Circulación extracorpórea

ASAIO J. 2022 Dec 1;68(12):1483-1489. doi: 10.1097/MAT.0000000000001692. Epub 2022 Mar 14.

ABSTRACT

Right heart failure (RHF) is a common, yet difficult to manage, complication of severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation (ECMO) that is associated with increased mortality. Reports of the use of percutaneous mechanical circulatory support devices for concurrent right heart and respiratory failure are limited. This series describes the percutaneous cannulation of the pulmonary artery for conversion from veno-venous to veno-pulmonary artery return ECMO in 21 patients who developed secondary RHF. All patients cannulated between May 2019 and September 2021 were included. Either a 19 or 21 French venous cannula was placed percutaneously into the pulmonary artery via the internal jugular or subclavian vein, providing a total of 821 days of support (median 23 [4-71] days per patient) with flows up to 6 L/min. Five patients underwent cannulation at the bedside, with the remainder performed in the cardiac catheterization laboratory. Pulmonary artery cannulation occurred after 12 [8.5-23.5] days of ECMO support. Vasoactive infusion requirements decreased significantly within 24 hours of pulmonary artery cannula placement (p = 0.0004). Nonetheless, 75% of these patients expired after a median of 12 [4-63] days of support, with three patients found to have had significant pericardial effusions peri-arrest. This cannulation technique may be an effective alternative to veno-arterial ECMO cannulation or the placement of a dual-lumen cannula for the treatment of RHF.

PMID:36469447 | DOI:10.1097/MAT.0000000000001692

Front Neurosci. 2022 Nov 18;16:952355. doi: 10.3389/fnins.2022.952355. eCollection 2022.

ABSTRACT

OBJECTIVE: Term congenital heart disease (CHD) neonates display abnormalities of brain structure and maturation, which are possibly related to underlying patient factors, abnormal physiology and perioperative insults. Our primary goal was to delineate associations between clinical factors and postnatal brain microstructure in term CHD neonates using diffusion tensor imaging (DTI) magnetic resonance (MR) acquisition combined with complementary data-driven connectome and seed-based tractography quantitative analyses. Our secondary goal was to delineate associations between mild dysplastic structural brain abnormalities and connectome and seed-base tractography quantitative analyses. These mild dysplastic structural abnormalities have been derived from prior human infant CHD MR studies and neonatal mouse models of CHD that were collectively used to calculate to calculate a brain dysplasia score (BDS) that included assessment of subcortical structures including the olfactory bulb, the cerebellum and the hippocampus.

METHODS: Neonates undergoing cardiac surgery for CHD were prospectively recruited from two large centers. Both pre- and postoperative MR brain scans were obtained. DTI in 42 directions was segmented into 90 regions using a neonatal brain template and three weighted methods. Clinical data collection included 18 patient-specific and 9 preoperative variables associated with preoperative scan and 6 intraoperative (e.g., cardiopulmonary bypass and deep hypothermic circulatory arrest times) and 12 postoperative variables associated with postoperative scan. We compared patient specific and preoperative clinical factors to network topology and tractography alterations on a preoperative neonatal brain MRI, and intra and postoperative clinical factors to network topology alterations on postoperative neonatal brain MRI. A composite BDS was created to score abnormal findings involving the cerebellar hemispheres and vermis, supratentorial extra-axial fluid, olfactory bulbs and sulci, hippocampus, choroid plexus, corpus callosum, and brainstem. The neuroimaging outcomes of this study included (1) connectome metrics: cost (number of connections) and global/nodal efficiency (network integration); (2) seed based tractography methods of fractional anisotropy (FA), radial diffusivity, and axial diffusivity. Statistics consisted of multiple regression with false discovery rate correction (FDR) comparing the clinical risk factors and BDS (including subcortical components) as predictors/exposures and the global connectome metrics, nodal efficiency, and seed based- tractography (FA, radial diffusivity, and axial diffusivity) as neuroimaging outcome measures.

