Advances in Extracorporeal Support Technologies in Critically Ill Children

The field of pediatric heart failure is evolving, and the patient population is growing as survival after complex congenital heart surgeries is improving. Mechanical circulatory support and extracorporeal respiratory support in critically ill children has progressed to a mainstay rescue modality in pediatric intensive care medicine. The need for mechanical circulatory support is growing, since the number of organ donors does not meet the necessity. This article aims to review the current state of available mechanical circulatory and respiratory support systems in acute care pediatrics, with an emphasis on the literature discussing the challenges associated with these complex support modalities

Application of extracorporeal membrane oxygenation in early allograft dysfunction after heart transplantation / 器官移植

Objective To evaluate the effect of extracorporeal membrane oxygenation (ECMO) on early allograft dysfunction (EAD) after heart transplantation. Methods Clinical data of 614 heart transplant recipients were retrospectively analyzed. All recipients were divided into the ECMO group (n=43) and non-ECMO group (n=571) according to postoperative application of ECMO. In the ECMO group, the conditions of recipients undergoing ECMO after heart transplantation were summarized. Perioperative status and long-term prognosis of recipients were compared between two groups. Results Among 43 recipients undergoing ECMO, 17 cases underwent thoracotomy due to bleeding, 10 cases of infection, 4 cases of venous thrombosis of the lower limbs, and 1 case of stroke, respectively. Twenty-six recipients were recovered and discharged after successful weaning from ECMO, six died during ECMO support, six died after weaning from ECMO, five received retransplantation due to unsuccessful weaning from ECMO, and only one survived after retransplantation. Compared with the non-ECMO group, intraoperative cardiopulmonary bypass duration was significantly longer, the proportion of recipients requiring postoperative intra-aortic balloon pump (IABP), dialysis due to renal insufficiency, reoperation for hemostasis, infection, mechanical ventilation time≥96 h and tracheotomy was significantly higher, and the length of postoperative intensive care unit (ICU) stay was significantly longer in the ECMO group (all P < 0.05). The survival rate after discharge and 90-d survival rate in the ECMO group were 63% and 96%, significantly lower than 97% and 100% in the non-ECMO group (both P < 0.05). Survival analysis showed that the long-term survival rate in the ECMO group was significantly lower than that in the non-ECMO group (P < 0.05). After excluding the recipients who died within 90 d after heart transplantation, no significant difference was observed in the long-term survival rate (P > 0.05). Conclusions ECMO is an effective treatment of EAD after heart transplantation. The short-term survival rate of recipients using ECMO after heart transplantation is lower than that of those who do not use ECMO, and there is no significant difference in long-term survival of recipients surviving 90 d after heart transplantation.

Current status and progress on the application of ventricular assist device / 器官移植

At present, heart transplantation is the most effective treatment for end-stage heart failure. Nevertheless, the shortage of donors is becoming an increasingly severe challenge. In recent years, rapid development of mechanical circulatory support technologies has provided multiple therapeutic options for patients with end-stage heart failure. As an important mechanical circulatory support device, ventricular assist device (VAD) are divided into durable VAD (dVAD) and temporary VAD (tVAD) according to the duration of assistance. dVAD shows application potential in bridging heart transplantation, destination therapy and bridge to decision. With technological progress and experience accumulation in clinical application, VAD is evolving towards the direction of more biocompatible, lighter, more bionic and intelligent. In this article, the development of VAD, application status at home and abroad and the overall application of VAD in our hospital were reviewed, aiming to provide reference for promoting the clinical application of VAD in China.

Mechanical Circulatory Support (MCS) for Cardiogenic Shock / 日本心臓血管外科学会雑誌

Mechanical Circulatory Support (MCS) is established to salvage cases with cardiogenic shock. MCS includes intra-aortic balloon pumping (IABP), veno-arterial extracorporeal membrane oxygenation (VA-ECMO), or pump-catheter. Prompt introduction of these devices enables 1) unloading of left and/or right ventricles, 2) sufficient supply of oxygenated blood to end-organs, and 3) maintenance of pulmonary circulation. Under MCS, then, cause of cardiogenic shock is explored and appropriate treatments are given to wean-off the MCS. In this review, selection of the MCS devices, technical tips of each MCS, and management of the cases under MCS are explained.

