Blood product transfusions on extracorporeal membrane oxygenation:a narrative review

Background and Objective: Extracorporeal membrane oxygenation (ECMO) remains amongst the most invasive measures to treat organ dysfunctions, such as refractory cardiogenic shock and/or respiratory failure, in many cases being considered a last resort. Hemodilution, hemolysis and coagulation disorders are very common during ECMO therapy, necessitating blood and blood products transfusions virtually in every patient undergoing ECMO. There exist no randomized data on blood product transfusion protocols in the ECMO population. The only evidence comes from observational studies and cardiopulmonary bypass experiences in patients undergoing cardiac surgery which should not be extrapolated to ECMO patients because of substantial differences in circuit composition, support duration, heparinization and access. Methods: The current review attempts to summarize the existing evidence on blood product transfusions in patients undergoing ECMO therapy. We screened PubMed and Google Scholar for all reports on blood product transfusion in ECMO patients up until December 2020. The review summarizes separately available data on red blood cells, platelets, fresh frozen plasma and coagulation factors. Key Content and Findings: There is a significant variability in-between centers regarding hemoglobin or hematocrit threshold for red blood cells transfusion in ECMO patients. Data from observational studies suggest that lower thresholds for red blood cell transfusion may not adversely influence survival while being more cost-effective. A gap in knowledge persists regarding the indications for platelet transfusions with some experienced centers adopting relatively low thresholds in non-bleeding patients. Conclusions: Randomized controlled trials accessing restrictive or liberal strategies in blood product transfusions are necessary. Reported worse prognosis in patients with multiple transfusions should be associated with their worse baseline status rather than transfusions themselves

Transcatheter aortic valve replacement with self-expandable ACURATE neo as compared to balloon-expandable SAPIEN 3 in patients with severe aortic stenosis: Meta-analysis of randomized and propensity-matched studies (J. Clin. Med., (2020) 9, 10.3390/jcm9020397)

The authors sincerely apologise for the imperfections made during the collection of the data and wish to make the following corrections to this paper [1]. (Figure Presented.)

Existential decision-making in a fatal progressive disease : how much do legal and medical frameworks matter?

Background: Healthcare legislation in European countries is similar in many respects. Most importantly, the framework of informed consent determines that physicians have the duty to provide detailed information about available therapeutic options and that patients have the right to refuse measures that contradict their personal values. However, when it comes to end-of-life decision-making a number of differences exist in the more specific regulations of individual countries. These differences and how they might nevertheless impact patient’s choices will be addressed in the current debate. Main text: In this article we show how the legal and medical frameworks of Germany, Poland and Sweden differ with regard to end-of-life decisions for patients with a fatal progressive disease. Taking Amyotrophic Lateral Sclerosis (ALS) as an example, we systematically compare clinical guidelines and healthcare law, pointing out the country-specific differences most relevant for existential decision-making. A fictional case report discusses the implications of these differences for a patient with ALS living in either of the three countries. Patients with ALS in Germany, Poland and Sweden are confronted with a similar spectrum of treatment options. However, the analysis of the normative frameworks shows that the conditions for making existential decisions differ considerably in Germany, Poland and Sweden. Specifically, these differences concern (1) the legal status of advance directives, (2) the conditions under which life-sustaining therapies are started or withheld, and (3) the legal regulations on assisted dying. Conclusion: According to the presented data, regulations of terminating life-sustaining treatments and the framework of “informed consent” are quite differently understood and implemented in the legal setting of the three countries. It is possible, and even likely, that these differences in the legal and medical frameworks have a considerable influence on existential decisions of patients with ALS

Transcatheter Aortic Valve Replacement with Self-Expandable ACURATE neo as compared to Balloon-Expandable SAPIEN 3 in Patients with Severe Aortic Stenosis: Meta-analysis of Randomized and Propensity-Matched Studies. J. Clin. Med. 2020, 9, 397

The authors sincerely apologise for the imperfections made during the collection of the data and wish to make the following corrections to this paper [...

