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Simon Schopka,
Alois Philipp,
Dirk Lunz,
Daniele Camboni,
Raffaela Zacher,
Leopold Rupprecht,
Markus Zimmermann,
Matthias Lubnow,
Andreas Keyser,
Matthias Arlt,
Christof Schmid,
Michael Hilker
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ABSTRACT: Extracorporeal membrane oxygenation (ECMO) has been successfully used to support patients with cardiac arrest failing to respond to conventional cardiopulmonary resuscitation (CPR). Preimplant factors being indicative for success are unknown up to now. The study describes single center experience with special focus on differences between survivors and nonsurvivors. Between 2002 and 2009, 103 patients were supported within the scope of CPR by means of ECMO. Besides primary diagnosis, duration, and outcome, pH, lactate, mean arterial pressure, aspartate aminotransferase, bilirubin, catecholamine dosage, and oxygenation ratio before ECMO, after 2 h, 1 day, and at explantation were analyzed. One hundred three patients (51.2 ± 16 years, 35 women, 68 men) were analyzed. Primary cardiac failure led to CPR in 54%. Duration of support was 4.8 ± 0.6 days. Twenty-nine (28.1%) patients survived to hospital discharge. On ECMO support, pH, lactate, and mean arterial pressure improved significantly. Catecholamine dosage was significantly reduced after ECMO implantation. Demographic data and primary diagnosis revealed no significant influence on outcome. pH, lactate, creatinine, and bilirubin differed significantly between survivors and nonsurvivors in the course of ECMO support. ECMO support during CPR reliably improves the circulatory and respiratory situation. Considering observed survival critical patient selection is mandatory. Although there are several significant differences between surviving patients and patients with fatal outcome, patient selection turns out to be difficult as clinically relevant factors show only limited predictive value. Future research should focus on better defining a population that may be best of all suited for the use of ECMO support in CPR.
Artificial Organs 02/2013; 37(2):150-6. · 2.00 Impact Factor
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Daniele Camboni,
Alois Philipp,
Matthias Lubnow,
Thomas Bein,
York Zausig,
Michael Hilker,
Bernhard Flörchinger,
Leopold Rupprecht,
Andreas Keyser,
Reinhard Kobuch,
Dirk Lunz, Simon Schopka,
Assad Haneya,
Christof Schmid,
Thomas Müller
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ABSTRACT: Veno-venous extracorporeal membrane oxygenation (vvECMO) conventionally requires the cannulation of two vessels. Here we report our initial experience with the "Wang-Zwische" (WZ) double-lumen cannula.In a group of n = 36 patients single venous cannulation for vvECMO was performed. A retrospective analysis was executed. A comparison of flow characteristics to standard two-vessel cannulation was performed. Mean age of the patient population was 48 ± 15 years (body mass index [BMI] 32 ± 13 kg/m). In n = 32 patients (89%) the cannula was implanted percutaneously under echo or fluoroscopic guidance in less than 30 minutes. Nine patients were partially mobilized on extracorporeal membrane oxygenation (ECMO) support. Oxygenation (partial arterial oxygen tension [PaO2]/fraction of inspired oxygen [FiO2]) improved significantly in all patients from 66 mm Hg (interquartile range [IQR] 58-87 mm Hg) before ECMO to 117 mm Hg (IQR 95-195 mm Hg, p = 0.001) after 24 hours. In seven patients (19%) nonfatal adverse events occurred, including three dislocations, two partial cannula thrombosis, one ventricular perforation, and one retroperitoneal hemorrhage. The negative pressures for drainage at a flow of 2.5 L/min were significantly lower in a standard (S) two-vessel approach compared with a WZ approach (S: -9 mm Hg; IQR -3 to -24 mm Hg, vs. WZ: -23 mm Hg; IQR -4 to -40 mm Hg; p = 0.04). The WZ cannula offers sufficient gas exchange in addition to certain advantages over standard cannulation, including facilitated cannulation in selected patients and improved mobilization.
