Left ventricular mechanical support with the impella during extracorporeal membrane oxygenation

Background: Venoarterial extracorporeal membrane oxygenation [ECMO] provides systemic arterial support without directly unloading the left heart, which causes an elevated left ventricular [LV] pressure. The aim of the present study was to investigate the adjunctive application of the Impella device for LV unloading in patients during ECMO

Methods: This retrospective cohort study included patients who received Impella support in addition to venoarterial ECMO between April 2012 and December 2015. ECMO cannulation was performed peripherally or centrally, while the Impella device was surgically inserted into the femoral artery or the right axillary artery

Results: Among 62 patients, 10 [16.1%] received an Impella device during ECMO support. Following Impella support, right atrial pressure improved from a median of 18 [IQR, 14-24] mmHg to 13 [IQR, 10-15] mmHg and pulmonary wedge pressure improved from 30 [IQR, 26-35] mmHg to 16 [IQR, 12-19] mmHg in all the patients [p value < 0.001]. Follow-up transthoracic echo car diagrams [n = 6] showed a median decrease of 0.8 cm in LV end-diastolic volume [p value = 0.021]. There were 5 [50%] in-hospital deaths due to sustained brain injury [n = 3] and refractory cardiogenic shock [n = 2]. The remaining 5 patients were discharged and successfully bridged to more permanent LV assist device [n = 2] or heart transplantation [n = 3]

Conclusion: The findings of the present study indicate that the application of the Impella device during ECMO support is effective in LV unloading and confers optimal hemodynamic support

Five-year follow-up of the local autologous transplantation of CD133+ enriched bone marrow cells in patients with myocardial infarction

The implantation of a CD133+ bone marrow cell population into an ischemic myocardium has emerged as a promising therapeutic modality for myocardial regeneration and restoration of ventricular contractility. While previous studies have documented the short-term safety and efficacy of CD133+ cell transplantation in patients with acute myocardial infarction, there are few reports of long-term follow-up results. Here, we present the results of long-term follow-up of our acute myocardial infarction patients who were treated with intra-myocardial injection of CD133+ cells after coronary bypass graft. After five years, 13 patients in the cell transplantation group and 5 patients in the control group underwent safety and efficacy investigations by New York Heart Association classification and two-dimensional echocardiography [2D echo]. During the five-year study period, no major cardiac adverse events were reported among patients who received CD133+ stem cells. Regarding efficiency, we observed no statistically significant treatment effects for the echocardiographic parameters [left ventricular end-diastolic and end-systolic volumes, and resting ejection fraction] measured during the follow-up period. However, detailed analysis of regional wall motion revealed an improvement in the Wall Motion Score Index from baseline to the six month follow-up, which was maintained during the follow-up period. Taken together, the long-term results of the present study indicate that transplantation of CD133+ is a safe and feasible procedure; however, we could not show any major benefits in our patients. Thus, this issue needs to be addressed by conducting other studies with more patients

Infectious and non-infectious complications among undiagnosed patients with common variable immunodeficiency

Common variable immunodeficiency [CVID] is a heterogeneous group of disorders, characterized by hypogammaglobulinemia, defective specific antibody responses to pathogens and increased susceptibility to recurrent bacterial infections. Delay in diagnosis and inadequate treatment can lead to irreversible complications and mortality. In order to determine infectious complications among undiagnosed CVID patients, 47 patients diagnosed in the Children's Medical Center Hospital during a period of 25 years [1984-2009] were enrolled in this study. Patients were divided into two groups including Group 1 [Gl] with long diagnostic delay of more than 6 years [24 patients] and Group 2 [G2] with early diagnosis [23 patients]. The clinical manifestations were recorded in a period prior to diagnosis in Gl and duration follow up in G2. The number of infections, non infectious complications, hospitalizations, and mortality rate was compared between the two groups. The patients in Gl group had 500 episodes of infections before diagnosis in 256 patient-years [0.08 per patient per year] and 203 times of hospitalization [0.03 per patient per year], which were significantly higher than in G2 patients, who had 75 episodes of infections [0.015 per patient per year] and 88 hospital admissions [0.018 per patient per year] during 207 patient follow-up years. Frequency of enteropathies and liver diseases in Gl were also significantly higher than in G2. Lack of awareness about nature of disease, especially among rural and suburban physicians, single organ involvement as a site of clinical presenting, and predomination of non infectious presentation in Gl were the major factors of delayed diagnosis. Diagnostic delay is a major concern in CVID patients, which could result in irreversible complications and mortality, while early diagnosis and proper initial treatment leads to better outcomes and quality of life

Presence of idiopathic thrombocytopenic purpura and autoimmune hemolytic anemia in the patients with common variable immunodeficiency

Common Variable Immunodeficiency [CVID] is a heterogeneous group of disorders characterized by hypogammaglobulinemia and an increased susceptibility to recurrent infections as well as autoimmunity and malignancies. Idiopathic Thrombocytopenic Purpura [ITP] and Autoimmune Hemolytic Anemia [AIHA] are two autoimmune disorders which may be seen in association with CVID. Among 85 CVID patients, seven cases had ITP and/or AIHA [8%]. Four of these patients had one or more episodes of ITP, one patient had AIHA, and two patients had both ITP and AIHA [Evans syndrome]. Almost, all patients experienced chronic and recurrent infections mostly in respiratory and gastrointestinal systems during the course of the disease. Among the seven patients, five presented their underlying disease with recurrent respiratory and/or gastrointestinal tract infections, while in two remaining patients, CVID was presented with ITP. Three patients died until now; two because of hepatic failure and one due to pulmonary hemorrhage. As CVID is prone to autoimmune disorders, it should be considered as a differential diagnosis of adult-onset ITP and possibly in children. Chronic and recurrent ITP, especially in the presence of propensity to respiratory and gastrointestinal infections mandate the evaluation for an underlying immune dysregulation such as CVID