The progress of mechanical circulatory support devices / 中国胸心血管外科临床杂志

@#As a global disease, heart failure affects at least 26 million people, and its prevalence is still rising. Besides, the mortality rate and readmission rate remain high. Advanced heart failure is the terminal stage of various heart diseases, and often requires some treatments other than drug intervention, such as heart transplantation which is the gold standard for treatment of heart failure. However, limited by the number of donors, the number of heart transplants in the world has reached a bottleneck. There is a huge gap between the number of patients who need heart transplants and patients who get hearts for survival successfully in reality. With the exploration and development of mechanical circulation support devices for more than half a century, they have become a wonderful treatment for patients with advanced heart failure. This article will introduce the latest progress of mechanical circulatory support devices at home and abroad from the aspects of temporary and long-term devices.

Learning Curve in Left Ventricular Assist Device Implantation: Low Volumes Do Not Equate Bad Outcomes

ABSTRACT Introduction: Most implantations of left ventricular assist devices (LVAD) are performed in low-volume centers. This study aimed to evaluate the procedural learning curve of HeartMate II (HM2) implantations by comparing outcomes between two time periods in a low-volume center. Methods: All 51 consecutive patients undergoing HM2 implantation between January 2009 and December 2017 were reviewed and allocated into 2 groups: early-era group (from 2009 to 2014; n=25) and late-era group (from 2015 to 2017; n=26). The primary outcome was the 90-day mortality rate, and the secondary outcome was a composite of mortality, neurological event, reoperation for bleeding, need for temporary right ventricular assist device, and pump thrombosis at 90 days. Median follow-up time was 51 months (0-136). A cumulative sum (CUSUM) control analysis was used to establish a threshold of implantations that optimizes outcomes. Results: Patients in the early era had a higher rate of diabetes, previous stroke, and inotrope support before HM2 implantation. The 90-day mortality rate was not significantly higher in the early era (24% vs. 15%, P=0.43), but the composite endpoint was significantly higher (76% vs. 42%, P=0.01). The CUSUM analysis found a threshold of 23 operations after which the composite endpoint was optimized. Conclusion: Patients undergoing HM2 implantation in a low-volume center have improving outcomes with number of cases and optimized results after a threshold of 23 cases. Significant changes in patient selection, surgical techniques, and patient management might lead to improved outcomes after LVAD implantation.

Incidence and Outcome of Anaphylaxis in Cardiac Surgical Patients

Introduction:Anaphylaxis is a rare but serious and potentially fatal complication of anesthesia. Little is known about the incidence and outcome of anaphylaxis in cardiac surgical patients, which we aimed to investigate. Methods: This was a 21?year retrospective study of cardiac surgical patients at Manchester Royal Infirmary, Manchester Foundation Trust, Manchester, UK. Results: A total of 19 cases of anaphylaxis were reported among 17,589 patients (0.108%) undergoing cardiac surgery.The majority (15/19) occurred before cardiopulmonary bypass (CPB), mostly during or within 30 min after the induction of anesthesia (10/19). Two occurred within 15 min of going onto CPB. Of these 17 cases, 11 were abandoned, and 6 proceeded. The severity of reactions in the patients who proceeded ranged from grade II to grade IV of the Ring and Messmer classification. Two cases occurred after the completion of surgery. All patients survived to 90 days. However, this did not appear to be related to CPB or protamine as most of the reactions occurred before CPB. Instead, the most common causative agents were gelofusine, antibiotics, muscle relaxants, and chlorhexidine. In 6 cases, surgery proceeded despite the anaphylaxis, in 11 cases the surgery was postponed, and in 2 cases the procedure had already been completed. Conclusion: As all patients survived, our results provide preliminary support for proceeding with surgery although we cannot speculate on the likely outcomes of patients who were postponed, had their surgery proceeded. Based on our data, the incidence of anaphylaxis in cardiac surgical patients may be 10–20 times higher than in the general surgical population.