ASAIO journal (American Society for Artificial Internal Organs: 1992) 09/2012; · 1.39 Impact Factor
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ABSTRACT: A surgical method for the implantation of a mechanical right ventricular assist device which avoids resternotomy/thoracotomy and related complications at the time of explantation is presented. In order to support the failing right heart, a Dacron vascular graft was sewn to the pulmonary artery. For venous drainage, a cannula was inserted into the right atrium via the femoral vein. Explantation of the system, after the right heart resumed its function, was accomplished by retracting and compressing the venous cannula in the groin as well as by retracting the arterial cannula from the Dacron vascular graft followed by suturing without opening the chest. Between 2006 and 2011, this system was used in 12 patients. The median duration of right heart support was 10.5 days. Seven patients were successfully weaned from the system, six patients survived. In all cases, explantation was free of complications. The technique described is a safe method to support the right heart and allows explantation without the risks and complications of reopening the thorax.
Artificial Organs 08/2012; 36(8):700-4. · 2.00 Impact Factor
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Assad Haneya,
Alois Philipp,
Claudius Diez, Simon Schopka,
Thomas Bein,
Markus Zimmermann,
Matthias Lubnow,
Andreas Luchner,
Ayman Agha,
Michael Hilker,
Stephan Hirt,
Christof Schmid,
Thomas Müller
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ABSTRACT: Cardiopulmonary resuscitation (CPR) using extracorporeal life support (ECLS) system has been successfully used to support patients with in- and out-of-hospital cardiac arrest (IHCA, OHCA) when conventional measures have failed. The purpose of the current study is to report on our experience with extracorporeal CPR in non-postcardiotomy patients.
We retrospectively analysed a total of 85 consecutive adult patients, who have been treated with ECLS between January 2007 and January 2012.
The mean CPR duration was 40min (20-70min). The mean ECLS support duration was 49h (12-92h). Twenty-eight patients (33%) had ECLS related complications. Forty patients (47%) were successfully weaned and 29 patients (34%) survived to hospital discharge. Among survivors, 93% were without severe neurologic deficit. Duration of CPR was shorter for survivors than for non-survivors [(25: 20-50min) vs. (50: 25-86min); p=0.003]. Immediately after ECLS start, the mean blood lactate level was lower (p=0.003), and the mean pH value was higher in the survivors' group (p<0.0001) compared to the non-survivors' group. The CPR duration for the IHCA group (25: 20-50min) was shorter compared to the OHCA group (70: 55-110min; p<0.0001). The survival rate in this group was higher compared to the OHCA group (42% vs. 15%; p<0.02).
CPR using modern miniaturized ECLS systems should be established in the treatment of prolonged cardiac arrest and unsuccessful conventional CPR in selected patients. CPR with ECLS for OHCA has worse outcomes compared to IHCA. Duration of CPR was independent risk factor for mortality after extracorporeal CPR.
Resuscitation 07/2012; 83(11):1331-7. · 3.60 Impact Factor
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ABSTRACT: Cardiocirculatory arrest during different types of interventions in the catheterization laboratory (cath-lab) requires mechanical cardiopulmonary resuscitation (CPR) to restore spontaneous circulation. However, mechanical chest compression leads to interruption of the procedure and can severely compromise the success of the percutaneous coronary intervention (PCI) or transcatheter aortic valve implantation (TAVI). Alternatives to mechanical chest compression are rare and mostly uncommon. The use of extracorporeal assistance for cardiopulmonary resuscitation (E-CPR) can be life-saving, but, up to now, it is not commonly and rapidly available in hospitals with cardiac-catheter laboratories but without cardiac-surgery departments. Here, we report our early experiences in using miniaturized extracorporeal membrane oxygenation (ECMO) systems for E-CPR in the cath-lab. We characterize the emergency uses and the bridging function of these simplified ECMO devices.
