Search

OBJECTIVES Infants awaiting paediatric heart transplantation (PHT) experience long waitlist duration and high mortality due to donor shortage. Using the United Network for Organ Sharing database, we explored if increasing donor–recipient weight ratio (DRWR) >2.0 (recommended cutoff) was associated with adverse outcomes. METHODS Between 2007 and 2020, 1392 infants received PHT. We divided cohort into 3 groups: A (DRWR ≤1.0, n  = 239, 17%), B (DRWR 1.0–2.0, n  = 947, 68%), C (DRWR >2.0, n  = 206, 15%). Group characteristics and PHT outcomes were analysed. RESULTS DRWR ranged between 0.5 and 4.1. Underlying pathology (congenital versus cardiomyopathy), gender, race, renal function and mechanical circulatory support were comparable between groups. Group C patients were more likely to be ventilated, to receive ABO blood group (ABO)-incompatible heart and to have longer donor ischaemic time. Waitlist duration was significantly shorter for group C (33 vs 50 days, P  < 0.1). Early outcomes for groups A, B and C were the following (respectively): operative death (6%, 4%, 3%, P  = 0.29), primary graft dysfunction (5%, 3%, 3%, P  = 0.30), renal failure (10%, 7%, 7%, P  = 0.42) and stroke (3%, 4%, 1%, P  = 0.36). The DRWR group was not associated with operative death in either congenital (odds ratio (OR) = 0.819, 95% confidence interval (CI) = 0.523–1.282) or cardiomyopathy (OR = 1.221, 95% CI = 0.780–1.912) patients and only significant factor was pre-PHT extracorporeal membrane oxygenation (OR = 4.400, 95% CI = 2.761–7.010). Additionally, survival at 1 year (87%, 87%, 85%, P  = 0.80) and 5 years (76%, 78%, 77%, P  = 0.80) was comparable between the DRWR groups. CONCLUSIONS Infants who received PHT with DRWR >2.0, up to 4.1, experienced shorter waitlist duration with no demonstrable increase in peri-transplant complications, operative or late mortality. Historic practice to avoid DRWR > 2.0 due to complications (e.g. hypertension-related stroke, graft dysfunction, death) is not currently supported in infants and stretching DRWR acceptance criteria would decrease PHT waitlist duration and potentially improve waitlist complications and mortality. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES The clinical profile and outcomes of patients with Coronavirus Disease 2019 (COVID-19) who require veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or veno-arterial-venous extracorporeal membrane oxygenation (VAV-ECMO) are poorly understood. We aimed to describe the characteristics and outcomes of these patients and to identify predictors of both favourable and unfavourable outcomes. METHODS ECMOSARS is a multicentre, prospective, nationwide French registry enrolling patients who require veno-venous extracorporeal membrane oxygenation (ECMO)/VA-ECMO in the context of COVID-19 infection (652 patients at 41 centres). We focused on 47 patients supported with VA- or VAV-ECMO for refractory cardiogenic shock. RESULTS The median age was 49. Fourteen percent of patients had a prior diagnosis of heart failure. The most common aetiologies of cardiogenic shock were acute pulmonary embolism (30%), myocarditis (28%) and acute coronary syndrome (4%). Extracorporeal cardiopulmonary resuscitation (E-CPR) occurred in 38%. In-hospital survival was 28% in the whole cohort, and 43% when E-CPR patients were excluded. ECMO cannulation was associated with significant improvements in pH and FiO2 on day 1, but non-survivors showed significantly more severe acidosis and higher FiO2 than survivors at this point (P  = 0.030 and P  = 0.006). Other factors associated with death were greater age (P  = 0.02), higher body mass index (P  = 0.03), E-CPR (P  = 0.001), non-myocarditis aetiology (P  = 0.02), higher serum lactates (P  = 0.004), epinephrine (but not noradrenaline) use before initiation of ECMO (P  = 0.003), haemorrhagic complications (P  = 0.001), greater transfusion requirements (P  = 0.001) and more severe Survival after Veno-Arterial ECMO (SAVE) and Sonographic Assessment of Intravascular Fluid Estimate (SAFE) scores (P  = 0.01 and P  = 0.03). CONCLUSIONS We report the largest focused analysis of VA- and VAV-ECMO recipients in COVID-19. Although relatively rare, the need for temporary mechanical circulatory support in these patients is associated with poor prognosis. However, VA-ECMO remains a viable solution to rescue carefully selected patients. We identified factors associated with poor prognosis and suggest that E-CPR is not a reasonable indication for VA-ECMO in this population. