Feng-Chun Tsai

Using extracorporeal life support to resuscitate adult postcardiotomy cardiogenic shock: Treatment strategies and predictors of short-term and midterm survival

BACKGROUNDnPostcardiotomy extracorporeal life support (ECLS) is a resource-demanding therapy with varied results among institutions. An organized protocol was necessary to improve the effectiveness of this therapy.nnnMETHODS AND RESULTSnA total of 110 patients received ECLS due to refractory postcardiotomy cardiogenic shock between January 2003 and June 2009, and were eligible for inclusion in this retrospective study. Preoperative, perioperative, and postoperative variables were collected, including the European system for cardiac operative risk evaluation (EuroSCORE) and markers of ECLS-related organ injuries. All variables were analyzed for possible associations with mortality in hospital, and after hospital discharge. The mean age, additive EuroSCORE, and left ventricular ejection fraction (LVEF) for all patients was 60 (+/-14) years, 9 (+/-6), and 43% (+/-20%) respectively. Sixty-seven patients were weaned from ECLS and 46 survived to hospital discharge. The mean duration of ECLS support was 143 h (+/-112 h). Multivariate analysis revealed that an age of >60 years, a necessity for postoperative continuous arteriovenous hemofiltration, a maximal serum total bilirubin >6 mg/dL, and a need for ECLS support for >110 h were independent predictors of in-hospital mortality. In addition, persistent heart failure with LVEF <30% was an independent predictor of mortality after hospital discharge. A risk-predicting score for in-hospital mortality associated with postcardiotomy ECLS was developed for clinical application.nnnCONCLUSIONnBased on the abovementioned findings, a comprehensive protocol for postcardiotomy ECLS was designed. The primary objective was to achieve adequate hemodynamics within the first 24h of initiating ECLS. Other objectives of the protocol included a consistent approach to safe anticoagulation while on ECLS, a process to make decisions within 7 days of initiating ECLS, and patient follow-up after hospital discharge.

Blunt traumatic cardiac rupture: therapeutic options and outcomes.

INTRODUCTIONnCardiac rupture following blunt thoracic trauma is rarely encountered by clinicians, since it commonly causes death at the scene. With advances in traumatology, blunt cardiac rupture had been increasingly disclosed in various ways. This study reviews our experience of patients with suspected blunt traumatic cardiac rupture and proposes treatment protocols for the same.nnnMETHODSnThis is a 5-year retrospective study of trauma patients confirmed with blunt traumatic cardiac rupture admitted to a university-affiliated tertiary trauma referral centre. The following information was collected from the patients: age, sex, mechanism of injury, initial effective diagnostic tool used for diagnosing blunt cardiac rupture, location and size of the cardiac injury, associated injury and injury severity score (ISS), reversed trauma score (RTS), survival probability of trauma and injury severity scoring (TRISS), vital signs and biochemical lab data on arrival at the trauma centre, time elapsed from injury to diagnosis and surgery, surgical details, hospital course and final outcome.nnnRESULTSnThe study comprised 8 men and 3 women with a median age of 39 years (range: 24-73 years) and the median follow-up was 5.5 months (range: 1-35 months). The ISS, RTS, and TRISS scores of the patients were 32.18+/-5.7 (range: 25-43), 6.267+/-1.684 (range: 2.628-7.841), and 72.4+/-25.6% (range: 28.6-95.5%), respectively. Cardiac injuries were first detected using focused assessment with sonography for trauma (FAST) in 4 (36.3%) patients, using transthoracic echocardiography in 3 (27.3%) patients, chest CT in 1 (9%) patient, and intra-operatively in 3 (27.3%) patients. The sites of cardiac injury comprised the superior vena cava/right atrium junction (n=4), right atrial auricle (n=1), right ventricle (n=4), left ventricular contusion (n=1), and diffuse endomyocardial dissection over the right and left ventricles (n=1). Notably, 2 had pericardial lacerations presenting as a massive haemothorax, which initially masked the cardiac rupture. The in-hospital mortality was 27.3% (3/11) with 1 intra-operative death, 1 multiple organ failure, and 1 death while waiting for cardiac transplantation. Another patient with morbid neurological defects died on the thirty-third postoperative day; the overall survival was 63.6% (7/11). Compared with the surviving patients, the fatalities had higher RTS and TRISS scores, serum creatinine levels, had received greater blood transfusions, and had a worse preoperative conscious state.nnnCONCLUSIONSnWe proposed a protocol combining various diagnostic tools, including FAST, CT, transthoracic echocardiography, and TEE, to manage suspected blunt traumatic cardiac rupture. Pericardial defects can mask the cardiac lesion and complicate definite cardiac repair. Comorbid trauma, particularly neurological injury, may have an impact on the survival of such patients, despite timely repair of the cardiac lesions.

