Extracorporeal membrane oxygenation(ECMO) in refractory cardiogenic shock: impact of acute versus chronic etiology on outcome

Refractory cardiogenic shock (CS) is a condition that continues to have a very high mortality despite advances in medical therapy. Conventional treatment typically comprises inotrope infusions, vasopressors and intra-aortic-balloon-pump (IABP). When circulatory instability is refractory to these treatments, mechanical circulatory support represents the only hope for survival, as indicated by current guidelines. As most of these patients present with critical circulatory instability requiring urgent or emergent therapy, the chosen mechanical assistance should be rapidly and easily implanted. For this reason ExtraCorporeal Membrane Oxygenation (ECMO) represents the ideal “bridge-to-life” and increasingly it is used to keep the patient alive while the optimal therapeutic management is determined (bridge-to-decision). Management may then follow one of three courses: “bridge-to-recovery”: patient recovery, and weaning from ECMO; “bridge-to-transplant”: direct heart transplantation; “bridge-to-bridge”: placement of ventricular-assist-device or total artificial longer-term support. There have been several large reports on the use of ECMO as a mechanical support in post-cardiotomy patients but relatively few, mostly small case-series focusing on its role in primary acute cardiogenic shock outside of the post-cardiotomy setting. We present the results of our centre’s experience (Padova) in the treatment of primary acute cardiogenic shock with the PLS-Quadrox ECMO system (Maquet) as a bridge to decision. Furthermore, we evaluated the impact of etiology on patient outcomes by comparing acute primary refractory CS secondary to acute myocardial infarction (AMI), myocarditis, pulmonary embolism (PE) and post-partum cardiomyopathy (PPCM) with acute decompensation of a chronic cardiomyopathy, including dilated cardiomyopathy (DCM), ischemic cardiomyopathy (ICM) and grown-up-congenital-heart-diseases (GUCHD). We also analyzed whether duration and magnitude of support may predict weaning and survival. Materials and Methods. Between January 2009 and March 2013, we implanted a total of 249 ECMO; in this study we focused on 64 patients where peripheral ECMO was the treatment for primary cardiogenic shock. Thirty-seven cases (58%) were “acute” (Group A-PCS: mostly acute myocardial infarction, 39%), while twenty-seven (42%) had an exacerbation of “chronic” heart failure (Group C-PCS: dilated cardiomyopathy 30%, post-ischemic cardiomyopathy 9%, congenital 3%). Results. In group C-PCS, 23 patients were bridged to a LVAD (52%) or heart transplantation (33%). In group A-PCS, ECMO was used as bridge-to-transplantation in 3 patients (8%), bridge-to-bridge in 9 (24%), and bridge-to-recovery in 18 patients (49%). One patient in both groups was bridged to conventional surgery. Recovery of cardiac function was achieved only in group A-PCS (18 vs 0 pts, p=0.0001). Mean-flow during support ≤60% of the theoretical flow (BSA*2.4) was a predictor of successful weaning (p=0.02). Average duration of ECMO support was 8.9 ±9 days. Nine patients (14%) died during support; 30-day overall survival was 80% (51/64 pts); 59% of patients were discharged, in whom survival at 48 months was 90%. Better survival was observed in patients supported for 8 days or less (74% vs 36%, p=0.002). Conclusions. In “chronic” heart-failure ECMO represents a bridge to VAD or heart-transplantation, while in “acute” settings it offers a considerable chance of recovery, often representing the only required therapy

Temporary coronary artery occlusion during off-pump surgery and endothelial vessel dysfunction: Is it still an unresolved mystery?

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Nonischemic Donor Heart Preservation: New Milestone in Heart Transplantation History

Heart transplantation is considered the gold standard for the treatment of advanced end-stage heart failure. However, standard donors after brain death are decreasing, whereas patients on the heart transplant waitlist are constantly rising. The introduction of the ex vivo machine perfusion device has been a turning point; in fact, these systems are able to significantly reduce ischemic times and have a potential effect on ischemia-related damage reduction. From a clinical standpoint, these machines show emerging results in terms of heart donor pool expansion, making marginal donors and donor grafts after circulatory death suitable for donation. This article aims to review mechanisms and preclinical and clinical outcomes of currently available ex vivo perfusion systems, and to explore the future fields of application of these technologies

Minimally invasive implantation of continuous flow left ventricular assist devices: the evolution of surgical techniques in a single centre experience

To evaluate the evolution of our surgical experience with the implantation of a continuous flow left ventricular assist device (LVAD), from the original full sternotomy approach to less invasive surgical strategies including mini-sternotomy and/or mini-thoracotomies

A step-by-step problem-solving strategy in a patient with heart failure and cerebral aneurysm

