cell lymphoma and hypereosinophilia. Imaging findings were consistent with both an infiltrative process of the lymphoma and a cardiac thrombus. An estimated very high risk for embolization led to the indication for open-heart surgery for the removal of the cardiac mass. Histopathological examination confirmed the presence of a thrombus; there were no signs of malignancy. The patient was discharged 11 days after surgery in good general condition and is now in outpatient care for follow-up and further management. This case highlights possible challenges in the diagnostic assessment of cardiac masses and their management in a patient with several underlying diseases and a complex medical history.(VLID)486715

A Peptide to Reduce Pulmonary Edema in a Rat Model of Lung Transplantation

<div><p>Background</p><p>Despite significant advances in organ preservation, surgical techniques and perioperative care, primary graft dysfunction is a serious medical problem in transplantation medicine in general and a specific problem in patients undergoing lung transplantation. As a result, patients develop lung edema, causing reduced tissue oxygenation capacity, reduced lung compliance and increased requirements for mechanical ventilatory support. Yet, there is no effective strategy available to protect the grafted organ from stress reactions induced by ischemia/reperfusion and by the surgical procedure itself.</p><p>Methods</p><p>We assessed the effect of a cingulin-derived peptide, XIB13 or a random peptide in an established rat model of allogeneic lung transplantation. Donor lungs and recipients received therapeutic peptide at the time of transplantation and outcome was analyzed 100min and 28 days post grafting.</p><p>Results</p><p>XIB13 improved blood oxygenation and reduced vascular leak 100min post grafting. Even after 28 days, lung edema was significantly reduced by XIB13 and lungs had reduced fibrotic or necrotic zones. Moreover, the induction of an allogeneic T cell response was delayed indicating a reduced antigen exchange between the donor and the host.</p><p>Conclusions</p><p>In summary, we provide a new tool to strengthen endothelial barrier function thereby improving outcomes in lung transplantation.</p></div