Inpatient characteristics, complications, and outcomes of patients with cardiac sarcoidosis: A study from the National Inpatient Sample

Although seen in ~5% of sarcoidosis patients, cardiac sarcoidosis (CS) accounts for nearly 25% of diseaserelated deaths. This study aimed to describe characteristics and outcomes among CS patients. Patients diagnosed with CS in 2016e2017 in the US National Inpatient Sample Database were evaluated to study patient characteristics, reasons ascribed to admission, in-hospital outcomes, and complications. A total of 2420 patients (median age 56 years) were included in the analysis. Most admissions occurred due to ventricular tachycardia (12.8%), followed by myocarditis (9.9%) with a mean length of stay of 7 ± 7 days. The overall incidence of in-hospital mortality was 2.5%

Current status and progress of left ventricular assist device for end-stage heart failure / 中国胸心血管外科临床杂志

@#Although heart transplantation remains to be the optimal treatment for advanced heart failure, its use has been largely limited due to shortage of available donor organs. Over the past two decades, left ventricular assist device (LVAD) has been significantly modified in size, durability and hemocompatibility. In addition to the bridge to transplantation, LVAD has become an attractive alternative to heart transplantation for end-stage heart failure as destination therapy for unsuitable candidates. Although the performance of LVAD has been improving greatly in recent years, there are still great challenges in the management of device complications and low quality of life after implantation. This review will summarize the types of LVAD, indications for implantation, postoperative management and adverse events.

Influence of continuous circulatory support of HeartCon type left ventricular assist device(LVAD) on liver and kidney function in experimental animals / 国际生物医学工程杂志

Objective:To determine the adverse effects of continuous circulatory support on liver and kidney function in experimental animals using left ventricular assist devices (LVAD).Methods:Six healthy experimental sheep were selected and implanted with HeartCon type LVAD. The liver and kidney indexes of experimental sheep before and 70 days after operation were detected, including urea (UREA), creatinine (CREA), alanine aminotransferase (ALT), aspartate aminotransferase (AST) and total bilirubin (TBIL), and the functional changes of liver and kidney were evaluated.Results:The preoperative levels of UREA, CREA, ALT, AST and TBIL in the six experimental sheep were (4.60±1.51) mmol/L, (94.80±23.10) μmol/L, (16.20±6.87) U/L, (82.60±17.33) U/L, and (0.52±0.25) μmol/L, respectively. Compared with the indexes before the LVAD implantation, there was no significant change in CREA levels in experimental sheep after the implantation (all P>0.05). After the implantation, the levels of UREA, ALT, AST and TBIL increased to varying degrees within 1 to 14 days after the implantation. At the end of the study, the levels of UREA, ALT, AST and TBIL have returned to the preoperative levels, and the differences were not statistically significant (all P>0.05). Conclusions:Within the 70 days of continuous circulatory support with HeartCon-type LVAD, no evidence of adverse effects of continuous flow LVAD on the liver and kidney function of experimental animals was found. HeartCon-type LVADs are able to provide adequate circulatory support to maintain proper end-organ function.

Dispositivos de asistencia ventricular en insuficiencia cardíaca avanzada

La insuficiencia cardíaca (IC) continúa siendo una enfermedad de alta prevalencia, afectando al 1-2% de la población en países desarrollados y constituye por ello un problema de salud por los altos costos que esto conlleva. A pesar de los avances en el tratamiento farmacológico y mediante dispositivos implantables presenta un pronóstico pobre. Aproximadamente un 5% de los pacientes con diagnóstico de IC se hallan en un estadio avanzado de la enfermedad o estadio D. En las últimas tres décadas el trasplante cardíaco (TC) se ha convertido en el tratamiento de elección para este grupo de altísimo riesgo. Desafortunadamente, un pequeño porcentaje de pacientes cumple con la edad adecuada y con la ausencia de comorbilidades necesarias para poder acceder a este tratamiento, además de la limitante de la escasez de donantes en la actualidad. Debido a ello y a las largas listas de espera a nivel mundial, cada vez es mayor el desarrollo y la utilización de dispositivos de asistencia ventricular (DAV), que han mejorado la supervivencia a corto y largo plazo, dada la calidad de vida de pacientes con esta grave afección, generando una reducción progresiva de la tasa de complicaciones. Estos beneficios no solo aportan una alternativa a pacientes que esperan un TC, sino que permiten a aquellos con contraindicaciones reversibles a disponer del tiempo y la oportunidad de convertirse en candidatos adecuados, o en caso de que esto no sea posible, su final utilización como terapia de destino. Aun así son muchas las limitaciones de estos dispositivos: su costo, su durabilidad, la tasa de complicaciones y su aplicación a un espectro limitado de pacientes. El avance tecnológico para paliar las complicaciones, la mayor experiencia en los centros de manejo y su generalización para permitir un costo más reducido son estrategias que permitirán que la utilización de DAV en los pacientes con IC avanzada se continúe afianzando.

