[Show abstract][Hide abstract] ABSTRACT: Purpose
This study was designed to identify factors associated with in-intensive care unit (ICU) death and develop a practical mortality risk score for venoarterial-extracorporeal membrane oxygenation (VA-ECMO)-treated acute myocardial infarction (AMI) patients. Long-term survivors’ health-related quality of life (HRQOL), anxiety, depression, and post-traumatic stress disorder (PTSD) frequencies were also assessed.
Data from 138 ECMO-treated AMI patients admitted to two French ICUs (2008–2013) were analyzed. ICU survivors contacted >6 months post-ICU discharge were assessed for HRQOL, psychological and PTSD status.
Sixty-five patients (47 %) survived to ICU discharge. On the basis of multivariable logistic regression analyses, the ENCOURAGE score was constructed with seven pre-ECMO parameters: age >60, female sex, body mass index >25 kg/m2, Glasgow coma score <6, creatinine >150 μmol/L, lactate (<2, 2–8, or >8 mmol/L), and prothrombin activity <50 %. Six months after ECMO, probabilities of survival were 80, 58, 25, 20, and 7 % for ENCOURAGE score classes 0–12, 13–18, 19–22, 23–27, and ≥28, respectively. The ENCOURAGE score ROC AUC [0.84 (95 % CI 0.77–0.91)] was significantly better than those of the SAVE, SAPS II, and SOFA scores. Survivors’ HRQOL evaluated after median follow-up of 32 months revealed satisfactory mental health but persistent physical and emotional-related difficulties, with 34 % (95 % CI 20–49 %) anxiety, 20 % (95 % CI 8–32 %) depression, and 5 % (95 % CI 0–12 %) PTSD symptoms reported.
The ENCOURAGE score might be a useful tool to predict mortality of severe cardiogenic shock AMI patients who received VA-ECMO. However, it now needs prospective validation on other populations of AMI patients.
Full-text · Article · Jan 2016 · Intensive Care Medicine
[Show abstract][Hide abstract] ABSTRACT: L’extracorporeal membrane oxygenation (ECMO) veinoartérielle périphérique permet de restaurer en urgence une hémodynamique et une perfusion tissulaire. La configuration la plus utilisée est la canulation de l’artère et de la veine fémorale. La technique de référence est un abord chirurgical des vaisseaux fémoraux canulés selon la technique de Seldinger. L’abord chirurgical est rapide, peut être réalisé sous anesthésie locale, au lit du patient (y compris sous massage cardiaque externe) et permet d’une part une canulation sécurisée des vaisseaux et une bonne hémostase, et d’autre part la mise en place d’un dispositif de reperfusion de membre. La mise en place de l’ECMO est importante, car elle conditionne à la fois l’efficacité de l’assistance et la survenue de complications immédiates ou retardées pouvant engager directement le pronostic vital du patient. Aussi l’implantation ne se limite-t-elle pas à la mise en place d’une canule artérielle et d’une canule veineuse. Elle nécessite une rigueur et une expertise chirurgicale pour assurer une assistance efficace, des suites simples et préparer la décanulation. Les complications sont nombreuses et parfois fatales, ce qui motive une prise en charge par des équipes rompues aux techniques d’assistance circulatoire et capables d’intervenir en urgence pour traiter ces complications.
Peripheral veno-arterial extracorporeal membrane oxygenation (ECMO) allows to secure patient’s hemodynamics and tissue perfusion. The most recommended route is the surgical canulation of the femoral artery and femoral vena using the Seldinger technique. Surgical implementation is rapid, can be performed under local anaesthetics, at the bedside, and even under cardiac massage. It allows safe cannulation of the vessels, good haemostasis, and reperfusion of the cannulated limb. ECMO implementation conditions further ECMO efficiency and possible onset of immediate as well as delayed life-threatening complications. ECMO implementation is not limited to cannula placement but requires surgical expertise to guarantee ECMO efficiency and simple postoperative course and facilitate further decannulation. Complications are numerous and can be even fatal, requiring management by trained teams available for emergent intervention and able to treat any ECMO complication.
