Dataset Information

Inhaled nitric oxide for ECPELLA management in fulminant myocarditis complicated with severe right ventricular dysfunction: A case report.

ABSTRACT: Combination therapy with venoarterial extracorporeal membrane oxygenation (VA-ECMO) and Impella (ECPELLA) has been known to be a favorable strategy of mechanical circulation support for patients with fatal cardiogenic shock. However, the practical strategy for weaning ECPELLA in patients with right ventricular (RV) dysfunction remains unclear. We describe a case of a 63-year-old male with fulminant myocarditis presenting with cardiogenic shock who required ECPELLA to improve hemodynamics. Because of persistent severe RV dysfunction despite the introduction of intravenous dobutamine and milrinone, VA-ECMO could not be weaned. Inhaled nitric oxide (iNO) was introduced at 20 ppm to reduce RV afterload, resulting in increased cardiac output (from 1.6 to 5.5 L/min) and ameliorated RV performance (the pulmonary artery pulsatility index was from 0.47 to 1.11). Subsequently, VA-ECMO could be weaned. iNO, a selective pulmonary vasodilator, reduces pulmonary vascular resistance, resulting in reduced RV afterload. This is the first case of iNO usage for the management of cardiogenic shock supported by ECPELLA. iNO could be a favorable strategy in ECPELLA patients with refractory RV dysfunction for weaning VA-ECMO through bridging to recovery.

Learning objective

The practical strategy for weaning venoarterial extracorporeal membrane oxygenation and Impella (ECPELLA) in patients with concomitant right ventricular dysfunction remains unclear. Inhaled nitric oxygen is a novel weaning strategy for patients with biventricular dysfunction supported by ECPELLA. If the response of inhaled nitric oxygen was insufficient under ECPELLA support, implantable ventricular assist devices or transplantation should be considered.

SUBMITTER: Oki T

PROVIDER: S-EPMC9352424 | biostudies-literature | 2022 Aug

REPOSITORIES: biostudies-literature

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Inhaled nitric oxide for ECPELLA management in fulminant myocarditis complicated with severe right ventricular dysfunction: A case report.

Oki Takumi T Ikeda Yuki Y Ishii Shunsuke S Ako Junya J

Journal of cardiology cases 20220422 2

Combination therapy with venoarterial extracorporeal membrane oxygenation (VA-ECMO) and Impella (ECPELLA) has been known to be a favorable strategy of mechanical circulation support for patients with fatal cardiogenic shock. However, the practical strategy for weaning ECPELLA in patients with right ventricular (RV) dysfunction remains unclear. We describe a case of a 63-year-old male with fulminant myocarditis presenting with cardiogenic shock who required ECPELLA to improve hemodynamics. Becaus ...[more]

PMID: 35949567

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Project description:BackgroundRight ventricular failure (RVF) is a leading driver of morbidity and death after major cardiac surgery for advanced heart failure, including orthotopic heart transplantation and left ventricular assist device implantation. Inhaled pulmonary-selective vasodilators, such as inhaled epoprostenol (iEPO) and nitric oxide (iNO), are essential therapeutics for the prevention and medical management of postoperative RVF. However, there is limited evidence from clinical trials to guide agent selection despite the significant cost considerations of iNO therapy.MethodsIn this double-blind trial, participants were stratified by assigned surgery and key preoperative prognostic features, then randomized to continuously receive either iEPO or iNO beginning at the time of separation from cardiopulmonary bypass with the continuation of treatment into the intensive care unit stay. The primary outcome was the composite RVF rate after both operations, defined after transplantation by the initiation of mechanical circulatory support for isolated RVF, and defined after left ventricular assist device implantation by moderate or severe right heart failure according to criteria from the Interagency Registry for Mechanically Assisted Circulatory Support. An equivalence margin of 15 percentage points was prespecified for between-group RVF risk difference. Secondary postoperative outcomes were assessed for treatment differences and included: mechanical ventilation duration; hospital and intensive care unit length of stay during the index hospitalization; acute kidney injury development including renal replacement therapy initiation; and death at 30 days, 90 days, and 1 year after surgery.ResultsOf 231 randomized participants who met eligibility at the time of surgery, 120 received iEPO, and 111 received iNO. Primary outcome occurred in 30 participants (25.0%) in the iEPO group and 25 participants (22.5%) in the iNO group, for a risk difference of 2.5 percentage points (two one-sided test 90% CI, -6.6% to 11.6%) in support of equivalence. There were no significant between-group differences for any of the measured postoperative secondary outcomes.ConclusionsAmong patients undergoing major cardiac surgery for advanced heart failure, inhaled pulmonary-selective vasodilator treatment using iEPO was associated with similar risks for RVF development and development of other postoperative secondary outcomes compared with treatment using iNO.RegistrationURL: https://www.Clinicaltrialsgov; Unique identifier: NCT03081052.

