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1
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Goffer EM, Lamberti KK, Spognardi A, Edelman ER, Keller SP. Steady Flow Left Ventricle Unloading Is Superior to Pulsatile Pressure Augmentation Venting During Venoarterial Extracorporeal Membrane Oxygenation Support. ASAIO J 2024; 70:929-937. [PMID: 38588597 PMCID: PMC11458817 DOI: 10.1097/mat.0000000000002208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024] Open
Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) shunts venous blood to the systemic arterial circulation to provide end-organ perfusion while increasing afterload that may impede left ventricle (LV) ejection and impair cardiac recovery. To maintain flow across the aortic valve and reduce risk of lethal clot formation, secondary mechanical circulatory support (MCS) devices are increasingly used despite limited understanding of their effects on cardiac function. This study sought to quantify the effects of VA-ECMO and combined with either intraaortic balloon pump (IABP) or percutaneous ventricular assist device (pVAD) on LV physiologic state and perfusion metrics in a porcine model of acute cardiogenic shock. Shock was induced through serial left anterior descending artery microbead embolization followed by initiation of VA-ECMO support and then placement of either IABP or pVAD. Hemodynamic measurements, LV pressure-volume loops, and carotid artery blood flow were evaluated before and after institution of combined MCS. The IABP decreased LV end-diastolic pressure by a peak of 15% while slightly increasing LV stroke work compared with decreases of more than 60% and 50% with the pVAD, respectively. The pVAD also demonstrated increased coronary perfusion and systemic pressure gradients in comparison to the IABP. Combined support with VA-ECMO and pVAD improves cardiovascular state in comparison to IABP.
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Affiliation(s)
- Efrat M. Goffer
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA
| | - Kimberly K. Lamberti
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA
| | | | - Elazer R. Edelman
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Steven P. Keller
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD
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2
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Moradi H, Seethala RR, Edelman ER, Keller SP, Nezami FR. Effect of upper body venoarterial ECMO on systemic hemodynamics and oxygenation: A computational study. Comput Biol Med 2024; 182:109124. [PMID: 39276613 PMCID: PMC11584320 DOI: 10.1016/j.compbiomed.2024.109124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 08/15/2024] [Accepted: 09/04/2024] [Indexed: 09/17/2024]
Abstract
BACKGROUND This study seeks to quantify the effects of upper body veno-arterial extracorporeal membrane oxygenation (VA ECMO) on the anatomical distribution of oxygen delivery in the setting of hypoxic respiratory failure and provide new insights that will guide clinical use of this support strategy to bridge patients to lung transplant. METHODS Employing a patient-specific vascular geometry and a quantitative model of oxygen transport, computational simulations were performed to determine hemodynamics and oxygen delivery in the ascending and descending aorta, left and right coronary arteries, and great vessels during upper body VA ECMO support. Oxygen content in ECMO circuit blood flow was varied while considering different degrees of lung failure severity. Using lumped parameter models to dynamically apply perfusion boundary conditions, hemodynamic parameters and oxygen content were analyzed to assess the effect of ECMO supply titration. RESULTS The results emphasize the importance of anatomical distribution for tissue oxygen delivery in severe lung failure, with ECMO-derived flow primarily augmenting oxygen content in specific vascular beds. They also demonstrate that although cannulating the subclavian artery can enhance cerebral oxygen delivery, its ability to ensure sufficient oxygen delivery to the coronary circulation seems to be comparatively restricted. CONCLUSIONS The oxygen delivery to a specific vascular area is primarily determined by the oxygen content in the source of perfusion. Caution is advised with upper body VA ECMO for patients with hypoxic respiratory failure and right ventricle dysfunction, due to potential coronary ischemia. Management of these patients is challenging due to disease progression and organ availability uncertainties.
