Xiaotong Hou

Early and Intermediate Results of Rescue Extracorporeal Membrane Oxygenation in Adult Cardiogenic Shock

BACKGROUNDnWe retrospectively evaluated the early and intermediate results of use of temporary extracorporeal membrane oxygenation (ECMO) support and examined its effect on quality of life (QOL).nnnMETHODSnOver four years 62 of 12,644 patients (0.49%) undergoing cardiac surgery (valve procedures, n = 39; coronary artery bypass grafting, n = 13; coronary artery bypass grafting plus valve procedures, n = 4; heart transplantation, n = 4; and total aortic arch replacement, n = 2) required temporary postoperative ECMO support. During a follow-up study (mean 2.3 +/- 1.5 years, 100% complete), 32 were still alive and answered the Short-Form 36 Health Survey QOL questionnaire.nnnRESULTSnThe mean duration of ECMO support was 61 +/- 37 hours. Forty patients (64.5%) were successfully weaned from ECMO. Thirty-four patients (54.8%) were discharged from the hospital after 44.3 +/- 17.6 days. The in-hospital mortality rate was 45.2% and the main cause of death was multiple organ failure. A risk factor for in-hospital death was a peak lactate level greater than 12 mol/L before ECMO initiation. There were few significant differences in the mean QOL scores between the ECMO survivors and other patients who had undergone cardiac surgery without ECMO support; only the measures of vitality and mental health were significantly lower in the ECMO survivors (p < 0.05). Both the ECMO survivors and the patients who did not receive ECMO support had significantly lower QOL scores (except for vitality and mental health) than the general Chinese population (p < 0.05).nnnCONCLUSIONSnExtracorporeal membrane oxygenation is an acceptable technique for the treatment of postoperative cardiogenic shock in adults, although early intervention and reduced complications could improve results. However, the use of ECMO has little influence on QOL.

Retrograde autologous priming of the cardiopulmonary bypass circuit reduces blood transfusion in small adults: a prospective, randomized trial.

Background and objective Extreme haemodilution occurring with cardiopulmonary bypass imposes a primary risk factor for blood transfusion in small adult cardiac surgical patients. Priming of the cardiopulmonary bypass circuit with patients own blood [retrograde autologous priming (RAP)] is a technique used to limit haemodilution and reduce transfusion requirements. We designed this study to evaluate the effects of RAP on reducing perioperative blood transfusion in small adults. Methods One hundred and twenty patients with a body surface area of less than 1.5 m2 undergoing first-time, nonemergency cardiac surgery were randomized to either the standard priming group or the RAP group. All patients followed strict transfusion criteria. Homologous transfusion, haematocrit, plasma colloid osmotic pressure and postoperative clinical outcomes were evaluated perioperatively. Results Patient characteristics and operative parameters were equal for patients in both groups. With autologous priming, a mean volume of 614.8 ± 138.8 ml of priming solution was replaced with autologous blood. This allowed a significantly higher haematocrit value during cardiopulmonary bypass (P < 0.05). Red blood cell transfusion was necessary in 83.3% of patients of the standard priming group on pump, whereas only 26.7% of patients of the RAP group required transfusion (P < 0.01). The overall transfusion rate of the RAP group was significantly less than that in the standard priming group during the hospitalization (90.0 vs. 50.0%, P < 0.01). Amongst patients who received transfusion on pump, the number of homologous units of packed red blood cells was less in the RAP group than that in the standard priming group intraoperatively and perioperatively (0.94 ± 0.32 vs. 1.48 ± 0.68 units, P = 0.03; 1.24 ± 0.54 vs. 1.69 ± 0.69 units, P = 0.15). Ten minutes after aortic cross-clamp, colloid osmotic pressure was reduced by 39.7 ± 2.8% in the standard priming group and by 28.6 ± 3.2% in the RAP group (P < 0.05). Clinical outcomes were similar with respect to pulmonary, renal and hepatic function, length of ICU stay and hospital stay. Conclusion RAP resulted in a significant decrease in intraoperative haemodilution and conserved the use of blood. This technique should be considered for patients with a small body surface area (<1.5 m2) undergoing open heart surgery.

