Noncardiac Surgery in Patients with Left Ventricular Assist Devices: A 11-Year Institutional Experience

ABSTRACT Introduction: Limited options in the end-stage treatment of heart failure have led to increased use of left ventricular assist devices. For this reason, the rate of non-cardiac surgeries in patients with left ventricular assist devices is also increasing. Our study aims to analyze surgical rate, anesthesia management, and results by reviewing our 11-year experience with patients who underwent non-cardiac surgery receiving left ventricular assist devices support. Methods: We retrospectively evaluated 57 patients who underwent non-cardiac surgery and 67 non-cardiac surgical procedures among 274 patients who applied between January 2011 and December 2022 and underwent left ventricular assist devices implantation with end-stage heart failure. Results: Fifty (74.6%) patients with left ventricular assist devices admitted to the hospital for non-cardiac surgery were emergency interventions. The most common reasons for admission were general surgery (52.2%), driveline wound revision (22.3%), and neurological surgery (14.9%). This patient group has the highest in-hospital mortality rate (12.8%) and the highest rate of neurological surgery (8.7%). While 70% of the patients who underwent neurosurgery were taken to surgery urgently, the International Normalized Ratio values of these patients were between 3.5 and 4.5 at the time of admission to the emergency department. Conclusion: With a perioperative multidisciplinary approach, higher morbidity and mortality risks can be reduced during emergencies and major surgical procedures.

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

Cumplimiento de los objetivos nutricionales durante el uso de dispositivos de asistencia ventricular / Nutritional objectives in patients with ventricular assist devices

Antecedentes: Los dispositivos de asistencia ventricular (VAD, sigla en inglés) se utilizan cada vez más para el manejo de la insuficiencia cardíaca descompensada en unidades de cuidados intensivos. El manejo nutricional es fundamental para la evolución clínica de estos pacientes. Objetivos: El objetivo fue evaluar en cuánto tiempo se puede alcanzar las necesidades nutricionales, utilizando distintas modalidades de apoyo nutricional, en pacientes que requirieron asistencia con VAD por insuficiencia cardíaca aguda en una clínica privada del país. Métodos: En una clínica privada se efectuó un estudio observacional retrospectivo analizando los datos clínicos relacionados al aporte nutricional de 12 pacientes que requirieron asistencia con VAD. Las vías de aporte nutricional evaluadas fueron la nutrición enteral (NE) y/o nutrición parenteral (NP). Se midió el tiempo de implementación del apoyo nutricional y su efecto se estimó por una valoración nutricional subjetiva y por la medición de indicadores de laboratorio. Además, se vigilaron las complicaciones asociadas al aporte nutricional. Resultados: El estudio incluyó a 12 pacientes. Los objetivos nutricionales se alcanzaron por completo en el 91% de los pacientes (n=11) en 3,7 ± 1 días después de iniciado el apoyo nutricional. En ese momento, 5 pacientes recibían NE exclusiva, 4 pacientes NP complementaria a la NE, 1 paciente NE complementaria a la alimentación oral y 1 paciente con vía oral. Al momento de alcanzar los requerimientos nutricionales ningún paciente tenía NP exclusiva. Conclusión: Concluimos que el apoyo nutricional precoz es factible y seguro en pacientes con VAD. Alcanzar los objetivos nutricionales es posible sin efectos adversos graves. Se necesitan estudios futuros para determinar el beneficio a largo plazo del apoyo nutricional agresivo para pacientes en estado crítico que requieren apoyo hemodinámico.

