Cardiogenic Shock in Obstructive Hypertrophic Cardiomyopathy Plus Apical Ballooning: Management With VA-ECMO and Myectomy.

A patient with known obstructive hypertrophic cardiomyopathy developed worsening left ventricular outflow tract obstruction, severe mitral regurgitation, and apical ballooning leading to cardiogenic shock, a combination in which treatment of each component could worsen the others. Emergency veno-arterial extracorporeal membrane oxygenation, levosimendan, and noradrenaline transiently restored adequate systemic perfusion and gas exchange. Surgical myectomy offered a more definitive solution. (Level of Difficulty: Intermediate.).

[Tips and tricks for using extracorporeal life support devices in the intensive cardiac care unit]. / "Tips and tricks" sulla gestione del supporto extracorporeo alle funzioni vitali in unità di terapia intensiva cardiologica.

In patients with severe cardiac dysfunction refractory to conventional therapies, extracorporeal membrane oxygenation used in veno-arterious modality can provide temporary circulatory assistance (extracorporeal life support, ECLS). Since it is an invasive and complex technique, its use is potentially burdened by severe complications, thus requiring careful nursing and medical care during intensive cardiac care unit stay. The use of ECLS requires specific skills such as knowledge of protective mechanical invasive ventilation, specific echocardiographic evaluation, accurate monitoring of hemodynamics and laboratory tests. A patient on ECLS is at high risk of thrombotic and hemorrhagic complications that could be fatal, hence specific pro- and anti-hemostatic therapy is needed. Moreover, the knowledge of some peculiar aspects of ECLS system and management can help doctors to avoid several complications such as limb ischemia, left ventricular overload and regional perfusion discrepancy. In conclusion, careful management by adequately trained personnel is required.

Right ventricular dysfunction and Pre Implantation Vasopressors in Refractory ARDS Supported by VV-ECMO.

BACKGROUND: Acute respiratory distress syndrome (ARDS) has been shown to be frequently associated with haemodynamic instability requiring the use of vasopressors. To date, there is still some uncertainty in the use of veno-venous Extracorporeal Membrane Oxygenation (VV-ECMO) in haemodynamically unstable ARDS patients. METHODS: We therefore assessed whether patients receiving pre ECMO vasopressors had a worse prognosis and, furthermore, we reviewed the factors associated with the use of pre ECMO vasopressors in 92 consecutive patients with refractory ARDS treated with VV-ECMO. All patients were submitted to an echocardiogram before implantation. RESULTS: In our series, 55 patients (59.7%) were given a vasopressor. Septic shock is the main cause of vasopressor requirement (45.5%). When compared with patients without vasopressors, the subgroup under vasopressors showed a significantly higher sequential organ failure assessment (SOFA) score (p=0.040), a lower pH (p=0.013), lower pO2 values (p=0.030) and higher lactate levels (p=0.024). A higher incidence of right ventricular (RV) dysfunction and of biventricular dysfunction were observed in patients under vasopressors (p=0.018 and p=0.036, respectively). The intensive care unit (ICU) mortality rate was 43.4% (40/92) with no difference between the two subgroups. CONCLUSIONS: In refractory ARDS requiring VV-ECMO, infusion of vasopressors is needed in a high proportion of patients, who did not exhibit a worse prognosis when compared to haemodynamically stable patients. Pre ECMO echocardiography helps in characterising these patients since they showed a higher incidence of RV (and biventricular) dysfunction. According to our data, in ARDS patients refractory to conventional treatment, haemodynamic instability should not be considered a contraindication to VV-ECMO support.

The 8-Year Experience of the Florence Referral ECMO Center and Retrieval Team for Acute Respiratory Failure.

OBJECTIVE: Many extracorporeal membrane oxygenation (ECMO) centers for respiratory failure and ECMO mobile teams were instituted during the H1N1 pandemic. Data on transportation are scarce and heterogeneous. The authors therefore described the experience of their referral ECMO center for severe respiratory failure from 2009 to 2016 and gave a comprehensive report of transfers performed by their mobile ECMO team. DESIGN: Observational retrospective study. SETTING: An intensive care unit (ECMO referral center) in a teaching hospital. PARTICIPANTS: One hundred and sixty consecutive patients with acute respiratory distress syndrome refractory to conventional treatment requiring veno-venous (VV)-ECMO. INTERVENTION: VV-ECMO implantation. MEASUREMENTS AND MAIN RESULTS: In this series, the transferred patients on ECMO averaged 57%, with annual percentages ranging from 28% to 90% over the years. No adverse event was observed during transportation. A progressive increase in simplified acute physiology score (SAPS) values and in the use of norepinephrine were detectable (p = 0.048 and p = 0.037, respectively) as well as in neuromuscular blockers use (p = 0.004). Dual-lumen cannule were more frequently used in recent years (p < 0.001). The overall mortality rate was 40% (64/160), with no differences over the years or between transferred and local patients. Body mass index and pre-ECMO neuromuscular blockers and SAPS were independent predictors for early mortality (when adjusted for age). CONCLUSIONS: The workload of the authors' referral center and mobile team did not change, documenting that severe respiratory failure requiring VV-ECMO support is still a clinical need. No difference in mortality rate was detectable during this period or between transferred and local patients who were managed by the same team.