RESULTS: A total of 133 term neonates with complex CHD were prospectively enrolled and 110 had analyzable DTI. Multiple patient-specific factors including d-transposition of the great arteries (d-TGA) physiology and severity of impairment of fetal cerebral substrate delivery (i.e., how much the CHD lesion alters typical fetal circulation such that the highest oxygen and nutrient rich blood from the placenta are not directed toward the fetal brain) were predictive of preoperative reduced cost (p < 0.0073) and reduced global/nodal efficiency (p < 0.03). Cardiopulmonary bypass time predicted postoperative reduced cost (p < 0.04) and multiple postoperative factors [extracorporeal membrane oxygenation (ECMO), seizures and cardiopulmonary resuscitation (CPR)] were predictive of postoperative reduced cost and reduced global/nodal efficiency (p < 0.05). Anthropometric measurements (weight, length, and head size) predicted tractography outcomes. Total BDS was not predictive of brain network topology. However, key subcortical components of the BDS score did predict key global and nodal network topology: abnormalities of the cerebellum predicted reduced cost (p < 0.0417) and of the hippocampus predicted reduced global efficiency (p < 0.0126). All three subcortical structures predicted unique alterations of nodal efficiency (p < 0.05), including hippocampal abnormalities predicting widespread reduced nodal efficiency in all lobes of the brain, cerebellar abnormalities predicting increased prefrontal nodal efficiency, and olfactory bulb abnormalities predicting posterior parietal-occipital nodal efficiency.

CONCLUSION: Patient-specific (d-TGA anatomy, preoperative impairment of fetal cerebral substrate delivery) and postoperative (e.g., seizures, need for ECMO, or CPR) clinical factors were most predictive of diffuse postnatal microstructural dysmaturation in term CHD neonates. Anthropometric measurements (weight, length, and head size) predicted tractography outcomes. In contrast, subcortical components (cerebellum, hippocampus, olfactory) of a structurally based BDS (derived from CHD mouse mutants), predicted more localized and regional postnatal microstructural differences. Collectively, these findings suggest that brain DTI connectome and seed-based tractography are complementary techniques which may facilitate deciphering the mechanistic relative contribution of clinical and genetic risk factors related to poor neurodevelopmental outcomes in CHD.

PMID:36466162 | PMC:PMC9717392 | DOI:10.3389/fnins.2022.952355

Braz J Cardiovasc Surg. 2022 Dec 1. doi: 10.21470/1678-9741-2022-0022. Online ahead of print.

ABSTRACT

INTRODUCTION: The objectives of this study were to investigate the main treatment strategies and long-term follow-up results of aortic dissection surgery after open-heart surgery (ADSOHS) and to analyze the risk factors that cause ADSOHS.

METHODS: One hundred thirty-seven patients with ADSOHS hospitalized in our hospital from January 2009 to December 2018 were selected as the research object. Long-term follow-up results, complications, mortality, and changes of cardiac function before and after operation were used to explore the value of Sun's operation.

RESULTS: The length of stay in intensive care unit of these 137 patients ranged from 9.5 to 623.75 hours (average of 76.41±97.29 hours), auxiliary ventilation time ranged from 6.0 to 259.83 hours (average of 46.16±55.59 hours), and hospital stay ranged from six to 85 days (average of 25.06±13.04 days). There were seven cases of postoperative low cardiac output, 18 cases of coma and stroke, and six cases of transient neurological dysfunction. A total of 33 patients died; 19 patients died during the perioperative period, 18 died during Sun's operation and one died during other operation; and 14 patients died during follow-up (January 2021), 12 cases of Sun's operation and two cases of other operations.

CONCLUSION: ADSOHS treatment strategy is of high application value, and the risk of neurological complications and mortality is low. The main risk factors are postoperative low cardiac output, coma, stroke, and transient neurological dysfunction. The extracorporeal circulation time is relatively long. Short- and long-term follow-up effects are good, and it is worthy of clinical promotion.

PMID:36459476 | DOI:10.21470/1678-9741-2022-0022

Semin Fetal Neonatal Med. 2022 Dec;27(6):101409. doi: 10.1016/j.siny.2022.101409. Epub 2022 Nov 25.

NO ABSTRACT

PMID:36456434 | DOI:10.1016/j.siny.2022.101409

Ulus Travma Acil Cerrahi Derg. 2022 Dec;28(12):1747-1753. doi: 10.14744/tjtes.2021.49383.

