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Pulmonary embolism (PE) is a common disease with an annual incidence rate ranging from 39–115 per 100,000 inhabitants. It is one of the leading causes of cardiovascular mortality in the USA and Europe. While the clinical presentation and severity may vary, it is a life-threatening condition in its most severe form, defined as high-risk or massive PE. Therapeutic options in high-risk PE are limited. Current guidelines recommend the use of systemic thrombolytic therapy as first-line therapy (Level Ib). However, this treatment has important drawbacks including bleeding complications, limited efficacy in patients with recurrent PE or cardiac arrest, and formal contraindications. In this context, the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in the management of high-risk PE has increased worldwide in the last decade. Strategies, including VA-ECMO as a stand-alone therapy or as a bridge to alternative reperfusion therapies, are associated with acceptable outcomes, especially if implemented before cardiac arrest. Nonetheless, the level of evidence supporting ECMO and alternative reperfusion therapies is low. The optimal management of high-risk PE patients will remain controversial until the realization of a prospective randomized trial comparing those cited strategies to systemic thrombolysis.

Resume La perfusion tissulaire d’un organe est a la fois tributaire de la circulation centrale et de la microcirculation. Bien que cette derniere entite soit la composante « vitale » du systeme cardiovasculaire, elle a longtemps ete negligee en comparaison a l’etude approfondie de la macrocirculation. Neanmoins, s’il y a une discipline medicale qui a rendu ses lettres de noblesse a la physiologie de la circulation sanguine capillaire, c’est bien la reanimation. En effet, en traitant le patient en etat de choc, le reanimateur a ete confronte a des maladies et des syndromes ou les dysfonctionnements majeurs de perfusion d’organes n’etaient pas toujours expliques par les determinants de la circulation centrale habituellement recueillis en reanimation. En effet, recemment, les connaissances physiopathologiques et les techniques de monitorage de la circulation capillaire sont devenues incontournables pour traiter les patients de reanimation. Le monitorage du comportement microcirculatoire permet de nos jours d’identifier puis de traiter les phenomenes fondamentaux a l’origine du decouplage macro-microcirculatoires. A cet egard, la presente revue expose quelques exemples d’alterations de la perfusion tissulaire observes en reanimation, ou l’ensemble arteres-arterioles et vaisseaux situes plus en aval ont perdu toute synchronie physiologique a meme de leur permettre une perfusion optimale des organes vitaux.

ECMO is the most frequently used mechanical support for patients suffering from low cardiac output syndrome. Combining IABP with ECMO is believed to increase coronary artery blood flow, decrease high afterload, and restore systemic pulsatile flow conditions. This study evaluates that combined effect on coronary artery flow during various load conditions using an in vitro circuit. In doing so, different clinical scenarios were simulated, such as normal cardiac output and moderate-to-severe heart failure. In the heart failure scenarios, we used peripheral ECMO support to compensate for the lowered cardiac output value and reach a default normal value. The increase in coronary blood flow using the combined IABP-ECMO setup was more noticeable in low heart rate conditions. At baseline, intermediate and severe LV failure levels, adding IABP increased coronary mean flow by 16%, 7.5%, and 3.4% (HR 60 bpm) and by 6%, 4.5%, and 2.5% (HR 100 bpm) respectively. Based on our in vitro study results, combining ECMO and IABP in a heart failure setup further improves coronary blood flow. This effect was more pronounced at a lower heart rate and decreased with heart failure, which might positively impact recovery from cardiac failure.