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Affiliation(s)
- Hamed Moradi
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Raghu R Seethala
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Elazer R Edelman
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA; Cardiovascular Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven P Keller
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA.
| | - Farhad R Nezami
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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3
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Shah D, Sen J. Mechanical Circulatory Support in Cardiogenic Shock: A Narrative Review. Cureus 2024; 16:e69379. [PMID: 39411633 PMCID: PMC11473205 DOI: 10.7759/cureus.69379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2024] [Accepted: 09/13/2024] [Indexed: 10/19/2024] Open
Abstract
Cardiogenic shock (CS) remains a critical condition with high mortality rates, often arising from acute myocardial infarction and advanced heart failure. Despite advancements in medical therapy, traditional interventions frequently fall short of reversing the profound hemodynamic instability seen in CS. Mechanical circulatory support (MCS) devices have emerged as crucial therapeutic options, offering temporary stabilization and bridging to recovery, heart transplantation, or long-term ventricular assist device implantation. This narrative review explores the current landscape of MCS in CS, highlighting the various types of support devices, including intra-aortic balloon pumps (IABP), veno-arterial extracorporeal membrane oxygenation (VA-ECMO), and percutaneous ventricular assist devices (pVADs) such as Impella and TandemHeart. We examine their mechanisms of action, clinical indications, and outcomes alongside the challenges and complications associated with their use. Additionally, we discuss the evolving guidelines and the role of MCS in contemporary CS management, emphasizing the need for timely intervention and a multidisciplinary approach. The review underscores the importance of individualized patient selection and device choice to optimize outcomes in this critically ill population.
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Affiliation(s)
- Dhruv Shah
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Jayshree Sen
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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4
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Singhvi A, Punnen J. Acute mechanical circulatory support for cardiogenic shock in India. Indian J Thorac Cardiovasc Surg 2023; 39:47-62. [PMID: 37525701 PMCID: PMC10387029 DOI: 10.1007/s12055-023-01530-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 08/02/2023] Open
Abstract
Cardiogenic shock continues to have high morbidity and mortality, despite advances in the field. Temporary mechanical circulatory support (TMCS) devices, if instituted in a timely fashion, can help stabilize critically ill patients with cardiogenic shock from various aetiologies and cardiac arrest, and provide time for organ recovery or till durable support or transplantation can be achieved. Currently, several options for TMCS devices exist. In this review, we discuss indications, contraindications, characteristics of the various available devices, and important issues pertaining to their management.
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Affiliation(s)
- Aditi Singhvi
- Narayana Institute of Cardiac Sciences, Narayana Health, Bommasandra Industrial Area, Bengaluru, Karnataka 560099 India
| | - Julius Punnen
- Narayana Institute of Cardiac Sciences, Narayana Health, Bommasandra Industrial Area, Bengaluru, Karnataka 560099 India
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5
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Tapaskar N, Tremblay-Gravel M, Khush KK. Contemporary Management of Cardiogenic Shock During Pregnancy. J Card Fail 2023; 29:193-209. [PMID: 36243342 DOI: 10.1016/j.cardfail.2022.09.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 09/13/2022] [Accepted: 09/20/2022] [Indexed: 11/07/2022]
Abstract
Cardiogenic shock is the most extreme cardiovascular disease state during pregnancy. Peripartum cardiomyopathy is the most common cause of cardiogenic shock toward the end of pregnancy and in the early postpartum period. Therapy for cardiogenic shock relies on appropriate phenotyping of shock etiology, severity and ventricular predominance, which are critical in the appropriate selection of medical and mechanical therapy. Mechanical circulatory support may be used as a bridge to recovery or as definitive therapy. Intra-aortic balloon pumps, percutaneous left ventricular assist devices and venoarterial extracorporeal circulatory devices have been successfully used in pregnancy and the postpartum period. The most commonly used mechanical therapy in the pregnant patient is extracorporeal membranous oxygenation circulatory support. The use of mechanical circulatory devices in peripartum cardiomyopathy has contributed to improved survival rates in recent years. Further efforts to identify the optimal mechanical circulatory support strategy for peripartum cardiomyopathy and cardiogenic shock in the peripartum period are needed.
