Hannan Dalyanoglu

Four-year experience of providing mobile extracorporeal life support to out-of-center patients within a suprainstitutional network—Outcome of 160 consecutively treated patients

AIM Mobile extracorporeal life support (ECLS) may soon be on the verge to become a fundamental part of emergency medicine. Here, we report on our four-year experience of providing advanced mechanical circulatory support for out-of-center patients within the Düsseldorf ECLS Network (DELSN). METHODS This retrospective cohort study analyses the outcome of 160 patients with refractory circulatory failure consecutively treated with mobile veno-arterial extracorporeal membrane oxygenation (vaECMO) between July 2011 and October 2015 within the DELSN. RESULTS Out of the 160 patients (56±16years, vaECMO initiation under CPR 68%), 59 patients (36%) survived to primary discharge, with 50 patients (31%) still alive after a median follow-up of 1.74 years. Time-discrete mortality was highest during the first 24h. There was no difference between survivors and non-survivors regarding age, etiology of circulatory failure, presence of CPR during implantation or distance to implantation site. Incidence of kidney injury requiring dialysis (61% vs. 24%, p<0.0001), shock liver (27% vs. 12%, p=0.031) and visceral ischemia (19% vs. 3%, p=0.013) were the only complications increased in non-survivors. Subgroup analysis showed no significant outcome difference for ECPR vs. non-ECPR patients. Outcome was significantly impaired with initial neuron-specific enolase ≥45.4μg/L (AUC 0.75, p<0.0001) and lactate ≥5.5mmol/L (AUC 0.70, p<0.0001). Program-year-dependent in-center mortality showed an increasing trend, while program-year-dependent follow-up mortality decreased over time. CONCLUSIONS This study illustrates that regional mobile ECLS rescue therapy can be provided with encouraging outcomes, although patient selection criteria and early outcome parameters reflecting on therapy success or futility still need to be refined.

Successful treatment of ventricular arrhythmic storm with percutaneous coronary intervention and catheter ablation in a patient with left ventricular assist device

Introduction: Ventricular arrhythmias are common in patients with advanced heart failure, which may also persist after sufficient intensive therapy for heart failure even with a left ventricular assist device. Although most ventricular arrhythmias have no hemodynamic relevance during left ventricular assist device support, some patients suffer from right ventricular decompensation due to ventricular arrhythmias resulting in severe hemodynamic deterioration and poor clinical outcomes. Methods: We describe herein an left ventricular assist device patient with refractory ventricular arrhythmic storm early after left ventricular assist device implantation. Results: The patient was admitted to our department after stenting of left anterior descending artery with subsequent polymorphic ventricular tachycardia and cardiogenic shock with ongoing multi-organ failure. After 6 days of extracorporeal life-support, a permanent left ventricular assist device was implanted. With postoperatively ongoing tachycardias, a subtotal right coronary artery occlusion was recanalized utilizing a drug-eluting stent. On the first post-intervention day, an additional catheter ablation was successfully performed. No further ventricular tachycardias were detected during the entire hospital stay and the further postoperative course was uneventful. The patient was transferred to a physiotherapy unit to improve his daily physical activities. He is currently at home and doing well 6 months after discharge. Conclusions: Our case report demonstrates the feasibility of a successful therapeutic approach with a combination of interventional therapies such as coronary stenting and catheter ablation in a patient with persistent ventricular arrhythmias after assist device implantation.

Anxiety and Depression in Patients Undergoing Mitral Valve Surgery: A Prospective Clinical Study

Background Impending cardiac surgery presents an existential experience that may induce psychological trauma. Moreover, quality of life long after successful coronary artery bypass graft surgery (CABG) can be impaired. Aim The aim of this study was to describe the time course of anxiety and depression in patients undergoing mitral valve surgery and compare it with our earlier results of patients undergoing CABG, a disease that is likely to be related to psychosomatic disorders. We hypothesized that patients undergoing mitral valve surgery can better manage stresses of cardiac surgery than patients undergoing CABG. Patients and Methods Of 117 patients undergoing mitral valve surgery, 100 patients (22 to 87 years; 53 females) completed the study and were interviewed before (pre), 1 week after (early), and 6 months after (late) surgery. The Hospital Anxiety and Depression Scale (HADS) was employed. Results The proportion of patients with elevated anxiety scores (AS ≥ 8) was higher than normal (19.8%): pre, 33.0%; early, 28.0%; and was normalized late (18.0%). Similarly, depression scores (DS ≥ 8) were increased: pre, 15.0%; early, 20.0%; and late 14.0%, respectively (normal: 3.2%). Conclusion Coronary heart disease of CABG patients is presented as a systemic disorder, associated with both higher and postoperatively increased distress levels than in mitral valve patients. Anxiety and depression should be recognized as possible symptoms of psychosomatic disorders necessitating psychotherapeutic intervention to prevent postoperative depression and warrant patient‐perceived surgical outcome that is additionally affected by expectations with respect to treatment and individual coping capacities. HADS is recommended to screen for vulnerable patients in the clinical routine, and psychosomatic support should be provided.

Surgery for bacterial endocarditis associated with bacteria of oral/dental origin – characteristics of the “typical host” and implications for prevention

Results Significant differences between the groups were found regarding poor oral health, metabolic syndrome and dental treatment with a higher incidence in Group A. In Group A, majority of cases had left-sided endocarditis (79%); in Group B, 63% of patients were diagnosed with left-sided-, 30% with left-and-right-sided-, and 7% with right-sided-endocarditis. The in-hospital mortality was 0% vs. 26% in Group A and Group B, respectively.

RE.: Extracorporeal circulatory systems in the interhospital transfer of critically ill patients: experience of a single institution.

REFERENCES 1. Andiran N, Sarikayalar F, Saraçlar M, Cağlar M. Autosomal recessive form of congenital cutis laxa: More than the clinical appearance. Pediatr Dermatol 2002;19:412-4. 2. Zhang MC, He L, Giro M, Yong SL, Tiller GE, Davidson JM. Cutis laxa arising from frameshift mutations in exon 30 of the elastin gene (ELN). J Biol Chem 1999;274:981-6. 3. Tassabehji M, Metcalfe K, Hurst J, Ashcroft GS, Kielty C, Wilmot C, et al. An elastin gene mutation producing abnormal tropoelastin and abnormal elastic fibers in a patient with autosomal dominant cutis laxa. Hum Mol Genet 1998;7:1021-8. 4. Agha A, Sakati NO, Higginbottom MC, Jones KL Jr, Bay C, Nyhan WL. Two forms of cutis laxa presenting in the newborn period. Acta Paediatr Scand 1978;67:775-80. 5. Hashimoto K, Kanzaki T. Cutis laxa: Ultrastructural and biochemical studies. Arch Dermatol 1975;111:861-73. 6. Kitano Y, Nishida K, Okada N, Mimaki T, Yabuuchi H. Cutis laxa with ultrastructural abnormalities of elastic fiber. J Am Acad Dermatol 1989;21:378-80. 7. Guía Torrent JM, Castro García F, Cuenca Gómez M, Gracián Gómez M. Cardiovascular changes in the Cutis laxa syndrome. Rev Esp Cardiol 1999;52:204-6. 8. Weir EK, Joffe HS, Blaufuss AH, Beighton P. Cardiovascular abnormalities in cutis laxa. Eur J Cardiol 1977;5:255-61.