ABSTRACT

Mediastinal masses can compress the respiratory or cardiovascular system, especially when anteriorly located. Obtaining histological material for diagnosis poses a challenge due to the major risk of cardiorespiratory collapse following anesthetic procedure. Our case shows the utility of rescue with venovenous extracorporeal membrane oxygenation (VV-ECMO) after occurrence of such an event and demonstrates the feasibility of administering chemotherapy during VV-ECMO. A 4-year-old boy was referred to the pediatric oncology clinic of our hospital after a large mediastinal mass was observed on chest radiography ordered due to persistent cough. Computed tomography of the thorax revealed a 100×85 mm mass in the anterior mediastinum, surrounding the heart, and showed that there was compression to the trachea, bronchiole, and vascular structures. Percutaneous needle biopsy accompanied by ultrasonography was planned for diagnostic purposes. Low-dose ketamine and midazolam were administered for procedural sedation in the operating room. After the biopsy procedure, the patient developed sudden airway obstruction requiring intubation. Despite 100% oxygen support with a mechanical ventilator, pulse oximeter saturation remained below 80%. Chest X-ray revealed total collapse of the left lung, and the patient's oxygen saturation did not increase with selective left bronchial intubation. Bi-caval dual-lumen ECMO cannula was placed in the internal jugular vein and VV-ECMO was initiated, resulting in swift improvement in hypoxemia. The patients's anterior mediastinal mass shrank rapidly and left lung improved with chemotherapy. The patient remained on ECMO for a total of 9 days and was extubated 2 days after ECMO termination, followed by discharge to the pediatric oncology ward on the 20th day of pediatric intensive care unit stay. It is well known that large, anteriorly-located mediastinal masses carry a considerable risk of causing cardio-pulmonary collapse during procedures involving anesthesia. All life-saving options, including emergency ECMO, should be available before any planned invasive procedures in these patients.

PMID:36453783 | DOI:10.14744/tjtes.2021.49383

Int Heart J. 2022;63(6):1187-1193. doi: 10.1536/ihj.22-237.

ABSTRACT

The combination of venoarterial extracorporeal membrane oxygenation (VA-ECMO) and Impella, referred to as ECPELLA, is a powerful transient mechanical circulatory support for patients with severe cardiogenic shock (CS). During ECPELLA support, VA-ECMO loads the left ventricle (LV) and Impella unloads the LV. Therefore, evaluating the degree of LV unloading during ECPELLA may be a prerequisite to protect the injured myocardium. Here we report a patient with CS due to an inferior ST-elevation myocardial infarction in which the degree of LV unloading on ECPELLA was confirmed by direct LV pressure (LVP) measurement. After the percutaneous coronary intervention for the right coronary artery on ECPELLA, the aortic pressure became nonpulsatile and the peak systolic LVP was reduced at approximately 10 mmHg with 20 mA of the Impella motor current (MC) amplitude, which we referred to as the total LV unloading condition. We maintained the condition in the early phase of ECPELLA by monitoring the Impella MC amplitude at 20 mA and less with nonpulsatile aortic pressure. The patient was successfully weaned off VA-ECMO on day 3, and Impella was explanted on day 8. Prior to the Impella explant, the Impella MC amplitude increased more than 100 mA and the estimated pressure gradient between the aortic pressure and LVP was well matched with the directly measured LVP. In this case, the patient was successfully treated by ECPELLA with the total LV unloading condition, and we showed that the degree of LV unloading on ECPELLA can be estimated from the aortic pressure and Impella MC amplitude at given Impella flows.

PMID:36450558 | DOI:10.1536/ihj.22-237

Anaesthesiologie. 2022 Dec;71(12):967-982. doi: 10.1007/s00101-022-01230-8. Epub 2022 Nov 30.

ABSTRACT

Extracorporeal support systems for the heart and lungs are employed for cardiac, pulmonary and also cardiopulmonary failure; however, neither the pure lung support by venovenous extracorporeal membrane oxygenation (vvECMO) nor the venoarterial (va) ECMO behave in a hemodynamically inert manner with respect to the patient's own cardiovascular system. The success of ECMO treatment is decisively dependent on monitoring before and during the execution and the pathophysiological understanding of the hemodynamic changes that occur during treatment. This article explicitly elucidates these "concomitant phenomena" and discusses fundamental aspects of cardiovascular physiology and the specific interplay with ECMO treatment.

