Thijs Delnoij

Modalities and Effects of Left Ventricle Unloading on Extracorporeal Life support: a Review of the Current Literature

Veno‐arterial extracorporeal membrane oxygenation (V‐A ECMO) support is increasingly used in refractory cardiogenic shock and cardiac arrest, but is characterized by a rise in afterload of the left ventricle (LV) which may ultimately either further impair or delay cardiac contractility improvement. The aim of this study was to provide a comprehensive overview regarding the different LV venting techniques and results currently available in the literature.

Atrial trans-septal thrombus in massive pulmonary embolism salvaged by prolonged extracorporeal life support after thrombo-embolectomy. A bridge to right-sided cardiovascular adaptation.

Massive pulmonary embolism poses a therapeutic challenge, especially when thrombolytics are controversial. We describe the complicated course of an exceptional case of massive pulmonary embolism exhibiting paradoxic embolization with a thrombus lodged in the foramen ovale. Thrombolysis was considered contraindicated and surgical intervention was performed. Postoperatively, persistent pulmonary hypertension and impending right ventricular (RV) failure necessitated the initiation of extracorporeal life support (ELS), accompanied by therapeutic heparinization, inhaled nitric oxide, levosimendan and sildenafil. On day 8, the patient was successfully weaned from ELS with excellent neurological recovery and virtual normalization of RV pressures and dimensions. (Contra-) indications for thrombolysis and surgical embolectomy are reviewed. The intriguing role of ELS in conjunction with therapeutic heparinization and pharmacological unloading of the right-sided vasculature and the RV is discussed.

In vivo histology by cardiovascular magnetic resonance imaging

A 65-year-old male patient with a blank cardiac history was admitted to our hospital after an out-of-hospital cardiac arrest due to ventricular fibrillation. Immediate coronary angiography showed significant three-vessel disease without culprit lesions and no intervention was performed. Cardiac enzymes remained within normal limits and he made a complete recovery. Cardiovascular magnetic resonance (CMR) imaging on day 6 revealed a dilated left ventricle with low ejection fraction (26%). Late gadolinium enhancement …

Brain monitoring in adult and pediatric ECMO patients: The importance of early and late assessments

Monitoring brain integrity and neurocognitive function is a new and important target for the management of a patient treated with extracorporeal membrane oxygenation (ECMO), in particular because of the increasing awareness of cerebral abnormalities that may potentially occur in this setting. Continuous regular monitoring, as well as repeated assessment for cerebral complications has become an essential element of the ECMO patient management. Besides well-known complications, like bleeding, ischemic stroke, seizures, and brain hypoperfusion, other less defined yet relevant injury and clinical manifestations are increasingly reported and impacting on ECMO patient prognosis at short term. Furthermore, it is becoming more evident that neurologic complication may not occur only in the early phase. Indeed, other potential adverse events related to the long-term neurocognitive function have been also recently documented either in children or adult ECMO patients. Despite increasing awareness of these aspects, generally accepted protocols and clinical management strategies in this respect are still lacking. Current means to monitor brain perfusion or detecting ongoing cerebral tissue injury are rather limited, and most techniques provide indirect or post-insult recognition of irreversible tissue injury. Continuous monitoring of brain perfusion, serial assessment of brain-derived serum biomarkers, timely neuro-imaging, and post-discharge counselling for neurocognitive dysfunction, particularly in pediatric patients, are novel pathways focusing on neurologic assessment with important implications in daily practice to assess brain function and integrity not only during the ECMO-related hospitalization, but also at long-term to re-evaluate the neuropsychological integrity, although well designed studies will be necessary to elucidate the cost-effectiveness of these management strategies.

Venovenous Extracorporeal Membrane Oxygenation in Intractable Pulmonary Insufficiency: Practical Issues and Future Directions

Venovenous extracorporeal membrane oxygenation (vv-ECMO) is a highly invasive method for organ support that is gaining in popularity due to recent technical advances and its successful application in the recent H1N1 epidemic. Although running a vv-ECMO program is potentially feasible for many hospitals, there are many theoretical concepts and practical issues that merit attention and require expertise. In this review, we focus on indications for vv-ECMO, components of the circuit, and management of patients on vv-ECMO. Concepts regarding oxygenation and decarboxylation and how they can be influenced are discussed. Day-to-day management, weaning, and most frequent complications are covered in light of the recent literature.

Cardiac rupture with giant left ventricular pseudoaneurysm following inferior wall myocardial infarction: A rare complication

A 47-year-old man with no medical history presented with abdominal pain, fatigue and dyspnea over the previous fi ve days. Patient was hypotensive (90/60 mm Hg), tachycardic (140 bpm), pale and diaphoretic. Electrocardiography showed ST elevation and Q-waves in the inferior leads. Coronary angiography showed signifi cant stenosis in right coronary artery. Echocardiography revealed rupture of the infero-posterior free wall of the left ventricle and formation of a giant pseudoaneurysm (11 12 cm) larger than the left