Outcome of Veno-Arterial Extracorporeal Membrane Oxygenation for Patients Undergoing Valvular Surgery

Background We evaluated retrospectively the early and midterm results of using veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support in patients undergoing valvular surgery. Methods A total of 87 patients undergoing valvular surgery received VA-ECMO due to refractory postcardiotomy cardiogenic shock (PCS), who were eligible for inclusion were enrolled in this study. Preoperative, perioperative, and postoperative variables were assessed and analyzed for possible associations with mortality in hospital and after discharge. Results The mean age, additive EuroSCORE, and left ventricular ejection fraction (LVEF) for all patients was 65±7 years, 6.1±1.9 points, and 46% ±12%, respectively. The mean duration of VA-ECMO support was 61±37 hours. Intra-aortic balloon pumps (IABP) were implanted in 47.1% of patients. Weaning from VA-ECMO was successful in 59% of patients, and 49% were discharged. Multivariate analysis revealed that being >65 years old (odds ratio [OR], 2.75), receiving postoperative renal replacement treatment (OR, 2.47), having a peak lactate level ≥12 mmol L–1 (OR, 2.18), and receiving VA-ECMO for >60 hours (OR, 3.2) were independent predictors of in-hospital mortality. IABP support (OR, 0.46) was protective. In addition, persistent heart failure with an LVEF <40% was an independent predictor of mortality after discharge. Conclusions VA-ECMO is an acceptable technique for the treatment of PCS in patients undergoing valvular surgery, who would otherwise die. It is justified by the good long-term outcomes of hospital survivors, but the use of VA-ECMO must be decided on an individual risk profile basis because of high morbidity and mortality rates.

Position paper for the organization of ECMO programs for cardiac failure in adults

Extracorporeal membrane oxygenation (ECMO) has been used increasingly for both respiratory and cardiac failure in adult patients. Indications for ECMO use in cardiac failure include severe refractory cardiogenic shock, refractory ventricular arrhythmia, active cardiopulmonary resuscitation for cardiac arrest, and acute or decompensated right heart failure. Evidence is emerging to guide the use of this therapy for some of these indications, but there remains a need for additional evidence to guide best practices. As a result, the use of ECMO may vary widely across centers. The purpose of this document is to highlight key aspects of care delivery, with the goal of codifying the current use of this rapidly growing technology. A major challenge in this field is the need to emergently deploy ECMO for cardiac failure, often with limited time to assess the appropriateness of patients for the intervention. For this reason, we advocate for a multidisciplinary team of experts to guide institutional use of this therapy and the care of patients receiving it. Rigorous patient selection and careful attention to potential complications are key factors in optimizing patient outcomes. Seamless patient transport and clearly defined pathways for transition of care to centers capable of providing heart replacement therapies (e.g., durable ventricular assist device or heart transplantation) are essential to providing the highest level of care for those patients stabilized by ECMO but unable to be weaned from the device. Ultimately, concentration of the most complex care at high-volume centers with advanced cardiac capabilities may be a way to significantly improve the care of this patient population.

Venoarterial Extracorporeal Membrane Oxygenation for Refractory Cardiogenic Shock in Elderly Patients: Trends in Application and Outcome From the Extracorporeal Life Support Organization (ELSO) Registry

BACKGROUNDnVenoarterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock (RCS) is increasingly used in adult patients, but age represents a controversial factor in this setting.nnnMETHODSnData from the Extracorporeal Life Support Organization registry was analyzed to assess in-hospital survival of elderly patients (≥70 years of age) undergoing VA-ECMO for RCS from 1992 to 2015. In-hospital survival and complications for elderly patients were compared with data in younger adults (≥18 to <70 years of age) supported with VA-ECMO during the same time period for similar indications.nnnRESULTSnThe mean age of the patient cohort (nxa0= 5,408) was 53.0 ± 15.7 years (range, 18 to 91 years). The elderly group included 735 patients (13.6%), with a mean age of 75.2 ± 4.4 years. In the elderly group, pre-ECMO cardiac procedures were performed in 134 cases (18.9%), and 2.2% received VA-ECMO for postcardiotomy support compared with 0.7% in the younger cohort. The mean duration of VA-ECMO in the elderly group was 101 ± 91 h compared with 138 ± 146 h in the younger group (p < 0.001). Overall, survival to hospital discharge for the entire adult cohort was 41.4% (2,240 of 5,408), with 30.5% (224 of 735) in the elderly patient group and 43.1% (2,016 of 4,673) in the younger patient group (pxa0<xa00.001). Elderly patients had a higher rate of multiorgan failure. At multivariable analysis age represented an independent negative predictor of in-hospital survival.nnnCONCLUSIONSnBased on the acceptable survival to hospital discharge in our study, older age alone should not represent an absolute contraindication when considering VA-ECMO support for RCS.