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Haemorrhagic and thrombotic complications are known obstacles in extracorporeal life support (ECLS), and patients requiring post-cardiotomy (PC)-ECLS are particularly prone. The objective of this study was to characterize the incidence, type and clinical relevance of bleeding and thrombotic events in patients on PC-ECLS. METHODS: A total of 504 patients receiving PC-ECLS between 2000 and 2021 at a single centre were included in a retrospective analysis. Incidence and type of haemorrhagic and thrombotic complications in patients on PC-ECLS were assessed. Overall survival was compared, and perioperative risk factors for bleeding and thrombotic events were assessed by binary logistic regression. RESULTS: Of the 504 patients requiring PC-ECLS, 196 patients (38.9%) had 235 bleeding events [surgical site: n = 135 (26.8%); cannulation site: n = 68(13.4%); requiring surgical revision: n = 39 (7.7%); cannulation site change: n = 17 (3.4%); fatal cannulation site bleeding: n = 4(0.8%); intracranial haemorrhage: n = 11 (2.1%); gastrointestinal haemorrhage: n = 8 (1.6%); pulmonary haemorrhage: n = 8 (1.6%); and intra-abdominal/retroperitoneal haemorrhage: n = 5 (1%)]. Overall mortality was higher in patients with major bleeding complications than in patients without bleeding complications (P < 0.0001). A total of 74 patients (14.7%) had 84 thrombotic events [ischaemic stroke, n = 39 (7.7%); cannula/circuit thrombosis, n = 26 (5.2%); peripheral embolism, n = 11 (2.2%); device exchange for haemolysis, n = 8 (1.6%)]. Another 246 patients (48.8%) had at least 1 haemocompatibility-related adverse event. Preoperative dual antiplatelet therapy [adjusted odds ratio (OR): 1.83, 95% confidence interval (CI): 1.063–3.137] and ECLS duration (adjusted OR: 1.14, 95% CI: 1.086–1.197) were identified as independent risk factors for haemorrhage. Prior stroke/transient ischaemic attack (adjusted OR: 1.91, 95% CI: 1.08–3.83) and ECLS duration (adjusted OR: 1.09, 95% CI: 1.04–1.15) were identified as risk factors for thrombotic events. CONCLUSIONS: Bleeding complications in patients on ECLS are common and significantly impair survival. Nearly half of the patients were affected by any haemocompatibility-related event. Extracorporeal life support (ECLS) is an effective and valuable treatment option for patients in cardiogenic shock requiring temporary mechanical circulatory support. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Extracorporeal membrane oxygenation (ECMO) support prior to ventricular assist device (VAD) therapy is frequently used for stabilizing INTERMACS 1 and 2 paediatric patients. Data regarding outcomes with this strategy is limited. METHODS Patient characteristics and outcomes post-VAD therapy with and without preop ECMO support were compared. Survival and risk factor analysis was performed for all patients and INTERMACS profile 1 subgroup. RESULTS Of 541 INTERMACS 1 and 2 patients enrolled in Paediatric Interagency Registry for Mechanical Circulatory Support registry, 391 received primary VAD implantation and ECMO prior to VAD therapy was utilized in 150 patients. Younger age (P  < 0.0001) and shock (P  < 0.0001) were more common in group 2, with lower survival at 1, 6 and 12 months compared to group 1 (P  < 0.0001). Freedom from infection (P  = 0.03) was higher in group 1. Freedom from stroke (P  = 0.7) was similar. Paracorporeal continuous flow devices led to poor survival in both groups 1 and 2 (P  = 0.4). Implantable continuous flow (P  < 0.0001) and paracorporeal pulsatile devices (P  = 0.007) had better survival in primary VAD group. INTERMACS profile 1, lower weight, hepatic dysfunction, renal failure, paracorporeal continuous and percutaneous devices were associated with higher mortality. Preop ECMO therapy was not associated with higher mortality (P  = 0.12). Survival of INTERMACS profile 1 patient was similar at 1, 6 and 12 months in both groups (P  = 0.1). CONCLUSIONS INTERMACS profile 1, lower weight, hepatic dysfunction, renal failure and use of paracorporeal continuous flow or percutaneous assist devices are associated with a higher postoperative mortality. Preop ECMO therapy however is not independently associated with higher postop mortality. [ABSTRACT FROM AUTHOR]