The SARS-CoV-2 pandemic has overwhelmed health care systems worldwide since its first wave. Intensive care units have been under a significant amount of pressure as patients with the most severe form of the disease presented with acute respiratory distress syndrome (ARDS). A proportion of them experienced refractory acute respiratory failure and had to be supported with veno-venous extracorporeal membrane oxygenation (VV-ECMO). The present retrospective study reports the experiences of our ECMO center in the management of COVID-19 patients with refractory ARDS. Patient characteristics and outcomes are presented through the different waves of the pandemic. A cohort study was conducted on patients with refractory ARDS due to COVID-19 infection who were admitted to the intensive care unit (ICU) at the Geneva University Hospital and supported with VV-ECMO between 14 March 2020 and January 2022. The VV-ECMO implementation criteria were defined according to an institutional algorithm validated by the local crisis unit of the hospital and the Swiss Society of Intensive Care Medicine. Among the 500 ARDS patients admitted to our ICU, 41 patients with a median age of 57 (52–63) years, a body mass index (BMI) of 28 (26–32) kg/m2, and a SAPS II score of 57 (47–67), and 27 (66%) of whom were men required VV-ECMO. None of the patients were vaccinated. The time of ventilation, including noninvasive ventilation (NIV) and mechanical ventilation (MV), and the time of MV before ECMO were 7 (4–11) days and 4 (1–7) days, respectively. The time under ECMO was 20 (10–27) days. The ICU and hospital lengths of stay were 36 (21–45) days and 45 (33–69) days, respectively. The survival rate for patients on ECMO was 59%. Comparative analysis between survivors and non-survivors highlighted that survivors had a significantly shorter ventilation duration before ECMO (NIV + MV: 5.5 (1.3–9) vs. 9 (6.5–13.5) days, p = 0.0026 and MV alone: 1.6 (0.4–5.5) vs. 5.8 (5–8) days, p < 0.0001). The management of patients on ECMO by an experienced ECMO team dedicated to this activity was associated with improved survival (78% vs. 28%, p = 0.0012). Between the first wave and the following waves, patients presented with a higher incidence of ventilator-associated pneumonia (100% vs. 82%, p = 0.0325) but had better survival rates (74% vs. 35%, p = 0.024). The present study suggests that both the prompt insertion of VV-ECMO to control refractory hypoxemia and the involvement of an ECMO team improve the survival of COVID-19 patients.

OBJECTIVES Sepsis is a common condition in the ICU. Despite much research, its prognosis remains poor. In 2017, a retrospective before/after study reported promising results using a combination of thiamine, ascorbic acid, and hydrocortisone called "metabolic resuscitation cocktail" and several randomized controlled trials assessing its effectiveness were performed. DESIGN We conducted a systematic review and meta-analysis of randomized controlled trials in septic ICU patients to assess the effects of this combination therapy. SETTING PubMed, Embase, and the Cochrane library databases were searched from inception to March of 2021. Data were extracted independently by two authors. The main outcome was the change in Sequential Organ Failure Assessment score within 72 hours. Secondary outcomes included renal composite endpoints (acute kidney injury) Kidney Disease - Improving Global Outcome organization stage 3 or need for renal replacement therapy, vasopressor duration, and 28-day mortality. SUBJECTS We included randomized controlled trials with patients admitted to the ICU with sepsis or septic shock. INTERVENTION The trials compared a combination of thiamine, ascorbic acid, and hydrocortisone to standard care or placebo in patients admitted to ICU with sepsis or septic shock. MEASUREMENTS AND MAIN RESULTS We included eight randomized controlled trials (n = 1,335 patients). Within 72 hours, the median of mean improvement was -1.8 and -3.2 in the control and intervention groups, respectively (eight randomized controlled trials, n = 1,253 patients); weighted mean difference -0.82 (95% CI, -1.15 to -0.48). Data were homogeneous and the funnel plot did not suggest any publication bias. Duration of vasopressor requirement was significantly reduced in the intervention group (six randomized controlled trials). There was no evidence of a difference regarding the ICU mortality and the renal composite outcome (acute kidney injury KDIGO 3 or need for renal replacement therapy, seven randomized controlled trials). CONCLUSIONS Metabolic resuscitation cocktail administrated in ICU septic patients improves change in Sequential Organ Failure Assessment score within 72 hours. However, this improvement is modest and its clinical relevance is questionable. The impact on renal failure and mortality remains unclear.