Patients who developed cardiocirculatory arrest during PCI and TAVI procedures were treated with E-CPR using percutaneous veno-arterial extracorporeal life-support. To provide extracorporeal life-support, we used two types of miniaturized ECMO systems that can act independently from wall their connection points for power and oxygen supply and are suitable for use in the cath-lab.
Between 2006 and 2011, E-CPR was used in 10 PCI and 4 TAVI patients. The mean age was 73.6 ± 8.8 years. In all patients, E-CPR could be established using percutaneous veno-arterial vessel access. On extracorporeal assistance, the return of beating heart circulation could be rapidly re-established in all patients. In the PCI group, the procedure was successfully completed in all patients while on ECMO. Two patients in the TAVI group were bridged on ECMO to surgical aortic valve replacement. In the clinical follow-up, seven patients (50%) survived to hospital discharge.
Miniaturized ECMO systems can be safe and highly effective in restoring circulation and gas exchange in patients with cardiocirculatory failure in the cath-lab. Additionally, the PCI and TAVI procedures can be finished successfully on ECMO, otherwise the patients can be bridged to cardiac surgery. Especially for patients in need of cardiac surgery, patient transfer to extracorporeal assistance can be more easily processed.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 05/2012; 42(5):858-63. · 2.40 Impact Factor
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ABSTRACT: Stroke is a devastating complication after coronary artery bypass grafting, occurring in 1.4% to 4.3% of patients. A major cause of stroke is cerebral embolization of aortic atheromatous debris or calcified plaques. This report analyzes the incidence of stroke in patients treated according to the clampless concept, i.e. avoiding side-clamping of the aorta, by means of off-pump coronary artery bypass surgery (OPCAB) in combination with the HEARTSTRING device.
During a period of 43 months (2005-2008), 412 consecutive patients were treated with the above-mentioned method by one single surgeon. A minimum of one proximal aortal anastomosis was performed in each patient. Altogether, 542 proximal anastomosis were applied, each created by means of the HEARTSTRING device.
The mean age of patients was 67+9.7 years, the predicted mortality 5.2% (logistic EuroSCORE) and the observed mortality 1.9%. Histories of preoperative neurological disorders or cerebrovascular diseases were documented in 15% of patients. The overall incidence of postoperative stroke was 0.48% in contrast to 1.3% according to the stroke risk score.
In accordance to previously published data, our results show that avoiding aortic side-clamping during OPCAB reduces postoperative stroke rates. The HEARTSTRING device is a safe option for creating proximal aortic anastomosis.
Journal of Cardiothoracic Surgery 03/2010; 5:14. · 1.19 Impact Factor
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ABSTRACT: Hypothermia-induced changes in endothelial cell (EC) morphology and function after organ storage may influence the initial outcome and development of transplant-associated coronary artery disease.
Human saphenous vein ECs were incubated with saline (NaCl), University of Wisconsin (UW), and histidine-tryptophan-ketoglutarate (HTK) solution, with and without protein additives, at 4 degrees C and 37 degrees C. After 6 hours, ECs were recultivated for 24 and 48 hours with culture medium (reperfusion). Mitochondrial activity, adenosine triphosphate concentration, cell count, and inflammatory responses were analyzed.
Cold preservation did not affect the mitochondrial activity of ECs and allowed a complete regeneration of the metabolic turnover after reperfusion. However, under normothermic conditions the metabolism of the cells was influenced by time and type of preservation solution. While both the mitochondrial activity and cell count did not change after treatment with NaCl and culture medium, the metabolic turnover of cells treated with HTK and UW solution significantly increased (twofold) and decreased (twofold, p < 0.05), respectively, after reperfusion. The endothelial reactivity remained unchanged after treatment with NaCl and HTK. The addition of serum proteins significantly improved mitochondrial activity of cells treated with warm NaCl and HTK (p < 0.05). The UW-treated cells burned out through a significant up-regulation of the ATP concentration resulting in a complete metabolic regression after reperfusion and induction of apoptosis.