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Affiliation(s)
- Natalie Tapaskar
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA.
| | | | - Kiran K Khush
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
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6
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Barssoum K, Patel HP, Abdelmaseih R, Hassib M, Victor V, Mohamed A, Jazar DA, Mai S, Ibrahim F, Patel B, Baeni AE, Khalife W, Bandyopadhay D, Rai D, Chatila K. Characteristics and Outcomes of Early vs Late Initiation of Mechanical Circulatory Support in Non-Acute Myocardial Infarction related Cardiogenic Shock: An Analysis of the National Inpatient Sample Database. Curr Probl Cardiol 2023; 48:101584. [PMID: 36642353 DOI: 10.1016/j.cpcardiol.2023.101584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 01/03/2023] [Indexed: 01/15/2023]
Abstract
Cardiogenic shock (CS) is significant cause of mortality. The use of mechanical circulatory support (MCS) in patients with non-acute myocardial infarction (Non-AMI) CS is lacking. We inquired data regarding the trends and outcomes early vs late initiation of MCS in non-AMI CS. We investigated National Inpatient Sample database between October 2015-December 2018, identifying hospitalizations with CS, either complicated by AMI or Non-AMI. Patients were divided into 2 cohorts, early initiation of MCS (<48 hours) and late initiation of MCS (>48 hours). The primary analysis included death within first 24 hours. A secondary analysis was adjusted after excluding patients who died in first 24 hours. A total of 85,318 patients with non-AMI-related CS with MCS placement were identified. Among this cohort, 54.6% (n=46,579) underwent early initiation of MCS within 48 hours, and 45.4% (n=38,739) underwent late initiation of MCS after 48 hours. In primary analysis, early MCS initiation was associated with more in-hospital mortality in primary outcome of all-cause hospital mortality (35.72% vs 27.63%, P<0.0001, OR 1.44, 95% CI: 1.40-1.49, P<0.0001), however, adjusted secondary analysis showed a statistically significant decrease in all-cause hospital mortality (23.63% vs 27.63%, P<0.0001, OR 0.80, 95% CI: 0.78-0.83, P<0.0001). In non-AMI-related CS and based on survival to 24 hours after admission, early initiation of MCS had statistically significant decrease in all-cause hospital mortality, with less incidence of vascular and renal complications, and shorter hospital stay. Late initiation of MCS was associated with a higher incidence of advanced therapies, including LVAD and transplant.
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Affiliation(s)
- Kirolos Barssoum
- Department of cardiology, University of Texas Medical Branch, Galveston, TX
| | - Harsh P Patel
- Department cardiology, Southern Illinois University, Carbondale, IL
| | - Ramy Abdelmaseih
- Department of cardiology, University of Texas Medical Branch, Galveston, TX
| | - Mohab Hassib
- Department of cardiology, University of Texas Medical Branch, Galveston, TX
| | | | - Ahmed Mohamed
- Department of cardiology, University of Texas Medical Branch, Galveston, TX
| | - Deaa Abu Jazar
- Department of internal medicine, University of Texas Medical Branch, Galveston, TX
| | - Steven Mai
- Department of internal medicine, University of Texas Medical Branch, Galveston, TX
| | - Fadi Ibrahim
- American University of Antigua, Antigua & Barbuda
| | - Bhavin Patel
- Department of internal medicine, Saint Joseph Mercy Oakland Hospital, Pontiac, MI
| | - Aiham El Baeni
- Department of cardiology, University of Texas Medical Branch, Galveston, TX
| | - Wissam Khalife
- Department of cardiology, University of Texas Medical Branch, Galveston, TX
| | | | - Devesh Rai
- Department of Cardiology, Sands-Constellation Heart Institute, Rochester Regional Health, Rochester, NY.