Objective The present study investigates whether ScvO2 variations induced by passive leg raising (PLR) are able to predict fluid responsiveness (FR) in mechanically ventilated patients. Design A monocentric prospective clinical study. Setting An intensive care division in a tertiary hospital. Patients The inclusion criteria were elective postoperative cardiac surgery patients who were over 18 years old, deeply sedated, mechanically ventilated and needed volume expansion (VE). Fluid responders (R) were defined as patients who increased their left ventricular outflow tract velocity time integral (VTI) ≥15% after VE. Intervention In patients included in this study, continuous ScvO2 monitoring (CeVOX device, Pulsion Medical Systems) and VTI (transthoracic echocardiography) were measured simultaneously before and during a PLR test and before and after VE (with 500 ml of saline). Measurements and main results Thirty‐three consecutive patients were included in this study. In 15 patients with a positive PLR test (increase in VTI ≥15%), ScvO2 increased during PLR by 9 ± 4%. In the 18 patients with a negative PLR test, ScvO2 did not significantly change during PLR. VE increased ScvO2 by 9 ± 6% and 2 ± 4% in responders and nonresponders, respectively. If ScvO2 increased by >4% during the PLR test, then a positive VTI response (≥15%) was diagnosed with a sensitivity of 93% (68–99%) and a specificity of 94% (63–99%) (Area under the receiver operating characteristic curve 0.92 ± 0.58, p, ScvO2 variation induced by PLR is a reliable, minimally invasive parameter for predicting FR at the bedside of deeply sedated, mechanically ventilated, critically ill patients undergoing cardiac surgery.

Introduction: Massive acute pulmonary embolism (MAPE) with obstructive cardiogenic shock is associated with a mortality rate of more than 50%. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been increasingly used in refractory cardiogenic shock with very good results. In MAPE, although it is currently recommended as part of initial resuscitation, it is not yet considered a stand-alone therapy. Material and Methods: All patients with MAPE requiring the establishment of VA-ECMO and admitted to our tertiary intensive care unit were analysed over a period of 10 years. The characteristics of these patients, before, during and after ECMO were extracted and analysed. Results: A total of 36 patients were included in the present retrospective study. Overall survival was 64%. In the majority of cases, the haemodynamic and respiratory status of the patient improved significantly within the first 24 h on ECMO. The 30-day survival significantly increased when ECMO was used as stand-alone therapy (odds ratio (OR) 15.58, 95% confidence interval (CI) 2.65–91.57, p = 0.002). Nevertheless, when ECMO was implanted following the failure of thrombolysis, the bleeding complications were major (17 (100%) vs. 1 (5.3%) patients, p &lt, 0.001) and the 30-day mortality increased significantly (OR 0.11, 95% CI 0.022–0.520, p = 0.006). Conclusions: The present retrospective study is certainly one of the most important in terms of the number of patients with MAPE and shock treated with VA-ECMO. This short-term mechanical circulatory support, used as a stand-alone therapy in MAPE, allows for the optimal stabilisation of patients.

Chronic obstructive pulmonary disease (COPD) exacerbation induces hypercapnic respiratory acidosis. Extracorporeal carbon dioxide removal (ECCO2R) aims to eliminate blood carbon dioxide (CO2) in order to reduce adverse effects from hypercapnia and the related acidosis. Hypercapnia has deleterious extra-pulmonary consequences in increasing intracranial pressure and inducing and/or worsening right heart failure. During COPD exacerbation, the use of ECCO2R may improve the efficacy of non-invasive ventilation (NIV) in terms of CO2 removal, decrease respiratory rate and reduce dynamic hyperinflation and intrinsic positive end expiratory pressure, which all contribute to increasing dead space. Moreover, ECCO2R may prevent NIV failure while facilitating the weaning of intubated patients from mechanical ventilation. In this review of the literature, the authors will present the current knowledge on the pathophysiology related to COPD, the principles of the ECCO2R technique and its role in acute and severe decompensation of COPD. However, despite technical advances, there are only case series in the literature and few prospective studies to clearly establish the role of ECCO2R in acute and severe COPD decompensation.

BackgroundChronic obstructive pulmonary disease (COPD) exacerbation and protective mechanical ventilation of acute respiratory distress syndrome (ARDS) patients induce hypercapnic respiratory acidosis.Main textExtracorporeal carbon dioxide removal (ECCO2R) aims to eliminate blood CO2to fight against the adverse effects of hypercapnia and related acidosis. Hypercapnia has deleterious extrapulmonary consequences, particularly for the brain. In addition, in the lung, hypercapnia leads to: lower pH, pulmonary vasoconstriction, increases in right ventricular afterload, acute cor pulmonale. Moreover, hypercapnic acidosis may further damage the lungs by increasing both nitric oxide production and inflammation and altering alveolar epithelial cells. During an exacerbation of COPD, relieving the native lungs of at least a portion of the CO2could potentially reduce the patient's respiratory work, Instead of mechanically increasing alveolar ventilation with MV in an already hyperinflated lung to increase CO2removal, the use of ECCO2R may allow a decrease in respiratory volume and respiratory rate, resulting in improvement of lung mechanic. Thus, the use of ECCO2R may prevent noninvasive ventilation failure and allow intubated patients to be weaned off mechanical ventilation. In ARDS patients, ECCO2R may be used to promote an ultraprotective ventilation in allowing to lower tidal volume, plateau (Pplat) and driving pressures, parameters that have identified as a major risk factors for mortality. However, although ECCO2R appears to be effective in improving gas exchange and possibly in reducing the rate of endotracheal intubation and allowing more protective ventilation, its use may have pulmonary and hemodynamic consequences and may be associated with complications.ConclusionIn selected patients, ECCO2R may be a promising adjunctive therapeutic strategy for the management of patients with severe COPD exacerbation and for the establishment of protective or ultraprotective ventilation in patients with ARDS without prognosis-threatening hypoxemia.