Normothermic preservation in UW prevented regeneration of ECs, while treatment with HKT solution did not irreversibly affect mitochondrial activity of ECs and allowed complete regeneration of metabolism and function. Serum proteins improved the preservation effect of HTK and NaCl.
The Annals of thoracic surgery 02/2010; 89(2):512-20. · 3.74 Impact Factor
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Bernhard Floerchinger,
Alois Philipp,
Maik Foltan,
Leopold Rupprecht,
Alexander Klose,
Daniele Camboni,
Frank Bruenger, Simon Schopka,
Mathias Arlt,
Michael Hilker,
Christof Schmid
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ABSTRACT: Extracorporeal membrane oxygenation is an effective rescue tool to treat cardiopulmonary failure. Pumpless systems treat lung failure only; they require adequate cardiac output.
We report on 18 patients initially provided with venoarterial extracorporeal membrane oxygenation and then downgraded to a pumpless arteriovenous shunt with a membrane oxygenator by removal of the pump from the circuit after hemodynamic stabilization in the face of persisting pulmonary failure. Main underlying diseases were adult respiratory distress syndrome (44%) and pneumonia (28%). Mean patient age was 44 years, and mean body mass index was 25.7 kg/m(2). Anticoagulation, hemodynamic, and respiratory variables were analyzed.
All patients exhibited severe cardiopulmonary failure with a mean oxygenation ratio (partial pressure of oxygen to fraction of inspired oxygen ratio) of 74 +/- 43 mm Hg (mean partial pressure of oxygen, 70 +/- 33 mm Hg) and a mean partial pressure of carbon dioxide of 68 +/- 32 mm Hg despite maximal (ventilatory) conservative therapy (fraction of inspired oxygen, 0.98 +/- 0.08). Initial serum lactate was 51 +/- 43 mg/dL. The sequential organ failure assessment score averaged 11.8 +/- 2.47, and the lung injury score was 3.1 +/- 0.58. Total mechanical respiratory support was performed for a mean of 13.6 +/- 15.7 days. After 24 hours an improvement in oxygenation and a decrease in carbon dioxide was achieved with a mean partial pressure of carbon dioxide of 40 +/- 11 mm Hg (p < 0.001) and a partial pressure of oxygen of 86 +/- 26 mm Hg (p = 0.031). After 6 +/- 3 days of extracorporeal membrane oxygenation, patients were hemodynamically stabilized. Extracorporeal membrane oxygenation was downgraded to pumpless extracorporeal lung assist for another 10 +/- 15 days (range, 2 to 71 days). Twelve patients (66.7%) could be weaned, with a 30-day mortality of 55.6%. Norepinephrine dosage could be reduced significantly within 24 hours (3.2 +/- 1.8 versus 1.5 +/- 1.5 mg/h; p = 0.008).
Respiratory support by an extracorporeal device used as last resort therapy allows rapid stabilization of patients with acute lung failure. Early replacement of extracorporeal membrane oxygenation by pumpless extracorporeal lung assist minimizes the negative side effects of extracorporeal circulation.
The Annals of thoracic surgery 01/2010; 89(1):125-31. · 3.74 Impact Factor
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ABSTRACT: High intensity focused ultrasound (HIFU) energy has evolved as a new surgical tool to treat atrial fibrillation (AF). We evaluated safety and efficacy of AF ablation with HIFU and analyzed predictors of success in a prospective clinical study.
From January 2007 to June 2008, 110 patients with AF and concomitant open heart surgery were enrolled into the study. Main underlying heart diseases were aortic valve disease (50%), ischemic heart disease (48%), and mitral valve disease (18%). AF was paroxysmal in 29%, persistent in 31%, and long standing persistent in 40% of patients, lasting for 1 to 240 months (mean 24 months). Mean left atrial diameter was 50 +/- 7 mm. Each patient underwent left atrial ablation with the Epicor system prior to open heart surgery. After surgery, the patients were treated with amiodarone and coumadin for 6 months. Follow-up studies including resting ECG, 24 h Holter ECG, and echocardiography were obtained at 6 and 12 months.