| | - Khaled Chatila
- Department of cardiology, University of Texas Medical Branch, Galveston, TX
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7
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Nezami FR, Ramezanpour M, Khodaee F, Goffer E, Edelman ER, Keller SP. Simulation of Fluid-Structure Interaction in Extracorporeal Membrane Oxygenation Circulatory Support Systems. J Cardiovasc Transl Res 2022; 15:249-257. [PMID: 34128180 PMCID: PMC11694477 DOI: 10.1007/s12265-021-10143-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 05/31/2021] [Indexed: 11/25/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a vital mechanical circulatory support modality capable of restoring perfusion for the patient in circulatory failure. Despite increasing adoption of ECMO, there is incomplete understanding of its effects on systemic hemodynamics and how the vasculature responds to varying levels of continuous retrograde perfusion. To gain further insight into the complex ECMO:failing heart circulation, computational fluid dynamics simulations focused on perfusion distribution and hemodynamic flow patterns were conducted using a patient-derived aorta geometry. Three case scenarios were simulated: (1) healthy control; (2) 90% ECMO-derived perfusion to model profound heart failure; and, (3) 50% ECMO-derived perfusion to model the recovering heart. Fluid-structure interface simulations were performed to quantify systemic pressure and vascular deformation throughout the aorta over the cardiac cycle. ECMO support alters pressure distribution while decreasing shear stress. Insights derived from computational modeling may lead to better understanding of ECMO support and improved patient outcomes.
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Affiliation(s)
- Farhad R Nezami
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Surgery (Thoracic and Cardiac Surgery), Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mehdi Ramezanpour
- Department of Mechanical Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Farhan Khodaee
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Efrat Goffer
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Elazer R Edelman
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Medicine (Cardiovascular Medicine), Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven P Keller
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA.
- Department of Medicine (Pulmonary and Critical Care Medicine), Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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8
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Navarro JC, Kofke WA. Perioperative Management of Acute Central Nervous System Injury. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00024-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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9
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Baljepally R, Tahir H. Effect of Atrioventricular Dyssynchrony on Impella Hemodynamics: Mechanism and Its Clinical Implications. Cardiol Res 2021; 12:219-224. [PMID: 34349862 PMCID: PMC8297037 DOI: 10.14740/cr1287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 06/18/2021] [Indexed: 11/12/2022] Open
Abstract
The physiologic importance of atrial systole and atrioventricular (AV) synchrony in maintaining cardiac performance is well established. However, the role of AV synchrony in maintaining adequate Impella output has not been fully evaluated. Despite the common belief that AV dyssynchrony does not affect Impella output, given that Impella is a continuous flow device, recent reports indicate that AV dyssynchrony can lead to low Impella output in patients with cardiogenic shock complicated by complete heart block. Temporary transvenous pacing without establishing AV synchrony may fail to improve Impella hemodynamics; therefore, understanding the mechanism of low Impella output in AV dyssynchrony and promptly restoring AV synchrony may improve Impella output in such cases and lead to better outcomes.
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Affiliation(s)
- Raj Baljepally
- Department of Cardiology, Heart Lung Vascular Institute, University of Tennessee Medical Center, Knoxville, TN, USA
| | - Hassan Tahir
- Department of Cardiology, Heart Lung Vascular Institute, University of Tennessee Medical Center, Knoxville, TN, USA
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10
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Nezami FR, Khodaee F, Edelman ER, Keller SP. A Computational Fluid Dynamics Study of the Extracorporeal Membrane Oxygenation-Failing Heart Circulation. ASAIO J 2021; 67:276-283. [PMID: 33627601 PMCID: PMC8130419 DOI: 10.1097/mat.0000000000001221] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is increasingly deployed to provide percutaneous mechanical circulatory support despite incomplete understanding of its complex interactions with the failing heart and its effects on hemodynamics and perfusion. Using an idealized geometry of the aorta and its major branches and a peripherally inserted return cannula terminating in the iliac artery, computational fluid dynamic simulations were performed to (1) quantify perfusion as function of relative ECMO flow and (2) describe the watershed region produced by the collision of antegrade flow from the heart and retrograde ECMO flow. To simulate varying degrees of cardiac failure, ECMO flow as a fraction of systemic perfusion was evaluated at 100%, 90%, 75%, and 50% of total flow with the remainder supplied by the heart calculated from a patient-derived flow waveform. Dynamic boundary conditions were generated with a three-element lumped parameter model to accurately simulate distal perfusion. In profound failure (ECMO providing 90% or more of flow), the watershed region was positioned in the aortic arch with minimal pulsatility observed in the flow to the visceral organs. Modest increases in cardiac flow advanced the watershed region into the thoracic aorta with arch perfusion entirely supplied by the heart.