Extracorporeal life support to terminate refractory ventricular tachycardia.

Objective:Extracorporeal life support (ECLS) has been applied successfully to patients with cardiopulmonary failure in extreme situations. Refractory ventricular tachycardia has high mortality and morbidity rates if not terminated in time. This study describes our preliminary experiences in using ECLS to treat patients with refractory ventricular tachycardia. Design:Retrospective chart review. Setting:Hospital. Patients:Eleven patients suffering from ventricular tachycardia refractory to antiarrhythmia agents and cardioversion attempts. Interventions:From January 2002 to December 2004, 11 patients suffering from ventricular tachycardia refractory to antiarrhythmia agents and cardioversion attempts were treated with ECLS. Mean patient age was 31 ± 21 yrs (range, 3–69 yrs). The triggering events were acute myocarditis (n = 8), coronary artery spasm (n = 1), and hypoxemia secondary to acute respiratory distress syndrome (n = 2). Nine (82%) patients received venoarterial mode support and the remaining two (18%) were supported with venovenous mode to correct hypoxemia. Pump flow was first maximized (mean, 3800 ± 1100 mL/min) to unload the heart, and an intra-aortic balloon pump was used to deal with the increased afterload (n = 8). Measurements and Main Results:Mean ventricular tachycardia duration before ECLS was 50 ± 16 mins (range, 20–75 mins) and soon converted to a sinus rhythm following ECLS deployment, including four patients who experienced spontaneous recovery without attempted cardioversion, in a mean of 7.4 mins (range, 1–20 mins). Four patients required temporary pacing but none needed a permanent pacemaker after recovery. Mean duration of ECLS support was 119 ± 69 hrs (range, 12–250 hrs). We excluded one patient who had permanent brain injury and another who succumbed to multiple organ failure. Nine (82%) patients were weaned and discharged with normal cardiac function. No recurrent ventricular tachycardia attack but one recurrent cardiomyopathy (ejection fraction = 15%) was reported during a mean 42-month follow-up. Conclusions:Using ECLS to terminate refractory ventricular tachycardia proved effective for selected patients when conventional therapeutic options were exhausted. Early deployment of ECLS to prevent secondary organ injury, maintain sufficient cardiac unloading, and avoid complications during ECLS support was central to successful outcomes.

Resuscitation of non-postcardiotomy cardiogenic shock or cardiac arrest with extracorporeal life support: The role of bridging to intervention

