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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.

The main disadvantage of a mechanical heart valve (MHV) is thrombosis, a serious complication that is associated with high morbidity and mortality. The early detection of thrombotic formations is crucial for a prompt diagnosis and correct therapy before critical symptoms appear in patients. The present study describes the in-vitro assessment of thrombotic deposits by ultrasound phonocardiography on five commercially available bileaflet MHVs.The closing sounds produced by bileaflet MHVs were acquired in the frequency range from 6 to 55 kHz. The corresponding power spectra were calculated and then analyzed by an artificial neural network (ANN) trained to classify the presence of simulated thrombotic formations of different weight and shape. Simulations were performed in a Sheffield pulse duplicator under different hydrodynamic regimes.Classification performances of the ANN depend on the range of frequency considered: better performances (up to 100% correct classification) are achieved when the entire spectrum is considered, rather than the audible (down to 87%) and ultrasound (down to 61%) regions, separately.Good and very good classification performances are achieved in vitro when phonocardiography is applied to detect and analyze the closing sounds produced by MHVs. Interestingly, extension of the analysis to the ultrasound region can improve classification efficiency. This finding allows the consideration of potential clinical applications of the proposed method to assign an MHV recipient to a risk class, thus enabling a prompt diagnosis.

To investigate the contribution of anti-platelet therapy and derangements of pre-operative classical coagulation and thromboelastometry parameters to major bleeding post-coronary artery bypass grafting (CABG).Two groups of CABG patients were studied: Group A, treated with aspirin alone (n = 50), and Group B treated with aspirin and clopidogrel (n = 50). Both had similar preoperative, clinical, biologic characteristics and operative management. Classic coagulation parameters and rotational thromboelastometry (ROTEM) profiles were determined preoperatively for both groups and the same heparin treatment was administered. ROTEM profiles (INTEM and EXTEM assays) were analyzed, both for traditional parameters, and thrombin generation potential, expressed by area-under-curve (AUC).There was no significant difference between rates of major bleeding between patients treated with aspirin alone, compared with those treated with aspirin and clopidogrel (12% vs 16%, P = 0.77). In the 14 cases of major bleeding, pre-operative classic coagulation and traditional ROTEM parameters were comparable. Conversely we observed that the AUC in the EXTEM test was significantly lower in bleeders (5030 ± 1115 Ohm*min) than non-bleeders (6568 ± 548 Ohm*min) (P0.0001).We observed that patients with a low AUC value were at a significantly higher risk of bleeding compared to patients with higher AUC, regardless of antiplatelet treatment. This suggests that thrombin generation potential, irrespective of the degree of platelet inhibition, correlates with surgical bleeding.