Background: Ventricular assist devices (VAD) are being used more frequently in patients with severe heart failure. Nutritional support is a critical factor for the outcome in these patients. Aim: to evaluate the time required and mode of nutritional support in patients with severe cardiac dysfunction being treated with VAD. Methods: 12 patients with VAD being treated in an intensive care unit were evaluated to determine the time and mode of support required to achieve adequate nutrition. Enteral and / or parenteral modes of nutritional support were used. The outcomes were evaluated by subjective appreciation, weight measurement and serum levels of albumin, pre-albumin and vitamin D. Results: Adequate nutritional support was achieved in 91% of patients a mean of 3 days after beginning of treatment (SD 1 day). At that time 5 patients were receiving only enteral nutrition, 4 patients enteral and parenteral nutrition, 1 patient enteral nutrition in addition to oral nutrition and 1 patients was receiving only oral nutrition. No patient was receiving only parenteral nutrition. Conclusion: early nutritional support is posible and safe in patients with an VAD. Further studies are needed to evaluate long term benefits of this strategy of nutritional support.

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.

Progress and prospect of heart transplantation in children / 器官移植

Pediatric heart transplantation is the standard treatment for children complicated with refractory heart failure which is difficult to be treated by conventional surgery or drugs. At present, an increasing quantity of pediatric heart transplantation is being performed worldwide, whereas relevant experience is still lacking in China. In recent 10 years, significant progress has been achieved in pediatric heart transplantation. On one hand, the number of pediatric heart transplantation has been increased year by year. On the other hand, ABO-incompatible heart transplantation, application of ventricular assist device in children, and recipient-donor weight mismatch transplantation have been widely employed to resolve the shortage of donor heart in pediatric heart transplantation. However, relevant experience of pediatric heart transplantation is lacking in China, especially in understanding the indications of pediatric heart transplantation and the application of specific strategies for pediatric heart transplantation, etc. In this article, the development history, advances in therapeutic strategy and clinical prognosis of pediatric heart transplantation were reviewed.

Application of ECMO in pediatric heart transplantation / 器官移植

Extracorporeal membrane oxygenation (ECMO) could pump the blood from human veins to the outside of the body, oxygenate the red blood cells in an artificial environment and then return them back into the body. ECMO could replace the heart and lungs to complete gas exchange and systemic blood perfusion in patients with severe cardiopulmonary insufficiency, which also plays an important role in the field of heart transplantation. Besides circulatory support treatment after heart transplantation, ECMO may also be used to prolong the waiting time for heart transplantation in patients with respiratory and circulatory failure before operation, as a bridging therapy for heart transplantation. However, at present, the application of ECMO in pediatric heart transplantation still exist challenges, such as high perioperative mortality and difficulty in determining the timing of treatment, etc. In this article, the development history of ECMO application in pediatric heart transplantation, use of ECMO before and after pediatric heart transplantation, ECMO-related complications in children, and application of ventricular assist device (VAD) in pediatric heart transplantation were briefly reviewed, aiming to provide reference for promoting the application of ECMO in pediatric heart transplantation.

Effect of neurally adjusted ventilatory assist ventilation in severe neurological cerebrovascular diseases patients undergoing mechanical ventilation / 中华危重病急救医学