BACKGROUNDnTo investigate the predictors of adverse outcomes of extracorporeal life support (ECLS) in rescuing adult non-postcardiotomy cardiogenic shock or cardiac arrest (non-PC CS/CA).nnnMATERIALS AND METHODSnThis retrospective study included 60 adult patients receiving ECLS for non-PC CS/CA in a single institution between June 2003 and June 2010. The exclusion criteria were (1) pre-ECLS cardiac surgeries in the same admission and (2) age<18 years. Pre-ECLS and ECLS characteristics were compared in patients surviving to hospital discharge and those who did not. Mortalities after hospital discharge were also investigated.nnnRESULTSnOf the 38 patients weaned from ECLS, 32 survived to discharge. Acute myocardial infarction (AMI) and myocarditis were the most common aetiologies in this study. Forty patients experienced pre-ECLS conventional cardiopulmonary resuscitation (C-CPR) and 29 required an ECLS-assisted CPR (E-CPR). Thirteen patients who received E-CPR had profound anoxic encephalopathy later. In-hospital mortality was similar in AMI patients who underwent emergent coronary artery bypass grafting (CABG) after a failed percutaneous coronary intervention (PCI, 43%, 5/11) and those who underwent PCI only (58%, 7/12). Aetiologies other than myocarditis (odds ratio (OR) 11.0, 95% confidence interval (CI) 1.5-78.5), requirement for E-CPR (OR 5.6, 95% CI 1.5-22.0) and profound anoxic encephalopathy (OR 8.9, 95% CI 2.0-40.5) were predictors of in-hospital mortality. No risk factors of mortality after hospital discharge were identified.nnnCONCLUSIONnECLS was effective in bridging adults with non-PC CS/CA to definite treatments. Their prognosis depended on the cause of collapse and the severity of the post-cardiac arrest syndrome.

Using extracorporeal membrane oxygenation to rescue acute myocardial infarction with cardiopulmonary collapse: The impact of early coronary revascularization?

OBJECTIVESnTo investigate the therapeutic impact of combining extracorporeal membrane oxygenation (ECMO) and early coronary revascularization on acute myocardial infarction (AMI)-induced cardiopulmonary collapse.nnnMATERIALS AND METHODSnThis retrospective study included 35 consecutive patients rescued by ECMO for AMI-induced cardiopulmonary collapse in a single institution between June 2003 and December 2011. Coronary revascularization was performed soon after ECMO initiation. Percutaneous coronary intervention (PCI) was the primary revascularization strategy. Coronary artery bypass grafting (CABG) was performed if an unsuitable anatomy or unsatisfactory result of PCI. Comparisons were performed in groups with different revascularization strategies and outcomes.nnnRESULTSnAmong the 35 patients, 16 underwent CABG and 1 was bridged to transplant after CABG. Compared to patients receiving PCI only, the CABG group showed similar results in ECMO weaning (58% vs. 69%, p=0.51), hospital discharge (32% vs. 50%, p=0.27), and left ventricular ejection fraction before discharge (45% vs. 49%, p=0.92). Regardless of revascularization strategies, this protocol achieved an ECMO-weaning rate of 63% and a hospital discharge rate of 40%. Dialysis-dependent acute renal failure (OR 5.4, 95% CI: 1.1-27.5) and profound anoxic encephalopathy (OR 5.4, 95% CI: 1.1-27.5) predicted non-weaning of ECMO. Age>60 years (OR 7.3, 95% CI: 1.1-51.0) and profound anoxic encephalopathy (OR 24.6, 95% CI: 2.3-263.0) predicted in-hospital mortality. The major cardiovascular adverse effect (MACE)-free survival was 77% in the first year after discharge.nnnCONCLUSIONnEarly revascularization on ECMO is practical to preserve myocardial viability and bridge patients collapsing with AMI to recovery.

Impact of preexisting organ dysfunction on extracorporeal life support for non-postcardiotomy cardiopulmonary failure

