D. Saeed

Femoro-Femoral Versus Atrio-Aortic Extracorporeal Membrane Oxygenation: Selecting the Ideal Cannulation Technique

Veno-arterial extracorporeal membrane oxygenation (ECMO) may be implanted using peripheral ECMO (pECMO) or central ECMO (cECMO) cannulation techniques. The aim of this study was to compare the outcome between these two cannulation techniques. A retrospective study was performed at Düsseldorf University Hospital from October 2009 through June 2011. Inclusion criteria were patients with veno-arterial ECMO support ≥24 h. Various pre- and postimplantation variables were investigated including postimplantation hemodynamic and ECMO parameters, oxygenation/ventilation parameters at 3, 6, 12, 24, 48, 72 h, as well as renal and liver function tests at first and third postoperative days following implantation. Outcome data of patients receiving pECMO were compared with those who received cECMO. The inclusion criteria were met by 37 patients (25 pECMO and 12 cECMO). There were no significant differences in baseline characteristics between these two groups except for younger age in pECMO patients (P=0.005). All postimplantation variables were comparable between the two groups except for higher PO2 and lower PCO2 values at the 3rd hour postimplantation in patients with pECMO (P=0.007 and 0.01, respectively). Eleven (44%) of the pECMO patients required re-exploration for bleeding versus 100% of patients with cECMO (P=0.01). Ischemic leg complication was observed in four pECMO and three cECMO patients. Thirty-day mortality in patients with pECMO and cECMO was 60% versus 67%, respectively (P=1.00). In this study, no particular oxygenation/ventilation, hemodymanic, or end-organ function advantage was observed with either cannulation technique. However, more bleeding and resternotomy complications were observed in cECMO patients.

Alternative right ventricular assist device implantation technique for patients with perioperative right ventricular failure

OBJECTIVES Temporary right ventricular assist devices (RVADs) may be required to support patients with perioperative refractory right ventricular failure (RVF). We report on our experience using a different technique of RVAD implantation that does not necessitate resternotomy at the time of RVAD removal. METHODS Patients with perioperative RVF who underwent temporary RVAD implantation between January 2010 and February 2014 were reviewed. A dacron graft was attached to the pulmonary artery and passed through a subxiphoid exit, where the RVAD outflow cannula was inserted. The inflow cannula was percutaneously cannulated in the femoral vein, and the sternum was primarily closed. On the day of RVAD explantation, the outflow graft of the RVAD was pulled and ligated, and the insertion site was secondarily closed. The RVAD inflow cannula was removed, and direct pressure was applied. RESULTS Twenty-one patients (age 58 ± 14 years) were supported. Seventeen patients (81%) had RVF after left ventricular assist device implantation, and 4 patients developed postcardiotomy RVF. The median duration of RVAD support was 9 days (range: 2-88 days). Eleven patients (52%) were successfully weaned from the RVAD. Two patients were bridged to transplantation. Eight patients died on left ventricular assist device and/or RVAD support. The survival rates to discharge or heart transplantation, and to 1-year, were 62% and 52%, respectively. CONCLUSIONS No technical issues were encountered in this large series of RVAD implantations using the described technique for various forms of postoperative RVF. Extended support duration and reduction of resternotomy risks may be the main advantages of this technique compared with conventional RVAD implantation methods.

Sexual Concerns of Patients With Implantable Left Ventricular Assist Devices

The growing field of implantable left ventricular assist devices (LVADs) lacks studies that evaluate the sexual and psychosocial concerns of LVAD patients. The aim of this prospective study was to determine the sexual and psychosocial behaviors of these patients. A sexual and psychosocial survey was conducted in patients who underwent the implantation of LVAD. Inclusion criteria were patients who were discharged home. The survey consisted of 17 questions with main focus on the sexual life and activities. The survey was sent to 38 patients. Twelve patients had either no partners or did not respond to the survey. Data of the remaining 26 patients with a mean age of 54 ± 13 years old were analyzed. The mean time between LVAD implantation and the first sexual activity was 16 ± 13 weeks (6-42 weeks). Following LVAD implantation, there was a steady improvement in the physical condition and quality of life. However, a remarkable decrease in the degree of satisfaction with sexual life following LVAD implantation (5.5 ± 2.2 vs. 4.1 ± 2.5) was observed (P = 0.05) (a scale of 1-7, with 7 being very satisfied and 1 not satisfied). Decreasing sexual activities after LVAD implantation was mainly to avoid partner disappointment, sudden cardiac arrest, and LVAD failure. There is a notable reduction in the degree of satisfaction with sexual life after LVAD implantation. The majority of the patients avoid discussing this issue with their physicians. Psychological and psychosocial support of LVAD patients is mandatory to improve their life quality.