PMID:36449054 | PMC:PMC9709734 | DOI:10.1007/s00101-022-01230-8

Cochrane Database Syst Rev. 2022 Nov 30;11(11):CD013494. doi: 10.1002/14651858.CD013494.pub2.

ABSTRACT

BACKGROUND: Cardiac surgery is performed worldwide. Most types of cardiac surgery are performed using cardiopulmonary bypass (CPB). Cardiac surgery performed with CPB is associated with morbidities. CPB needs an extracorporeal circulation that replaces the heart and lungs, and performs circulation, ventilation, and oxygenation of the blood. The lower limit of mean blood pressure to maintain blood flow to vital organs increases in people with chronic hypertension. Because people undergoing cardiac surgery commonly have chronic hypertension, we hypothesised that maintaining a relatively high blood pressure improves desirable outcomes among the people undergoing cardiac surgery with CPB.

OBJECTIVES: To evaluate the benefits and harms of higher versus lower blood pressure targets during cardiac surgery with CPB.

SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search of databases was November 2021 and trials registries in January 2020.

SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing a higher blood pressure target (mean arterial pressure 65 mmHg or greater) with a lower blood pressure target (mean arterial pressure less than 65 mmHg) in adults undergoing cardiac surgery with CPB.

DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Primary outcomes were 1. acute kidney injury, 2. cognitive deterioration, and 3. all-cause mortality. Secondary outcomes were 4. quality of life, 5. acute ischaemic stroke, 6. haemorrhagic stroke, 7. length of hospital stay, 8. renal replacement therapy, 9. delirium, 10. perioperative transfusion of blood products, and 11. perioperative myocardial infarction. We used GRADE to assess certainty of evidence.

MAIN RESULTS: We included three RCTs with 737 people compared a higher blood pressure target with a lower blood pressure target during cardiac surgery with CPB. A high blood pressure target may result in little to no difference in acute kidney injury (risk ratio (RR) 1.30, 95% confidence interval (CI) 0.81 to 2.08; I² = 72%; 2 studies, 487 participants; low-certainty evidence), cognitive deterioration (RR 0.82, 95% CI 0.45 to 1.50; I² = 0%; 2 studies, 389 participants; low-certainty evidence), and all-cause mortality (RR 1.33, 95% CI 0.30 to 5.90; I² = 49%; 3 studies, 737 participants; low-certainty evidence). No study reported haemorrhagic stroke. Although a high blood pressure target may increase the length of hospital stay slightly, we found no differences between a higher and a lower blood pressure target for the other secondary outcomes. We also identified one ongoing RCT which is comparing a higher versus a lower blood pressure target among the people who undergo cardiac surgery with CPB.

AUTHORS' CONCLUSIONS: A high blood pressure target may result in little to no difference in patient outcomes including acute kidney injury and mortality. Given the wide CIs, further studies are needed to confirm the efficacy of a higher blood pressure target among those who undergo cardiac surgery with CPB.

PMID:36448514 | PMC:PMC9709767 | DOI:10.1002/14651858.CD013494.pub2

J Interv Cardiol. 2022 Nov 7;2022:8167011. doi: 10.1155/2022/8167011. eCollection 2022.

ABSTRACT

OBJECTIVES: To compare two different forms of mechanical circulatory support (MCS) in patients with complex high-risk indicated PCI (CHIP): the Impella CP system and veno-arterial extracorporeal membrane oxygenation (VA-ECMO).

BACKGROUND: To prevent hemodynamic instability in CHIP, various MCS systems are available. However, comparable data on different forms of MCS are not at hand.

METHODS: In this multicenter observational study, we retrospectively evaluated all CHIP procedures with the support of an Impella CP or VA-ECMO, who were declined surgery by the heart team. Major adverse cardiac events (MACE), mortality at discharge, and 30-day mortality were evaluated.

RESULTS: A total of 41 patients were included, of which 27 patients were supported with Impella CP and 14 patients with VA-ECMO. Baseline characteristics were well-balanced in both groups. No significant difference in periprocedural hemodynamic instability was observed between both groups (3.7% vs. 14.3%; p = 0.22). The composite outcome of MACE showed no significant difference (30.7% vs. 21.4%; p = 0.59). Bleeding complications were higher in the Impella CP group, but showed no significant difference (22.2% vs. 7.1%; p = 0.22) and occurred more at the non-Impella access site. In-hospital mortality was 7.4% in the Impella CP group versus 14.3% in the VA-ECMO group and showed no significant difference (p = 0.48). 30-Day mortality showed no significant difference (7.4% vs. 21.4%; p = 0.09).