All patients had successful application of the system on the beating heart prior to initiation of extracorporeal circulation. On average, 11 +/- 1 ultrasound transducer elements were used to create the box lesion. The hand-held probe for additional linear lesions was employed in 83 cases. No device-related deaths occurred. Postoperative pacemaker insertion was necessary in 4 patients. At 6 months, 62% of patients presented with sinus rhythm. No significant changes were noted at 12 months. Type of AF and a left atrial diameter > 50 mm were predictors for failure of AF ablation.
AF ablation with the Epicor system as a concomitant procedure during open heart surgery is safe and acceptably effective. Our overall conversion rate was lower than in previously published reports, which may be related to the lower proportion of isolated mitral valve disease in our study population. Left atrial size may be useful to determine patients who are most likely to benefit from the procedure.
Journal of Cardiothoracic Surgery 01/2010; 5:34. · 1.19 Impact Factor
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ABSTRACT: The biocompatibility of different commercially available poly(ether)urethane (PUR), medically used as main component for pump chambers of implantable ventricular assist devices (VAD), was evaluated. We investigated the influence of the PUR manufacturing process in an in vitro cytotoxicity screening assay. Human saphenous vein endothelial cells (HSVEC) and a mouse fibroblast cell line (L929) were cultivated with different PUR specimens. Tissue-cultured polystyrole (TCP) was used as a reference. The cytotoxic effect was evaluated by morphology (phase contrast microscopy), cell viability (mitochondrial acitvity), cell growth kinetics, and proliferation (incorporation of (3)H-methyl-thymidine) tests. Fibronectin-coating guaranteed the adhesion of both cell types onto the reference material. Sterilization procedure of test materials did not affect adhesion properties. L929 completely covered the surfaces of Tecothane, Carbothane, and Mecora specimens, whereas HSVEC formed an imperfect monolayer onto the PUR. The mitochondrial activity was reduced in all cell types attached to PUR. In addition, proliferation of cells was not observed when using these materials. Commercially available PUR provided an unfavorable support for colonization of patient-derived HSVEC, which demanded a surface modification.
Journal of Biomedical Materials Research Part B Applied Biomaterials 01/2009; 90(1):312-8. · 2.15 Impact Factor
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ABSTRACT: Coverage of cardiovascular bioprostheses with autologous endothelium is used for the purpose of improving blood compatibility. The aim of our study was to analyze endothelialization potential of glutaraldehyde-fixed heart valves, cellular functions of seeded endothelial cells (EC), and the impact of a two-stage seeding protocol using human vascular fibroblasts (FB) and EC from saphenous veins (HSVEC) on cellular functional properties in vitro. Adherence and morphology of adhered cells were assessed by scanning electronic microscopy and immunohistochemistry. Reproducible, complete surface coverage with EC was established on decellularized and glutaraldehyde-fixed bovine pericardium. Analyzing functional properties of cells directly adhered to biomaterial revealed nonproliferative cells, which were capable of inflammatory stimulation in terms of TNF-induced increase in interleukin-6 secretion and adhesion of inflammatory cells. Furthermore, EC showed sustained antithrombotic properties quantified by platelet adhesion onto EC and prostacyclin secretion by EC. Preseeding with vascular fibroblasts using a two-stage seeding protocol induced EC proliferation and improved inflammatory and anti-thrombotic functions. Cardiovascular biomaterials differ significantly in their potential to allow for adhesion of human EC. Successfully endothelialized biomaterial, however, revealed cellular properties which are likely to be favorable to improving performance of biomaterials. Two-stage seeding adds regenerative potential and improves cell functions of adherent EC.
Journal of Biomedical Materials Research Part B Applied Biomaterials 08/2008; 88(1):130-8. · 2.15 Impact Factor