Survival Predictors in Ventricular Assist Device Patients With Prior Extracorporeal Life Support: Selecting Appropriate Candidates

Several centers turn patients down for long-term ventricular assist devices (VADs) once they have received extracorporeal life support (ECLS) due to the expected poor outcome in these patients. The aim of this study was to identify survival predictors in this cohort of patients. Data of patients undergoing VAD support between January 2010 and November 2013 were retrospectively reviewed. Patients on ECLS support before implantation were considered eligible for inclusion. Outcome in survivors following long-term VAD support was compared with outcomes in nonsurvivors. Students t-test and χ(2)-test were used as applicable. A total of 65 long-term VADs were implanted. The inclusion criteria were met by 24 patients. Eight patients did not survive the first 30 days. All preoperative characteristics were comparable between the two groups except for statistically higher Model for End-stage Liver Disease (MELD) score, bilirubin, white blood cell count, and blood urea nitrogen in nonsurvivors (P = 0.002, 0.01, 0.01, and 0.003, respectively). Stepwise discriminant analysis revealed MELD score as the most important survival predictor. Based on this analysis, an outcome predictor formula was generated. The 30-day and 1-year survival rates were 67% and 54%, respectively. In this study, we were able to determine survival predictors in VAD patients with prior ECLS support. The outcome in these patients is limited and associated with higher postoperative complications, particularly right ventricular and respiratory failure. The pre-VAD MELD score is an important predictor of poor outcome.

Implanting permanent left ventricular assist devices in patients on veno-arterial extracorporeal membrane oxygenation support: do we really need a cardiopulmonary bypass machine?

OBJECTIVES Selected patients who failed to be weaned off temporary veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support may be considered for long-term left ventricular assist devices (LVADs). Activation of the systemic inflammatory response due to the cardiopulmonary bypass (CPB) machine and its associated deleterious effects on the coagulation system have been well documented. The aim of the study was to compare the outcome of patients receiving VAD on VA-ECMO with patients who were converted to CPB at the time of VAD implantation. METHODS Data of patients undergoing LVAD implantation between January 2010 and September 2015 were retrospectively reviewed. Inclusion criteria were patients with prior VA-ECMO. Perioperative characteristics and postoperative outcome of patients who received LVAD after VA-ECMO with (CPB group) or without CPB (no-CPB group) were compared. RESULTS A total of 110 permanent VADs were implanted during this time frame. Forty patients had VA-ECMO prior to VAD implantation and met the inclusion criteria. The CPB was used in 23 patients and 17 patients received VAD on VA-ECMO without using CPB. The preoperative characteristics of the patients were comparable except for lower body mass index, higher international normalized ratio (INR) and higher rate of preoperative intra-aortic balloon pump usage in the CPB group (P = 0.035, 0.008 and 0.003, respectively). The incidence of postoperative right VAD implantation and survival rate was comparable between both groups. However, the chest tube blood loss and amount of blood product usage was higher in the CPB group. The total blood loss in the first 24 h after surgery (2469 ± 2067 vs 1080 ± 941 ml, P= 0.05) and number of units of intraoperative fresh frozen plasma administered (4 ± 3 vs 1 ± 2, P= 0.02) remained higher in the CPB group even after adjustment for differences in preoperative INR value by propensity score matching. CONCLUSIONS This study demonstrates that the CPB machine can be safely omitted when a long-term VAD is implanted on VA-ECMO support. Blood loss in the first 24 h after surgery was less and a significantly lower number of blood products were necessary in these patients compared with patients in whom the CPB machine was used. However, similar survival rates between these two groups were observed.

An Alternative Approach for Perioperative Extracorporeal Life Support Implantation

Central veno-arterial extracorporeal membrane oxygenation (ECMO) is traditionally implanted using direct cannulation of the aorta and right atrium. We aim to summarize the outcome of patients who underwent perioperative central ECMO implantation using an alternative surgical approach, which allows sternum closure and does not require resternotomy at the time of explantation. We retrospectively reviewed patients who required veno-arterial ECMO support at our institution between January 2013 and July 2014. Inclusion criteria were patients undergoing central ECMO implantation using the above-mentioned implantation technique. Nine patients (65 ± 14 years) were supported using this technique. Four patients underwent coronary bypass surgery as a primary surgery and the other five patients had combined coronary and valve surgeries. The average duration of ECMO support was 9 ± 7 days (range 1-24 days). The dominant postoperative complication was renal failure, which occurred in eight patients (89%). In four patients (44%), the ECMO was successfully removed. Survival rate to discharge was 22%. In conclusion, this study showed the feasibility of this alternative ECMO implantation technique. No technical issues were encountered. Extended support duration and reducing resternotomy risks may be the main advantages of this technique compared with conventional ECMO implantation methods.