CONCLUSIONS: In patients with CHIP, there were no significant differences in hemodynamic instability and overall MACE between VA-ECMO or Impella CP device as mechanical circulatory support. Based on this study, the choice of either VA-ECMO or Impella CP does not alter the outcome.

PMID:36447936 | PMC:PMC9663242 | DOI:10.1155/2022/8167011

Arch Argent Pediatr. 2022 Dec 1:e202202568. doi: 10.5546/aap.2022-02568.eng. Online ahead of print.

ABSTRACT

Introduction. Complex congenital heart defects are the most frequent malformations and entail a significant burden of disease. The objective of this study was to determine the health status and disability of children who underwent surgery at a tertiary care hospital. Population and methods. A total of 84 patients aged 21 to 39 months who had a surgery with extracorporeal circulation during their first year of life were assessed in terms of growth, neurodevelopment, and disability. Results. In most children, growth was below the 50 th percentile in all 3 parameters, and greater involvement was observed in those with an associated genetic disorder. The frequency of disability was 55%. In the group with isolated congenital heart disease, the severity of disease and a pathological neurological examination at discharge were associated with disability (p = 0.047 and p = 0.03). Having only public health coverage was associated with less access to timely interventions (p = 0.02). Conclusions. Nearly half of the patients develop moderate-severe disability. Being aware of morbidities beyond the cardiovascular aspect and risk factors is part of the health care team's scope. Barriers in access to appropriate interventions caution health care providers of the relevance of seeking strategies to overcome them and achieve the maximum development potential of patients.

PMID:36445172 | DOI:10.5546/aap.2022-02568.eng

J Med Case Rep. 2022 Nov 29;16(1):447. doi: 10.1186/s13256-022-03644-9.

ABSTRACT

BACKGROUND: Methotrexate is an antifolate antimetabolite that inhibits the activity of dihydrofolate reductase by acting as a false substrate, which leads to defects of DNA synthesis, specifically the inhibition of purine and pyrimidine synthesis. Thus, methotrexate is a powerful agent for treating autoimmune diseases and cancer. In general, methotrexate is thought to be cardioprotective and reports of methotrexate-induced cardiomyopathy are rare. We present a case of methotrexate-induced severe cardiotoxicity diagnosed by exclusion of all other potential causes.

CASE PRESENTATION: The patient was a 54-year-old Caucasian man presenting to an outside hospital with a chief complaint of abdominal pain and bloating who reported taking methotrexate up to 20 mg per week for systemic sclerosis. After a transthoracic echocardiogram found a left ventricular ejection fraction of 10% and coronary catheterization demonstrated no significant disease, he was transferred to our hospital for advanced heart failure therapies. His condition deteriorated, and he was eventually placed on veno-arterial extracorporeal membrane oxygenation. Owing to a lack of an identifiable etiology of cardiac failure, toxicology consultation recommended 24 hours of intravenous leucovorin therapy to overcome any residual and potentially cardiotoxic methotrexate still in his system. Over the next 5 days, his cardiac function improved daily, such that on day 5 of extracorporeal membrane oxygenation, he had a left ventricular ejection fraction of 40% and was able to be decannulated. Two days later, his ejection fraction improved to 60% and normal right ventricular function. Initially, his renal function improved while on extracorporeal membrane oxygenation, but over the next week deteriorated such that he required intermittent hemodialysis until hospital discharge.

CONCLUSIONS: After a process of elimination, the most likely cause of this patient's acute decline and rapid recovery of bi-ventricular function was methotrexate toxicity. Leucovorin may have aided the reversal of methotrexate toxicity.

PMID:36443884 | PMC:PMC9707053 | DOI:10.1186/s13256-022-03644-9

J Clin Med. 2022 Nov 18;11(22):6815. doi: 10.3390/jcm11226815.