Objective:To explore the prognostic effect and safety of neurally adjusted ventilatory assist (NAVA) mode on the patients with severe neurological cerebrovascular disease undergoing mechanical ventilation.Methods:A prospective study was conducted. Fifty-four patients with cerebrovascular disease undergoing mechanical ventilation admitted to the neurosurgery intensive care unit (NSICU) of the First Affiliated Hospital of Wannan Medical College (Yijishan Hospital) from December 2020 to May 2022 were enrolled. They were divided into NAVA group and pressure support ventilation (PSV) group by computer random number generator with 27 patients in each group. The ventilation time of the two groups was ≥72 hours. The general basic data of the two groups were recorded. The time without mechanical ventilation 28 days after enrollment, total length of mechanical ventilation, survival rate of 90 days after enrollment, length of NSICU stay, total length of hospital stay, NSICU mortality, in-hospital mortality, Glasgow outcome score (GOS), complications related to mechanical ventilation, and changes of respiratory mechanics indexes, arterial blood gases, vital signs, and diaphragm function indexes were observed.Results:The time without mechanical ventilation 28 days after enrollment in the NAVA group was significantly longer than that in the PSV group [days: 22 (15, 26) vs. 6 (0, 23), P < 0.05]. However, there were no significant differences in the total length of mechanical ventilation, 90-day survival rate, length of NSICU stay, total length of hospital stay, NSICU mortality, in-hospital mortality, GOS score, and incidence of mechanical ventilator-related complications between the two groups. In terms of respiratory mechanics parameters, the expiratory tidal volume (VTe) on 3 days after mechanical ventilation of patients in the NAVA group was significantly lower than that on 1 day and 2 days, and significantly lower than that in the PSV group [mL: 411.0 (385.2, 492.6) vs. 489.0 (451.8, 529.4), P < 0.01]. Minute ventilation (MV) at 2 days and 3 days in the NAVA group was significantly higher than that at 1 day, and significantly higher than that in the PSV group at 2 days [L/min: 9.8 (8.4, 10.9) vs. 7.8 (6.5, 9.8), P < 0.01], while there was no significant change of MV in the PSV group. At 1 day, peak airway pressure (Ppeak) and mean airway pressure (Pmean) in the NAVA group were significantly lower than those in the PSV group [Ppeak (cmH 2O, 1 cmH 2O≈0.098 kPa): 14.0 (12.2, 17.0) vs. 16.6 (15.0, 17.4), Pmean (cmH 2O): 7.0 (6.2, 7.9) vs. 8.0 (7.0, 8.2), both P < 0.05]. However, there was no significant difference in the Ppeak or Pmean at 2 days and 3 days between the two groups. In terms of arterial blood gas, there was no significant difference in pH value between the two groups, but with the extension of mechanical ventilation time, the pH value at 3 days of the two groups was significantly higher than that at 1 day. Arterial partial pressure of oxygen (PaO 2) at 1 day in the NAVA group was significantly lower than that in the PSV group [mmHg (1 mmHg≈0.133 kPa): 122.01±37.77 vs. 144.10±40.39, P < 0.05], but there was no significant difference in PaO 2 at 2 days and 3 days between the two groups. There was no significant difference in arterial partial pressure of carbon dioxide (PaCO 2) or oxygenation index (PaO 2/FiO 2) between the two groups. In terms of vital signs, the respiratory rate (RR) at 1, 2, and 3 days of the NAVA group was significantly higher than that of the PSV group [times/min: 19.2 (16.0, 25.2) vs. 15.0 (14.4, 17.0) at 1 day, 21.4 (16.4, 26.0) vs. 15.8 (14.0, 18.6) at 2 days, 20.6 (17.0, 23.0) vs. 16.7 (15.0, 19.0) at 3 days, all P < 0.01]. In terms of diaphragm function, end-inspiratory diaphragm thickness (DTei) at 3 days in the NAVA group was significantly higher than that in the PSV group [cm: 0.26 (0.22, 0.29) vs. 0.22 (0.19, 0.26), P < 0.05]. There was no significant difference in end-expiratory diaphragm thickness (DTee) between the two groups. The diaphragm thickening fraction (DTF) at 2 days and 3 days in the NAVA group was significantly higher than that in the PSV group [(35.18±12.09)% vs. (26.88±8.33)% at 2 days, (35.54±13.40)% vs. (24.39±9.16)% at 3 days, both P < 0.05]. Conclusions:NAVA mode can be applied in patients with neuro-severe cerebrovascular disease, which can prolong the time without mechanical ventilation support and make patients obtain better lung protective ventilation. At the same time, it has certain advantages in avoiding ventilator-associated diaphragm dysfunction and improving diaphragm function.