BACKGROUNDnExtracorporeal life support (ECLS) is associated with a high mortality rate in patients with preexisting multiple organ failure. To achieve better outcomes of ECLS in this high risk group, an understanding of the real impact of preexisting organ dysfunction on ECLS-associated mortality is necessary.nnnMETHODSnFrom January 2003 to March 2007, a total of 45 patients (mean age: 48 years) were placed on ECLS for acute cardiopulmonary failure and survived longer than 24h. The medical records of these 45 patients were retrospectively reviewed. The indications for ECLS were acute respiratory distress syndrome (n=23), acute myocarditis (n=10) and acute myocardial infarction (n=12). Organ failure was assessed based on the Sequential Organ Failure Assessment (SOFA) score, which was calculated daily until ECLS termination. The demographic variables, SOFA score variables, and ECLS-related complications, including renal dialysis, severe brain damage and limb ischemia, were analysed.nnnRESULTSnTwenty-seven patients (60%) were weaned from ECLS and 21 (47%) survived to discharge. Multivariate analysis revealed that the necessity of renal dialysis was an independent risk factor associated with failure to wean and non-survival, and the necessity of cardiopulmonary resuscitation (CPR) before ECLS was an independent risk factor for non-survival. Preexisting organ dysfunction, quantified by the pre-ECLS SOFA score, was predictive of survival to discharge. A pre-ECLS SOFA score greater than 14 predicted mortality in this study.nnnCONCLUSIONSnSOFA score is a practical assessment tool and is predictive of ECLS-associated mortality in non-postcardiotomy patients. Patients having cardiac arrest requiring CPR or acute renal failure requiring dialysis before ECLS may have inferior ECLS outcomes.

Extracorporeal life support in post-traumatic respiratory distress patients

BACKGROUNDnExtracorporeal life support (ECLS) has been applied successfully to patients with acute cardiopulmonary failure. However, ECLS remains controversial for traumatized patients who are prone to bleeding.nnnPATIENTS AND METHODSnFrom March 2004 to October 2007, nine patients with post-traumatic respiratory distress refractory to ventilator support were treated with ECLS. Mean patient age was 35.1+/-9.7 (range, 18-47) years, average injury severity score (ISS) was 44.56+/-4.93 (range, 35-50), and Sequential Organ Failure Assessment score (SOFA) score was 12.1+/-3.67 (range, 7-16). Before ECLS, all patients had received thoracic interventions, including four lung resections, with a mean PaO(2) of 49.04+/-9.82 (range, 31-64) mmHg and PaCO(2) of 66.4+/-15.72 (range, 45-86) mmHg. Seven patients were supported in standard veno-venous mode, and the other two were initially supported in veno-arterial mode due to hemodynamic instability.nnnRESULTSnMedian interval from trauma to ECLS was 33 (range, 4-384) h, and median duration of ECLS was 145 (range, 69-456) h. Six (66.7%) patients received additional surgeries during ECLS. One died of sepsis from occult colon rupture and the other of acute liver failure, 6 and 13 days respectively after trauma. Seven (77.8%) patients were weaned and discharged.nnnCONCLUSIONSnUsing ECLS to resuscitate traumatic respiratory distress proved to be safe and effective when conventional therapies had been exhausted. Early deployment of ECLS to preserve systemic organ perfusion, aggressive treatment of coexisting injuries and tailored anticoagulation protocols are crucial to a successful outcome.

Impact of Acute Kidney Injury on One-Year Survival After Surgery for Aortic Dissection

BACKGROUNDnSurgical treatment is an option for both type A aortic dissection and complicated type B aortic dissection. Acute kidney injury (AKI) influences the disease course after surgery. Our hypothesis was that AKI should be an important prognostic factor for aortic dissection after surgical treatment.nnnMETHODSnBetween July 2005 and October 2010, 268 patients (mean age 53 ± 14 years; range, 16 to 88) underwent open surgery for aortic dissection. We reviewed the clinical presentations, surgical variables, and postoperative outcomes to identify the risk factors of death. The 256 patients were divided into groups, with and without AKI, within 24 hours after operation according to the RIFLE (acronym for risk, injury, failure, loss, end stage) criteria.nnnRESULTSnThe in-hospital mortality rate was 17.9%, the 1-year mortality rate was 18.7%, and the major adverse cardiac events rate within 1 year was 29.9%. In multivariate analysis, patients more than 70 years of age (hazard ratio [HR] 2.390, p = 0.029), cardiogenic shock (HR 2.895, p = 0.005), preoperative ventilator use (HR 4.137, p = 0.018), operation at midnight (HR 2.295, p = 0.028), longer bypass time (HR 1.007, p < 0.001), and AKI (HR 2.552, p = 0.041) were clinical predictors of mortality. Kaplan-Meier analysis showed that the survival rate was strongly correlated with the severity of AKI by the RIFLE criteria. The independent predictors of AKI included hypertension (odds ratio 2.340, p = 0.027), sepsis (odds ratio 2.594, p = 0.043), and lower limb malperfusion (odds ratio 4.558, p = 0.022).nnnCONCLUSIONSnOur study provides outcomes of postoperative aortic dissection. We found that AKI was a predictor of 1-year mortality by using the RIFLE criteria. Factors associated with increased 1-year mortality and AKI should be taken into consideration for surgery and postoperative care.