ABSTRACT

Background: Extracorporeal hemadsorption eliminates proinflammatory mediators in critically ill patients with hyperinflammation. The use of a pumpless extracorporeal hemadsorption technique allows its early usage prior to organ failure and the need for an additional medical device. In our animal model, we investigated the feasibility of pumpless extracorporeal hemadsorption over a wide range of mean arterial pressures (MAP). Methods: An arteriovenous shunt between the femoral artery and femoral vein was established in eight pigs. The hemadsorption devices were inserted into the shunt circulation; four pigs received CytoSorb® and four Oxiris® hemadsorbers. Extracorporeal blood flow was measured in a range between mean arterial pressures of 45-85 mmHg. Mean arterial pressures were preset using intravenous infusions of noradrenaline, urapidil, or increased sedatives. Results: Extracorporeal blood flows remained well above the minimum flows recommended by the manufacturers throughout all MAP steps for both devices. Linear regression resulted in CytoSorb® blood flow [mL/min] = 4.226 × MAP [mmHg] - 3.496 (R-square 0.8133) and Oxiris® blood flow [mL/min] = 3.267 × MAP [mmHg] + 57.63 (R-square 0.8708), respectively. Conclusion: Arteriovenous pumpless extracorporeal hemadsorption resulted in sufficient blood flows through both the CytoSorb® and Oxiris® devices over a wide range of mean arterial blood pressures and is likely an intriguing therapeutic option in the early phase of septic shock or hyperinflammatory syndromes.

PMID:36431292 | PMC:PMC9692831 | DOI:10.3390/jcm11226815

J Am Heart Assoc. 2022 Dec 6;11(23):e025216. doi: 10.1161/JAHA.121.025216. Epub 2022 Nov 24.

ABSTRACT

Background Mechanical circulatory support devices, such as the intra-aortic balloon pump (IABP) and Impella, are often used in patients on veno-arterial extracorporeal life support (VA-ECLS) with cardiogenic shock despite limited supporting clinical trial data. Methods and Results Hospitalizations for cardiogenic shock from 2016 to 2018 were identified from the National Inpatient Sample. Trends in the use of VA-ECLS with and without an IABP or Impella were assessed semiannually. Multivariable logistic regression and general linear regression evaluated the association of Impella and IABP use with in-hospital outcomes. Overall, 12 035 hospitalizations with cardiogenic shock and VA-ECLS were identified, of which 3115 (26%) also received an IABP and 1880 (16%) an Impella. Use of an Impella with VA-ECLS substantially increased from 10% to 18% over this period (P<0.001), whereas an IABP modestly increased from 25% to 26% (P<0.001). In-hospital mortality decreased 54% to 48% for VA-ECLS only, 61% to 58% for VA-ECLS with an Impella, and 54% to 49% for VA-ECLS with an IABP (P<0.001 each). Most (57%) IABPs or Impellas were placed on the same day as VA-ECLS. After adjustment, there were no differences in in-hospital mortality or length of stay with the addition of an IABP or Impella compared with VA-ECLS alone. Conclusions From 2016 to 2018 in the United States, use of an Impella and IABP with VA-ECLS significantly increased. More than half of Impellas and IABPs were placed on the same day as VA-ECLS, and the use of a second mechanical circulatory support device did not impact in-hospital mortality. Further studies are needed to decipher the optimal timing and patient selection for this growing practice.

PMID:36420809 | DOI:10.1161/JAHA.121.025216

Circ J. 2022 Nov 23. doi: 10.1253/circj.CJ-22-0439. Online ahead of print.

ABSTRACT

BACKGROUND: Fulminant myocarditis (FM) is rare but has an extremely poor prognosis. Impella, a catheter-based heart pump, is a new therapeutic strategy, but reports regarding its health economics are lacking.Methods and Results: This retrospective cohort study compared Impella treatment (Group I) with existing treatments (Group E) using medical data collected from October 2017 to September 2021, with a 1-year analysis period. Cost-effectiveness indices were life-years (LY; effect index) and medical fee amount (cost index). Results were validated using probabilistic sensitivity analysis. The incremental cost-effectiveness ratio (ICER) was calculated using quality-adjusted LY (QALY) and medical costs. Each group included 7 patients, and more than half (57.1%) received combined Impella plus extracorporeal membrane oxygenation. There was no significant difference between Groups I and E in 1-year mortality rates (28.6% vs. 57.1%, respectively) or LY (mean [±SD] 163.1±128.3 vs. 107.8±127.3 days, respectively), but mortality risk was significantly lower in Group I than Group E (95% confidence interval 0.02-0.96; P<0.05). Compared with Group E, Group I had higher total costs (9,270,597±4,121,875 vs. 6,397,466±3,801,364 JPY/year; P=0.20) and higher cost-effectiveness (32,443,987±14,742,966 vs. 92,637,756±98,225,604 JPY/LY; P=0.74), which was confirmed in the sensitivity analysis. ICER probability distribution showed 23.2% and 51.5% reductions below 5 million and 10 million JPY/QALY, respectively.

