Rescue extracorporeal life support for acute verapamil and propranolol toxicity in a neonate.

Extracorporeal life support (ECLS) to manage acute antiarrhythmic drugs toxicity in neonates has never been reported. Here presented is a case of venoarterial extracorporeal membrane oxygenation support in a newborn with refractory low cardiac output as a result of acute Ca-channel and ß-receptor antagonist toxicity for treatment of paroxysmal supraventricular tachycardia (SVT). Shortly after onset of ECLS, the baby recovered sinus rhythm and subsequent bouts of SVT were controlled by amiodarone infusion and repeated DC shocks. Weaning was possible on the 5th day after implant, once recovery of the left ventricular function and optimization of the antiarrhythmic medication were achieved. In neonates with severe but potentially reversible cardiac dysfunction caused by drug toxicity, ECLS can maintain cardiac output and vital organ perfusion while allowing time for drug redistribution, metabolism, and clearance.

Pulsatile pulmonary perfusion with oxygenated blood ameliorates pulmonary hemodynamic and respiratory indices in low-risk coronary artery bypass patients.

OBJECTIVE: Acute lung injury still accounts for postoperative mortality after cardiopulmonary bypass (CPB). The safety and the efficacy of pulsatile pulmonary perfusion (PPP) during CPB were analyzed. Preliminary results of the first PPP trial in human beings are reported. METHODS: Thirty low-risk coronary artery bypass grafting (CABG) patients were prospectively randomized to receive PPP with oxygenated blood during CPB and aortic cross-clamping (15 patients, PPP-group) or to conventional CPB (15 patients, control group). Alveolo-arterial oxygen gradient (A-aDO(2)) was set as the primary end point and collected preoperatively, at intensive care unit (ICU) arrival (T1), 3h postoperatively (T2), and post extubation (T3). Secondary end points were collected at the same time points and consisted of respiratory indices (partial pressure of arterial oxygen/fraction of inspired O(2) (PaO(2)/FiO(2)), lung compliance, mixed-venous partial pressure of oxygen (pO(2))) and hemodynamic pulmonary parameters (indexed pulmonary vascular resistances (PVRI), pulmonary arterial pressure (PAP), pulmonary capillary wedge pressure (PCWP), and cardiac index (CI)). Bronchoalveolar lavage (BAL) fluid was collected preoperatively, at ICU arrival (T1-BAL) and after 4h. RESULTS: There were no PPP-related complications. Patients undergoing PPP showed a better preserved A-aDO(2) (group-p=0.001) throughout the study period (group × time-p = 0.0001). PaO(2)/FiO(2) and lung compliance were better preserved by PPP (group-p and group × time-p ≤ 0.05 for all). Pulmonary hemodynamic status was positively influenced by PPP, as shown by the higher CI (group-p=0.0001, group × time-p = 0.0001), and the lower PVRI, PAP, and PCWP (group-p ≤0.001, group × time-p=0.0001 for all). Postoperative BAL specimens demonstrated a lower absolute count of white blood cells (group-p=0.0001), a higher percentage of monocytes/macrophages (group-p=0.027), and a lower percentage of neutrophils (group-p=0.015) after PPP. CONCLUSIONS: Oxygenated blood PPP proved safe and significantly ameliorated pulmonary hemodynamic parameters and respiratory indices in low-risk CABG.

Insights from continued use of a Novacor Left Ventricular Assist System for a period of 6 years.

We report a patient supported with the Novacor Left Ventricular Assist System for more than 6 years and chronicle his progress as an illustration of the clinical, practical, and emotional challenges of this therapy and the benefits of an intervention that can return a morbidly ill patient to an essentially normal lifestyle. This experience underlines the importance of patient selection, optimal timing of intervention, and the potential impact of psychologic issues on outcome.

Hemodynamic effects of inhaled nitric oxide and phosphodiesterase inhibitor (dipyridamole) on secondary pulmonary hypertension following heart valve surgery in adults.

BACKGROUND: Inhaled nitric oxide (iNO) is proposed in the management of pulmonary hypertension (PH) in patients undergoing cardiac surgery. Secondary PH related to a long-standing heart valve disease however may be refractory to iNO. Aim of this prospective study was to determine whether the combination of iNO plus dipyridamole (DP), a cyclic guanosine monophosphate-specific phosphodiesterase inhibitor (PDE5), may enhance and/or prolong the response to iNO in adult patients with secondary valve-related PH undergoing cardiac surgery, and attenuate rebound events related to its discontinuation. METHODS: Responses in 27 patients, 11 male, mean age 72+/-11 years, with PH due to mitral and/or aortic valve disease, were studied in the Intensive Care Unit after cardiac surgery, during sedation and stable hemodynamic conditions. The effect of isolated iNO administration (40 ppm), iNO combined with DP (0.2 mg/kg i.v.), and DP alone (1 mg/kg/24 h) on pulmonary vascular resistance, mean pulmonary artery pressure, cardiac index, mixed venous O2Sat%, and mean arterial pressure were determined. RESULTS: All patients showed at least a 10% decrease in pulmonary vascular resistance vs. baseline after administration of iNO [responders]. Inhaled NO and the combination of iNO/DP produced a reduction of pulmonary vascular resistance and mean pulmonary artery pressure (p<0.05). Cardiac index improved with a significant difference between iNO and the association iNO/DP versus baseline (p<0.05). This significant hemodynamic improvement versus baseline was maintained during isolated DP administration (p<0.05), but not during isolated iNO discontinuation. Mixed venous oxygen saturation showed an overall improvement of 17% (p<0.05). CONCLUSIONS: Inhaled NO and DP infusion might represent a valuable association in the management of PH secondary to a heart valve disease in patients undergoing cardiac surgery. Their beneficial hemodynamic effects might be particularly valuable in the management of patients with associated right ventricular dysfunction.