Po-Shun Hsu

Extracorporeal membrane oxygenation for refractory cardiogenic shock after cardiac surgery: predictors of early mortality and outcome from 51 adult patients

OBJECTIVE Extracorporeal membrane oxygenation (ECMO) offers temporary haemodynamic support for those with refractory cardiogenic shock after cardiac surgery. We review our 5-year experience regarding ECMO use on those who cannot be weaned from cardiopulmonary bypass after cardiac surgery. We analyse our cases, predict the prognostic factors of survival and compare the short-term and medium-term results. METHODS From January 2002 to December 2006, 1764 patients underwent cardiac surgery with cardiopulmonary bypass in our division. Among these, 51 patients (2.9%) required venoarterial-mode ECMO for haemodynamic support because of refractory postcardiotomy cardiogenic shock. The indication of ECMO was refractory cardiogenic shock despite adequate filling volumes, large-dose inotropes and intra-aortic balloon pump support. The following cardiac surgical procedures were performed: coronary artery bypass grafting (CABG), n=27; valvular surgery, n=11; CABG plus valvular surgery, n=7; heart transplantation, n=4 and other procedures, n=2. RESULTS Average age was 63.0+/-15.7 years. There were 36 male and 15 female patients. Average duration of ECMO was 7.5+/-6.7 days. Twenty-seven (53%) patients could be successfully weaned from ECMO. The 30-day and 3-month mortalities were 49% (25/51) and 65% (33/51). The in-hospital mortality was 67% (34/51 patients). Seventeen (33%) patients could be successfully discharged. Fifteen (29%) patients were still alive at 1-year outpatient department (OPD) follow-up. CONCLUSIONS ECMO provides a good temporary cardiopulmonary support in patients with postcardiotomy shock. The preoperative risk factors of failure to withdraw ECMO are poor left-ventricular ejection fraction, systolic blood pressure <90 mmHg and refractory severe metabolic acidosis. The peri-ECMO predictors of mortality include low serum albumin level, low platelet count, low oxygen pressure of the venous tube of the ECMO and poor cardiac systolic function.

Benefit of extracorporeal membrane oxygenation in major burns after stun grenade explosion: Experience from a single military medical center

INTRODUCTION Explosion injury is very common on the battlefield and is associated with major burn and inhalation injuries and subsequent high mortality and morbidity rates. Here we report six victims who suffered from explosion injuries caused by stun grenade; all were treated with extracorporeal membrane oxygenation (ECMO) as salvage therapy. This study was aimed to evaluate the indications and efficacy of ECMO in acute and critically ill major burn patients. METHODS This was a retrospective analysis of six patients from Tri-Service General Hospital, National Defense Medical Center in Taiwan. All suffered from major burns with 89.0±19.1% average of total body surface area over second degree (TBSA; range, 50-99%). ECMO was used due to inhalation injury in five patients and cardiogenic shock in one patient. The average interval to start ECMO was 26.5±19.0h (range, 14-63h). Venoarterial ECMO was used on in four patients due to unstable hemodynamic status, whereas venovenous ECMO was used in two patients for sustained hypoxemia. RESULTS All patients had rhabdomyolysis with acute renal failure. The average duration of ECMO was 169.6±180.9h (range, 27-401h). All patients developed coagulopathy and needed debridement surgery during ECMO support, and five underwent torso escharotomy due to inspiratory compromise. Only one patient whose second and third degree burns covered 50% TBSA was successfully weaned from ECMO and survived; he was discharged after 221 hospital days. All patients who died had second and third degree burns covering over 90% of their TBSA. Three patients died of multiple organ failure, one died of septic shock, and the other died of cardiogenic shock. Overall survival rate was 16.7%. CONCLUSIONS In acute and critically ill major burn patients, ECMO could be considered as a salvage therapy, particularly in those with inhalation injury and burn-related acute respiratory distress syndrome. However, ECMO does not seem to provide benefits for circulatory support in those with hemodynamic compromise. The use of ECMO in these patients is still investigational, as our data provided no benefit in terms of the outcomes or survival, particularly in those with more than 90% TBSA burns.

