M. Ando

A continuous-flow external ventricular assist device for cardiogenic shock: Evolution over 10 years

Background: The use of percutaneous mechanical circulatory support (MCS) in the treatment of cardiogenic shock has increased. However, limitations in flow capability, ventricular unloading effect, durability, and mobility remain. We reviewed our single‐center experience with continuous‐flow external ventricular assist devices (VADs) to determine the role of temporary VADs for cardiogenic shock in the contemporary MCS era. Methods: We retrospectively reviewed 252 patients who underwent continuous‐flow external VAD insertion between January 2007 and December 2016. To investigate the change in indications, device configurations, and outcomes, we divided the cohort into 2 groups—2007 to 2011 (Era 1; n = 127) and 2012 to 2016 (Era 2; n = 125)—and compared early and late outcomes. Results: Indications and device configurations changed significantly over time. The use of preoperative percutaneous MCS (53% vs 23%; P < .01) and use of minimally invasive VAD configurations (23% vs 6.7%; P < .01) were greater in Era 2 compared with Era 1. The rate of bridge to the next destinations, including myocardial recovery, transplantation, and durable VAD, was similar in the 2 groups. In‐hospital mortality was significantly better in Era 2 (50% vs 37%; P = .04). Overall survival at 1 year was 57% in Era 2 versus 43% in Era 1 (P = .04). Conclusions: Better outcomes in the recent era could be associated with the changes in practice patterns using continuous‐flow external VAD in patients with refractory cardiogenic shock.

Minimally invasive CentriMag ventricular assist device support integrated with extracorporeal membrane oxygenation in cardiogenic shock patients: a comparison with conventional CentriMag biventricular support configuration

OBJECTIVES We recently developed a novel minimally invasive surgical approach that combines extracorporeal membrane oxygenation and CentriMag ventricular assist device (Ec-VAD) for the treatment of cardiogenic shock as a short-term circulatory support. We compared the outcomes of this new approach to conventional CentriMag biventricular assist device (BiVAD) support through a median sternotomy. METHODS Between July 2015 and August 2016, 22 patients were implanted with CentriMag Ec-VAD and 90 patients were implanted with conventional CentriMag BiVAD. The Ec-VAD circuit was configured with left ventricular apical cannulation via a mini-thoracotomy and femoral venous cannulation as inflows and right axillary artery cannulation as an outflow. RESULTS Patients with Ec-VAD were older (58 ± 9.9 vs 53 ± 13 years, P = 0.06), had more preoperative percutaneous mechanical circulatory support use (82% vs 44%, P < 0.01) and less cardiopulmonary bypass use intraoperatively (0% vs 66%, P < 0.01). Patients who received Ec-VAD required less transfusions. The Ec-VAD group had a significantly lower incidence of major bleeding events during support (32% vs 72%, P < 0.01). Average systemic flow was similar (Ec-VAD: 5.5 ± 0.94 vs BiVAD: 5.7 ± 1.1 l/min, P = 0.4). Seventeen patients (77%) with Ec-VAD survived to the next destination compared with 66 patients (73%) with BiVAD (P = 0.45). Thirty-day survival was similar between groups (Ec-VAD 86% vs BiVAD 76%, P = 0.39), and overall 1-year survival was 61% in Ec-VAD and 55% in BiVAD (P = 0.7). CONCLUSIONS Ec-VAD is a unique approach for the treatment of patients in cardiogenic shock. It eliminates the need for cardiopulmonary bypass and reduces blood product utilization and bleeding events.

Floating Clots in the Descending Aorta: A Rare Complication of Femoral Venoarterial Extracorporeal Membrane Oxygenation Combined With Microaxial Pump for Cardiogenic Shock

Left ventricular (LV) distension during femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO) support is an untoward complication, leading to pulmonary edema, insufficient myocardial recovery, and LV thrombosis.1 Impella (Abiomed, Danvers, MA) has been reported to effectively decompress such a distended LV with minimal invasion.2 However, we encountered a rare case who developed a huge thrombus in the descending aorta resulting from the stagnation of blood flow because of interaction between antegrade (Impella) and retrograde (VA-ECMO) flows despite adequate anticoagulation. A 67-year-old man with history of hypertension, hyperlipidemia, diabetes mellitus, and chronic tobacco use presented to an outside hospital with chest pain and orthopnea. He was in a shock state, and his ECG showed ST elevations in the anterior leads. Emergent left heart catheter revealed total occlusion of proximal left anterior descending artery. He got intubated and was placed on an intra-aortic balloon pumping via right femoral artery. Thrombus extraction followed by coronary stenting was performed, but ultimately only thrombolysis in myocardial infarction grade 1 flow was …

Living, and living well, after cardiac surgery

From the Division of Cardiothoracic and Vascular Surgery and Department of Anesthesiology, Columbia University Medical Center, New York, NY. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication May 24, 2018; revisions received May 24, 2018; accepted for publication May 30, 2018. Address for reprints: Hiroo Takayama, MD, PhD, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, 177 Ft Washington Ave, New York, NY 10019 (E-mail: ht2225@cumc. columbia.ed). J Thorac Cardiovasc Surg 2018;-:1 0022-5223/

VA-ECMO for cardiogenic shock in the contemporary era of heart transplantation: Which patients should be urgently transplanted?

36.00 Copyright 2018 by The American Association for Thoracic Surgery https://doi.org/10.1016/j.jtcvs.2018.05.121

(600) – Pulmonary Vascular Resistance Is Not an Independent Predictor of Post-Transplant Outcome in Bridge-to-Transplant Patients; It's Time to Re-Evaluate Our Current Heart Transplant Eligibility

With the impending United Network for Organ Sharing (UNOS) heart allocation policy giving VA‐ECMO supported heart transplant (HT) candidates highest priority status (Tier 1), identifying patients in cardiogenic shock (CS) with severe and irreversible heart failure (HF) appropriate for urgent HT is critically important. In a center where wait times currently preclude this approach, we retrospectively reviewed 119 patients (ages 18‐72) with CS from 1/2014 to 12/2016 who required VA‐ECMO for >24 hours. Underlying aetiologies included postcardiotomy shock (45), acute coronary syndromes (33), and acute‐on‐chronic HF (16). Eighty‐four percent of patients (100) had ≥1 contraindication to HT with 61.3% (73) having preexisting contraindications (eg, multiorgan dysfunction and substance abuse), and 68.1% (81) experienced preclusive complications (eg, renal failure, coagulopathy, and infection). Potential HT candidates were significantly more likely to survive to discharge (potential HT candidates 84.2% vs preexisting contraindications 43.8% vs contraindications developing on VA‐ECMO 33.3%, P = 0.001). Among potential HT candidates, 11 (68.8%) were discharged without advanced therapies and 4 received durable left ventricular assist device (25.0%). Importantly, 1‐year survival was 100% for the 11 patients with follow‐up. Thus, further work is critical to define appropriate candidates for HT from VA‐ECMO while avoiding preemptive transplantation in those with otherwise favorable outcomes.