Introduction Current knowledge on the use of extracorporeal membrane oxygenation (ECMO) in COVID‐19 remains limited to small series and registry data. In the present retrospective monocentric study, we report on our experience, our basic principles, and our results in establishing and managing ECMO in critically ill COVID‐19 patients. Methods A cohort study was conducted in patients with severe acute respiratory distress syndrome (ARDS) related to COVID‐19 pneumonia admitted to the ICU of the Geneva University Hospitals and supported by VV‐ECMO from March 14 to May 31. The VV‐ECMO implementation criteria were defined according to an institutional algorithm validated by the local crisis unit and the Swiss Society of Intensive Care Medicine. Results Out of 137 ARDS patients admitted to our ICU, 10 patients (age 57 ± 4 years, BMI 31.5 ± 5 kg/m2, and SAPS II score 56 ± 3) were put on VV‐ECMO. The mean duration of mechanical ventilation before ECMO and mean time under ECMO were 7 ± 3 days and 19 ± 11 days, respectively. The ICU and hospital length of stay were 26 ± 11 and 35 ± 10 days, respectively. The survival rate for patients on ECMO was 40%. The comparative analysis between survivors and non‐survivors highlighted that survivors had a significantly shorter mechanical ventilation duration before ECMO (4 ± 2 days vs. 9 ± 2 days, p = 0.01). All the patients who had more than 150 h of mechanical ventilation before the application of ECMO ultimately died. Conclusion The present results suggest that VV‐ECMO can be safely utilized in appropriately selected COVID‐19 patients with refractory hypoxemia. The main information for clinicians is that late VV‐ECMO therapy (i.e., beyond the seventh day of mechanical ventilation) seems futile., Time‐course of COVID‐19 pneumoniafrom the onset of symptoms to the decision to implement VV‐ECMO according to the results of this study. HFNO, high‐flow nasal oxygen; CPAP, continuous positive airway pressure

Type A lactic acidosis is a potentially life‐threatening complication in critically ill patients and is the hallmark of a shock state as a result of tissue hypoperfusion and dysoxia. Type B lactic acidosis results from mechanisms other than dysoxia and is a rare condition in patients with solid tumors or hematological malignancies. We present a case of a 60‐year‐old man with lactic acidosis who was found to have a Burkitt lymphoma related to a posttransplant lymphoproliferative disorder. Lactagenic cancers are characterized by increased aerobic glycolysis and excessive lactate formation, a phenomenon described by Warburg in 1923 that is correlated with cancer aggressiveness and poor survival. There is increased glucose utilization with the purpose of lactagenesis under fully oxygenated conditions, as lactate seems to be a potent signaling molecule for angiogenesis, immune escape, cell migration, metastasis and self‐sufficient metabolism, which are five essential steps of carcinogenesis. Type B lactic acidosis in association with malignancies carries an extremely poor prognosis. Currently, effective chemotherapy seems to be the only hope for survival., Lactagenic cancers are characterized by increased aerobic glycolysis and excessive lactate formation, a phenomenon described by Warburg in 1923 that is correlated with cancer aggressiveness and poor survival. Type B lactic acidosis in association with malignancies carries an extremely poor prognosis. Currently, effective chemotherapy seems to be the only hope for survival.

The IABP gives rise to greater myocardial perfusion by increasing the coronary pressure gradient from the aorta to the coronary circulation at a time when the aortic valve is closed [...]