CONCLUSIONS: Impella treatment is more cost-effective than conventional FM treatments. Large-scale studies are needed to validate the added effects and increasing costs.

PMID:36418111 | DOI:10.1253/circj.CJ-22-0439

JAMA. 2022 Nov 22;328(20):2067-2068. doi: 10.1001/jama.2022.17491.

NO ABSTRACT

PMID:36413237 | DOI:10.1001/jama.2022.17491

Eur J Cardiothorac Surg. 2022 Nov 3;62(6):ezac543. doi: 10.1093/ejcts/ezac543.

ABSTRACT

OBJECTIVES: The use of extracorporeal life support for cardiogenic shock has significantly increased over the past decade. However, there are insufficient data for the presence of sex-associated outcomes differences. Our study assesses differences between male and female patients placed on venoarterial extracorporeal life support (VA-ECLS) for cardiogenic shock from an international database.

METHODS: This is a multicentre, retrospective study on 9888 adult patients on VA-ECLS for cardiogenic shock from the Extracorporeal Life Support Organization registry from 2011 to 2019. The 1:1 nearest neighbour propensity score matching was performed. The primary end point was in-hospital mortality. Secondary end points include bleeding, infection and other complications.

RESULTS: There were 6747 (68%) male patients and 3141 (32%) female patients. Male patients were more likely to have history of myocardial infarction, coronary artery disease, diabetes, chronic kidney disease and congestive heart failure. Female patients were more likely to be centrally cannulated. After propensity score matching, there was no difference seen in in-hospital mortality. In regards to complications, female patients were more likely to experience limb ischaemia, whereas males were more likely to receive renal replacement therapy and have longer hospital stays. Multivariable logistic regression confirmed sex was not independently associated with mortality.

CONCLUSIONS: There was no difference in-hospital mortality between male and female patients receiving VA-ECLS for cardiogenic shock. Female patients were more likely to have limb ischaemia as a complication. Varying cannulation approaches for female patients should be further investigated.

PMID:36413062 | DOI:10.1093/ejcts/ezac543

Future Cardiol. 2022 Dec;18(12):925-929. doi: 10.2217/fca-2022-0078. Epub 2022 Nov 22.

ABSTRACT

We present a case of a 30-year-old female with no pertinent medical history who presented with 4 days of chest pressure, dyspnea and fever. She had hemodynamic compromise and had elevated cardiac and inflammatory markers consistent with cardiogenic shock. ECG demonstrated anterior ST-segment elevations with reciprocal changes. Coronary angiography revealed normal coronaries and echocardiogram showed severe biventricular dysfunction. Endomyocardial biopsy showed signs of lymphocytic myocarditis and viral testing was positive for Coxsackie A. She was initially supported with an intra-aortic balloon pump and later escalated to venoarterial extracorporeal membrane oxygenation due to electromechanical compromise. With supportive care, she was weaned off venoarterial extracorporeal membrane oxygenation and made a full myocardial recovery on follow up echocardiogram and cardiac MRI.

PMID:36412923 | DOI:10.2217/fca-2022-0078

Zhong Nan Da Xue Xue Bao Yi Xue Ban. 2022 Sept 28;47(9):1235-1243. doi: 10.11817/j.issn.1672-7347.2022.220217.

ABSTRACT

OBJECTIVES: Acute Stanford type A aortic dissection is an extremely dangerous and life-threatening cardiovascular disease, usually treated with extracorporeal circulation heart surgery. Histidine-tryptophan-ketoglutarate (HTK) cardioplegia is a protective intracellular myocardial fluid that has been used extensively in different types of extracorporeal circulation surgeries. Del Nido cardioplegia is an extracellular myocardial protection fluid, which was first used in pediatric heart surgery and has been gradually used in a variety of pediatric and adult heart procedures. This study aims to compare the myocardial protection effect between Del Nido and HTK in patients undergoing extracorporeal circulation heart surgery for acute Stanford type A dissection and its impact on patients' prognosis by analyzing selected parameters and clinical manifestations at different time points.