Extracorporeal membrane oxygenation implantation via median sternotomy for fulminant pulmonary edema after cold water submersion with cardiac arrest.

d p a a h c a s m SEVERE HYPOTHERMIA with core temperatures 28°C secondary to environmental exposure (eg, drowning in cold water) has an estimated mortality rate of 30% to 80%.1,2 The ost important and detrimental consequence of drowning is ypoxia.3 In the pediatric population 5 years of age, submersion injuries rank as the second most frequent cause of death.4 Children who survive drowning are at an increased risk of developing an acute respiratory distress syndrome (ARDS).5 Various techniques have been used successfully for resuscitation from severe hypothermia, yet the optimal therapy remains controversial. Several advisory statements and guidelines have proposed cardiopulmonary bypass (CPB) for the rewarming of children.6-8 Although functional modifications, such as extracorporeal membrane oxygenation (ECMO) implantation, have been advocated,6,9 their use has been reported only anecdotally1,10-13 and the reports have referred primarily to ewarming using femorofemoral cannulation. This report decribes a boy who was resuscitated successfully and recovered ompletely without major neurologic deficits from severe hyothermia and a cardiac arrest 75 minutes using CPB and CMO therapy.

Bariatric Surgery at the Time of Ventricular Assist Device Implantation for Morbidly Obese Patients Prior to Heart Transplantation

Severe obesity may preclude end-stage heart failure patients from listing and heart transplantation. We report the clinical course of a 50-year-old patient with dilated cardiomyopathy who underwent open adjustable gastric band insertion for morbid obesity at the time of left ventricular assist device implantation. The patient lost 25 kg within a 13-month period. The weight loss allowed patient listing and heart transplantation. However, this procedure was limited by regaining weight after heart transplantation.

Six-month outcomes after treatment of advanced heart failure with a full magnetically levitated continuous flow left ventricular assist device: report from the ELEVATE registry

Aims The ELEVATE registry was planned to study post-approval outcomes with HeartMate 3™ (HM3), a fully magnetically levitated continuous flow left ventricular assist device (LVAD). Methods and results A total of 482 patients provided consent to participate in ELEVATE (enrolled cohort). Data collection included baseline demographics, survival, adverse events, quality of life (QOL) [EuroQoL-5 Dimensions visual analogue scale (VAS), and 6-minute walk distance (6MWD)]. An additional 58 patients were implanted with HM3 during the same period but expired or were explanted prior to consent, and only survival data were collected (anonymized cohort). We report the 6-month outcomes of the patients who received HM3 as their primary implant (n = 463) and the survival of the 540 patients in the full cohort (enrolled + anonymized). Baseline characteristics included a mean age of 55.6 ± 11.7 years, 89% male, 48% ischaemic aetiology, and 70% on inotropes. The majority of patients (66%) were bridge-to-transplantation (BTT) and 32% were INTERMACS profile 1-2. Full cohort survival at 6 months was 82 ± 2%. In the enrolled primary implant patients, there was no incidence of pump thrombosis, major bleeding was 25%, major infection 35%, and any stroke type 5%. Functional capacity improved significantly (Δ6MWD 230 ± 191 m) as did QOL (ΔVAS 31 ± 23). Freedom from unplanned rehospitalizations at 6 months was 68 ± 2%. Conclusion The 6-month outcomes of the HM3 LVAD demonstrate a highly reliable, thrombosis free, device with low incidence of stroke and improved functional capacity, and QOL. ClinicalTrials. gov Identifier NCT02497950.

Complete recovery of fulminant peripartum cardiomyopathy on mechanical circulatory support combined with high-dose bromocriptine therapy

Peripartum cardiomyopathy (PPCM) is an idiopathic cardiomyopathy presenting with heart failure due to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is found. We report a case of a woman with PPCM who developed a critical cardiogenic shock with repeated cardiopulmonary resuscitation. We show for the first time that mechanical circulatory support combined with high‐dose bromocriptine therapy to suppress systemic prolactin levels may serve as an effective therapeutic option in patients with fulminant PPCM and cardiogenic shock. Myocardial cathepsin D was overexpressed in our patient underscoring a potential role of cathepsin D‐induced cleavage of prolactin in the pathophysiology of PPCM.