Video-Assisted Coronary Artery Bypass Grafting During Hypothermic Fibrillatory Arrest

BACKGROUNDnHypothermic fibrillatory arrest without aortic cross-clamping is a technique for quieting the heart during coronary artery bypass grafting. This report reviews the preliminary results with this technique in 4 patients having video-assisted coronary artery bypass grafting.nnnMETHODSnFour male patients 28.5 to 64.5 years old (mean age, 45.4 years) underwent operation for unstable angina. With video-assisted techniques, coronary artery bypass grafting was performed through a left anterior minithoracotomy with femoral-femoral cardiopulmonary bypass without cross-clamping the aorta. The myocardium was protected by continuous coronary perfusion during hypothermic fibrillatory arrest.nnnRESULTSnA left internal thoracic artery graft was anastomosed to the left anterior descending coronary artery in each patient. The posterior descending branch of the right coronary artery was grafted with a pedicled right gastroepiploic artery in 1 patient. The duration of cardiopulmonary bypass was 72 to 127 minutes (mean duration, 92 +/- 21 minutes). The postoperative course of each patient was uneventful. Follow-up (range, 3.9 to 5.8 months; mean follow-up, 4.9 months) was complete for all patients. There were no late deaths. Coronary angiography showed patent grafts. All patients were in New York Heart Association functional class I or II (mean class, 1.25).nnnCONCLUSIONSnHypothermic fibrillatory arrest is a simple and effective method of quieting the heart, thereby providing a motionless operative field for video-assisted coronary artery bypass grafting.

Surgical Risk and Outcome of Repair Versus Replacement for Late Tricuspid Regurgitation in Redo Operation

BACKGROUNDnLate tricuspid regurgitation after previous cardiac operation remains controversial in terms of when to repair and who will benefit. We reviewed our surgical experiences and stratified the risk factors for death and morbidity.nnnMETHODSnFrom September 2005 to September 2010, 77 consecutive patients (36 men [47%]) underwent redo open heart operations with the tricuspid valve (TV) procedure. Their mean age was 56±13 years (range, 27 to 83 years). TV repair was performed in 44 (57%) and TV replacement in 33 (43%): 23 received bioprostheses; 10 received mechanical prostheses.nnnRESULTSnFourteen (18%) patients died after the operation. Risk factors of hospital death by multivariate analysis were age (>65 years), preoperative renal insufficiency (creatinine>2 mg/dL), and preoperative severe liver cirrhosis (Child classification C). Compared with the group that underwent TV repair, those who underwent TV replacement tended to have had previous TV operations (46% vs 9%; p<0.001) and preoperative Child class C liver cirrhosis (21% vs 2%; p=0.018). Although in-hospital mortality was insignificant (24% vs 14%; p=0.232), postoperative morbidities of tracheotomy, gastrointestinal bleeding, and late death were higher in the replacement group.nnnCONCLUSIONSnPatients who had previous TV operations and preoperative severe liver cirrhosis were more likely to undergo TV replacement in tricuspid reoperations. Compared with patients in the repair group, patients in the replacement group had higher morbidities and low late survival. Earlier intervention, before decompensated heart failure occurs, is warranted to improve the outcome.