Acute coronary syndrome with cardiogenic shock is a life-threatening condition, but with planned staged treatment combined with coronary revascularization and mechanical circulatory supports its management is increasingly possible. Here, we present our successful life-saving case. A 76-year-old male patient was diagnosed with ST-elevation myocardial infarction with cardiogenic shock due to severe stenosis of the left main coronary artery based on the severe triple vessel disease. We initially introduced Impella CP and performed a percutaneous coronary intervention without stenting on the patient. We maintained hemodynamics with Impella CP and performed coronary artery bypass grafting after a week. Intraoperatively, Impella CP was left to function as a left ventricular vent. The patient required upgrading to Impella 5.5 plus veno-arterial extracorporeal membrane oxygenation postoperatively, but his condition gradually improved, all mechanical circulatory supports could be weaned off, and he eventually survived. [ABSTRACT FROM AUTHOR]

Transplantation of donation after circulatory death (DCD) donor hearts is gaining acceptance. However, DCD heart selection has been understandably cautious. We report a case of reconditioning a DCD heart using thoraco-abdominal normothermic regional perfusion in a 46-year-old donor who suffered irreversible brain injury following emergency type-A aortic dissection repair. The DCD heart was procured with cold preservation and directly transplanted into a 63-year-old male who was bridged to transplant with extracorporeal life support. The recipient required a brief period of mechanical circulatory support post-transplant but made a good recovery. To our knowledge, this is the first report of successful heart transplantation from such an extended criteria DCD donor. [ABSTRACT FROM AUTHOR]

A 38-year-old male with sickle cell trait and acute refractory heart failure received an axillary intra-aortic balloon pump and short-term biventricular assist device. He underwent orthotopic heart transplantation 45 days later, which was complicated by major bleeding necessitating significant intra-operative transfusion. Support with veno-arterial extracorporeal membrane oxygenation was provided and successfully weaned five days later. He made a full recovery and remains alive and well 34 months after discharge. We hypothesize that the protective peri-operative measures undertaken, including normothermia during surgery and post-operative haemodynamic stability due to the use of mechanical circulatory support, conveyed a degree of protection against complications associated with sickle cell dysfunction and contributed to the successful outcome. [ABSTRACT FROM AUTHOR]

This article discusses the use of extracorporeal membrane oxygenation (ECMO) for patients with cardiopulmonary arrest (CPA) caused by acute aortic dissection type A (AAD). The effectiveness of ECMO for these patients is controversial, and the mortality rates are high. The article suggests that ECMO may be used for out-of-hospital cardiac arrest (OHCA) patients with AAD due to shorter CPR times and unknown causes of OHCA. The article also mentions that age and differences in medical services and insurance may contribute to the overuse of ECMO in Japan. The authors agree that aortic repair is the best treatment for CPA patients caused by AAD. [Extracted from the article]

Peripheral extracorporeal membrane oxygenation (ECMO) is one of the most common strategies for cardiogenic shock. ECMO cannulation is associated with an increased risk of complications. We describe a minimally invasive, off-pump technique to provide adequate hemodynamic support and left ventricular unloading. A 54-year-old male with nonischemic cardiomyopathy and severe peripheral vascular disease with cardiogenic shock was initially supported with inotropes and an intra-aortic balloon pump. Despite continued support, he continued to deteriorate, and we escalated to a temporary left ventricular support with a CentriMag, using a transapical ProtekDuo Rapid Deployment cannula via mini left-thoracotomy. This approach provides adequate hemodynamic support, left ventricular unloading and early ambulation. After 9 days, the patient's functional status was improved and was medically optimized. The patient received a left ventricular assist device as destination therapy. He was discharged home, resumed his normal activities and has been doing well for more than 27 months. [ABSTRACT FROM AUTHOR]

