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Sepsis-induced cardiomyopathy (SCM) is an increasingly recognized problem encountered in critical care medicine. It generally is characterized as a decrease in left, right, or biventricular ejection fraction followed by a recovery of function over a period of days to weeks. Venoarterial extracorporeal membrane oxygenation (ECMO) has been used for the treatment of adults with various etiologies of shock, including cardiogenic and septic shock. This review summarizes current pathophysiologic mechanisms leading to SCM and provides a detection and treatment algorithm for SCM, as well as a discussion about the rationale and recent clinical data surrounding the use of ECMO and other forms of mechanical circulatory support for SCM.

Objectives The aim of the present study was to describe a bicaval endovascular occlusion technique in minimally invasive tricuspid valve (TV) surgery in patients with previous cardiac surgery. Design Case series. Setting Single tertiary university center. Participants The study comprised ten patients. Interventions Endovascular occlusion of vena cavae for minimally invasive TV redo surgery. Measurements and Main Results Between 2008 and 2017, ten patients with previous cardiac surgery underwent TV minimally invasive surgery (repair or replacement; isolated or with concomitant procedures) using the Coda balloon catheter (Cook Medical, Bloomington, IN) to occlude both vena cavae. Data were collected retrospectively from electronic medical records. Superior and inferior vena cava occlusion with Coda balloon catheters was successful with no complications. The drainage of the vena cavae was optimal with excellent surgical exposure. Cardiopulmonary bypass time was 131 ± 119 minutes, with 30% of patients undergoing aortic clamping (two with a Chitwood clamp, one with an endoaortic balloon). Intensive care unit length of stay was 3.9 ± 2.7 days, and the in-hospital mortality rate was 30%. Conclusion Bicaval endovascular occlusion of vena cavae is a feasible and effective technique in patients with previous cardiac surgery who are undergoing a minimally invasive TV procedure. The high mortality rate is associated with the inherent risk of a redo surgery involving the TV.

Right ventricular (RV) dysfunction is a cause of increased morbidity and mortality in both cardiac surgery and noncardiac surgery and in the intensive care unit. Early diagnosis of this condition still poses a challenge. The diagnosis of RV dysfunction traditionally is based on a combination of echocardiography, hemodynamic measurements, and clinical symptoms. This review describes the method of using RV pressure waveform analysis to diagnose and grade the severity of RV dysfunction. The authors describe the technique, optimal use, and pitfalls of this method, which has been used at the Montreal Heart Institute since 2002, and review the current literature on this method. The RV pressure waveform is obtained using a pulmonary artery catheter with the capability of measuring RV pressure by connecting a pressure transducer to the pacemaker port. The authors describe how RV pressure waveform analysis can facilitate the diagnosis of systolic and diastolic RV dysfunction, the evaluation of RV-arterial coupling, and help diagnose RV outflow tract obstruction. RV pressure waveform analysis also can be used to guide pharmacologic treatment and fluid resuscitation strategies for RV dysfunction.

Objective To report the authors’ 12 years of experience with intratracheal milrinone administration and to assess the efficacy and limitations of intratracheal milrinone bolus administration for the treatment of unexpected acute right ventricular (RV) failure in patients undergoing cardiac surgery. Design Retrospective analysis. Setting Single-center university hospital. Participants One hundred seventy-six patients (4.6%) undergoing on-pump cardiac surgery. Interventions Endotracheal tube administration of milrinone (5-mg bolus) after unexpected acute RV failure during separation from cardiopulmonary bypass (CPB) weaning. RV failure was defined as the simultaneous presence of all of the following criteria: (1) hemodynamic instability or difficult separation from CPB with associated elevated central venous pressure or abnormal RV pressure waveform, (2) >20% reduction of RV fractional area change from baseline evaluated by transesophageal echocardiography, and (3) anatomical visualization of impaired or absent RV wall motion by direct intraoperative visual inspection. Measurements and Main Results Intratracheal milrinone administration was found to improve RV failure in 109 patients (61.9%) whereas RV failure persisted in 67 patients (38.1%). Using a multiple logistic regression model, severely decreased left ventricular ejection fraction ( 50%) (adjusted odds ratio [OR] 3.72; 95% confidence interval [CI] 1.2-11.3; p = 0.012), longer CPB time (adjusted OR 1.014; CI 1.01-1.02; p = 0.001) and elevated postoperative fluid balance (adjusted OR 1.39; CI 1.1-1.8; p = 0.02) were found to be significant predictors of persistent RV failure. Conclusion Intratracheal instillation of milrinone was associated with clinical improvement of RV failure occurring during separation from CPB in almost two-thirds of patients. Factors limiting its therapeutic efficacy include severe left ventricular dysfunction, increased fluid balance, and long CPB time.