[Show abstract][Hide abstract] ABSTRACT: La conduite d’une assistance circulatoire temporaire par extracorporeal membrane oxygenation (ECMO) veinoartérielle est délicate et expose le patient à de nombreuses complications pouvant engager le pronostic vital, parfois très brutalement. La gestion de ces complications impose une accessibilité en urgence à un plateau médicotechnique lourd et à des compétences pluridisciplinaires (réanimateurs, chirurgiens cardiothoraciques et perfusionnistes). De plus, l’ECMO n’assure qu’une assistance temporaire en attente de récupération ou d’une alternative thérapeutique. En absence de récupération, une stratégie thérapeutique faisant discuter la transplantation cardiaque et/ou l’assistance circulatoire de longue durée doit être rapidement définie et réévaluée quotidiennement en fonction de l’évolution du patient. Une prise en charge par des équipes médicochirurgicales expérimentées et rompues aux techniques d’implantation et de conduite de ces assistances, mais également à la gestion de leurs complications (y compris en extrême urgence), apparaît comme une condition nécessaire à la prise en charge de ces patients dans des conditions satisfaisantes de sécurité.
Management of venoarterial extracorporeal membrane oxygenation (ECMO) is difficult and exposes the patient to the onset of life-threatening complications, sometimes occurring even suddenly. Treating ECMO complications requires available medico-technical support with multidisciplinary competences including intensivists, cardio thoracic surgeons, and perfusionnists. ECMO allows temporary life support as bridge to recovery or to alternative therapies. In the absence of recovery, the indication of heart transplantation or long-term assist device implementation should be considered and regularly revaluated on a daily basis in relation to patient’s improvement. Thus, ECMO management by experienced medico-surgical team is mandatory to guarantee ECMO-treated patients’ safety.
[Show abstract][Hide abstract] ABSTRACT: Aim:
Biventricular support can be achieved using paracorporeal ventricular assist devices (p-BiVAD) or the Syncardia temporary total artificial heart (t-TAH). The purpose of the present study was to compare survival and morbidity between these devices.
Data from 2 French neighboring hospitals were reviewed. Between 1996 and 2009, 148 patients (67 p-BiVADs and 81 t-TAH) underwent primary, planned biventricular support. There were 128 (86%) males aged 44±13 years.
Preoperatively, p-BiVAD recipients had significantly lower systolic and diastolic blood pressures, more severe hepatic cytolysis and higher white blood cell counts than t-TAH recipients. In contrast, t-TAH patients had significantly higher rates of pre-implant ECLS and hemofiltration. Mean support duration was 79±100 days for the p-BiVAD group and 71±92 for t-TAH group (P=0.6). Forty two (63%) p-BiVAD recipients were bridged to transplantation (39, 58%) or recovery (3, 5%), whereas 51 (63%) patients underwent transplantation in the t-TAH group. Death on support was similar between groups (p-BiVAD, 26 (39%); t-TAH, 30 (37%); P=0.87). Survival while on device was not significantly different between patient groups and multivariate analysis showed that only preimplant diastolic blood pressure and alanine amino-transferase levels were significant predictors of death. Post-transplant survival in the p-BiVAD group was 76±7%, 70±8%, and 58±9% at 1, 3, and 5 years after transplantation, respectively, and was similar to that of the t-TAH group (77±6%, 72±6%, and 70±7%, P=0.60).
Survival while on support and up to 5 years after heart transplantation was not significantly different in patients supported by p-BiVADs or t-TAH. Multivariate analysis revealed that survival while on transplantation was not affected by the type of device implanted.
Full-text · Article · Jan 2014 · The Journal of cardiovascular surgery
[Show abstract][Hide abstract] ABSTRACT: Purpose: Impella 5.0 is a short-term left ventricle assist device (LVAD), inserted retrograde into
the left ventricle across the aortic valve through a surgical peripheral access. Impella has been utilized for various indications but in the setting of bridge-to-bridge application there are limited reports.
Methods: We performed a retrospective observational analysis of Impella utilization at our institution as bridge to long-term LVADs. The primary end-point was survival during Impella support.