Effects of Left Ventricular Assist and Aortic Graft Angle on Aortic Valve: A Hemodynamic Study / 医用生物力学

Objective To investigate the effect of left ventricular assist device (LVAD) and aortic graft angle on hemodynamics of aortic valve. Methods Three models of aorta and aortic valve with 45°, 60° and 90° anastomosis angles between LVAD and aorta were constructed, and an in vitro pulsating table was built for in vitro experiments. Using particle image velocimetry (PIV) system, three moments in the cardiac cycle ( T1 systolic peak, T rapid closure, T3 diastolic peak), were selected to study the hemodynamic state of aortic valve. Results Velocity vector, vorticity and viscous shear stress were used to evaluate the effect of LVAD anastomosis angle on hemodynamics of aortic valve. During the period of rapid valve closure, with the increase of graft angle, the blood flow velocity near the valve wall, the average vorticity and the maximum viscous shear stress all increased. Conclusions When the graft angle is lower, the impact velocity of blood on the valve is smaller, and the shear force on the valve decreases, so that the valve is in a better hemodynamic environment. This study provides references for the selection of anastomotic angles in clinical operations.

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.

Current status and progress of implantable left ventricular assist devices / 中国胸心血管外科临床杂志

@#Implantable left ventricular assist device (LVAD) has become an essential treatment for end-stage heart failure, and its effect has been continuously improved. In the world, magnetic levitation LVAD has become mainstream and is increasingly used as a destination treatment. China has also entered the era of ventricular assist device. The continuous improvement of the ventricular assist device will further improve the treatment effect. This article reviews the current situation and development trend of LVAD treatment in China and abroad.

A prospective multicenter clinical trial study of a domestic HeartCon third-generation magnetic and hydrodynamic levitation LVAD for the treatment of 50 cases of end-stage heart failure / 中华胸心血管外科杂志

Objective:To analyze and evaluate the safety and efficacy of a Chinese domestically manufactured Heart Con-type implantable third-generation magnetic and hydrodynamic levitation left ventricular assist device(LVAD) for the treatment of end-stage heart failure(ESHF), by reporting the results of eleven-center clinical trial on 50 cases.Methods:This study was a multicenter clinical trial, designed by means of prospective, multicenter and single-group target value. 50 subjects with ESHF were competitively enrolled and treated with HeartCon as the LVAD in eleven centers. The primary efficacy measure was survival, defined as either the subjects experiencing the transition to heart transplantation(HT) or myocardial recovery assisted by the device within 90 days, or as successfully assisted by the LVAD for full 90 days after implantation. The target survival rate was 60%, other observations included implantation success rate, mortality, pump failure needing replacement or emergency heart transplantation.Results:All enrolled 50 patients received LVAD implantation successfully, 46 survived with the pump for 90 days, 1 patient transitioned to heart transplantation, and 3 patients experienced pump thrombosis, within which 2 patients underwent pump replacement and continued to live with the pump for 90 days, and the other one received emergency heart transplantation. There were no dropout subjects. The survival rate at full 90 days after HeartCon implantation was 100%. The survival rates with pump in the full set analysis and the protocol set analysis were 96.00% and 95.92% respectively, which were higher than the target value of 60%. The differences were both statistically significant( P<0.05). Conclusion:The results of the multicenter clinical trial with the largest sample size in China using domestically manufactured third-generation LVAD has demonstrated that, HeartCon is a safe and effective LVAD to treat ESHF patients.

Clinical experience of REcanalisation and balloon-oriented puncture for Re-insertion of long- term dialysis catheter in nonpatent central veins / 中华肾脏病杂志

It is difficult to insert long-term dialysis catheters after severe stenosis or occlusion of the internal jugular vein and innominate vein. We used REcanalisation and balloon-oriented puncture for Re-insertion of dialysis catheter in nonpatent central veins (REBORN) in seven patients with severe central venous lesions, and all patients were inserted with long-term dialysis catheters successfully. None had severe complications such as pneumothorax, hemothorax, or pulmonary embolism during operation. All catheters functioned well after postoperative follow-up of 2 months. REBORN provides a novel approach to establish difficult dialysis pathways.