Objective The authors aimed to assess the hemodynamic effects and demonstrate the feasibility of inhaled nitric oxide (iNO) in hemodynamically unstable patients with acute right ventricular (RV) dysfunction and to explore the safety profile of this approach. Design Retrospective cohort study. Setting Intensive care unit (ICU) of 2 tertiary care centers between January 2013 and 2017. Participants All patients with RV dysfunction in whom iNO was initiated without invasive mechanical ventilation. Intervention Noninvasive administration of iNO. Measurements and Main Results Eighteen patients received the intervention during the study period; 8 of these patients had a pulmonary artery catheter and 2 had a pulse contour analysis device. Median (interquartile range) iNO concentration was 20 (20-20) ppm, and therapy duration was 24 (12-46) hours. Most patients received iNO through nasal prongs (66.7%) or a high-flow nasal cannula (27.8%). Within 1 hour, iNO reduced pulmonary vascular resistance from 219.1 to 165.4 dyn•s/cm5 (n = 7; p Conclusion Noninvasively administered iNO was associated with favorable hemodynamic effects in ICU patients with acute RV dysfunction. These results suggest the safety and feasibility of this therapy for which further prospective study is warranted.

In this report, the clinical evolution of a 72-year-old patient transferred to the surgical intensive care unit after cardiac surgery is described. The presence of a pulsatile Doppler signal of the common femoral vein was noted after surgery. On postoperative day 5, diuretics in addition to a combination of inhaled epoprostenol and milrinone were associated with normalization of femoral vein pulsatility. The observations seen in peripheral venous flow reinforce the hypothesis that pulsatility of the common femoral vein represents an associated echocardiographic sign of right ventricular dysfunction and may be used to monitor systemic venous congestion. Pulsatility in the venous system may be improved by reducing volume overload and improving right ventricular function.

Objective To compare antegrade and retrograde cardioplegia administration in minimally invasive mitral valve surgery (MIMS) and open mitral valve surgery (OMS) for myocardial protection. Design Retrospective study. Setting Tertiary care university hospital. Participants The study comprised 118 patients undergoing MIMS and 118 patients undergoing OMS. Interventions The data of patients admitted for MIMS from 2006 to 2010 were reviewed. Patients undergoing isolated elective OMS from 2004 to 2006 were used as a control group. Cardioplegia in the MIMS group was delivered via the distal port of the endoaortic clamp and an endovascular coronary sinus catheter positioned using echographic and fluoroscopic guidance. Antegrade and retrograde cardioplegia were used in OMS. Data regarding myocardial infarction (MI) (creatine kinase [CK]-MB, troponin T, electrocardiography); myocardial function; and hemodynamic stability were collected. Measurements and Main Results There was no difference in the perioperative MI incidence between both groups (1 in each group, p = 0.96). No statistically significant difference was found for maximal CK-MB (35.9 µg/L [25.1-50.1] v 37.9 µg/L [28.6-50.9]; p = 0.31) or the number of patients with CK-MB levels >50 µg/L (29 v 33; p = 0.55) or CK-MB >100 µg/L (3 v 4; p = 0.70) between the OMS and MIMS groups. However, maximum troponin T levels in the MIMS group were significantly lower (0.47 µg/L [0.32-0.79] v 0.65 µg/L [0.45-0.94]; p = 0.0007). No difference in the incidence of difficult weaning from bypass and intra-aortic balloon pump use between the MIMS and OMS groups was found. Conclusions Antegrade and retrograde cardioplegia administration during MIMS and OMS provided comparable myocardial protection.