Transcatheter aortic valve replacement with self-expandable ACURATE neo as compared to balloon-expandable SAPIEN 3 in patients with severe aortic stenosis: Meta-analysis of randomized and propensity-matched studies

Frequent occurrence of paravalvular leak (PVL) after transcatheter aortic valve replacement (TAVR) was the main concern with earlier-generation devices. Current meta-analysis compared outcomes of TAVR with next-generation devices: ACURATE neo and SAPIEN 3. In random-effects meta-analysis, the pooled incidence rates of procedural, clinical and functional outcomes according to VARC-2 definitions were assessed. One randomized controlled trial and five observational studies including 2818 patients (ACURATE neo n = 1256 vs. SAPIEN 3 n = 1562) met inclusion criteria. ACURATE neo was associated with a 3.7-fold increase of moderate-to-severe PVL (RR (risk ratio): 3.70 (2.04\u20136.70); P < 0.0001), which was indirectly related to higher observed 30-day mortality with ACURATE valve (RR: 1.77 (1.03\u20133.04); P = 0.04). Major vascular complications, acute kidney injury, periprocedural myocardial infarction, stroke and serious bleeding events were similar between devices. ACURATE neo demonstrated lower transvalvular pressure gradients both at discharge (P < 0.00001) and at 30 days (P < 0.00001), along with lower risk of patient\u2013prosthesis mismatch (RR: 0.29 (0.10\u20130.87); P = 0.03) and pacemaker implantation (RR: 0.64 (0.50\u20130.81); P = 0.0002), but no differences were observed regarding composite endpoints early safety and device success. In conclusion, ACURATE neo, as compared with SAPIEN 3, was associated with higher rates of moderate-to-severe PVL, which were indirectly linked with increased observed 30-day all-cause mortality

Transcatheter aortic valve replacement with Lotus and Sapien 3 prosthetic valves: A systematic review and meta-analysis

none20Background: Frequent occurrence of paravalvular leak (PVL) after transcatheter aortic valve replacement (TAVR) was the main concern with early-generation devices and focused technological improvements. Current systematic review and meta-analysis sought to compare outcomes of TAVR for severe native valve stenosis with next-generation devices: Lotus and Sapien 3. Methods: Electronic databases were screened for studies comparing outcomes of TAVR with Lotus and Sapien 3. In a random-effects meta-analysis, the pooled incidence rates of procedural, clinical and functional outcomes according to VARC-2 definitions were assessed. Results: Eleven observational studies including 2,836 patients (Lotus N=862 vs. Sapien 3 N=1,974) met inclusion criteria. No differences were observed regarding composite endpoints—device success and early safety. Similarly, 30-day mortality, major vascular complications, acute kidney injury and serious bleeding events were similar with both devices. Lotus valve demonstrated 35% reduction of the risk for mild PVL: risk ratio (RR) 0.65, 95% confidence interval (CI): 0.49–0.85, P=0.002; but there were no statistical differences with regard to moderate/severe PVL (RR 0.56, 95% CI: 0.18–1.77, P=0.320). Lotus valves produced significantly higher mean transaortic gradients: mean difference (MD) 0.88 mmHg, 95% CI, 0.24–1.53 mmHg, P=0.007; however, without translation into higher rate of prosthesis-patient mismatch (RR 1.10, 95% CI: 0.82–1.47, P=0.540). As compared to Sapien 3, Lotus device placement was associated with significantly higher rate of permanent pacemaker implantation (RR 2.30, 95% CI: 1.95–2.71, P<0.00001) and cerebrovascular events (RR 1.76, 95% CI: 1.03–2.99, P=0.040). Conclusions: Lotus valve, as compared with Sapien 3, was associated with lower risk for PVL but higher risk for permanent pacemaker implantation and cerebrovascular events.noneGozdek M.; Ratajczak J.; Arndt A.; Zielinski K.; Pasierski M.; Matteucci M.; Fina D.; Jiritano F.; Meani P.; Raffa G.M.; Malvindi P.G.; Pilato M.; Paparella D.; Slomka A.; Landes U.; Kornowski R.; Kubica J.; Lorusso R.; Suwalski P.; Kowalewski M.Gozdek, M.; Ratajczak, J.; Arndt, A.; Zielinski, K.; Pasierski, M.; Matteucci, M.; Fina, D.; Jiritano, F.; Meani, P.; Raffa, G. M.; Malvindi, P. G.; Pilato, M.; Paparella, D.; Slomka, A.; Landes, U.; Kornowski, R.; Kubica, J.; Lorusso, R.; Suwalski, P.; Kowalewski, M