Left ventricular assist devices (LVAD) implantation is an established treatment for patients with end-stage heart failure. HeartMate 3 (HM3) is a continuous-flow centrifugal pump, recently introduced in the clinic, which has shown greater hemocompatibility compared to similar devices of previous generations. Nevertheless, anticoagulation is still required after HM3 implant to avoid pump dysfunction. Hereafter, we describe the case of a patient candidate to LVAD implantation for end-stage heart failure presenting a concomitant cerebrovascular lesion, accidentally found during pre-operative assessment, which would have contraindicated the procedure (for the prohibitive risk of cerebral hemorrhage), unless a step by step problem-solving approach was adopted

Technology and technique for left ventricular assist device optimization: A Bi-Tech solution

Background We investigated the synergistic effect of the new cone-bearing design of Jarvik 2000 (Jarvik Heart Inc., NY) together with a minimally-invasive approach to outcomes of LVAD patients. Methods We retrospectively reviewed all patients from 5 institutions involved in the Jarvik 2000 Italian Registry, from October 2008 to October 2016. Patients were divided into three groups according to pump design and implantation technique: pin-bearing design and conventional approach (Group 1); cone-bearing and conventional approach (Group 2); cone-bearing and minimally-invasive implantation (Group 3). Results A total of 150 adult patients with end-stage heart failure were enrolled: 26 subjects in Group 1, 74 in Group 2, and 50 in Group 3. Nineteen patients (73%) in Group 1, 51 (69%) in Group 2, and 36 (72%) in Group 3 were discharged. During follow-up, 22 patients underwent transplantation, while in 3 patients the LVAD was explanted. The overall 1-year survival was 58 +/- 10%, 64 +/- 6%, and 74% +/- 7% in Groups 1, 2, and 3, respectively (p = 0.034). The competing-risks-adjusted cumulative incidence rate for adverse events was 42.1 [27-62.7] per 100 patient-years in Group 1, 35.4 [25.3-48.2] in Group 2, and 22.1 [12.4-36.4] in Group 3 (p = 0.046 for Group 1 vs. 3). Conclusions The association of the modern cone-bearing configuration of Jarvik 2000 and minimally invasive surgery improved survival and minimized the risk for cardiovascular events, as a result of combining technology and technique

Colchicine for prevention of postpericardiotomy syndrome and postoperative atrial fibrillation : the COPPS-2 randomized clinical trial

IMPORTANCE: Postpericardiotomy syndrome, postoperative atrial fibrillation (AF), and postoperative effusions may be responsible for increased morbidity and health care costs after cardiac surgery. Postoperative use of colchicine prevented these complications in a single trial. OBJECTIVE: To determine the efficacy and safety of perioperative use of oral colchicine in reducing postpericardiotomy syndrome, postoperative AF, and postoperative pericardial or pleural effusions. DESIGN, SETTING, AND PARTICIPANTS: Investigator-initiated, double-blind, placebo-controlled, randomized clinical trial among 360 consecutive candidates for cardiac surgery enrolled in 11 Italian centers between March 2012 and March 2014. At enrollment, mean age of the trial participants was 67.5 years (SD, 10.6 years), 69% were men, and 36% had planned valvular surgery. Main exclusion criteria were absence of sinus rhythm at enrollment, cardiac transplantation, and contraindications to colchicine. INTERVENTIONS: Patients were randomized to receive placebo (n=180) or colchicine (0.5 mg twice daily in patients 6570 kg or 0.5 mg once daily in patients <70 kg; n=180) starting between 48 and 72 hours before surgery and continued for 1 month after surgery. MAIN OUTCOMES AND MEASURES: Occurrence of postpericardiotomy syndrome within 3 months; main secondary study end points were postoperative AF and pericardial or pleural effusion. RESULTS: The primary end point of postpericardiotomy syndrome occurred in 35 patients (19.4%) assigned to colchicine and in 53 (29.4%) assigned to placebo (absolute difference, 10.0%; 95% CI, 1.1%-18.7%; number needed to treat\u2009=\u200910). There were no significant differences between the colchicine and placebo groups for the secondary end points of postoperative AF (colchicine, 61 patients [33.9%]; placebo, 75 patients [41.7%]; absolute difference, 7.8%; 95% CI, -2.2% to 17.6%) or postoperative pericardial/pleural effusion (colchicine, 103 patients [57.2%]; placebo, 106 patients [58.9%]; absolute difference, 1.7%; 95% CI, -8.5% to 11.7%), although there was a reduction in postoperative AF in the prespecified on-treatment analysis (placebo, 61/148 patients [41.2%]; colchicine, 38/141 patients [27.0%]; absolute difference, 14.2%; 95% CI, 3.3%-24.7%). Adverse events occurred in 21 patients (11.7%) in the placebo group vs 36 (20.0%) in the colchicine group (absolute difference, 8.3%; 95% CI; 0.76%-15.9%; number needed to harm\u2009=\u200912), but discontinuation rates were similar. No serious adverse events were observed. CONCLUSIONS AND RELEVANCE: Among patients undergoing cardiac surgery, perioperative use of colchicine compared with placebo reduced the incidence of postpericardiotomy syndrome but not of postoperative AF or postoperative pericardial/pleural effusion. The increased risk of gastrointestinal adverse effects reduced the potential benefits of colchicine in this setting. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT0155218