Inter-hospital transfer of extracorporeal membrane oxygenation-assisted patients: the hub and spoke network.

BACKGROUND: The treatment of cardiogenic shock (CS) in peripheral hospitals may be challenging when acute mechanical circulatory support (MCS) is not available. Tertiary care centers may provide mobile extracorporeal membrane oxygenation (ECMO) teams to support the treatment of CS-patients externally. METHODS: We retrospectively analyzed our single-center experience with a mobile ECMO team focussing on decision-making and survival data of CS-patients retrieved by ECMO support from peripheral hospitals to our tertiary care center between January 2012 and October 2018. RESULTS: A total number of 134 CS-patients have been retrieved by ECMO support to our center within the observation period. Forty-three (32%) died on the acute MCS device, while 59 (44%) patients could be weaned from the acute MCS. Twenty-nine (22%) were bridged to implantation of a durable MCS system and 6 were finally transplanted. The overall 1-year survival was 33%. Interestingly, advanced patient age did not significantly affect survival. CONCLUSIONS: Acute MCS for CS may be provided by experienced mobile teams allowing for retrieval of patients from peripheral hospitals to tertiary care centers. Relatively low survival rates oppose intensive material and human resources. It is therefore mandatory to constantly refine logistics and selection criteria.

Bilateral antegrade perfusion of the superficial femoral artery to prevent limb ischaemia during combined use of Impella CP left ventricular assist device and extracorporeal life support.

The combined use of extracorporeal cardiac life support and the Impella left ventricular assist device is feasible in severe cardiogenic shock. Ischaemic complications due to the arterial cannulation may occur. The following cases show how the use of a perfusion adapter for bilateral antegrade leg perfusion prevents malperfusion of the lower extremities.

First successful combination of ECMO with cytokine removal therapy in cardiogenic septic shock: a case report.

PURPOSE: A new hemoadsorption device intended as adjunctive treatment for patients with elevated cytokine levels in the setting of SIRS and sepsis has shown promising results. We report on the beneficial application of the device in a patient with cardiogenic septic shock receiving combined extracorporeal life support with rECMO, LVAD, and CVVH despite his highly septic condition. METHODS: A 39-year-old patient presented with fulminant ARDS and cardiogenic septic shock. A veno-arterial ECMO was implanted for circulatory support. During the course of illness, the patient developed acute renal failure in addition to his chronic renal insufficiency, making initiation of CVVH necessary. Due to a complete cardiac arrest in both ventricles, a left ventricular assist device (LVAD) in combination with right ECMO (rECMO) was implanted despite manifest septic conditions. In the post-operative course IL-6 levels and vasopressor dosages increased drastically. A CytoSorb hemoadsorption device was therefore installed in the CVVH circuit and 3 sessions were run during the following 4 days. RESULTS: During CytoSorb treatment, inflammatory markers IL-6, procalcitonin, and C-reactive protein decreased concomitant with significantly reduced vasopressor support. No adverse device-related side effects were documented during or after the treatment sessions. CONCLUSIONS: This is the first clinical case report of a highly septic patient treated with the combined use of LVAD, rECMO, CVVH, and CytoSorb. The combination was practical, technically feasible, and beneficial for the patient. This combination represents a reasonable approach to improve survival in patients with multiple organ dysfunction necessitating several organ supportive techniques.

Temporary right ventricular mechanical circulatory support for the management of right ventricular failure in critically ill patients.

BACKGROUND: Management of right ventricular (RV) failure after left ventricular assist device (LVAD) implantation is not evidence based. Temporary circulatory assistance has recently been reported to be of value for managing postoperative RV failure after LVAD implantation, but only in small series of patients or isolated case reports. We report here our experience with the use of temporary right ventricular assist devices (RVADs) in LVAD recipients. METHODS: Forty-five of the 488 (9%) patients undergoing LVAD implantation between 2001 and 2011 at the Clinic for Thoracic and Cardiovascular Surgery in Bad Oeynhausen had RV failure requiring temporary RVAD. We analyzed preoperative data, complications, mortality at 6 months, and risk factors of death. RESULTS: The LVAD patients receiving temporary RVAD were younger than the 443 recipients of LVAD alone. They were more likely to have mechanical ventilation and haemofiltration and their Michigan right ventricular risk score was higher. The LVAD patients with temporary RVAD had a higher mortality at 6 months: 53%, versus 25% for patients receiving LVAD only (P < .001). The univariate risk factors for death were high blood urea nitrogen and C-reactive protein concentrations, preoperative mechanical ventilation, preoperative hemofiltration, destination therapy, the use of temporary RVAD, and the development of RV failure. Multivariate analyses did not identify predictors of death. CONCLUSIONS: The development of RV failure in LVAD recipients is a serious problem associated with high mortality. Temporary RV mechanical support is an acceptable way to manage postoperative RV failure in these severely ill LVAD recipients.