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Affiliation(s)
- Farhad Rikhtegar Nezami
- From the Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Farhan Khodaee
- From the Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Elazer R Edelman
- From the Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Department of Medicine (Cardiovascular Medicine), Brigham and Women's Hospital, Boston, Massachusetts
| | - Steven P Keller
- From the Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Department of Medicine (Pulmonary and Critical Care Medicine), Brigham and Women's Hospital, Boston, Massachusetts
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11
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Dort DIM, Thannhauser J, Gommans FDH, Ten Cate TJ, Duncker DJ, Suryapranata H, Morshuis WJ, Geuzebroek GSC. Proof of principle of a novel co‐pulsating intra‐ventricular membrane pump. Artif Organs 2020; 44:1267-1275. [DOI: 10.1111/aor.13757] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 06/04/2020] [Accepted: 06/08/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Daniël I. M. Dort
- Department of Cardiothoracic Surgery Radboudumc Nijmegen The Netherlands
| | - Jos Thannhauser
- Department of Cardiology Radboudumc Nijmegen The Netherlands
| | | | - Tim J. Ten Cate
- Department of Cardiology Radboudumc Nijmegen The Netherlands
| | - Dirk J. Duncker
- Department of Experimental Cardiology Erasmus MC Rotterdam The Netherlands
| | | | - Wim J. Morshuis
- Department of Cardiothoracic Surgery Radboudumc Nijmegen The Netherlands
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12
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Faluk M, Hasan SM, Jiang T, Abdelmaseih R, Patel J. Mechanical Circulatory Assist Devices: Available Modalities and Review of Literature. Heart Views 2020; 21:269-275. [PMID: 33986926 PMCID: PMC8104314 DOI: 10.4103/heartviews.heartviews_92_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 11/03/2020] [Indexed: 11/04/2022] Open
Abstract
Despite advancements in the field interventional cardiology, the prognosis in patients who suffer from cardiogenic shock is poor. Over the years, the use of percutaneous mechanical circulatory support (MCS) devices has increased with the aim to improve short- and long-term outcomes. In this article, we aim to review the different modalities available for MCS devices and current literature comparing their uses.
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Affiliation(s)
- Mohammed Faluk
- Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, Florida, USA,Ocala Regional Medical Center, Internal Medicine Residency Program, Ocala, Florida, USA
| | - Syed Mustajab Hasan
- Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, Florida, USA,Ocala Regional Medical Center, Internal Medicine Residency Program, Ocala, Florida, USA,Address for correspondence: Dr. Syed Mustajab Hasan, 1431 SW 1st Ave., Ocala, FL 34471, USA. E-mail:
| | - Tianyu Jiang
- Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, Florida, USA,Ocala Regional Medical Center, Internal Medicine Residency Program, Ocala, Florida, USA
| | - Ramy Abdelmaseih
- Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, Florida, USA,Ocala Regional Medical Center, Internal Medicine Residency Program, Ocala, Florida, USA
| | - Jigar Patel
- Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, Florida, USA,Ocala Regional Medical Center, Internal Medicine Residency Program, Ocala, Florida, USA
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13
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Affiliation(s)
- Cyrus Vahdatpour
- Department of MedicinePennsylvania HospitalUniversity of Pennsylvania Health System (UPHS)PhiladelphiaPA
| | - David Collins
- Department of MedicinePennsylvania HospitalUniversity of Pennsylvania Health System (UPHS)PhiladelphiaPA
| | - Sheldon Goldberg
- Department of CardiologyPennsylvania HospitalUniversity of Pennsylvania Health System (UPHS)PhiladelphiaPA
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14
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Shah Z, Alraies MC, Soud M, Kaki A. Ex-vivo percutaneous bypass: Limb perfusion in the setting of occlusive large bore sheath. Catheter Cardiovasc Interv 2019; 93:673-677. [PMID: 30549188 DOI: 10.1002/ccd.28022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 11/17/2018] [Accepted: 11/25/2018] [Indexed: 11/06/2022]
Abstract
Successful cardiac catheterization procedure begins with safe vascular access and ends with effective hemostasis after equipment removal. These new and advanced technologies in the cath lab require large-bore arterial accesses. Large-bore sheaths are associated with blood flow obstruction resulting in limb ischemia. In this case we present a 48-year-old woman was admitted NSTEMI and cardiogenic shock requiring mechanical circulatory support. Selective left common iliac angiography demonstrated obstructive flow at the level of the left CFA (access site). Therefore, ipsilateral bypass circuit was done. The current case illustrates the utility of a temporary ex-vivo bypass circuit to preserve limb perfusion in the presence of an occlusive large bore sheath. The technique permits sufficient hemodynamic support while maintaining limb perfusion and can be used for any occlusive large bore sheath.