Heart failure (HF) continues to be a highly prevalent disease, affecting 1-2% of the population in developed countries and is therefore a health problem due to the high costs that this entails. Despite advances in pharmacological treatment and implantable devices, it has a poor prognosis. Approximately 5% of patients diagnosed with HF are in an advanced stage of the disease or stage D. In the last three decades, heart transplantation (HT) has become the treatment of choice for this group of very high risk. Unfortunately, a small percentage of patients meet the appropriate age and the absence of comorbidities necessary to access this treatment, in addition to the limitation of the shortage of donors at present. Due to this and the long waiting lists worldwide, the development and use of ventricular assist devices (VAD), which have improved short and long-term survival, due to the quality of life of patients with This serious condition, generating a progressive reduction in the rate of complications. These benefits not only provide an alternative for patients waiting for a HT, but also allow those with reversible contraindications to have the time and opportunity to become suitable candidates, or in case this is not possible, their final use as therapy of destiny. Even so, there are many limitations of these devices: their cost, their durability, the rate of complications and their application to a limited spectrum of patients. The technological advance to alleviate the complications, the greater experience in the centers of management and its generalization to allow a lower cost are strategies that will allow the use of VAD in patients with advanced HF to continue strengthening.

A insuficiência cardíaca (IC) continua a ser uma doença altamente prevalente, afetando 1-2% da população nos países desenvolvidos e, portanto, é um problema de saúde devido aos altos custos que isso acarreta. Apesar dos avanços no tratamento farmacológico e dispositivos implantáveis, tem um mau prognóstico. Aproximadamente 5% dos pacientes com diagnóstico de IC estão em estágio avançado da doença ou estágio D. Nas últimas três décadas, o transplante cardíaco (TC) tornou-se o tratamento de escolha para esse grupo de risco muito alto. Infelizmente, uma pequena porcentagem de pacientes atinge a idade adequada e a ausência de comorbidades necessárias para acessar esse tratamento, além da limitação da falta de doadores no momento. Devido a isso e as longas listas de espera em todo o mundo, o desenvolvimento e uso de dispositivos de assistência ventricular (DAV), que melhoraram a sobrevivência a curto e longo prazo, devido à qualidade de vida dos pacientes com Esta condição séria, gerando uma redução progressiva na taxa de complicações. Esses benefícios não apenas fornecem uma alternativa para pacientes que aguardam um TC, mas também permitem que aqueles com contraindicações reversíveis tenham tempo e oportunidade de se tornarem candidatos adequados ou, caso isso não seja possível, seu uso final como terapia. de destino. Mesmo assim, existem muitas limitações desses dispositivos: seu custo, sua durabilidade, a taxa de complicações e sua aplicação a um espectro limitado de pacientes. O avanço tecnológico para aliviar as complicações, a maior experiência nos centros de gestão e sua generalização para permitir um menor custo são estratégias que permitirão que o uso do DAV em pacientes com IC avançada continue fortalecendo-se.

Management issues during postinfarction ventricular septal defect and role of perioperative optimization: A case series

The development of a myocardial infarction ventricular septal rupture is a rare fatal complication, and the surgical repair is the treatment of choice. In most of the scenarios, the operation will be done as an emergency procedure that carries high mortality. Prognosis of these patients depends on prompt echocardiographic diagnosis and the proactive medical and surgical therapy. More recently, various options have been put forward including the timing for surgery, percutaneous closure devices, and the improved outcome with initial stabilization with medical treatment including mechanical support. In this retrospective case series, we are presenting the management of these patients who presented us in different clinical scenarios and trying to identify the risks for the poor outcome and to formulate a strategy to improve the outcome.

