A 20-year multicentre outcome analysis of salvage mechanical circulatory support for refractory cardiogenic shock after cardiac surgery

Abstract Background Refractory post-cardiotomy cardiogenic shock (PCCS) is a relatively rare phenomenon that can lead to rapid multi-organ dysfunction syndrome and is almost invariably fatal without advanced mechanical circulatory support (AMCS), namely extra-corporeal membrane oxygenation (ECMO) or ventricular assist devices (VAD). In this multicentre observational study we retrospectively analyzed the outcomes of salvage venoarterial ECMO (VA ECMO) and VAD for refractory PCCS in the 3 adult cardiothoracic surgery centres in Scotland over a 20-year period. Methods The data was obtained through the Edinburgh, Glasgow and Aberdeen cardiac surgery databases. Our inclusion criteria included any adult patient from April 1995 to April 2015 who had received salvage VA ECMO or VAD for PCCS refractory to intra-aortic balloon pump (IABP) and maximal inotropic support following adult cardiac surgery. Results A total of 27 patients met the inclusion criteria. Age range was 34–83 years (median 51 years). There was a large male predominance (n = 23, 85 %). Overall 23 patients (85 %) received VA ECMO of which 14 (61 %) had central ECMO and 9 (39 %) had peripheral ECMO. Four patients (15 %) were treated with short-term VAD (BiVAD = 1, RVAD = 1 and LVAD = 2). The most common procedure-related complication was major haemorrhage (n = 10). Renal failure requiring renal replacement therapy (n = 7), fatal stroke (n = 5), septic shock (n = 2), and a pseudo-aneurysm at the femoral artery cannulation site (n = 1) were also observed. Overall survival to hospital discharge was 40.7 %. All survivors were NYHA class I-II at 12 months’ follow-up. Conclusion AMCS for refractory PCCS carries a survival benefit and achieves acceptable functional recovery despite a significant complication rate

Extracorporeal membrane oxygenation for 2009 influenza A (H1N1) acute respiratory distress syndrome: single-centre experience with 1-year follow-up

OBJECTIVES: During 2009, pandemic influenza A (H1N1) affected France and several patients developed influenza A (H1N1)-associated acute respiratory distress syndrome. The use of extracorporeal membrane oxygenation (ECMO) could be advocated as therapeutic solution. We present our experience with ECMO utilized in patients with influenza A (H1N1)-associated respiratory failure. METHODS: We conducted a retrospective observational analysis of our experience with veno-venous ECMO for 2009 influenza A (H1N1)-associated respiratory failure. We have excluded from our study all not confirmed cases of influenza A (H1N1). Veno- venous ECMO was always instituted using a percutaneous cannulation technique. Mechanical circulatory support was maintained until respiratory function recovery. RESULTS: Between October 2009 and February 2010, we performed veno-venous ECMO support in 12 patients with influenza A (H1N1)-associated respiratory failure. Mean age was 33 \ub1 12 years (14\u201363 years) and there was a prevalence of female sex. Median time from influenza A (H1N1) onset to mechanical ventilation (MV) initiation was 6 days (1\u201317 days); median time from MV to veno-venous ECMO support was 3 days (1\u201320 days). Six patients (50%) suffered ventilator-associated pneumonia during ECMO support. Eight patients (66.6%) suffered significant haemorrhage requiring transfusion of more than 2 packed red cells. In two patients (16.6%), there was a thrombosis of the inferior vena cava and one of them experienced pulmonary embolism. Mean duration of ECMO support was 23\ub114 days (3\u201347 days); mean duration of mechanical ventilatory support was 24\ub121 days (6\u201370 days). ECMO was weaned in 10 patients (83.3%) and all these patients are still alive after a period of follow-up of 13.8\ub11.12 months (11.03\u201314.83 months). Two patients (in-hospital mortality of 16.6%) died under ECMO support for refractory septic shock. CONCLUSIONS: Veno-venous ECMO for 2009 H1N1-associated respiratory failure gives good results with a very low mortality rate. The use of a mobile unit is a safe procedure and may improve survival of patients who might not be otherwise eligible for transfer to our institution. Larger studies are however required in order to optimize and refine the best treatment strategy in this subgroup of patients

Contemporary cardiac surgery for adults with congenital heart disease

Objective Advances in early management of congenital heart disease (CHD) have led to an exponential growth in adults with CHD (ACHD). Many of these patients require cardiac surgery. This study sought to examine outcome and its predictors for ACHD cardiac surgery. Methods This is an observational cohort study of prospectively collected data on 1090 consecutive adult patients with CHD, undergoing 1130 cardiac operations for CHD at the Royal Brompton Hospital between 2002 and 2011. Early mortality was the primary outcome measure. Midterm to longer-term survival, cumulative incidence of reoperation, other interventions and/or new-onset arrhythmia were secondary outcome measures. Predictors of early/total mortality were identified. Results Age at surgery was 35±15 years, 53% male, 52.3% were in New York Heart Association (NYHA) class I, 37.2% in class II and 10.4% in class III/IV. Early mortality was 1.77% with independent predictors NYHA class ≥ III, tricuspid annular plane systolic excursion (TAPSE) <15 mm and female gender. Over a mean follow-up of 2.8±2.6 years, 46 patients died. Baseline predictors of total mortality were NYHA class ≥ III, TAPSE <15 mm and non-elective surgery. The number of sternotomies was not independently associated with neither early nor total mortality. At 10 years, probability of survival was 94%. NYHA class among survivors was significantly improved, compared with baseline. Conclusions Contemporary cardiac surgery for ACHD performed at a single, tertiary reference centre with a multidisciplinary approach is associated with low mortality and improved functional status. Also, our findings emphasise the point that surgery should not be delayed because of reluctance to reoperate only

Management of recurrent mechanical prosthetic tricuspid valve thrombosis in the perioperative period of noncardiac surgery: a case report

<p>Abstract</p> <p>Introduction</p> <p>Mechanical valves in the tricuspid position may be prone to thrombosis with even brief lapses in anticoagulation. The management of patients with a history of recurrent mechanical tricuspid valve thrombosis who require noncardiac surgery is complex.</p> <p>Case presentation</p> <p>A 43-year-old Pakistani woman with a mechanical tricuspid valve and a history of multiple episodes of mechanical valve thrombosis presented for noncardiac surgery. After her surgery she was found to have another episode of valve thrombosis and underwent a redo tricuspid valve replacement.</p> <p>Conclusion</p> <p>This case brings up the important dilemma that exists when patients with a mechanical tricuspid valve and a history of recurrent valve thrombosis require noncardiac surgery.</p