Vasoplegic syndrome during heart transplantation: A systematic review and meta-analysis.

BACKGROUND: Vasoplegic syndrome (VS) is a common occurrence during heart transplantation (HT). It currently lacks a uniform definition between transplant centers, and its pathophysiology and treatment remain enigmatic. This systematic review summarizes the available published clinical data regarding VS during HT. METHODS: We searched databases for all published reports on VS during HT. Data collected included the incidence of VS in the HT population, patient and intraoperative characteristics, and postoperative outcomes. RESULTS: Twenty-two publications were included in this review. The prevalence of VS during HT was 28.72% (95% confidence interval: 27.37%, 30.10%). Factors associated with VS included male sex, higher body mass index, hypothyroidism, pre-HT left ventricular assist device or venoarterial extracorporeal membrane oxygenation (VA-ECMO), pre-HT calcium channel blocker or amiodarone usage, longer cardiopulmonary bypass time, and higher blood product transfusion requirement. Patients who developed VS were more likely to require postoperative VA-ECMO support, renal replacement therapy, reoperation for bleeding, longer mechanical ventilation, and a greater 30-day and 1-year mortality. CONCLUSIONS: The results of our systematic review are an initial step for providing clinicians with data that can help identify high-risk patients and avenues for potential risk mitigation. Establishing guidelines that officially define VS will aid in the precise diagnosis of these patients during HT and guide treatment. Future studies of treatment strategies for refractory VS are needed in this high-risk patient population.

Monitored Anesthesia Care for Axillary Impella 5.5 Placement: A Feasible Option for Patients With Severe Cardiogenic Shock With Relative Contraindication to Intubation.

The Impella 5.5 left ventricular assist device (LVAD) is typically placed in a hybrid operating room with fluoroscopic and echocardiographic guidance under general anesthesia. In this case report, we describe a patient with severe cardiopulmonary failure necessitating an Impella 5.5 as a bridge to heart/lung transplant. Here, we describe the successful placement of the Impella 5.5 with sedation and local anesthesia in order to avoid general anesthesia and the sequelae of positive pressure ventilation in a fragile patient. Impella placement was confirmed with transesophageal echocardiography. This case report demonstrates a novel strategy for placing the Impella 5.5 and, more importantly, opens the possibility to future prospective studies of this technique.

Left-Sided Double-Lumen Tube vs EZ-Blocker for One-Lung Ventilation in Thoracic Surgery: A Systematic Review and Meta-Analysis.

Background. The EZ-Blocker is the newest generation of bronchial blocker and offers a potential alternative to left-sided double lumen tubes for lung isolation and one-lung ventilation during thoracic surgery. Methods. Databases were searched for randomized controlled trials comparing left-sided double lumen tube to the EZ-Blocker for one-lung ventilation during thoracic surgery. The time for placement, incidence of intraoperative displacement, and surgeons' rating of lung collapse quality were designated as coprimary outcomes. The safety profiles of the two devices, including the incidence of airway trauma and post-extubation discomfort were also examined. Results. Six randomized controlled trials (495 patients) were analyzed. Compared to the EZ-Blocker, the left-sided double lumen tube was faster to place by a weighted mean difference of [95% CI] of -61.24 seconds [-102.48, -20.00] (P = .004) and was much less likely to become displaced during lung isolation with an odds ratio [95% CI] of .56 [.34, .91] (P = .02). The left-sided double lumen tube and the EZ-Blocker provided similar surgeon-rated quality of lung isolation. Although the left-sided double lumen tube caused a greater degree of post-extubation sore throat, there was a similar incidence of carinal trauma and post-extubation hoarseness compared to the EZ-Blocker. Conclusion. Our analysis suggests that the left-sided double lumen tube can be placed more quickly and is less prone to intraoperative displacement compared to the EZ-Blocker; the quality of lung collapse is similar. Thus, evidence appears to support the continued utilization of the left-sided double lumen tube for routine thoracic surgery requiring one-lung ventilation.

Intracardiac thrombosis and pulmonary thromboembolism during liver transplantation: A systematic review and meta-analysis.

Intracardiac thrombosis and/or pulmonary thromboembolism (ICT/PE) is a rare but devastating complication during liver transplantation. Its pathophysiology remains poorly understood, and successful treatment remains a challenge. This systematic review summarizes the available published clinical data regarding ICT/PE during liver transplantation. Databases were searched for all publications reporting on ICT/PE during liver transplantation. Data collected included its incidence, patient characteristics, the timing of diagnosis, treatment strategies, and patient outcomes. This review included 59 full-text citations. The point prevalence of ICT/PE was 1.42%. Thrombi were most often diagnosed during the neohepatic phase, particularly at allograft reperfusion. Intravenous heparin was effective in preventing early-stage thrombus from progressing further and restoring hemodynamics in 76.32% of patients it was utilized for; however, the addition of tissue plasminogen activator or sole use of tissue plasminogen activator offered diminishing returns. Despite all resuscitation efforts, the in-hospital mortality rate of an intraoperative ICT/PE was 40.42%, with nearly half of these patients dying intraoperatively. The results of our systematic review are an initial step for providing clinicians with data that can help identify higher-risk patients. The clinical implications of our results warrant the development of identification and management strategies for the timely and effective treatment of these tragic occurrences during liver transplantation.

Pulmonary artery pulsatility index as a predictor of right ventricular failure in left ventricular assist device recipients: A systematic review.

BACKGROUND: It is critical to identify patients at increased risk of right ventricular failure (RVF) before left ventricular assist device (LVAD) implantation. Pulmonary artery pulsatility index (PAPi) is a hemodynamic parameter that is a specific measure of right ventricular function and may better identify LVAD recipients at risk for RVF. This systematic review analyzes the predictive value of preoperative PAPi to RVF in the setting of LVAD implantation. METHODS: Databases were searched for all studies reporting on PAPi and RVF after LVAD implantation. Data collected included: number of patients, patient characteristics, incidences of RVF, PAPi, central venous pressure (CVP), CVP/pulmonary capillary wedge pressure, tricuspid annular plane systolic excursion, and right ventricular stroke work index. RESULTS: Thirty-two studies (4,756 patients) were included in this review. The incidence of RVF was found to be 27.48% (1,307 patients). The weighted mean (standard deviation) of preoperative PAPi associated with RVF vs No RVF was 2.17 (2.36) and 2.87 (3.21), respectively. When comparing LVAD recipients with RVF and No RVF, patients who developed RVF had a significantly lower preoperative PAPi by a WMD (95% CI) of -0.74 [-1.00, -0.49] (p < .001). The remaining variables (CVP; CVP/pulmonary capillary wedge pressure; tricuspid annular plane systolic excursion; and right ventricular stroke work index) were also confirmed as predictors of RVF after LVAD implantation. CONCLUSIONS: This systematic review demonstrates the utility of PAPi as a clinical predictor of RVF after LVAD implantation. Based on our findings, we recommend that PAPi be used in conjunction with traditional hemodynamic parameters when risk stratifying LVAD recipients for RVF.