Results: Between December 2010 and February 2012, we implanted 20 Impella in patients with cardiogenic shock and, among these, 5 were implanted as bridge to long-term LVADs. In this latter group, mean age at the time of implantation was 44 ± 15.6 (range 27-68) years and there was a prevalence of males (80%). Etiology of cardiogenic shock was: decompensated anthracycline-induced cardiomyopathy (n = 1), myocardial infarction (n = 4). There was no major bleeding requiring surgical revision or infectious complications at the right axillary access. One patient required Impella replacement due to a pump stop. After a mean period of 14.2 ± 9.0 (range 6-27) days of Impella support, patients were switched to a long-term LVAD (Jarvik 2000, n = 2; HeartMate II, n = 3). One patient died 70 days after implantation of the long-term LVAD due to multi-organ failure, while the remaining patients are still alive after a mean period of follow-up of 108.6 ± 66.2 (range 19-191) days.
Conclusions: Our experience shows that an Impella 5.0 implanted through the right axillary artery
approach is a valid option as bridge to long-term LVADs.
Full-text · Article · Aug 2013 · The International journal of artificial organs
[Show abstract][Hide abstract] ABSTRACT: Background:
The SynCardia temporary total artificial heart (t-TAH) provides complete circulatory support by replacing both native cardiac ventricles and all cardiac valves.
We performed a retrospective analysis of demographics, clinical characteristics and survival of patients bridged to transplantation using the SynCardia t-TAH (SynCardia Systems Inc, Tucson, AZ).
From 2000 to 2010, the SynCardia t-TAH was implanted in 90 consecutive patients (80 males; mean age, 46 ± 13 years) suffering cardiogenic shock secondary to idiopathic (n = 40, 46%) or ischemic (n = 24, 27%) cardiomyopathy or other causes. Before implantation, 7 (9%) patients had cardiac arrest, 27 (33%) were on ventilator, and 18 (22%) were on extracorporeal life support. Pre-implant creatinine values were 1.7 ± 0.97 mg/dL and total bilirubin levels were 45 ± 32 μmol/L; mean duration of support was 84 ± 102 days. Thirty-five (39%) patients died while on support after a mean of 62 ± 107 days. Actuarial survival on device was 74% ± 5%, 63% ± 6%, and 47% ± 8% at 30, 60, and 180 days after implantation. While on support, 9 (10%) patients suffered stroke, 13 (14%) had mediastinitis, and 35 (39%) required surgical reexploration for bleeding, hematoma, or infection. Multivariate analysis revealed that older recipient age and preoperative mechanical ventilation were risk factors for death while on support. Fifty-five (61%) patients were transplanted after a mean of 97 ± 98 days of support. Actuarial survival rates were 78% ± 6%, 71% ± 6%, and 63% ± 8% at 1, 5, and 8 years after transplantation.
The SynCardia t-TAH provided acceptable survival to transplantation rates with a remarkably low incidence of neurologic events. Posttransplant survival was similar to that of patients undergoing primary heart transplantation in France.
No preview · Article · Apr 2013 · The Annals of thoracic surgery
[Show abstract][Hide abstract] ABSTRACT: We present the case of a patient with cardiac tamponade secondary to late intrapericardial migration of a disrupted ventriculo-atrial
shunt (VAS). A 48-year old woman was referred for cardiac tamponade. She had a history of congenital hydrocephalus with implantation
of a VAS (Codman®) in 1994. The initial neurological examination was normal. Tomodensitometry showed a discontinuity of the VAS at the cervical
level with its distal part floating in the pericardium. Immediate surgery through sternotomy allowed the draining of the pressurized
translucid liquid. The distal part of the VAS was extracted and the perforation site on the right ventricle was sutured. The
patient showed no neurological trouble 3 months after operation. Surprisingly, cardiac tamponade was not related to bleeding
but to the accumulation of translucid liquid whose gross aspect and biochemistry were very suggestive of cerebrospinal fluid
(CSF). We hypothesize that a fibrin sheath had developed around the VAS at the time of its disconnection and acted as a fibrous
tunnel allowing continued CSF drainage through its distal part. Surgical strategies to prevent late VAS disconnection should
be considered at the time of implantation.
