Efficacy of Cardiac Computed Tomography for Obstructive Mechanical Valve Thrombosis Under Venoarterial Extracorporeal Membrane Oxygenation
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SUBMITTER: Chen W
PROVIDER: S-EPMC9700072 | biostudies-literature | 2022 Nov
REPOSITORIES: biostudies-literature
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| S-EPMC8112184 | biostudies-literature
Project description:BackgroundVenoarterial extracorporeal membrane oxygenation (VA-ECMO) increases left ventricular (LV) afterload, potentially provoking LV distention and impairing recovery. LV mechanical unloading (MU) with intra-aortic balloon pump (IABP) or percutaneous ventricular assist device (pVAD) can prevent LV distension, potentially at the risk of more complications, and net clinical benefit remains uncertain.ObjectivesThis study aims to determine the association between MU and outcomes for patients undergoing VA-ECMO.MethodsThe authors queried the Extracorporeal Life Support Organization registry for adults receiving peripheral VA-ECMO from 2010 to 2019 and stratified them by MU with IABP or pVAD. The primary outcome was in-hospital mortality; secondary outcomes included on-support mortality and complications during VA-ECMO.ResultsAmong 12,734 VA-ECMO patients, 3,399 (26.7%) received MU: 2,782 (82.9%) IABP and 580 (17.1%) pVAD. MU patients were older (age 56.3 vs 52.7 years) and, before extracorporeal membrane oxygenation, more often required >2 vasopressors (41.7% vs 27.2%) and had respiratory (21.1% vs 15.9%), renal (24.6% vs 15.8%), and liver failure (4.4% vs 3.1%) (all P < 0.001). MU patients had lower in-hospital mortality (56.6% vs 59.3%, P = 0.006), which persisted in multivariable modeling (adjusted OR [aOR]: 0.84; 95% CI: 0.77-0.92; P < 0.001). MU was associated with more cannula site bleeding (aOR: 1.25; 95% CI: 1.11-1.40; P < 0.001) and hemolysis (aOR: 1.27; 95% CI: 1.03-1.57; P = 0.02). Compared to pVAD, MU patients with IABP had similar mortality (aOR: 0.80; 95% CI: 0.64-1.01; P = 0.06) and less medical bleeding (aOR: 0.45; 95% CI: 0.31-0.64; P < 0.001), cannula site bleeding (aOR: 0.72; 95% CI: 0.54-0.96; P = 0.03), and renal injury (aOR: 0.78; 95% CI: 0.62-0.98; P = 0.03).ConclusionsAmong adults receiving VA-ECMO, MU was associated with lower in-hospital mortality despite increased complications including hemolysis and cannulation site bleeding. Compared to pVAD, MU with IABP was associated with similar mortality and lower complication rates.
| S-EPMC9187498 | biostudies-literature
Project description:Cardiogenic shock and cardiac arrest contribute pre-dominantly to mortality in acute cardiovascular care. Here, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has emerged as an established therapeutic option for patients suffering from these life-threatening entities. VA-ECMO provides temporary circulatory support until causative treatments are effective and enables recovery or serves as a bridging strategy to surgical ventricular assist devices, heart transplantation or decision-making. However, in-hospital mortality rate in this treatment population is still around 60%. In the recently published ARREST trial, VA-ECMO treatment lowered mortality rate in patients with ongoing cardiac arrest due to therapy refractory ventricular fibrillation compared to standard advanced cardiac life support in selected patients. Whether VA-ECMO can reduce mortality compared to standard of care in cardiogenic shock has to be evaluated in the ongoing prospective randomized studies EURO-SHOCK (NCT03813134) and ECLS-SHOCK (NCT03637205). As an innate drawback of VA-ECMO treatment, the retrograde aortic flow could lead to an elevation of left ventricular (LV) afterload, increase in LV filling pressure, mitral regurgitation, and elevated left atrial pressure. This may compromise myocardial function and recovery, pulmonary hemodynamics-possibly with concomitant pulmonary congestion and even lung failure-and contribute to poor outcomes in a relevant proportion of treated patients. To overcome these detrimental effects, a multitude of venting strategies are currently engaged for both preventive and emergent unloading. This review aims to provide a comprehensive and structured synopsis of existing venting modalities and their specific hemodynamic characteristics. We discuss in detail the available data on outcome categories and complication rates related to the respective venting option.