Molecular adsorbent recirculating system technique for liver failure due to cardiogenic shock.

BACKGROUND: Systematic data on clinical outcome in patients with liver failure due to cardiogenic shock are scarce. METHODS: We performed a monocentric retrospective data analysis in 197 cardiogenic shock patients with serum bilirubin levels above 102 µmol/L receiving molecular adsorbent recirculating system (MARS). We assessed clinical outcome, recorded laboratory parameters, and tried to assess risk factors for survival. RESULTS: The median duration of MARS was 87 hours (range, 20-315 hours) during a median time period of 9 days (range, 3-736 days). During MARS, 48 to 75% of patients developed infections and gastrointestinal, respiratory, and neurological complications, respectively. Inhospital mortality was 66% (n = 129). Baseline bilirubin levels were comparable between survivors and non-survivors. During MARS, bilirubin values decreased significantly in survivors but not in non-survivors. Of various clinical and biochemical parameters assessed at baseline, the sepsis-related Organ Failure Assessment score remained the only independent predictor of inhospital mortality. CONCLUSION: Inhospital mortality is still unsatisfyingly high in cardiogenic shock patients with liver failure. Future studies should clarify whether MARS can definitively improve survival in these patients.

Heparin-induced thrombocytopenia in patients receiving mechanical circulatory support.

OBJECTIVES: Patients receiving mechanical circulatory support are at risk for the development of heparin-induced thrombocytopenia due to the prolonged postoperative use of heparin. We evaluated their antibody status and outcome. METHODS: Between 2003 and 2004, 115 patients received mechanical circulatory support for more than 5 days. Blood samples from postoperative day 7 were retrospectively analyzed for anti-platelet factor 4/heparin antibodies and heparin-induced platelet activation. RESULTS: Overall, 12 (10.6%) patients had heparin-induced thrombocytopenia as defined by in vitro platelet activation, 28 (24.8%) had nonactivating antibodies, and 73 (64.6%) were classified as negative for antibodies. Patients positive for heparin-induced thrombocytopenia had the highest levels of anti-platelet factor 4/heparin immunoglobulin G antibodies. Freedom from thromboembolism was 33%, 33%, and 16% at 1, 3, and 6 months for positive patients, 77%, 68%, and 55% for negative patients (P < .001), and 70%, 53%, and 53% for patients with nonactivating antibodies (P = .068), respectively. The relative risk for thromboembolism in antibody positive patients peaked in the first month of support (odds ratio 7.46, P = .002). Independent risk factors for thromboembolic events included higher anti-platelet factor 4/heparin antibody titers, female gender, and higher fibrinogen levels. CONCLUSION: Heparin-induced thrombocytopenia was more prevalent in patients receiving mechanical circulatory support than in other cardiac patients. Frequent antibody screening is recommended due to the increased risk of thromboembolism. Heparin alternatives should be subjected to clinical trials in these high-risk patients.

CardioWest total artificial heart: Bad Oeynhausen experience.

BACKGROUND: The use of ventricular assist devices (VAD) has become a widely accepted therapeutic option. However, there are still limitations to the patient collective eligible for VAD placement, who might therefore benefit from the implantation of a total artificial heart. We present the first German single-center experience with the CardioWest total artificial heart (TAH) (SynCardia Systems, Tucson, AZ) in 42 patients. METHODS: Between February 2001 and December 2003, 42 patients (37 men, 5 women, mean age 51 +/- 13 years) received a TAH at our Center. Their body surface area ranged between 1.5 and 2.4 (mean, 1.9 +/- 0.19) m2. All patients were in persistent cardiogenic shock in spite of maximum inotropic support and had numerous preoperative risk factors (intraaortic balloon pumping, mechanical ventilation, acute renal failure, previous cardiac surgery, recent cardiopulmonary resuscitation). RESULTS: Duration of support was 1 to 291 days. Eleven patients (26%) underwent successful transplantation; 9 of them could be discharged home. Twenty-two patients died under support, 21 of them from multiple organ failure and 1 patient from a technical problem. Nine patients are still on the device, 4 of them at home after the original CardioWest console was replaced by the Berlin Heart EXCOR driver (Berlin Heart, Berlin, Germany). Exceptional results were achieved in patients with cardiogenic shock after cardiac surgery or after acute myocardial infarction. CONCLUSIONS: Against the background of the extremely poor preoperative situation of our patients, the overall survival rate of 48% can be considered as favorable. A prospective, randomized study is planned to find out whether patients with idiopathic dilated or ischemic cardiomyopathy are more likely to benefit from a biventricular assist device or a total artificial heart.