Pharmacotherapy of patients with left ventricular assist devices / 中国临床药理学与治疗学

Left ventricular assist devices (LVAD) are increasingly used in patients with end-stage heart failure. Devices significantly affect patient physiology, leading to unique complications and different drug treatment strategies. The pharmacist is an integral part of a multidisciplinary team and has the responsibility to help patients use their medicines safely and appropriately. It is important to anticipate common postoperative complications and prepare appropriate treatments for them. This article reviews the current guidelines and research literature on the management of pharmacotherapy in patients with LVAD, integrates clinical research practice, summarizes the medication relevant experience and presents a review.

The ProtekDuo as Double Lumen Return Cannula in V?VP ECMO Configuration: A First?In?Man Method Description

We present a case of acute respiratory distress syndrome (ARDS) secondary to COVID?19 who required venovenous extracorporeal membrane oxygenation (V?V ECMO). Initially, a right ventricular assist device (RVAD), the ProtekDuo with an oxygenator, was placed in an outside heart center and the patient was transferred to us for ECMO management. Due to severe hypoxia, the configuration was later modified, and a 25 Fr femoral drainage cannula was inserted for venous drainage only. The arterial return tubing was spliced and using a Y?connector, arterialized blood was returned through both limbs of the ProtekDuo resulting in a significantly increased oxygenation and flow.

Effectiveness of competency-based teaching and comparison to traditional teaching of Phase I MBBS students

Background: During MBBS course, the students’ study about cardiovascular system (CVS) in physiology, pathology, pharmacology, preventive medicine, pediatrics, and medicine for the management and diagnosis of cardiovascular disorders. Blood pressure measurement is a common and a beneficial tool for the diagnosis of cardiovascular disorders (hypertension, hypotension, etc.) along with their treatment and management. Thus, knowing the proper technique of measuring blood pressure becomes an essential part of learning the course and management of cardiovascular disease. This study is designed to teach and train the first phase undergraduate students to measure blood pressure in a proper way so that they do not stumble on the first step of examination of CVS. Competency-based training is an outcome-based approach that involves identifying the skills acquired by Indian medical graduate. Competency-based teaching involves teaching of undergraduate students to support their achievement and assessment of the communication and technical skills and to develop their ability to interpret the results of blood pressure measurement for apt patient management. Aim and Objectives: This study aims to assess and compare the effect of competency-based teaching and traditional teaching in learning the skill of blood pressure measurement. Materials and Methods: Two hundred students were taken from Phase I undergraduate medical students which were randomly divided in two Groups A and B. Competency-based teaching of blood pressure measurement was done in Group A in by teaching method of demonstrate, observe, assist, and perform and Group B was taught by traditional demonstration. Pre-test questionnaire was given to both the groups before beginning of the practical session. The students learning of skill to measure blood pressure was assessed by directly observed procedural skills (DOPS) checklist after which student feedback was provided along with filling up of the post-test questionnaire. Furthermore, feedback from both student and teacher was collected. Results: Highly significant difference was found between pre-test and post-test of both Group A and Group B. Significant difference was found between Group A and Group B post-test scores. It was found that Group A in which competency-based teaching was done scored higher post-test scores then Group B. Furthermore, highly significant difference was seen among the scores of DOPS checklist between Group A and Group B. Conclusion: In the present research study, it was found that the students who underwent competency-based training of the skill of blood pressure measurement showed significantly higher scores in learning and performing the skill. Furthermore, on feedback provided by the students, 96% of the students strongly agree that the competency-based teaching and learning is better than traditional teaching.