Preview · Article · Dec 2012 · Interactive Cardiovascular and Thoracic Surgery
[Show abstract][Hide abstract] ABSTRACT: 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.
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.
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 ± 12 years (14-63 years) and there was a prevalence of female sex. Median time from influenza A (H1N1) onset to mechanical ventilation (MV) initiation was 6 days (1-17 days); median time from MV to veno-venous ECMO support was 3 days (1-20 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 ± 14 days (3-47 days); mean duration of mechanical ventilatory support was 24 ± 21 days (6-70 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 ± 1.12 months (11.03-14.83 months). Two patients (in-hospital mortality of 16.6%) died under ECMO support for refractory septic shock.
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.
No preview · Article · Mar 2012 · European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery
[Show abstract][Hide abstract] ABSTRACT: Leukocytes in allogeneic blood transfusions cause several immunomodulatory events. This before-and-after cohort study evaluated clinical outcomes after adoption of prestorage leukoreduction program for blood transfusions, with particular focus on acute kidney injury.
One thousand thirty-four consecutive patients who underwent on-pump coronary artery bypass grafting between January 2004 and December 2007 were included. Propensity score analysis for transfusion was performed in the whole population; patients who were actually transfused were then divided according to leukoreduction. From these 2 groups, 147 pairs matched for propensity score were considered to evaluate with bivariate and multivariable analyses the effects of leukoreduction, with all-cause in-hospital mortality and morbidity as main outcomes.
Unadjusted in-hospital mortalities were 6.6% for the entire cohort and 44.2% for those with acute kidney injury. In the matched population, after introduction of leukoreduction, mortality rates decreased to 5.4% (vs 11.4%) and acute kidney injury (RIFLE [Risk, Injury, Failure, Loss of function, End-stage renal disease] class R or greater) dropped from 51.7% to 41.5% (relative risk -20%, P < .045). No difference emerged regarding other major complications. At multivariable analysis, intra-aortic balloon pump, RIFLE score, and propensity score for transfusion proved independent predictors of in-hospital mortality. Intra-aortic balloon pump and nonleukodepleted transfusion emerged as independent predictors of acute kidney injury. Multivariable analysis on the overall cohort of transfused patients confirmed that nonleukodepleted transfusion was an independent predictor of acute kidney injury.
Leukoreduction of allogeneic blood products is associated with decreased acute kidney injury and mortality in highly transfused patients.
No preview · Article · Jul 2010 · The Journal of thoracic and cardiovascular surgery
[Show abstract][Hide abstract] ABSTRACT: Superimposed acute right ventricular dysfunction in the setting of preexisting pulmonary hypertension is a nearly fatal complication after heart transplantation. The optimal treatment modality remains a matter of debate. Recently, sildenafil citrate, a nonselective pulmonary vasodilator, has gained popularity in the treatment of pulmonary hypertension in transplant candidates.
Herein we have presented a series of 13 patients in whom sildenafil was used to treat right ventricular dysfunction and pulmonary hypertension as detected by transesophageal echocardiography and Swan-Ganz right heart catheterization after heart transplant. Their characteristics were mean age 49+/-11.4 years; 38.4% with previous cardiac procedures, 30.8% status I, basal pulmonary vascular resistance index 10.4+/-4.6 WoodU, mean transpulmonary gradient 18.7+/-5.4 mmHg. In addition to conventional inodilator support, we administered 1 to 3 mg per kilogram of sildenafil. Complete hemodynamic measurements were obtained before and after the institution of the therapy and at 1-month follow-up.
Within the first 72 hours, acute right ventricular dysfunction resolved in all cases without untoward side effects or significant systemic impact. Sildenafil significantly decreased the transpulmonary gradient and pulmonary vascular resistance index relative to baseline values; 5.6+/-1.82 versus 10.4+/-4.6 WU, (P< .05), 13.5+/-3.4 mm Hg versus 18.7+/-5.4 mm Hg (P< .05), respectively. Improved indices of right ventricular function were observed on echocardiographic monitoring. After 1 month, sildenafil treatment was discontinued.
Management of acute right ventricular dysfunction in heart transplant recipients with pulmonary hypertension using sildenafil proved safe and effective.