Project description:AimsRight heart catheterization (RHC) is indicated in all candidates for heart transplantation (HT). An acute vasodilator challenge is recommended for those with pulmonary hypertension (PH) to assess its reversibility. The effects of inhaled nitric oxide (iNO) on pulmonary and systemic haemodynamics have been reported only in small series. Our purpose was to describe the response to iNO in a larger population and its potential clinical implications.Methods and resultsFrom 210 RHC procedures performed between 2010 and 2019, vasodilator challenge with iNO was used in 108 patients, of which 66 had advanced heart failure undergoing assessment for HT (55±11 years old; 74.2% male gender; 43.9% ischaemic cardiomyopathy; left ventricular ejection fraction 28.4 ± 11,4%; and peak VO2 12.1 ± 3.0 mL/kg/min). iNO was administered through a tight-fitting facial mask regardless of baseline pulmonary pressures. Clinical endpoints (all-cause mortality and acute right heart failure) were assessed according to baseline haemodynamic findings over the available follow-up period. There were no side effects from iNO administration. Typical response consisted of a reduction in pulmonary vascular resistance, consequent to an increase in left ventricular filling pressures, no significant change in mean pulmonary artery pressure (resulting in a lower mean transpulmonary gradient) and a mild increase in cardiac ouput. Pulmonary arterial compliance increased significantly, whereas systemic vascular resistance was only mildly affected. In five cases (7.6%), pulmonary vascular resistance increased paradoxically. All-cause mortality and post-HT right heart failure events were overall low and similar in patients without PH or reversible PH.ConclusionsVasodilator challenge with iNO is safe in advanced heart failure patients undergoing RHC prior to HT listing. It produces a reasonably predictable haemodynamic response, which occurs predominantly at the pulmonary circulation level. Clinical implications of iNO-induced reversibility may be relevant, but further systematic validation is warranted in larger cohorts.

Project description:ObjectivesTo characterize contemporary use of inhaled nitric oxide in pediatric acute respiratory failure and to assess relationships between clinical variables and outcomes. We sought to study the relationship of inhaled nitric oxide response to patient characteristics including right ventricular dysfunction and clinician responsiveness to improved oxygenation. We hypothesize that prompt clinician responsiveness to minimize hyperoxia would be associated with improved outcomes.DesignAn observational cohort study.SettingEight sites of the Collaborative Pediatric Critical Care Research Network.PatientsOne hundred fifty-one patients who received inhaled nitric oxide for a primary respiratory indication.Measurements and main resultsClinical data were abstracted from the medical record beginning at inhaled nitric oxide initiation and continuing until the earliest of 28 days, ICU discharge, or death. Ventilator-free days, oxygenation index, and Functional Status Scale were calculated. Echocardiographic reports were abstracted assessing for pulmonary hypertension, right ventricular dysfunction, and other cardiovascular parameters. Clinician responsiveness to improved oxygenation was determined. One hundred thirty patients (86%) who received inhaled nitric oxide had improved oxygenation by 24 hours. PICU mortality was 29.8%, while a new morbidity was identified in 19.8% of survivors. Among patients who had echocardiograms, 27.9% had evidence of pulmonary hypertension, 23.1% had right ventricular systolic dysfunction, and 22.1% had an atrial communication. Moderate or severe right ventricular dysfunction was associated with higher mortality. Clinicians responded to an improvement in oxygenation by decreasing FIO2 to less than 0.6 within 24 hours in 71% of patients. Timely clinician responsiveness to improved oxygenation with inhaled nitric oxide was associated with more ventilator-free days but not less cardiac arrests, mortality, or additional morbidity.ConclusionsClinician responsiveness to improved oxygenation was associated with less ventilator days. Algorithms to standardize ventilator management may improve signal to noise ratios in future trials enabling better assessment of the effect of inhaled nitric oxide on patient outcomes. Additionally, confining studies to more selective patient populations such as those with right ventricular dysfunction may be required.

Dataset Information

Inhaled nitric oxide for ECPELLA management in fulminant myocarditis complicated with severe right ventricular dysfunction: A case report.

Learning objective

Publications

Inhaled nitric oxide for ECPELLA management in fulminant myocarditis complicated with severe right ventricular dysfunction: A case report.

Similar Datasets

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