| S-EPMC10050067 | biostudies-literature
Project description:Biological mitral valve restenosis after replacement in rheumatic heart disease is a rare complication. This case illustrates venoarterial extracorporeal membrane oxygenation to facilitate transcatheter mitral valve replacement in a patient with suprasystemic pulmonary pressure and cardiogenic shock with multiorgan failure secondary to critical mitral stenosis of a bioprosthetic valve.(Level of Difficulty: Advanced.) Central Illustration
| S-EPMC9175201 | biostudies-literature
Project description:Venoarterial extracorporeal membrane oxygenation (vaECMO) is a well-established treatment option for severe cardiogenic shock of various etiologies. Although trials have explored weaning strategies, a brief and conclusive overview is lacking. We present the different aspects of weaning and provide an evidence- and experienced-based guide for clinicians managing patients under vaECMO in the preweaning, weaning, and postweaning phases.
| S-EPMC7190048 | biostudies-literature
Project description:(1) Alkaline phosphatase (AP) is consumed during cardiopulmonary bypass (CPB). A high AP depletion leads to an impaired outcome after cardiac surgery. However, data is scarce on the postoperative course of AP under venoarterial ECMO (VA-ECMO) support. (2) A total of 239 patients with VA-ECMO support between 2000 and 2019 at the Department of Cardiac Surgery (Vienna General Hospital, Austria) were included in this retrospective analysis. Blood samples were collected at several timepoints (baseline, postoperative day (POD) 1-7, POD 14 and 30). Patients were categorized according to the relative AP drop (<60% vs. ≥60%) and ECMO duration (<5 days vs. ≥5 days). (3) Overall, 44.4% reached the baseline AP values within 5 days-this was only the case for 28.6% with a higher AP drop (compared to 62.7% with a lower drop; p = 0.000). A greater AP drop was associated with a significantly higher need for renal replacement therapy (40.9% vs. 61.9%; p = 0.002) and an impaired 1-year survival (51.4% vs. 66.0%; p = 0.031). (4) CPB exceeds the negative impact of VA-ECMO; still, ECMO seems to delay alkaline phosphatase recovery. A greater initial AP drop bears the risk of higher morbidity and mortality.
| S-EPMC8156119 | biostudies-literature
Project description:BackgroundRespiratory complications are common in patients who require venoarterial (VA) extracorporeal membrane oxygenation (ECMO) for cardiac indications. We aimed to examine the frequency and characteristics of patients who develop multi-lobar atelectasis early in the course of VA ECMO and to identify factors associated with its occurrence.MethodsWe performed a single-center retrospective review of consecutive pediatric subjects on VA ECMO in the cardiovascular ICU from 2014 to 2019. Chest radiographs before VA ECMO initiation and daily for up to 5 d of VA ECMO support were reviewed. Multi-lobar atelectasis was defined as the collapse of ≥2 lobes of the same lung. Patients with multi-lobar atelectasis before or immediately after VA ECMO cannulation were excluded. Bivariate comparisons and multivariable logistic regression analyses were performed to identify factors independently associated with lung collapse. Results of the multivariable analysis are provided as odds ratio (OR) with 95% CI.ResultsWe reviewed 119 VA ECMO runs in 101 unique subjects. Multi-lobar atelectasis occurred in 36 runs (30%), with an isolated collapse of the left lung occurring most frequently (no. runs = 20). VA ECMO runs complicated by multi-lobar atelectasis were significantly longer and associated with lower hospital survival (51% vs 77%, survival in subjects without multi-lobar atelectasis; P = .01). Multivariable logistic regression analysis identified a subsequent ECMO run during the same admission to be independently associated with multi-lobar atelectasis (OR 5.4, 95% CI 1.2-21.5). Subanalysis of the subjects with isolated left lung collapse revealed male sex (OR 8.9, 95% CI 1.6-48.2) and subsequent ECMO run during the same admission (OR 4.0, 95% CI 1.2-13.6) to be independently associated with this complication, and mechanical ventilation at least 12 h before ECMO may be protective (OR 0.22, 95% CI 0.07-0.76).ConclusionsMulti-lobar atelectasis commonly occurred in children who were receiving VA ECMO for cardiac failure and was associated with worse outcomes. Male patients, a subsequent VA ECMO run during the same hospitalization, and patients in whom mechanical ventilation was initiated shortly before ECMO cannulation may be at increased risk for this complication.