Heart Transplantation for Ventricular Arrhythmia Caused by a Rare Hamartoma

Hamartoma of mature cardiac myocytes is a form of cardiac tumor that shares some features with hypertrophic cardiomyopathy and rhabdomyomas. Here we describe a patient with a ventricular hamartoma complicated with ventricular tachycardia. Resection was not practical because of difficulty in maintaining the ventricular geometry, so heart transplantation was done.

Myocardial protection in donor heart preservation: a comparison between Bretschneider's histidine-tryptophan-ketoglutarate solution and cold blood cardioplegia.

BACKGROUND Optimal myocardial protection for donated hearts is crucial to improve outcomes of heart transplantation and reduce morbidity and mortality. This study aimed to compare the efficacy of myocardial protection using single dose of Bretschneiders histidine-tryptophan-ketoglutarate (HTK) solution and repeated doses of cold blood cardioplegia (CBC) in donor heart preservation. METHODS Sixty-seven patients undergoing heart transplantation in Tri-Service General Hospital, Taipei, Taiwan between 2002 and 2012 were enrolled in this study. Patients were divided into an HTK group and a CBC group based on the preservation solution used to protect the donated hearts. The perioperative variables and postoperative outcomes were retrospectively reviewed. RESULTS There were no statistic differences about demographic data in donors and recipients between the 2 groups. There were no significant differences in postoperative cardiac enzymes, hemodynamic data, length of stay in intensive care, or 30-day mortality between the groups. The HTK group showed a trend of shorter pumping time (P = .091). Multivariate analyses reveal that the HTK group had higher postoperative inotropic score (P < .001) and shorter pumping time (P = .02). CONCLUSIONS Single dose of Bretschneiders HTK solution could effectively reduce pumping time and afford similar myocardial protection compared with repeated doses of CBC in the preservation of donated hearts.

Cardiac Tamponade As the Initial Manifestation of Metastatic Adenocarcinoma from the Colon: A Case Report

Metastatic cardiac malignancies mainly come from the lung, breast, and the lymphoreticular system by direct invasion or hematogenous or lymphatic spread. Metastasis from colorectal cancer to the heart or pericardium is seldom reported and only sporadic antemortem cases have been reported. We report an unusual case of malignant pericardial effusion caused by metastatic adenocarcinoma of colon. Malignant pericardial effusion and subsequent tamponade was the earliest manifestation without any other confirmed clinical metastases. Pericardiotomy was performed to relieve the life-threatening cardiac tamponade. We report this rare case and review the literature.

Successful Treatment of Acute Fulminant Myocarditis with Double Sets of Extracorporeal Membrane Oxygenation: Report of a Case and Review of the Literature

We report a case of acute fulminant myocarditis (AFM) with cardiogenic shock and hemodynamic collapse. We performed emergency extracorporeal life support (ECLS) with right femoral venoarterial cannulation by Seldinger procedure. Because of poor systemic perfusion over the upper trunk with low O₂ saturation due to inadequate venous return, a second ECLS was applied 16 hours after the first ECLS with right subclavian venoarterial cannulation by cut-down procedure. Total flow of both ECLS sets can achieve a flow of up to 6-8  l/min without massive destruction of blood cells. Combined with supportive intravenous immunoglobulin (IVIG) treatment, cardiac function recovered well and the ECLS sets were removed one-by-one. Follow-up studies one year after admission showed good cardiac systolic function and no sequelae of AFM.

Emergency endovascular aortic repair of a ruptured mycotic aorto-iliac aneurysm presenting with lumbar radiculopathy : case report

Ruptured abdominal aortic aneurysm is life-threatening without immediate management. The initial clinical presentation is non-specific and impending rupture is easily missed, especially without a CT scan. We present a case of a 56-year-old man with low-back pain and left lower-extremity numbness, which was diagnosed as a herniated intervertebral disc (HIVD) with left acute sciatica syndrome. He also complained of persistent fever and abdominal discomfort. Routine blood work-up revealed leukocytosis and decreasing haemoglobin levels. CT angiography (CTA) showed impending rupture of the left aorto-iliac aneurysm. We therefore performed endovascular aneurysm repair (EVAR). Blood culture revealed Salmonella enterica, for which he received antibiotics. No acute sciatica syndrome was present immediately after the EVAR. No EVAR-related complications were noted in the one-year CTA follow up.