Stress hyperglycemia is a transient increase in blood glucose during acute physiological stress in the absence of glucose homeostasis dysfunction. Its's presence has been described in critically ill patients who are subject to many physiological insults. In this regard, hyperglycemia and impaired glucose tolerance are also frequent in patients who are admitted to the intensive care unit for heart failure and cardiogenic shock. The hyperglycemia observed at the beginning of these cardiac disorders appears to be related to a variety of stress mechanisms. The release of major stress and steroid hormones, catecholamine overload, and glucagon all participate in generating a state of insulin resistance with increased hepatic glucose output and glycogen breakdown. In fact, the observed pathophysiological response, which appears to regulate a stress situation, is harmful because it induces mitochondrial impairment, oxidative stress‐related injury to cells, endothelial damage, and dysfunction of several cellular channels. Paradigms are now being challenged by growing evidence of a phenomenon called glucotoxicity, providing an explanation for the benefits of lowering glucose levels with insulin therapy in these patients. In the present review, the authors present the data published on cardiac glucotoxicity and discuss the benefits of lowering plasma glucose to improve heart function and to positively affect the course of critical illness., A review of the pathophysiological and clinical evidence surrounding the impact of stress hyperglycemia and cardiac glucotoxicity on cardiac physiology.

Extracorporeal carbon dioxide removal (ECCO2R) is a low blood flow veno-venous extracorporeal membrane oxygenation technique that provides artificial blood CO2removal. Recently, a new ECCO2R system (PrismaLung), providing very low blood flow has been commercialized. The aim of this study is to report its use in severe chronic obstructive pulmonary disease (COPD) patients needing an ECCO2R therapy. Six severe COPD patients with acute exacerbation leading to refractory hypercapnic respiratory acidosis were treated with ECCO2R therapy. Two different systems were used: a PrismaLung system and a conventional ECCO2R device. The maximum blood flow provided by PrismaLung was significantly lower than that with the conventional ECCO2R system. In three patients initially treated with PrismaLung, there were no improvements in pH, PaCO2, or RR. Thus, the therapy was switched to a conventional ECCO2R system in these three patients, and three others were treated from the outset by the conventional ECCO2R system, providing significant improvement in pH, PaCO2, and RR. The present retrospective study describes the first use of PrismaLung in severe COPD patients with acute exacerbation. When compared with a higher blood flow ECCO2R system, our results show that this novel, very low-flow device is not able to remove sufficient CO2, normalize pH or decrease respiratory rate.

Understanding the respiratory mechanics of ARDS patients is crucial to avoid ventilator-induced lung injury (VILI), and this is much more challenging if not only lung compliance is altered but the whole compliance of the respiratory system is abnormal, as in obese patients. We face this problem daily in the ICU, and to optimize ventilation, we estimate respiratory mechanics using an oesophageal balloon. The balloon position is crucial to assess reliable values. In the present technical note, we describe the use of echocardiography to confirm the correct position of this instrument.

Cardiac arrest (CA) is a frequent cause of death and a major public health issue. To date, conventional cardiopulmonary resuscitation (CPR) is the only efficient method of resuscitation available that positively impacts prognosis. Extracorporeal membrane oxygenation (ECMO) is a complex and costly technique that requires technical expertise. It is not considered standard of care in all hospitals and should be applied only in high-volume facilities. ECMO combined with CPR is known as ECPR (extracorporeal cardiopulmonary resuscitation) and permits hemodynamic and respiratory stabilization of patients with CA refractory to conventional CPR. This technique allows the parallel treatment of the underlying etiology of CA while maintaining organ perfusion. However, current evidence does not support the routine use of ECPR in all patients with refractory CA. Therefore, an appropriate selection of patients who may benefit from this procedure is key. Reducing the duration of low blood flow by means of performing high-quality CPR and promoting access to ECPR, may improve the survival rate of the patients presenting with refractory CA. Indeed, patients who benefit from ECPR seem to carry better neurological outcomes. The aim of this present narrative review is to present the most recent literature available on ECPR and to clarify its potential therapeutic role, as well as to provide an in-depth explanation of equipment and its set up, the patient selection process, and the patient management post-ECPR.