METHODS: Clinical data were collected from 431 patients with acute Stanford type A dissection who were diagnosed and underwent surgery between January 1, 2018 and December 31, 2020 at Xiangya Hospital, Central South University. After excluding some of the data based on exclusion criteria, patients were divided into a HTK group and a Del Nido (DN) group based on type of intraoperative cardioplegia. Propensity score-matching was performed subsequently using the the R statistical software to determine the DN group (n=40) and HTK group (n=41). The matching factors were age, sex, hypertension, cardiopulmonary bypass time, and aortic occlusion time. Perioperative data, postoperative complications, blood gas data, and myocardial injury data were collected from the patients, and SPSS 26.0 was used to analyze the data of each group.

RESULTS: The DN group had a higher rate of spontaneous cardioversion (41.5% vs 15.0%, P=0.005) and a lower postoperative hospital stay [10.0(8.0,14.0) d vs 13.0(11.0,19.0) d, P<0.05] compared to the HTK group. In terms of changes in blood gas analysis, immediate sodium and potassium concentrations were significantly higher in the DN group than that in the HTK group (both P<0.05). There was no significant difference in myocardial injury indexes between the two groups at different time points (all P>0.05). In terms of postoperative complications, the cardiac complications in DN group were much lower than those in the HTK Group (0 vs 12.5%, P=0.026).

CONCLUSIONS: Del Nido cardioplegia has similar myocardial protective effects as HTK cardioplegia used in Stanford type A aortic dissection, with a higher rate of cardiac recurrence and fewer cardiac complications. Del Nido cardioplegia should play an important role in future application for acute Stanford type A aortic dissection, but our findings need to be further validated in a large sample of prospective clinical studies.

PMID:36411707 | DOI:10.11817/j.issn.1672-7347.2022.220217

Eur J Cardiothorac Surg. 2022 Nov 3;62(6):ezac545. doi: 10.1093/ejcts/ezac545.

NO ABSTRACT

PMID:36409037 | DOI:10.1093/ejcts/ezac545

Physiol Rep. 2022 Nov;10(22):e15421. doi: 10.14814/phy2.15421.

ABSTRACT

Acute right ventricular pressure overload (RVPO) occurs following congenital heart surgery and often results in low cardiac output syndrome. We tested the hypothesis that the RV exhibits limited ability to modify substrate utilization in response to increasing energy requirements during acute RVPO after cardiopulmonary bypass (CPB). We assessed the RV fractional contributions (Fc) of substrates to the citric acid cycle in juvenile pigs exposed to acute RVPO by pulmonary artery banding (PAB) and CPB. Sixteen Yorkshire male pigs (median 38 days old, 12.2 kg of body weight) were randomized to SHAM (Ctrl, n = 5), 2-h CPB (CPB, n = 5) or CPB with PAB (PAB-CPB, n = 6). Carbon-13 (13 C)-labeled lactate, medium-chain, and mixed long-chain fatty acids (MCFA and LCFAs) were infused as metabolic tracers for energy substrates. After weaning from CPB, RV systolic pressure (RVSP) doubled baseline in PAB-CPB while piglets in CPB group maintained normal RVSP. Fc-LCFAs decreased significantly in order PAB-CPB > CPB > Ctrl groups by 13 C-NMR. Fc-lactate and Fc-MCFA were similar among the three groups. Intragroup analysis for PAB-CPB showed that the limited Fc-LCFAs appeared prominently in piglets exposed to high RVSP-to-left ventricular systolic pressure ratio and high RV rate-pressure product, an indicator of myocardial oxygen demand. Acute RVPO after CPB strongly inhibits LCFA oxidation without compensation by lactate oxidation, resulting in energy deficiency as determined by lower (phosphocreatine)/(adenosine triphosphate) in PAB-CPB. Adequate energy supply but also metabolic interventions may be required to circumvent these RV energy metabolic abnormalities during RVPO after CPB.

PMID:36394073 | PMC:PMC9669618 | DOI:10.14814/phy2.15421