Research and application progress of mechanical circulatory support devices for univentricular circulation / 中国胸心血管外科临床杂志

@#The single ventricular circulation is notable for coexisting systemic venous hypertension and pulmonary arterial hypotension. The use of mechanical circulatory support (MCS) devices is a viable therapeutic treatment option for patients with congestive heart failure. Ventricular assisted devices, cavopulmonary assisted devices, and total artificial heart pumps continue to gain acceptance as viable treatment strategies for single ventricular physiology patients as bridge-to transplantation, bridge-to-recovery, and longer-term circulatory support alternatives. Patients with single ventricular physiology had the lower survival rates compared with those with biventricular circulation. We present a review of the current and future MCS devices for patients with univentricular circulations.

Current Treatments of Refractory Heart Failure / 医药导报

Although great progress has been made in the treatment of heart failure,refractory heart failure is still a difficult problem.It has high incidence and poor prognosis,which brings huge financial burden to patients, families and society. Recently,the clinical application of sacubitril/ valsartan and ivabradine,mechanical circulatory support,and heart transplantation have been greatly improved.This article reviews current treatments of refractory heart failure from aspects of new breakthroughs in drug treatment,mechanical circulatory support,and heart transplantation.

Advancement on the use of percutaneous mechanical circulatory support devices in severe cardiovascular diseases / 中华危重病急救医学

Percutaneous mechanical circulatory support (PMCS) devices are effective in the treatment of patients with cardiogenic shock and acute decompensated heart failure, as a bridge to the recovery of heart function or further treatment. The intra-aortic balloon pump (IABP) is now the most widely used PMCS. New PMCS devices including Transseptal device of Tandem-Heart, transaortic valve device of Impella and extracorporeal membrane oxygenation (ECMO) might provide more effective hemodynamic supports. Doctors should choose appropriate PMCS devices and their working modes, according to patient's clinical conditions, based on the working principles and hemodynamic effects of the devices, in order to achieve the best effects and help patients live through the crisis of diseases.

Percutaneous Extracorporeal Membrane Oxygenation (ECMO) for Acute Fulminant Myocarditis / 계명의대학술지

Acute fulminant myocarditis can be developed by viral infection, toxic materials, autoimmune disorder to heart and can cause left ventricular dysfunction that predisposes the patients to critical condition. When conventional therapy failed to manage the patients and the failing myocardium to recovery, cardiovascular collapse or even death was followed. Mechanical circulatory support is a useful option for the patient whose condition is resistant to medical therapy. We report a case which successful management of acute fulminant myocarditis patient with percutaneous extracorporeal membrane oxygenation.

Asistencia circulatoria mecánica en pediatría: Experiencia en el Hospital de Pediatría Dr. Juan P. Garrahan. Argentina / Mechanical circulatory support in pediatrics: Experience at the Hospital de Pediatría Dr. Juan P. Garrahan. Argentina

Introducción: La asistencia circulatoria mecánica permite aportar oxígeno a los tejidos en pacientes con enfermedades cardiacas y/o respiratorias reversibles refractarios a tratamientos convencionales. Objetivo: Mostrar los resultados iniciales de asistencia circulatoria mecánica en niños con cardiopatía en nuestra institución. Método: Estudio de cohorte descriptivo retrospectivo entre marzo de 2006 y marzo de 2012. Datos demográficos (edad, sexo, peso, diagnóstico cardiológico), de la cirugía (técnica, tiempo de bomba y de pinzamiento aórtico) y de la asistencia circulatoria mecánica (tipo, indicación, duración, complicaciones y evolución). Resultados: Fueron asistidos 33 pacientes (1.3% del total de cirugías), con oxigenación por membrana extracorpórea en 32 casos y un caso con dispositivo de asistencia ventricular. Mediana de edad 7.4 meses (un día-18 años) y peso 6 kg (2.3-75). Las malformaciones cardiacas que se asistieron con mayor frecuencia son las trasposiciones de grandes arterias asociadas a otras anomalías y las trasposiciones corregidas (inversión ventricular-doble discordancia). El motivo de ingreso más frecuente fue disfunción biventricular poscardiotomía. En 28 pacientes la asistencia circulatoria mecánica fue postoperatoria y en 4 preoperatoria. Un paciente presentó miocarditis. Mediana de asistencia 3 días (1-10). Complicaciones más frecuentes: infección el 21% y sangrado el 21%. Decanulación electiva en un 94% de los casos. Supervivencia con alta hospitalaria: 52%. Conclusiones: La asistencia circulatoria mecánica en nuestra institución es una herramienta segura con procedimiento estandarizado. Se utiliza en un reducido número de casos, con supervivencia similar a informes internacionales. Es un procedimiento complejo, plenamente justificado que permitió la recuperación en más de la mitad de los pacientes que de otro modo hubieran fallecido.

