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.

Home discharge and out-of-hospital follow-up of total artificial heart patients supported by a portable driver system.

To enhance ambulation and facilitate hospital discharge of total artificial heart (TAH)-supported patients, we adapted a mobile ventricular assistance device (VAD) driver (Excor) for TAH use and report on the performance of Excor-driven TAH patients discharged home. Ten patients stabilized on a TAH, driven by the CSS ("Circulatory Support System"), were progressively switched over to the Excor in hospital over 14 days as a pilot, with daily hemodynamics and laboratory parameters measured. Twenty-two stable TAH patients were subsequently placed on the Excor, trained, and discharged home. Clinical and hemodynamic parameters were followed. All pilot study patients were clinically stable on the Excor, with no decrease in TAH output noted (6.3 + 0.3 L/min [day 1] vs. 5.8 + 0.2 L/min [day 14], p = 0.174), with a trend suggesting improvement of both hepatic and renal function. Twenty-two TAH patients were subsequently successfully discharged home on the portable driver and were supported out of hospital for up to 598 days (range, 2-598; mean = 179 ± 140 days), remaining ambulatory, New York Heart Association (NYHA) class I or II, and free of readmission for 88.5% of the time of support. TAH patients may be effectively and safely supported by a mobile drive system. As such, the utility of the TAH may be extended to support patients beyond the hospital, at home, with overall ambulatory freedom.

Mechanical ventricular circulatory support in children; Bad Oeynhausen experience.

INTRODUCTION: Recently various mechanical circulatory support systems are being used all over the world, nevertheless the size of the devices limits the implantation in pediatric cases. Accordingly we report our experiences with assist devices applied for pediatric patients. PATIENTS AND METHODS: Twenty-nine children underwent mechanical circulatory support implantation operation. The diagnoses of preoperation were dilated cardiomyopathy in 16, congenital heart disease in 12 and allograft dysfunction in 1. RESULTS: From November 1987 to January 2004 we implanted 7 LVAD, 11 BVAD and 11 ECMO in pediatric patients. The 29 patients were supported from 11 to 231 days (mean 32.3 days). Three children were supported by Thoratec LVAD. Biventricular Thoratec VAD was used in 3 children. Three children were supported by Medos-HIA system LVAD, and 8 children by biventricular VAD using the Medos-HIA system. One child was supported by Novacor LVAD. Fourteen children were supported by ECMO. We succeeded in heart transplantation in 10 cases, but lost 16 children during the support. Bleeding occurred in 7 cases, thrombosis occurred in 6 cases, infection occurred in 8 cases, pneumothorax occurred in 3 cases and neurological deficit occurred in 2 cases. CONCLUSION: The development of assist device for children which has long durability and small in size as a future subject is desired. Further clinical and experimental research and application of those assist devices for children are in progress.