Early reduction of pulmonary arterial hypertension in patients using a long-term mechanical ventricular assistance device: a cross-sectional study

ABSTRACT BACKGROUND: Severe pulmonary arterial hypertension (PAH) is a contraindication for heart transplantation (HT). It has been correlated with increased early and late mortality, mainly associated with right ventricular failure. Ventricular assistance devices (VADs) can promote reduction of intracardiac pressures and consequent reduction of PAH over the medium and long terms, thus enabling future candidature for HT. The diminution of early pulmonary pressure within this scenario remains unclear. OBJECTIVE: To evaluate the reduction of PAH and correlate data from right catheterization with the earliness of this reduction. DESIGN AND SETTING: Cross-sectional study in a general hospital in São Paulo, Brazil. METHODS: This was a retrospective analysis on the medical records of patients undergoing VAD implantation in a single hospital. Patients for whom VAD had been indicated as a bridge to candidature for HT due to their condition of constant PAH were selected. RESULTS: Four patients with VADs had constantly severe PAH. Their mean pulmonary artery systolic pressure (PASP) before VAD implantation was 66 mmHg. Over the 30-day period after the procedure, all the patients evolved with a drop in PASP to below 60 mmHg. Their new average was 36 mmHg, which was a drop of close to 50% from baseline values. The one-year survival of this sample was 100%. CONCLUSION: VAD implantation can reduce PAH levels. Early reduction occurred in all patients. Thus, use of VAD is an important bridge tool for enabling candidature for HT among patients with constantly severe PAH.

Dispositivos de asistencia ventricular en el shock cardiogénico posinfarto: importancia del soporte hemodinámico: reporte de caso / Ventricular assist devices in post-infarction cardiogenic shock: importance of hemodynamic support: case report / Dispositivos de assistência ventricular no choque cardiogênico pós-infarto: importância do suporte hemodinâmico: relato de caso

El shock cardiogénico posinfarto caracterizado por un estado de insuficiencia circulatoria sistémica requiere de un tratamiento precoz en vistas a restablecer la estabilidad hemodinámica y la función ventricular. Este consta de la reperfusión coronaria mediante revascularización miocárdica; en algunos casos es necesaria la utilización de dispositivos de asistencia ventricular. El ECMO venoarterial es un sistema de circulación extracorpórea que permite un soporte biventricular oxigenando la sangre y reintroduciéndola mediante un flujo continuo hacia la circulación arterial sistémica. El uso de dicho dispositivo en pacientes con shock cardiogénico ha mostrado una mejoría significativa de la sobrevida a 30 días en comparación con el uso del balón de contrapulsación intraaórtico. No obstante, sus potenciales complicaciones, como dificultad en el vaciamiento ventricular izquierdo, síndrome de Arlequín, sangrados e infecciones, hacen fundamental la formación y el trabajo en equipo del heart team. Un porcentaje no menor de estos pacientes presentarán una severa disfunción ventricular permanente, por lo que podrían ser candidatos a dispositivos de asistencia ventricular izquierda de larga duración tipo Heartmate III como puente al trasplante cardíaco, el cual ha mostrado resultados satisfactorios con una excelente sobrevida a mediano plazo.

Post-infarction cardiogenic shock characterized by a state of systemic circulatory failure requires early treatment in order to restore hemodynamic stability and ventricular function. This consists of coronary reperfusion through myocardial revascularization, requiring in some cases the use of ventricular assist devices. Veno-arterial ECMO is an extracorporeal circulation system that allows biventricular support by oxygenating the blood and reintroducing it through a continuous flow towards the systemic arterial circulation. The use of this device in patients with cardiogenic shock has shown a significant improvement in survival at 30 days compared to the use of intra-aortic balloon pump. However, its potential complications, such as difficulty in left ventricular emptying, Harlequin syndrome, bleeding and infections, make the training and teamwork of the heart team essential. A great percentage of these patients will present a severe permanent ventricular dysfunction, so they could be candidates for long-term mechanical circulatory support devices like Heartmate III as a bridge to transplant or myocardial recovery, or destination therapy, which has shown satisfactory results with excellent medium-term survival.