Introduction: Mechanical circulatory support provides oxygen to the tissues in patients with cardiac and/or respiratory reversible disease refractory to conventional treatments. Objective: The aim of this study is to show our initial results of mechanical circulatory support in children with heart disease. Method: Retrospective cohort between March 2006 and March 2012. Demographic data (age, sex, weight, cardiac diagnosis), surgery (technique, pump, aortic cross clamping time) and mechanical circulatory support (type of assistance, indication, duration, complications and outcome) were collected. Results: Thirty-three patients were supported (1.3% of all surgeries), extracorporeal membrane oxygenation 32 cases and one ventricular assist device. The median age 7.4 months (one day-18 years) and weight 6 kg (2.3-75). The most frequent cardiac malformations supported were the transpositions of the great arteries associated with other anomalies and the corrected transpositions (ventricular inversion or double discordance). The most common reason for admission was post-cardiotomy biventricular dysfunction. Twenty-eight patients were supported in the postoperative period, 4 in the preoperative period and in one with myocarditis. Median days of support were 3 days (1-10). The most common complications were infection (21%), bleeding (21%). Elective decannulation was achieved in 94% of cases. Hospital discharge survival: 52%. Conclusions: The mechanical circulatory support in our institution is a safe and standard procedure. We have been using it in a small number of cases with a similar survival to that reported internationally. This complex procedure is widely justified because it allows for the recovery of more than half of the patients who otherwise would have died.

The Successful Implantation of Continuous-Flow Left Ventricular Assist Device as a Destination Therapy in Korea: Echocardiographic Assessment

Left ventricular assist device (LVAD) is a good treatment option for the patients ineligible for cardiac transplantation. Several studies have demonstrated that a ventricular assist device improves the quality of life and prognosis of the patients with end-stage heart failure. A 75-yr-old man debilitated with New York Heart Association (NYHA) functional class III-IV due to severe left ventricular systolic dysfunction received LVAD implantation as a destination therapy. The patient was discharged with improved functional status (NYHA functional class II) after appropriate cardiac rehabilitation and education about how to manage the device and potential emergency situations. This is the first case of successful continuous-flow LVAD implantation as a destination therapy in Korea.

Asistencia circulatoria mecánica / Mechanical circulatory support

La insuficiencia cardiaca constituye una verdadera epidemia a nivel mundial, y Chile no es la excepción. Como respuesta, la medicina ha ido ofreciendo un número cada vez mayor de alternativas para enfrentarla, con mejoras significativas en el tratamiento farmacológico, dispositivos de resincronización cardiaca y diferentes alternativas quirúrgicas, todo lo cual ha mejorado la sintomatología y ha prolongado parcialmente la supervivencia de esta patología en las fases iniciales. Sin embargo en las fases más avanzadas de esta enfermedad, sólo el trasplante cardiaco y actualmente la asistencia circulatoria, han demostrado una mejoría significativa de la supervivencia de este complejo grupo de pacientes. En esta revisión, intentamos revisar en profundidad los aspectos epidemiológicos, clínicos y terapéuticos en el enfrentamiento de esta patología, haciendo hincapié en diferentes aspectos quirúrgicos y en la indicación y manejo de la asistencia circulatoria mecánica, aspectos que son fundamentales a la hora de usar en forma segura esta nueva tecnología.

Heart failure is an epidemic worldwide disease, affecting mainly developed countries. In response, medicine has been offering an increasing number of treatment alternatives with significant improvements in drug therapy, cardiac resynchronization devices and surgical alternatives, all of which have improved symptoms and prolonged survival in the early stages of this pathology. However, in final stages, only heart transplantation has shown significant improvement in survival, and in the last years, Mechanical Circulatory Assistance has shown good results in this complex group of patients. In this article we review epidemiological, clinical and therapeutic aspects of Mechanical Circulatory Support, emphasizing on indications and contraindications, management, quality assurance and education of this therapeutic alternative for heart failure.