Liberal transfusion strategy improves survival in perioperative but not in critically ill patients. A meta-analysis of randomised trials

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2019 EACTS Expert Consensus on long-term mechanical circulatory support

Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many-sometimes contradictory-observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device

Selection criteria and triage in extracorporeal membrane oxygenation during coronavirus disease 2019

Purpose of reviewCoronavirus disease 2019 (COVID-19) pandemic changed the way we had to approach hospital- and intensive care unit (ICU)-related resource management, especially for demanding techniques required for advanced support, including extracorporeal membrane oxygenation (ECMO).Recent findingsAvailability of ICU beds and ECMO machines widely varies around the world. In critical conditions, such a global pandemic, the establishment of contingency capacity tiers might help in defining to which conditions and subjects ECMO can be offered. A frequent reassessment of the resource saturation, possibly integrated within a regional healthcare coordination system, may be of help to triage the patients who most likely will benefit from advanced techniques, especially when capacities are limited.SummaryIndications to ECMO during the pandemic should be fluid and may be adjusted over time. Candidacy of patients should follow the same prepandemic rules, taking into account the acute disease, the burden of any eventual comorbidity and the chances of a good quality of life after recovery; but the current capacity of healthcare system should also be considered, and frequently reassessed, possibly within a wide hub-and-spoke healthcare system

Selection criteria and triage in extracorporeal membrane oxygenation during coronavirus disease 2019

Purpose of reviewCoronavirus disease 2019 (COVID-19) pandemic changed the way we had to approach hospital- and intensive care unit (ICU)-related resource management, especially for demanding techniques required for advanced support, including extracorporeal membrane oxygenation (ECMO).Recent findingsAvailability of ICU beds and ECMO machines widely varies around the world. In critical conditions, such a global pandemic, the establishment of contingency capacity tiers might help in defining to which conditions and subjects ECMO can be offered. A frequent reassessment of the resource saturation, possibly integrated within a regional healthcare coordination system, may be of help to triage the patients who most likely will benefit from advanced techniques, especially when capacities are limited.SummaryIndications to ECMO during the pandemic should be fluid and may be adjusted over time. Candidacy of patients should follow the same prepandemic rules, taking into account the acute disease, the burden of any eventual comorbidity and the chances of a good quality of life after recovery; but the current capacity of healthcare system should also be considered, and frequently reassessed, possibly within a wide hub-and-spoke healthcare system

Sympathetic modulation by carvedilol and losartan reduces angiotensin II-mediated lipolysis in subcutaneous and visceral fat

Advanced heart failure is characterized by increased activation of the renin-angiotensin system and the development of cachexia. Angiotensin II (Ang II) has been proposed as a lipid metabolism regulator. The effects of exogenous Ang II (osmotic minipump, 525 ng/kg/min for 12 d) on interstitial sc glycerol and norepinephrine levels, indexes of lipolysis, and sympathetic activation, respectively, were measured in Sprague Dawley rats by consecutive microdialysis performed in vivo in white adipose tissue. Higher sustained interstitial glycerol and norepinephrine levels were found after 7 and 12 d of Ang II infusion. Triglyceride to DNA content ratio and adipocyte diameter were reduced in sc and visceral (retroperitoneal and epididymal) fat tissues of Ang II-infused rats, whose body weight was lower and blood pressure higher. Losartan, an Ang II receptor 1 blocker, and carvedilol, an α1-nonselective-β1,2,3-adrenergic blocker, but not doxazosin, an α1-selective-adrenergic blocker, lowered glycerol and norepinephrine levels, preventing lipolysis and weight loss. Our results indicate that Ang II stimulates lipolysis in sc and visceral adipocytes by sympathetic activation and β-adrenergic-receptor stimulation. Nonselective-β-adrenergic and Ang II-receptor1 blockade markedly attenuated the rise of norepinephrine, preventing catabolic effects. The metabolic benefits of carvedilol and losartan, in addition to recognized protective cardiovascular effects, may be relevant in cachectic patients with advanced heart failure

2019 EACTS Expert Consensus on long-term mechanical circulatory support

PubMed ID: 31100109Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many - sometimes contradictory - observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device. © 2019 The Author(s)