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Affiliation(s)
- Zeel Shah
- School of Medicine, Wayne State University, Detroit Medical Center, Detroit, Michigan
| | - M Chadi Alraies
- School of Medicine, Wayne State University, Detroit Medical Center, Detroit, Michigan
| | - Mohamad Soud
- MedStar Washington Hospital Center, Washington, District of Columbia
| | - Amir Kaki
- St. John Hospital and Medical Center, Detroit, Michigan
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15
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Acromegalic Cardiomyopathy With Malignant Arrhythmogenic Pattern Successfully Treated With Mechanical Circulatory Support and Heart Transplantation. Can J Cardiol 2017; 33:830.e9-830.e11. [DOI: 10.1016/j.cjca.2017.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 02/12/2017] [Accepted: 02/12/2017] [Indexed: 11/23/2022] Open
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Romeo F, Acconcia MC, Sergi D, Romeo A, Francioni S, Chiarotti F, Caretta Q. Percutaneous assist devices in acute myocardial infarction with cardiogenic shock: Review, meta-analysis. World J Cardiol 2016; 8:98-111. [PMID: 26839661 PMCID: PMC4728111 DOI: 10.4330/wjc.v8.i1.98] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 09/19/2015] [Accepted: 11/11/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the impact of percutaneous cardiac support in cardiogenic shock (CS) complicating acute myocardial infarction (AMI), treated with percutaneous coronary intervention.
METHODS: We selected all of the studies published from January 1st, 1997 to May 15st, 2015 that compared the following percutaneous mechanical support in patients with CS due to AMI undergoing myocardial revascularization: (1) intra-aortic balloon pump (IABP) vs Medical therapy; (2) percutaneous left ventricular assist devices (PLVADs) vs IABP; (3) complete extracorporeal life support with extracorporeal membrane oxygenation (ECMO) plus IABP vs IABP alone; and (4) ECMO plus IABP vs ECMO alone, in patients with AMI and CS undergoing myocardial revascularization. We evaluated the impact of the support devices on primary and secondary endpoints. Primary endpoint was the inhospital mortality due to any cause during the same hospital stay and secondary endpoint late mortality at 6-12 mo of follow-up.
RESULTS: One thousand two hundred and seventy-two studies met the initial screening criteria. After detailed review, only 30 were selected. There were 6 eligible randomized controlled trials and 24 eligible observational studies totaling 15799 patients. We found that the inhospital mortality was: (1) significantly higher with IABP support vs medical therapy (RR = +15%, P = 0.0002); (2) was higher, although not significantly, with PLVADs compared to IABP (RR = +14%, P = 0.21); and (3) significantly lower in patients treated with ECMO plus IABP vs IABP (RR = -44%, P = 0.0008) or ECMO (RR = -20%, P = 0.006) alone. In addition, Trial Sequential Analysis showed that in the comparison of IABP vs medical therapy, the sample size was adequate to demonstrate a significant increase in risk due to IABP.