Supplemental Digital Content is available in the text., Objectives: In many countries, large numbers of critically ill patients with coronavirus disease 2019 are admitted to the ICUs within a short period of time, overwhelming usual care capacities. Preparedness and reorganization ahead of the wave to increase ICU surge capacity may be associated with favorable outcome. The purpose of this study was to report our experience in terms of ICU organization and anticipation, as well as reporting patient characteristics, treatment, and outcomes. Design: A prospective observational study. Setting: The division of intensive care at the Geneva University Hospitals (Geneva, Switzerland). Patients: All consecutive adult patients with acute respiratory failure due to coronavirus disease 2019 admitted in the ICU between March 9, 2020, and May 19, 2020, were enrolled. Patients’ demographic data, comorbidities, laboratory values, treatments, and clinical outcomes were collected. Interventions: None. Measurements and Main Results: The ICU was reorganized into cells of six to eight patients under the care of three physicians and five nurses. Its capacity increased from 30 to 110 beds, fully equipped and staffed, transforming the surgical intermediate care unit, the postoperative care facility, and operating theaters into ICUs. Surge capacity has always exceeded the number of patients hospitalized. Among 129 critically ill patients with severe acute hypoxemic respiratory failure, 96% required invasive mechanical ventilation. A total of 105 patients (81%) were discharged alive and 24 died, corresponding to a mortality of 19%. Patients who died were significantly older, with higher severity scores at admission, had higher levels of d-dimers, plasma creatinine, high-sensitive troponin T, C-reactive protein, and procalcitonin, and required more frequent prone sessions. Conclusions: A rapid increase in ICU bed capacity, including adequate equipment and staffing, allowed for a large number of critically ill coronavirus disease 2019 patients to be taken care of within a short period of time. Anticipation and preparedness ahead of the wave may account for the low mortality observed in our center. These results highlight the importance of resources management strategy in the context of the ongoing coronavirus disease 2019 pandemic.

Background: In many countries, large numbers of critically ill patients with coronavirus disease 2019 (COVID-19) are admitted to the intensive care units (ICU) within a short period of time. These patients rapidly overwhelm usual emergency care capacities and sacrificing triage before ICU admission may become necessary. Preparedness and reorganization ahead of the wave to increase ICU surge capacity may be associated with favourable outcome. Methods: In this prospective single-centred observational study, all consecutive adult patients with acute respiratory failure due to COVID-19 admitted in the intensive care unit of University Hospitals of Geneva (Geneva, Switzerland) between March 9, 2020, and April 16, 2020 were enrolled. Patients’ demographic data, comorbidities, laboratory values, treatments, and clinical outcomes are collected. Findings: Within two weeks, ICU capacity increased from 30 to 110 beds, fully equipped and staffed. Since then, surge capacity has always exceeded the number of patients hospitalized in the ICU. Among 120 patients admitted to the ICU with severe and acute hypoxemic respiratory failure, 96% required invasive mechanical ventilation. Less than six weeks after the first admission, 68 (57%) patients have been discharged alive, 36 (30%) remain hospitalized in the ICU, and 16 have died, corresponding to a mortality of 13% (95% confidence interval 8-21). 99 (83%) patients were overweight, 46 (38%) obese, and 32 (27%) had no comorbidities. Patients who died were older, with a higher SAPS II score, higher levels of D-dimers, plasma creatinine, high-sensitive troponin T, and procalcitonin, required more frequent prone sessions and longer periods of paralysis, and developed more secondary sepsis. Interpretation: A rapid increase in ICU bed capacity, including adequate equipment and staffing allowed for a large number of critically ill COVID-19 patients to be taken care of within a short period of time, translating into low mortality rate and preventing a sacrificing triage. Funding Statement: None. Declaration of Interests: The authors declare no conflict of interest. Ethics Approval Statement: The institutional ethics committee approved the study (BASEC number: 2020-00917). An informed consent was obtained either from the patient or the next-of-kin.

Even if the HeartMate 3TM left ventricular assist device is associated with excellent outcomes, complications, such as pump thrombosis continue to affect patients on hemodynamic support. We report the history of a 68-year-old man who underwent implantation of an HeartMate 3TM as a bridge to transplantation. Nineteen months later, he developed signs of heart failure leading to cardiogenic shock. Neither clinical examination nor parameters from the device allowed a clear-cut diagnosis. Only surgical exploration revealed the presence of clots between the polyethylene terephthalate (Dacron®) and polytetrafluoroethylene tubes. This constitutes a weakness of this device for which we propose to the manufacturer for minimal modifications to overcome the problem.