O choque cardiogênico pós-infarto caracterizado por um estado de insuficiência circulatória sistêmica requer tratamento precoce para restabelecer a estabilidade hemodinâmica e a função ventricular. Esta consiste na reperfusão coronariana por meio de revascularização miocárdica, necessitando, em alguns casos, do uso de dispositivos de assistência ventricular. A ECMO venoarterial é um sistema de circulação extracorpórea que permite o suporte biventricular oxigenando o sangue e reintroduzindo-o através de um fluxo contínuo para a circulação arterial sistêmica. O uso desse dispositivo em pacientes com choque cardiogênico mostrou melhora significativa na sobrevida em 30 dias em relação ao uso de contrapulsação com balão intra-aórtico. No entanto, suas potenciais complicações, como dificuldade de esvaziamento ventricular esquerdo, síndrome de Harlequin, sangramentos e infecções, tornam imprescindível o treinamento e o trabalho em equipe do time do coração. Não uma pequena porcentagem desses pacientes apresentará uma condição ventricular permanente grave, podendo ser candidatos a dispositivos de assistência ventricular esquerda de longa duração do tipo Heartmate III como ponte para o transplante cardíaco, que tem demonstrado resultados satisfatórios com excelente sobrevida em médio prazo.

Left Ventricular Assist Device Thrombosis: Combined Approach by Echocardiography and Logfiles Review for Diagnosis and Management

ABSTRACT Introduction: Left ventricular assist devices are an established therapy for end-stage heart failure. Follow-up of these patients showed complications, such as thrombosis. Our objective was to evaluate the contribution of echocardiography — in association with HeartWare HVAD online logfiles reviews and lactate dehydrogenase titration — for diagnosis and treatment of thrombosis. Methods: Seventeen episodes of thrombosis were diagnosed in 8/20 patients with HVAD. Diagnosis was made by trans-thoracic echocardiographic blood flow velocities, logfiles review of power consumption and pump flows, and titration of lactate dehydrogenase. Data were collected at baseline routine control (Group A), during thrombosis (Group B), after thrombolysis (Group C). Results: Thrombolysis was successful in all cases; one patient died of cerebral haemorrhage. Echocardiographic maximal blood flow velocity near the inflow cannula was 598±42 cm/sec (Group B), 379.41±21 cm/sec (Group C), and 378.24±28 cm/sec (Group A) (P<0.00001). In eight (47%) cases, thrombi were visualized in the left ventricle by three-dimensional modality. Logfiles recordings of blood flows were 9.52±0.9 L/min (Group B), 4.02±0.4 L/min (Group C), and 4.04±0.4 L/min (Group A) (P<00001). Power consumption was 5.01±0.7 W (Group B), 3.45±0.2 W (Group C), and 3.46±0.2 W (Group A) (P<0.00001). Lactate dehydrogenase was 756±54 IU (Group B), 234±22 IU (Group A), and 257±36 IU (Group C) (P<0.00001). Conclusions: Echocardiography of increased maximal velocity near the inflow cannula is a sign of HVAD obstruction. Logfile reviews provide a clear picture of HVAD obstruction. Combination of echocardiographic data and review of logfiles detects signs of left ventricular assist devices thrombosis leading to a successful treatment.

Uso y abuso de substancias en adultos mayores atendidos en Servicios de Salud Mental

RESUMEN El uso de drogas por los ancianos se caracteriza por ser un grave problema de salud pública. El número de usuarios de mayor edad ha aumentado a nivel internacional durante los últimos 40 años, pero el tema sigue siendo descuidado. Este estudio se centra en pacientes ancianos con síntomas de enfermedades mentales concomitantes. Así, se investigó el tiempo de uso, patrones de consumo de sustancias de abuso y el perfil sociodemográfico de los pacientes atendidos en los Centros de Atención Psicosocial por Alcohol y Drogas (CAPS-AD), ubicados en la ciudad de Río de Janeiro. Se trata de un estudio observacional descriptivo con un diseño cuantitativo transversal sobre la frecuencia de abuso de sustancias en la población mencionada. Las prevalencias obtenidas en este estudio son inferiores a las encontradas en la población general y a las reportadas en estudios internacionales. Esta diferencia puede estar relacionada con las características socioculturales de la muestra y el hecho de que los pacientes ya están en contacto con un servicio de salud mental, lo que puede indicar la importancia del contacto regular con los servicios de salud como factor protector y espacio de ayuda.