Endovascular repair for primary adult coarctation of the aorta complicated with acute epidural hematoma leading to paraplegia: A case report

The incidence of neurovascular complications with paraplegia in patients of coarctation of the aorta (CoA) is very rare, and the prognosis of the outcome is poor. The traditional standardized management for the aortic coarctation is surgical repair, which can be associated with considerable intraoperative risk and postoperative morbidity. In this article, we present a case of diagnosis of the primary CoA complicated with acute epidural hematoma and paraplegia treated with endovascular repair with balloon angioplasty and stent placement successfully.

Comparison of vascular ring connector and conventional suture technique in the surgical management of acute type A aortic dissection

Background: The aim of this study was to examine the utility of the vascular ring connector (VRC) and compare the clinical outcomes to conventional suture technique in the operation for acute type A aortic dissection (AAAD). Methods: We retrospectively enrolled 64 consecutive patients (mean age 57.4 ± 12.7 years, range 24-82 years) with AAAD who underwent emergent surgery in our institution from September 2010 to November 2014. Patients were divided into VRC group (55 patients) and conventional suture group (nine patients) based on the use of VRC during the operation. The preoperative characteristics, operative variables, and postoperative outcomes were collected and analyzed. Results: Male patients predominated in both groups. The mean times of cardiopulmonary bypass and aortic cross-clamp were 200.1 ± 99.9 and 193.6 ± 54.7 min (P = 0.425) and 107.5 ± 56.2 and 112.3 ± 40.8 min (P = 0.404) in the VRC group and suture group, respectively. There were more blood transfusions within 24 h (1513.3 ± 949.2 vs. 841.8 ± 801.1 ml) and more mediastinal drainage amount (1314.4 ± 650.3 ml vs. 942.1 ± 527.2 ml) in the suture group than in the VRC group. In the VRC group, 36.3% of patients did not require blood transfusion. Moreover, the pumping time and cardiac ischemic times were longer in the one-VRC group than in the two-VRC group. Operative mortality did not differ between the two groups (10.9% in VRC and 11.1% in suture group, P = 0.985). No dislodgement of VRC during or after operation and no bleeding from sutureless anastomosis site were noted. Conclusion: Use of VRC is associated with equivalent operative mortality and morbidity compared to suture group in patients with AAAD undergoing an emergent operation. This study demonstrates the clinical safety and efficacy of VRC in reducing the need of blood transfusion within 24 h and mediastinal drainage within 72 h. However, further randomized studies and long-term surveillance of the use of VRC in AAAD are still mandatory.

Subclavian artery cannulation provides better myocardial protection in conventional repair of acute type A aortic dissection: experience from a single medical centre in Taiwan.

Summary Background Although many reports have detailed the advantages and disadvantages between femoral and subclavian arterial cannulations for acute aortic dissection type A (AADA), the confounding factors caused by disease severity and surgical procedures could not be completely eliminated. We compared femoral and subclavian artery cannulation and report the results for reconstruction of only the ascending aorta. Methods From January 2003 to December 2010, 51 AADA cases involving reconstruction of only the ascending aorta were retrospectively reviewed and categorised on the basis of femoral (n = 26, 51%) or subclavian (n = 25, 49%) arterycannulation. Bentall’s procedures, arch reconstruction and hybrid operations with stent-grafts were all excluded to avoid confounding factors due to dissection severity. Surgical results, postoperative mortality, and short- and mid-term outcomes were compared between the groups. Results Subclavian cannulation had a lower incidence of cerebral and myocardial injury and lower hospital mortality than femoral cannulation (8 vs 34%, p = 0.04). Ventilation duration as well as intensive care unit (ICU) and hospital stay were also shorter with subclavian cannulation. Risk factors for hospital mortality included pre-operative respiratory failure (odds ratio: 12.84), peri-operative cardiopulmonary bypass (CPB) time > 200 minutes (odds ratio: 13.49), postoperative acidosis (pH < 7.2, odds ratio: 88.63), and troponin I > 2.0 ng/ml (odds ratio: 20.08). The overall hospital mortality rate was 21%. The 40 survivors were followed up for three years with survival of 75% at one year and 70% at three years. Conclusions Our results show that subclavian cannulation had a lower incidence of cerebral and myocardial injury as well as better postoperative recovery and lower hospital mortality rates for reconstruction of only the ascending aorta.