CONCLUSION: Inhospital mortality was significantly higher with IABP vs medical therapy. PLVADs did not reduce early mortality. ECMO plus IABP significantly reduced inhospital mortality compared to IABP.
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Ergle K, Parto P, Krim SR. Percutaneous Ventricular Assist Devices: A Novel Approach in the Management of Patients With Acute Cardiogenic Shock. Ochsner J 2016; 16:243-249. [PMID: 27660572 PMCID: PMC5024805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Despite recent advances in the management of heart failure, cardiogenic shock remains a challenging and devastating condition with significant morbidity and mortality. METHODS We review currently available percutaneous mechanical circulatory support (MCS) devices and address each device's characteristics, mechanism of action, specific clinical indications, and contraindications. RESULTS Four types of percutaneous MCS devices are currently available: the intraaortic balloon pump (IABP), Impella devices, the TandemHeart, and extracorporal membrane oxygenation (ECMO). IABPs provide less hemodynamic support compared to the Impella, TandemHeart, and ECMO devices. However, because of its ease of placement and relatively small access catheter size, the IABP remains the most commonly used MCS device for the treatment of cardiogenic shock. When full cardiopulmonary support is needed, ECMO is the best option. CONCLUSION Temporary MCS has emerged as a therapeutic option in the management of patients with acute cardiogenic shock. However, clinician familiarity with the indications, limitations, and benefits of individual MCS devices and enhanced patient comfort with the placement are paramount to improve patient outcomes.
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Affiliation(s)
- Kevin Ergle
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA
| | - Parham Parto
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA
| | - Selim R. Krim
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
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Fazekas L, Sax B, Hartyánszky I, Pólos M, Horkay F, Varga T, Rácz K, Németh E, Székely A, Paulovich E, Heltai K, Zima E, Szabolcs Z, Merkely B. [Mechanical circulatory support saves lives -- three years' experience of the newly established assist device program at Semmelweis University, Budapest, Hungary]. Orv Hetil 2015; 156:521-7. [PMID: 25796280 DOI: 10.1556/oh.2015.30115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Since the celebration of the 20th anniversary of the first heart transplantation in Hungary in 2012 the emerging need for modern heart failure management via mechanical circulatory support has evolved. In May 2012 the opening of a new heart failure and transplant unit with 9 beds together with the procurement of necessary devices at Semmelweis University accomplished this need. AIM The aim of the authors was to report their initial experience obtained in this new cardiac assist device program. METHOD Since May, 2012, mechanical circulatory support system was applied in 89 cases in 72 patients. Indication for support were end stage heart failure refractory to medical treatment and acute left or right heart failure. RESULTS Treatment was initiated for acute graft failure after heart transplantation in 27 cases, for end stage heart failure in 24 cases, for acute myocardial infarction in 21 cases, for acute postcardiotomy heart failure in 14 cases, for severe respiratory insufficiency in 2 cases and for drug intoxication in one case. Among the 30 survivor of the whole program 13 patients were successfully transplanted. CONCLUSIONS The available devices can cover all modalities of current bridge therapy from short term support through medium support to heart transplantation or long term support and destination therapy. These conditions made possible the successful start of a new cardiac assist device program.
