Extra-corporeal membrane oxygenation for refractory cardiogenic shock after adult cardiac surgery:a systematic review and meta-analysis

Background - Postcardiotomy cardiogenic shock (PCCS) refractory to inotropic support and intra-aortic balloon pump (IABP) occurs rarely but is almost universally fatal without mechanical circulatory support. In this systematic review and meta-analysis we looked at the evidence behind the use of veno-arterial extra-corporeal membrane oxygenation (VA ECMO) in refractory PCCS from a patient survival rate and determinants of outcome viewpoint. Methods - A systematic review was performed in January 2017 using PubMed (with no defined time period) using the keywords “postcardiotomy”, “cardiogenic shock”, “extracorporeal membrane oxygenation” and “cardiac surgery”. We excluded papers pertaining to ECMO following paediatric cardiac surgery, medical causes of cardiogenic shock, as well as case reports, review articles, expert opinions, and letters to the editor. Once the studies were collated, a meta-analysis was performed on the proportion of survivors in those papers that met the inclusion criteria. Meta-regression was performed for the most commonly reported adverse prognostic indicators (API). Results - We identified 24 studies and a cumulative pool of 1926 patients from 1992 to 2016. We tabulated the demographic data, including the strengths and weaknesses for each of the studies, outcomes of VA ECMO for refractory PCCS, complications, and APIs. All the studies were retrospective cohort studies. Meta-analysis of the moderately heterogeneous data (95% CI 0.29 to 0.34, p 70 years, 95% CI −0.057 to 0.001, P = 0.058), and long ECMO support (95% CI −0.068 to 0.166, P = 0.412). Postoperative renal failure, high EuroSCORE (>20%), diabetes mellitus, obesity, rising lactate whilst on ECMO, gastrointestinal complications had also been reported. Conclusion - Haemodynamic support with VA ECMO provides a survival benefit with reasonable intermediate and long-term outcomes. Many studies had reported advanced age, renal failure and prolonged VA ECMO support as the most likely APIs for VA ECMO in PCCS. EuroSCORE can be utilized to anticipate the need for prophylactic perioperative VA ECMO in the high-risk category. APIs can be used to aid decision-making regarding both the institution and weaning of ECMO for refractory PCCS

Surgical Extirpation of Apical Left Ventricular Thrombus in Takotsubo Cardiomyopathy

We report a patient with takotsubo cardiomyopathy who underwent surgical resection of apical left ventricular thrombus. A 59-year-old woman was transferred to our hospital in shock with hypothermia and diabetic ketoacidosis. The electrocardiogram showed ST segment elevation, while echocardiography revealed a reduced ejection fraction with apical and midventricular akinesis. Emergency coronary angiography showed normal coronary arteries, so takotsubo cardiomyopathy was diagnosed. Follow-up echocardiography revealed improvement of the ejection fraction. A mobile apical thrombus was also detected. Thrombectomy was performed via a left apical incision and postoperative recovery was uneventful

Ruptured Common Femoral Artery Aneurysm or Abdominal Aortic Aneurysm?

We encountered a patient with a large retroperitoneal hematoma due to rupture of a common femoral artery aneurysm. A 77-year-old man was transferred to our hospital with left groin pain and shock. Computed tomography demonstrated a large retroperitoneal hematoma involving the left iliofemoral segment with extravasation of contrast into the left groin from a ruptured left common femoral artery aneurysm. The patient also had an abdominal aortic aneurysm. Reconstruction of the common femoral artery with a graft was performed successfully. The patient had an uneventful postoperative course and subsequently underwent Y-graft replacement of the abdominal aortic aneurysm

イライ ノ キコウ : ニチエイ ニオケル ハツワ ジショウ ノ タイショウ ケンキュウ

The purpose of this paper is to determine the characteristics of the overall organization of requests in speech events in Japanese and English through discourse analysis based on transcripts of written conversations and natural conversations by native speakers of each language in a fixed setting. The paper takes a cross-cultural pragmatic approach to discuss the factors that influence the organization of requests such as social distance, personality, age, gender and power between the interlocutors as well as cultural features of conversation