New generation devices for long-term mechanical circulatory support are centrifugal pumps having fully magnetically levitated rotors to reduce blood trauma. Recently, the novel HeartMate 3 was cleared for clinical application in Switzerland. In two Swiss University Hospitals part of the "Lausanne-Geneva Transplantation Network," 10 consecutive patients in end-stage heart failure received the HeartMate 3 (Thoratec Corporation, Pleasanton, CA). Device implantation criteria were persistent low output syndrome despite optimal medical treatment. The primary end-point of the study was survival or transplantation to 90 days on the device. Five patients (50%) were in Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) class 1 and 2 (two were under venoarterial extracorporeal membrane oxygenation [VA-ECMO]), and five were in class 3 and 4. The indication was bridge-to-transplant in seven patients, and destination therapy in three. Two patients (20%) received concomitant aortic valve surgery. Four patients (40%) required temporary right ventricle support (tRVAD) for a mean of 8 ± 1.5 days. Bleeding requiring surgical revision occurred in five (50%) patients, two during the tRVAD support. At the 90 day end-point, survival was 90%, one (10%) died due to respiratory failure. Three (30%) experienced critical illness polyneuropathy. Two had body temperature over 38.5°C for more than 7 days after implant, without infections. Two (20%) had late driveline infection. The pump allowed rapid improvement of patients' clinical conditions even in severely compromised patients. Postoperative bleeding occurred in the setting of anticoagulation. No hemolysis or pump thrombosis occurred. Fever occurred frequently but was not associated with mortality. Hemodynamic support was consistent over time without significant adverse events.

Even if the HeartMate 3

The development of extracorporeal membrane oxygenation (ECMO) technology allows a new approach for the intensive care management of acute cardiac and/or respiratory failure in adult patients who are not responsive to conventional treatment. Current ECMO therapies provide a variety of options for the multidisciplinary teams who are involved in the management of these critically ill patients. In this regard, veno-venous ECMO (VV-ECMO) can provide quite complete respiratory support, even if this highly complex technique presents substantial risks, such as bleeding, thromboembolic events and infection. While VV-ECMO circuits usually include the cannulation of two vessels (double cannulation) in its classic configuration, the use of a single cannula is now possible for VV-ECMO support. Recently, experienced centers have employed more advanced approaches by cannulating three vessels (triple cannulation) which follows veno-arterio-venous (VAV) or veno-arterio-pulmonary-arterial cannulation (VAPa). However, 'triple' cannulation expands the field of application but increases the complexity of ECMO systems. In the present review, the authors focus on the indications for VV-ECMO, patient assessment prior to cannulation, the role of ultrasound-guided vessel puncture, double lumen single bicaval cannulations, and finally triple cannulation in VV-ECMO.

Measuring cardiac output (CO) is an integral part of the diagnostic and therapeutic strategy in critically ill patients. During the last decade, the single transpulmonary thermodilution (TPTD) technique was implemented in clinical practice. The purpose of this paper was to systematically review and critically assess the existing data concerning the reproducibility of CO measured using TPTD (COTPTD). A total of 16 studies were identified to potentially be included in our study because these studies had the required information that allowed for calculating the reproducibility of COTPTD measurements. 14 adult studies and 2 pediatric studies were analyzed. In total, 3432 averaged CO values in the adult population and 78 averaged CO values in the pediatric population were analyzed. The overall reproducibility of COTPTD measurements was 6.1 ± 2.0 % in the adult studies and 3.9 ± 2.9 % in the pediatric studies. An average of 3 boluses was necessary for obtaining a mean CO value. Achieving more than 3 boluses did not improve reproducibility; however, achieving less than 3 boluses significantly affects the reproducibility of this technique. The present results emphasize that TPTD is a highly reproducible technique for monitoring CO in critically ill patients, especially in the pediatric population. Our findings suggest that obtaining a mean of 3 measurements for determining CO values is recommended.

Extracorporeal membrane oxygenation (ECMO) allows a new approach for the intensive care management of acute cardiac and/or respiratory failure in patients who are not responsive to conventional treatment (1,2).