Keywords: Extracorporeal membrane oxygenation; Ventricular assist device; INTERMACS profile EN Extracorporeal membrane oxygenation Ventricular assist device INTERMACS profile 1 2 2 12/05/22 20221201 NES 221201 The article written by Peer I et al. i [[1]] deals with a very fascinating topic that is gaining interest in recent publications. In summary, the most critically ill patients, representing 67% of E-VAD patients versus 25% of P-VAD patients, had a worse outcome compared to less critical patients. If the patient needs ECMO to be rescued and survive (INTERMACS 1), the discussion should not concern the ECMO itself, but rather the critical condition of the patient. [Extracted from the article]

An editorial on the usage of extracorporeal life support (ELS) methods following a thoracic surgery, lung transplantation, and cardiorespiratory failure is presented. The authors talks about how ELS can provide short to mid-term extracorporeal mechanical support by helping in carbon dioxide (CO2) clearance, aiding oxygen (O2) enrichment and providing cardiocirculatory support. The authors also discuss the usage of Novalung lung assist device and Pumpless interventional lung assist device.

In addition, the respective dissection flap was found to inhibit aortic valve function, resulting in moderate AR - which mirrors an evident explanation for respiratory failure after initiation of vaECMO via flow-associated pulmonary fluid overload (C and D). CONSENT Patient deceased - therefore a signed patient or guardian consent is not available. [Extracted from the article]

Long-term survival and major outcomes in post-cardiotomy extracorporeal membrane oxygenation for adult patients in cardiogenic shock. Keywords: Extracorporeal life support; Post-cardiotomy; Cardiogenic shock; Mechanical circulatory assistance EN Extracorporeal life support Post-cardiotomy Cardiogenic shock Mechanical circulatory assistance 1186 1187 2 05/05/22 20220501 NES 220501 Extracorporeal life support (ECLS) represents one of the most frequent types of mechanical circulatory support used in case of post-cardiotomy acute cardiac failure [[1]]. [Extracted from the article]

OBJECTIVES: To address the safety (rate of thromboembolic events and circuit complications) and efficacy (rate of bleeding control) of recombinant activated coagulation factor VII (rFVIIa) to treat severe bleeding refractory to all surgical and medical treatments in patients under veno-arterial (VA) or veno-venous (VV) extracorporeal membrane oxygenation (ECMO) support. METHODS: In a tertiary referral University Cardiothoracic Surgery Centre including three intensive care units, 30 patients received the rFVIIa during ongoing VA or VV ECMO support (8.6% of ECMO activity from 2005 to 2014; N = 347). Early and late clinical results were analysed (retrospective analysis of prospectively collected data). In a substudy, a case-matching procedure was performed among ECMO patients who received (Group A) or did not receive (Group B) rFVIIa treatment. RESULTS: The mediastinum was the most common site of refractory bleeding (after heart transplantation or other cardiac surgery; 90%); 90% (n = 27) of patients were on VA ECMO and the remainder on VV ECMO. The survival rate at ECMO explantation and at the 30th post-implantation day was 67 and 50%, respectively. The final efficacy rate of rFVIIa in stopping bleeding was 93.3%. The rate of thromboembolic events was 3.3% (1 case) and the rate of circuit change was 16.7% (without instances of overt circuit clotting). After case-matching, Group A comprised 23 patients and Group B included 43 patients. No statistically significant differences were observed among groups in terms of thromboembolic events (P = 0.99), circuit change, ventilation time (P = 0.71), infectious complications (P = 06) and survival at both ECMO explantation and the 30th post-implantation day. Late survival was comparable (Kaplan-Meier analysis; P = 0.42). CONCLUSIONS: In case of life-threatening bleeding refractory to all conventional therapies, rFVIIa presents an acceptable safety profile in patients under ECMO support. No circuit dysfunctions and limited rates of thromboembolism are observed. [ABSTRACT FROM AUTHOR]