ABSTRACT The use of drugs by the elderly is characterized for being a serious public health problem. The number of older users has increased internationally over the past 40 years, but the problem remains neglected. This study focuses on elderly patients with symptoms of concomitant mental illness. Thus, the time of use, patterns of consumption of abuse substances and the sociodemographic profile of the patients attended in the Psychosocial Care Centers for Alcohol and Drugs (CAPS-AD), located in the city of Rio de Janeiro, were investigated. This was a descriptive observational study with a cross-sectional quantitative design on the frequency of use of psychoactive substances in the aforementioned population. The prevalence obtained in this study is lower than those found in the general population and those reported in international studies. This difference may be related to the socio-cultural characteristics of the sample and the fact that patients were already in contact with a mental health service, which may indicate the importance of regular contact with health services as a protective factor and space for help.

Short-term effect of HeartCon left ventricular assist device on the treatment of 20 adult patients with end-stage heart failure / 中华危重病急救医学

Objective:To investigate and evaluate the efficacy of HeartCon left ventricular assist device (LVAD) in the treatment of adult patients with end-stage heart failure (ESHF).Methods:A prospective and observational study was conducted. Patients with ESHF who underwent LVAD implantation in the department of cardiac surgery of Teda International Cardiovascular Hospital from September 2020 to August 2021 were selected. The left ventricular end-diastolic diameter (LVEDD), left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) classification, N-terminal pro-B type natriuretic peptide (NT-proBNP), and six minute walk distance (6MWD) before operation and 90 days after operation were compared. The incidence of equipment failures and major adverse events within 90 days after operation were recorded.Results:A total of 20 patients with ESHF were included, with 15 males and 5 females. Patients' age ranged from 20 to 67 years old, with an average of (50.2±13.6) years old. The range of body weight was 49.8-106.1 kg, with an average of (67.9±15.5) kg, and the body surface area (BSA) was from 1.49 to 2.32 m 2, with an average of (17.6±0.22) m 2. The operation process of all the patients were successful. The length of hospital stay ranged from 33 to 90 days, and the average was 56.0 (42.8, 75.0) days. Complications within 90 days after operation as follows, 2 cases with pericardial tamponade (10%), 1 case with cerebral hemorrhage (5%), 1 case with mediastinum infection (5%), 3 cases with acute renal injury (AKI, 15%), 5 cases with gastrointestinal bleeding (25%). There were no mechanical failure of LVAD and hemolysis events, right ventricular failure (RVF), cerebral infarction and death occurred. Compared with preoperative, the LVEDD significantly decreased (mm: 67.50±13.98 vs. 77.40±9.73), LVEF significantly increased (%: 34.80±9.76 vs. 22.70±5.62), NT-proBNP significantly decreased (ng/L: 2 028.65±1 752.05 vs. 4 796.45±4 355.40), 6MWD significantly increased (m: 385.20±144.12 vs. 85.81±63.50) at 90 days after operation, and the differences were statistically significant (all P < 0.05). 18 cases (90%) of the 20 patients reached NYHA classification Ⅰ and 2 cases (10%) reached NYHA classification Ⅱ, which were significantly improved compared with those before surgery (all patients' NYHA classification were Ⅳ before surgery). Conclusion:HeartCon LVAD can effectively improve the life quality of patients with ESHF, which has been proved safe and effective in clinical trials, but its long-term effects and complications need further observation and study.