| S-EPMC9994273 | biostudies-literature
Project description:BackgroundBioprosthetic mitral valves on average have a median durability between 8 and 10 years. After the failure of a bioprosthetic valve, surgical replacement is often indicated. However, the options for those patients at high or prohibitive surgical risks are limited. Here, we describe a case of a successful trans-catheter mitral valve-in-valve (TMViV) replacement on venoarterial extracorporeal membrane oxygenation (VA-ECMO).Case summaryWe describe a case of a 39-year-old female with a history notable for systemic lupus erythematosus, severe pulmonary arterial hypertension (now mixed pre and post) thought to be secondary to prior substance use, and infective endocarditis complicated by severe mitral stenosis status post-bioprosthetic mitral valve replacement who presented with symptoms of acute hypoxic respiratory failure secondary to severe bioprosthetic mitral valve stenosis. The patient had a prolonged hospital course complicated by a pulseless electrical activity arrest, (continuous renal replacement therapy) for acute renal failure, and hypertonic saline due to cerebral oedema. Due to her significant co-morbidities and haemodynamic instability with acute kidney injury and recent neurologic insult, the patient was thought not to be a good surgical candidate. However, given her young age and overall improved neurologic status, it was thought the patient could benefit from a TMViV with bi-ventricular support given her right- and left-sided heart failure and was placed on VA-ECMO in anticipation of a TMViV procedure for circulatory support. The patient underwent a successful TMViV replacement using a trans-septal approach with a 26 mm SAPIEN 3 valve and atrial septal defect closure with a 14 mm Amplatzer device on hospital Day 12. The patient was successfully de-cannulated from VA-ECMO on hospital Day 13. The patient had a prolonged hospital course but eventually had renal recovery and tracheostomy de-cannulation. A trans-thoracic echocardiogram prior to discharge was notable for a well-functioning valve and normal ejection fraction. The patient was discharged to a nursing home for further rehabilitation.DiscussionThe gold standard for bioprosthetic mitral valve stenosis is surgical replacement of the valve. However, the options for those at high or prohibitive surgical risk are lacking. Recent studies have demonstrated TMViV is a safe alternative to surgical mitral valve redo cases in high-risk patients. To our knowledge, there are limited data on trans-catheter valve placement while on VA-ECMO. Successful implantation in our patient suggests that TMViV in a stenotic bioprosthesis is feasible in very high-risk patients with the use of VA-ECMO to support haemodynamics.
| S-EPMC10500414 | biostudies-literature
Project description:There are limited data on the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) or cardiopulmonary bypass (CPB) to provide hemodynamic support periprocedurally during transcatheter aortic valve replacement. This study sought to evaluate patients receiving transcatheter aortic valve replacement with concomitant use of CPB/VA-ECMO. We systematically reviewed the published literature from 2000 to 2018 for studies evaluating adult patients requiring CPB/VA-ECMO periprocedurally during transcatheter aortic valve replacement. Studies reporting short-term and long-term mortality were included. Given the significant methodological and statistical differences between published studies, meta-analysis of the association of CPB/VA-ECMO with mortality was not performed. Of the 537 studies identified, 9 studies representing 5191 patients met our inclusion criteria. Median ages were between 75 and 87 years with 33% to 75% male patients. Where reported, the Edwards SAPIEN™ transcatheter heart valve was the most frequently used. A total of 203 (3.9%) patients received periprocedural hemodynamic support with CPB/VA-ECMO. Common indications for CPB/VA-ECMO included left ventricular or aortic annular rupture, rapid hemodynamic deterioration, aortic regurgitation, cardiac arrest, and left main coronary artery obstruction. The use of CPB/VA-ECMO was predominantly an emergent strategy and was used for durations of 1 to 2 hours. Short-term mortality (in-hospital and 30-day) was 29.8%, and 1-year mortality was 52.4%. Major complications such as bleeding, vascular injury, tamponade, stroke, and renal failure were noted in 10% to 50% of patients. CPB/VA-ECMO was used in 4% in the early experience of patients undergoing transcatheter aortic valve replacement, most commonly for periprocedural complications. There are limited data on preprocedural planned use of VA-ECMO, and the characteristics of this population remain poorly defined.
| S-EPMC6064861 | biostudies-literature
Project description: Not available
| S-EPMC9390622 | biostudies-literature