Free-floating right atrial thrombus with acute pulmonary embolism.

A 70-year-old man had an episode of dyspnoea followed by syncope 2 months after a stroke. Deep venous thrombosis was found in his right lower extremity by venous Doppler ultrasound. Transoesophageal echocardiography revealed a 33×38 mm highly mobile mass floating in his right atrium with no attachment to any atrium structure (fig 1A). The right heart chambers were dilated with mild tricuspid valve regurgitation and a systolic pulmonary artery pressure of …

The Myocardial Protection of Polarizing Cardioplegia Combined With Delta-Opioid Receptor Agonist in Swine

BACKGROUNDnThe purpose of this study was to determine whether polarized arrest using adenosine/lidocaine cold crystalloid cardioplegia in combination with the hibernation inductor δ-opioid receptor agonist pentazocine would give satisfactory myocardial protection rather than using depolarized supranormal potassium cardioplegia, supranormal potassium cardioplegia with pentazocine, or adenosine/lidocaine cardioplegia.nnnMETHODSnTwenty pigs were randomly divided into four groups (n=5 each) to receive the four types of cold crystalloid cardioplegia with an aortic cross-clamp time of 1 hour. Hemodynamic data were continuously measured, as was the left ventricular end-diastolic pressure (LVEDP), left ventricular end-systolic pressure (LVESP), plus or minus derivative of change in diastolic pressure over time (±dp/dt), cardiac output, pulmonary artery pressure, pulmonary capillary wedge pressure, cardiac troponin I, and left ventricular ultrastructure.nnnRESULTSnBoth the adenosine/lidocaine/pentazocine group and the adenosine/lidocaine group got significantly better results than the hyperkalemic and hyperkalemic pentazocine groups in improving hemodynamic values, pulmonary capillary wedge pressure, LVEDP, LVESP, ±dp/dt, cardiac output, cardiac troponin I values, and left ventricular ultrastructure. There were no statistical differences between the adenosine/lidocaine/pentazocine group and the adenosine/lidocaine group at 1 hour after cross-clamp removal; but at 2 hours after cross-clamp removal, the adenosine/lidocaine/pentazocine group stands out (LVEDP 3.3±0.5, LVESP 122.5±18.9, +dp/dt 2.9±0.1, -dp/dt 2.0±0.6, cardiac output 2.6±0.4, and troponin I 4.9±0.5), with significant differences from the adenosine/lidocaine group (LVEDP 5.8±1.0, LVESP 98.5±10.1, +dp/dt 2.5±0.2, -dp/dt 1.0±0.2, cardiac output 2.2±0.2, troponin I 8.2±0.8; p<0.05). The defibrillation rate was largely decreased after the cross-clamp was released in the group containing pentazocine in cardioplegia.nnnCONCLUSIONSnAdenosine/lidocaine/pentazocine cold crystalloid cardioplegia gave satisfactory cardiac arrest and better myocardial protection than the other three groups, especially with regard to improving prolonged postoperative cardiac function.