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Affiliation(s)
- Levente Fazekas
- Semmelweis Egyetem, Általános Orvostudományi Kar Városmajori Szív- és Érgyógyászati Klinika Budapest Városmajor u. 68. 1122
| | - Balázs Sax
- Semmelweis Egyetem, Általános Orvostudományi Kar Városmajori Szív- és Érgyógyászati Klinika Budapest Városmajor u. 68. 1122
| | - István Hartyánszky
- Semmelweis Egyetem, Általános Orvostudományi Kar Városmajori Szív- és Érgyógyászati Klinika Budapest Városmajor u. 68. 1122
| | - Miklós Pólos
- Semmelweis Egyetem, Általános Orvostudományi Kar Városmajori Szív- és Érgyógyászati Klinika Budapest Városmajor u. 68. 1122
| | - Ferenc Horkay
- Semmelweis Egyetem, Általános Orvostudományi Kar Városmajori Szív- és Érgyógyászati Klinika Budapest Városmajor u. 68. 1122
| | - Tamás Varga
- Semmelweis Egyetem, Általános Orvostudományi Kar Aneszteziológiai és Intenzív Terápiás Klinika Budapest
| | - Kristóf Rácz
- Semmelweis Egyetem, Általános Orvostudományi Kar Aneszteziológiai és Intenzív Terápiás Klinika Budapest
| | - Endre Németh
- Semmelweis Egyetem, Általános Orvostudományi Kar Aneszteziológiai és Intenzív Terápiás Klinika Budapest
| | - Andrea Székely
- Semmelweis Egyetem, Általános Orvostudományi Kar Aneszteziológiai és Intenzív Terápiás Klinika Budapest
| | - Erzsébet Paulovich
- Semmelweis Egyetem, Általános Orvostudományi Kar Aneszteziológiai és Intenzív Terápiás Klinika Budapest
| | - Krisztina Heltai
- Semmelweis Egyetem, Általános Orvostudományi Kar Városmajori Szív- és Érgyógyászati Klinika Budapest Városmajor u. 68. 1122
| | - Endre Zima
- Semmelweis Egyetem, Általános Orvostudományi Kar Városmajori Szív- és Érgyógyászati Klinika Budapest Városmajor u. 68. 1122
| | - Zoltán Szabolcs
- Semmelweis Egyetem, Általános Orvostudományi Kar Városmajori Szív- és Érgyógyászati Klinika Budapest Városmajor u. 68. 1122
| | - Béla Merkely
- Semmelweis Egyetem, Általános Orvostudományi Kar Városmajori Szív- és Érgyógyászati Klinika Budapest Városmajor u. 68. 1122
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Propofol infusion syndrome in adults: a clinical update. Crit Care Res Pract 2015; 2015:260385. [PMID: 25954513 PMCID: PMC4410753 DOI: 10.1155/2015/260385] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 03/21/2015] [Accepted: 03/28/2015] [Indexed: 12/18/2022] Open
Abstract
Propofol infusion syndrome is a rare but extremely dangerous complication of propofol administration. Certain risk factors for the development of propofol infusion syndrome are described, such as appropriate propofol doses and durations of administration, carbohydrate depletion, severe illness, and concomitant administration of catecholamines and glucocorticosteroids. The pathophysiology of this condition includes impairment of mitochondrial beta-oxidation of fatty acids, disruption of the electron transport chain, and blockage of beta-adrenoreceptors and cardiac calcium channels. The disease commonly presents as an otherwise unexplained high anion gap metabolic acidosis, rhabdomyolysis, hyperkalemia, acute kidney injury, elevated liver enzymes, and cardiac dysfunction. Management of overt propofol infusion syndrome requires immediate discontinuation of propofol infusion and supportive management, including hemodialysis, hemodynamic support, and extracorporeal membrane oxygenation in refractory cases. However, we must emphasize that given the high mortality of propofol infusion syndrome, the best management is prevention. Clinicians should consider alternative sedative regimes to prolonged propofol infusions and remain within recommended maximal dose limits.
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Gafoor S, Franke J, Lam S, Reinartz M, Bertog S, Vaskelyte L, Hofmann I, Sievert H. Devices in heart failure--the new revolution. Circ J 2015; 79:237-44. [PMID: 25744737 DOI: 10.1253/circj.cj-14-1354] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Heart failure is a growing epidemic, with more patients living longer and suffering from this disease. There is a growing segment of patients who have persistent symptoms despite pharmacologic therapy. In an era when transplants are rare, the need for devices and interventions that can assist ventricular function is paramount. This review goes through the devices used in heart failure, including left ventricular reconstruction, aortic counterpulsation, short-term mechanical circulatory support, long-term mechanical circulatory support, and right heart interventions.
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Affiliation(s)
- Sameer Gafoor
- CardioVascular Center Frankfurt (CVC), Frankfurt, Germany
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