Dear Editor, We read with interest the comments by Nusmeier et al. [1] regarding our article entitled ‘‘Transpulmonary thermodilution curves for detection of shunt’’ [2]. The authors found that our explanation (Appendix, page 1086) was confused [2]! Thus, these authors proposed a much simpler and easier mathematical method to support our explanations [1]. Indeed, they calculated mean transit time (MTt) as the ratio of intrathoracic thermal volume (ITTV) to cardiac output (CO) and the down slope time (DSt) as the ratio of intrapulmonary thermal volume (IPTV) to CO (see Fig. 1). In the end, their observations and conclusions were similar to our findings [1, 2]. However, retrospective calculations performed by these authors are based on mean values of three transpulmonary thermodilution (TPTD) curves [1, 2]. In this regard, although some of these disagreements may be only semantic, these differences are important in trying to explain our results (Fig. 1). Indeed, the retrospective calculated absolute values of MTt and DSt displayed in Table 1 are extrapolated from an inauthentic curve derived from the average of three TPTD curves [1]. From a physiological point of view, we feel that even if Nusmeier et al. used a coupled mathematical analysis [3] to clarify our interpretations, the values of MTt and DSt they displayed [1] are not original. In contrast, as we had considered that no approach could provide absolute values of MTt and DSt in the absence of direct measurements on a curve [3], we proposed our ‘‘relative confused mathematical formulation.’’ We hope to have clarified the key issues for the journal readers.

The present pilot study investigated whether respiratory variation in subclavian vein (SCV) diameters correlates with fluid responsiveness in mechanically ventilated patients. Monocentric, prospective clinical study on fluid responsiveness in adult sedated, mechanically ventilated ICU patient, monitored with the PiCCO™ system (Pulsion Medical System, Germany), and requiring a fluid challenge (FC). A 10-min fluid bolus of 500 mL of 0.9% saline was administered. Cardiac output (CO) and dynamic parameters [stroke volume variation (SVV) and pulse pressure variation (PPV)] measured by transpulmonary thermodilution and pulse contour analysis (PiCCO™) as well as classical hemodynamic parameters were recorded at baseline and after FC. Fluid responsiveness was described as an increase in CO of ≥ 15%. Ultrasound measurements obtained in the subclavian long-axis view were used to calculate the SCVvariability index. A cut-off value for SCV variation for the prediction of fluid responsiveness was determined using receiver operating curve (ROC) analysis. Nine of 20 FCs (45%) induced an increase in CO of ≥ 15%. At baseline, the SCVvariability index was greater in responders than in non-responders (34.0 ± 21.4 vs. 9.0 ± 5.5; p = 0.0005). Diagnostic performance for the SCVvariability index revealed a cut-off value of 14 with a sensitivity of 100% [Confidence interval (CI) 95% (90; 100)] and a specificity of 82% [CI 95% (48; 98)] for the prediction of fluid responsiveness. Other parameters, such as SVV and PPV, could not predict fluid responsiveness. The correlation coefficient between CO variation and the SCVvariability index was 0.73 (p

Survival after cardiac arrest depends on prompt and effective cardiopulmonary resuscitation (CPR). Resuscitative teams are more frequently using mechanical chest compression devices, as documented in physiologic and experimental data, suggesting that these devices are more effective than manual CPR. A 41-year-old male patient presented with an ST-elevation myocardial infarction with cardiac arrest. The patient was immediately resuscitated by manual chest compressions; CPR was continued with a mechanical chest compression device (LUCAS 2). The patient had experienced a 15-minute period of "low-flow" without "no-flow" episode. After a discussion with the heart team, we decided that the patient was a candidate for extracorporeal membrane oxygenation (ECMO) therapy. During the ECMO implantation, we noticed that while performing transesophageal echocardiography, chest compressions were ineffective with the machine. After the ECMO implantation, we observed myocardial damage in the right-sided heart cavities. The present case report illustrates the likelihood that the mechanical chest compression device has limitations that might contribute to inadequate CPR. Therefore, rescuers should consider the efficacy of their chest compression through a continuous hemodynamic monitoring during CPR.

The ever-increasing use of immune checkpoint inhibitors in cancer is leading to a high incidence of autoimmune side effects. This report discusses an autoimmune fulminant myocarditis in an elderly patient with metastatic pulmonary adenocarcinoma in whom the most advanced invasive heart failure therapies were used successfully. She was treated with nivolumab. This case illustrates a severe cardiovascular complication of immunotherapy and highlights to cardiologists the importance of aggressive treatments in patients with metastatic cancers whose prognosis has improved dramatically.