Immature monocytes contribute to cardiopulmonary bypass-induced acute lung injury by generating inflammatory descendants

Background As immune regulatory and effector cells, monocytes play an important role in the blood–extracorporeal circuit contact-related acute lung injury in patients undergoing cardiopulmonary bypass (CPB). However, circulating monocytes are phenotypically and functionally heterogeneous, so we characterised how immature monocytes affect acute lung injury induced by CPB. Methods The identification and dynamic changes in monocyte subsets were monitored by flow cytometry in patients undergoing CPB and in a rat model of CPB. The differentiation and migration of monocyte subsets were explored by in vitro cultures and adoptive transfer in the CPB rat model. Results We observed a dramatic increase of two monocyte subsets in the peripheral blood of patients undergoing CPB, involving tumour necrosis factor (TNF)-α-producing, mature intermediate CD14highCD16+ monocytes and a novel immature CD14lowCD16− subset. The immature CD14lowCD16− monocytes possessed limited ability for TNF-α production, and failed to suppress T-cell proliferation mediated by T-cell receptor signalling. However, these immature cells were highly proliferative and could differentiate into TNF-α producing, mature CD14highCD16+ monocytes. In the rat model of CPB, we further demonstrated that CPB induced migration of immature monocytes into the lungs, either from the bone marrow or from the spleen. Moreover, we confirmed the hypothesis that immature subsets could contribute to CPB-induced acute lung injury by giving rise to TNF-α producing descendants. Conclusions The immature CD14lowCD16− monocytes might contribute to blood-circuit contact-induced acute lung injury by generating TNF-α-producing, mature monocytes. New strategies based on monocyte manipulation could be a promising therapeutic approach for minimising CPB-related lung injury.

Preoperative intra-aortic balloon pump improves the clinical outcomes of off-pump coronary artery bypass grafting in left ventricular dysfunction patients.

Severe left ventricular (LV) dysfunction patients undergoing off-pump coronary artery bypass grafting (OPCAB) are often associated with a higher mortality. The efficacy and safety of the preoperative prophylactic intra-aortic balloon pump (IABP) insertion is not well established. 416 consecutive patients with severe LV dysfunction (ejection fraction ≤35%) undergoing isolated OPCAB were enrolled in a retrospective observational study. 191 patients was enrolled in the IABP group; the remaining 225 patients was in control group. A total of 129 pairs of patients were propensity-score matched. No significant differences in demographic and preoperative risk factors were found between the two groups. The postoperative 30-day mortality occurred more frequently in the control group compared with the IABP group (8.5% vs. 1.6%, pu2009=u20090.02). There was a significant reduction of low cardiac output syndrome in the IABP group compared with the control group (14% vs. 6.2%, pu2009=u20090.04). Prolonged mechanical ventilation (≥48u2009h) occurred more frequently in the control group (34.9% vs. 20.9%, pu2009=u20090.02). IABP also decreased the postoperative length of stay. Preoperative IABP was associated with a lower 30-day mortality, suggesting that it is effective in patients with severe LV dysfunction undergoing OPCAB.

Veno‐Arterial Extracorporeal Membrane Oxygenation Support in Patients Undergoing Aortic Surgery

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an option for mechanical support for patients with postcardiotomy cardiogenic shock (PCS). However, the use of VA-ECMO in patients suffering from aortic disease with PCS has not been greatly reported. This is a retrospective review of adult patients undergoing aortic surgery who received VA-ECMO support to treat refractory PCS from August 2009 to May 2016. A total of 36 patients who underwent aortic surgery with VA-ECMO support for refractory PCS were included. Preoperative, perioperative, and postoperative variables were assessed and analyzed for possible correlation with in-hospital mortality. After a mean duration of 3.6u2009±u20092.9 days, 24 patients (67%) were weaned off VA-ECMO, and 18 patients (50%) were discharged from the hospital. The overall in-hospital mortality was 50%. The main cause of death was multiple organ dysfunction. The survivors had a lower level of preoperative creatine kinase-MB (CK-MB), a higher rate of antegrade cannulation, and a lower lactate level at 12 h, respectively. Relevant factors for in-hospital mortality were retrograde-flow cannulation (odds ratio [OR], 2.49), peak lactate levels greater than 20 mmol/L (OR, 5.0), and preoperative CK-MB greater than 100 IU/L (OR, 6.40). Antegrade cannulation may provide better perfusion and should be emphasized to improve outcomes. Additionally, levels of peak serum lactate and preoperative CK-MB may be relevant factors for in-hospital mortality in aortic patients with PCS.