OBJECTIVES A significant number of children affected by congenital heart disease (CHD) develop heart failure early or late after surgery, and heart transplantation (OHTx) remains the last treatment option. Due to shortage of donor organs in paediatric group, mechanical circulatory support (MCS) is now routinely applied as bridging strategy to increase survival on the waiting list for OTHx. We sought to assess the impact of MCS as intention to bridge to OHTx in patients with CHD less than 16 years of age. METHODS From 1998 to 2013, 106 patients received 113 episodes of MCS with paracorporeal devices as intention to bridge to OHTx. Twenty-nine had CHD, 15 (52%) with two-ventricle (Group A) and 14 (48%) with single-ventricle physiology (Group B). In Group A, 5 children had venoarterial extracorporeal membrane oxygenation (VA ECMO), 6 left ventricular assist device (LVAD), 2 biventricular assist device (BIVAD), 1 VA ECMO followed by BIVAD and 1 BIVAD followed by VA ECMO. In Group B, VA ECMO was used in 7 children, univentricular assist device (UVAD) changed to VA ECMO in 4, UVAD in 2 and surgical conversion to two-ventricles physiology with BIVAD support changed to VA ECMO in 1. RESULTS Twenty-one of 29 (72%) children survived to recovery/OHTx. Seven of 29 (59%) survived to discharge. In Group A, 11/15 (73%) survived to recovery/OHTx and 9/15 (60%) survived to discharge. Four of 15 (27%) died awaiting OHTx. One child had graft failure requiring VA ECMO and was bridged successfully to retransplantation. One child dying after OHTx had acute rejection, was supported with VA ECMO and then BIVAD but did not recover. One patient had an unsuccessful second run on BIVAD 1 year after recovery from VA ECMO. In Group B, 10/14 (71%) survived to recovery/OHTx and 8/14 (57%) survived to discharge. Four of 14 (29%) died awaiting OHTx. Of deaths after OHTx, 1 occurred intraoperatively and 1 was consequent to graft failure and had an unsuccessful second run with VA ECMO. CONCLUSIONS Children with CHD can be successfully bridged with MCS to heart transplantation. Single-ventricle circulation compared with biventricular physiology does not increase the risk of death before transplant or before hospital discharge. [ABSTRACT FROM AUTHOR]

OBJECTIVES We observed early acute lung injury (ALI) after a switch from veno-arterial extracorporeal life support (VA-ECLS) to long-term mechanical circulatory support (MCS). The aim of our study was to analyse the frequency, impact on mortality and characteristics of patients presenting ALI after MCS implantation in the bridge-to-bridge (BTB) strategy. METHODS We retrospectively analysed data from 55 consecutive cardiogenic shock patients who underwent a BTB strategy between January 2004 and March 2012 in our centre. ALI was defined as severe acute respiratory failure (PaO2/FiO2 <200) with or without need for iterative VA-ECLS or veno-venous (VV)-exracorporeal membrane oxygenation (ECMO) occurring within 48 h of MCS implantation. RESULTS ALI was observed in 15 of 55 (27%) patients. Eleven patients required VV-ECMO or VA-ECLS and 4 were treated medically. The median (interquartile range) duration of support under a long-term device was 47.5 (168.8) days. Mortality while on long-term support was significantly higher in patients who developed ALI (13 of 15, 87%) than in those who did not (21 of 40, 53%; P = 0.03). Hazard ratio for death while on support in patients who developed ALI when compared with those who did not was 3.390 (95% confidence interval, 1.636–7.026, P = 0.001). Univariate risk factors for postimplant ALI included: signs of pulmonary oedema while under extracorporeal life support (ECLS) during the week preceding long-term device implantation; mechanical ventilation, the incomplete recovery of renal and hepatic functions and the number of red blood cell units transfused at the time of long-term device implantation, and use of pulsatile, biventricular support. CONCLUSIONS Implantation of a long-term MCS device in patients on ECLS can result in severe ALI, which is associated with ominous outcomes. Various preimplant risk factors for ALI have been identified and might allow devising strategies to prevent this complication. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To define the outcomes following Ross and Yasui procedures for complex biventricular repair of critical left ventricular outflow tract obstruction (LVOTO). Methods: Of 1217 neonates presenting with critical LVOTO enrolled in the Congenital Heart Surgeons Society studies (1994–2008), 52 underwent the Ross or Yasui procedure and their outcomes were investigated using univariate and multivariable parametric models. Results: ROSS (N =39): The Ross procedure (median age 87 days) was rarely the primary intervention (5/39, 13%). A significant number of cases were performed to treat iatrogenic aortic regurgitation after other previous interventions (25/39, 64%). Co-existing functional morphological defects were also common: 72% had preoperative evidence of mitral dysfunction, moderate-to-severe left ventricular dysfunction or endocardial fibroelastosis. Emergency iatrogenic aortic regurgitation (P =0.005) and co-existing abnormalities (mitral stenosis, P =0.02; mitral regurgitation, P =0.05; LV dysfunction, P =0.03) were strong determinants of death. Severe postoperative ventricular dysfunction or need for extracorporeal membrane oxygenation (ECMO) conferred negligible survival. Younger age was associated with disproportionately worse late outcome (5-year survival 44±10% for neonates vs 76±8% for age >3 months, P =0.0013). However, mitral and left ventricular dysfunction and emergency presentation were significantly more common in the younger age groups. Infants less than 3 months of age without co-existing abnormalities had acceptable late survival (≈75±20%). YASUI (N =13): Yasui repair (median age 22 days) was usually the primary intervention (nine of 13) but occasionally followed Norwood palliation (four of 13). None was an emergency. All had a ventricular septal defect. Survival was 69±13% at 10 years, which is not significantly different from other biventricular repair strategies in neonates. Aortic atresia was associated with better survival than stenosis (90±12% vs 30±14% at 3 years, P =0.039). None reverted to univentricular physiology later. Conclusions: Case selection is key for complex biventricular repair and the importance of appropriate case selection is exaggerated at young ages. All available options should be considered before pursuing the Ross operation in the presence of co-existing functional morphological abnormalities or emergent iatrogenic aortic regurgitation. However, both the Ross and Yasui operations in children (including neonates and young infants) with favourable functional morphology offer good survival, at least matching that of other biventricular repair strategies. [Copyright &y& Elsevier]

The article cites the challenges in procuring organs for transplantation after death. It says that many organs for donations are declined due to non-function of the transplant and although scoring systems exist to aid donor and recipient selection, these have not been widely validated and are only used as guide. It adds that extracorporeal membrane oxygenation (ECMO) and extracorporeal organ perfusion are two of the most promising techniques to optimize the function of donated organs.

We report a case of acute tamponade of the left paracorporeal pump house in a patient supported by a Berlin Heart EXCOR biventricular assist device (BiVAD) caused by mechanical defect in the membrane of the arterial chamber. A 36-year old male was admitted for composite graft surgery due to a large aortic regurgitation and consecutive heart failure, decompensated postoperatively and was rescued by with an extracorporeal membrane oxygenation (ECMO) device. He was accepted for heart transplantation, and a BiVAD (Berlin Heart EXCOR) was implanted as bridge-to-transplantation. Two months after discharge, he experienced dyspnoea and received error signals from his BiVAD. Relatives released him from his BiVAD companion driver, connected him to the hand pump and transported him to our institution. On arrival, he was in cardiogenic shock and was stabilized by ECMO. Inspection of the arterial chamber revealed a wear hole and delamination of the diaphragm, which had led to a tamponade by air insufflation into the three-layer membrane. New BiVAD paracorporeal pumps were connected, and the patient was subsequently successfully transplanted. The case depicts the difficulty of diagnosis in this specific patient setting. Despite transparent design of the BiVAD chambers, the development of a chamber tamponade remained undetected until explantation of the system. [ABSTRACT FROM AUTHOR]

The author discusses the challenges in providing mechanical circulatory support to children with congenital heart disease in. The author cites the success of a team from Newcastle, England with bridge to heart transplantation with extracorporeal membrane oxygenator (ECMO). The author believes that using VAD as a rescue strategy is link with high mortality but mechanical support can successfully bridge congenital heart disease to transplantation.