Lactate and Echocardiography Before Veno-Venous Extracorporeal Membrane Oxygenation Support.

BACKGROUND: Lactate has been recognised as a prognostic factor in several critical conditions. Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) is a well-established therapy in patients with Acute Respiratory Disease Syndrome (ARDS) unresponsive to conventional therapy and echocardiography pre ECMO initiation has been recently reported to help in risk stratifying these patients. METHODS: We assessed whether the detection of hyperlactataemia could be associated with the presence of left ventricle (LV) or right ventricle (RV) dysfunction in 121 consecutive patients with refractory ARDS. RESULTS: The mortality rate was 42.9% (52/121). Higher dosages of norepinephrine and dobutamine were administered to non survivors (p=0.023 and p=0.047, respectively) who showed significantly higher levels of lactate (p=0.002). At echocardiography, non survivors showed higher values of systolic pulmonary artery pressure (sPAP) (p=0.05) and a higher incidence of RV dysfunction (as indicated by lower Tricuspid Annular Plane Excursion (TAPSE)) and RV dilatation (p=0.001). At multivariate logistic regression analysis, the following variables were independent predictors of death: body mass index (BMI) (OR: 0.914, 95%CI 0.857-0.975, p=0.006), RV dilatation (OR: 0.239, 95%CI 0.101-0.561, p=0.001) and lactate (OR: 1.292, 95%CI 1.015-1.645, p=0.038). Lactate values were directly correlated with the simplified acute physiology score (SAPS) II (r=0.38, p<0.001), while they showed an indirect correlation with left ventricular ejection fraction (LVEF) (r=-0.24, p=0.009) and TAPSE (r=-0.21, p=0.024). CONCLUSIONS: In refractory ARDS, hyperlactataemia before VVV-ECMO identified a subset of patients at higher risk of death, being an independent predictor of in-Intensive Care Unit (ICU) mortality. Lactate values are mainly related to disease severity (as indicated by SAPS II) and haemodynamic impairment (as inferred by LVEF) and RV failure, as (indicated by TAPSE).

Body mass index and echocardiography in refractory ARDS treated with veno-venous extracorporeal membrane oxygenation.

The aims of the present investigation, performed in 118 consecutive patients with refractory ARDS treated with veno-venous extracorporeal membrane oxygenation (VV-ECMO), were as follows: (a) to assess ICU mortality in overweight, obese and morbid obese patients in respect to normal weight; (b) to evaluate echocardiographic findings according to BMI subgroups. Echocardiography was performed before VV-ECMO implantation. Forty-five patients (38.1%) showed normal BMI, 37 patients (31.4%) were overweight and the remaining were obese (21.2%), or morbid obese (9.3%). Morbid obese showed the lowest ICU mortality rate (p = 0.003). No differences were detectable among BMI subgroups in echocardiographic findings apart from the fact that obese patients showed the lowest incidence of LV dysfunction (p = 0.015). At stepwise regression analysis the following variables were independent predictor of ICU mortality (when adjusted for age): RV dilatation (OR 4.361, 95 % CI 1.809-10.512, p < 0.001), BMI (OR 0.884, 95% CI 0.821-0.951, p < 0.001). In other terms, the presence of RV dilatation is an independent predictor of ICU mortality. In refractory ARDS treated with VV-ECMO, BMI > 30 kg/m2 is common (accounting for one-third of the entire population) but it is not associated with a worse outcome, so that it cannot be considered per se a contraindication to ECMO implantation. The incidence of RV dilatation and failure, which are known to negatively affect prognosis in ARDS patients, were comparable among BMI subgroups.

Cooling techniques in mild hypothermia after cardiac arrest.

: Therapeutic hypothermia has been shown to reduce brain damage due to postcardiac arrest syndrome. Actually, there is no agreement on which is the best device to perform therapeutic hypothermia. The 'ideal' device should not only 'cool' patient until 33-34°C as fast as possible, but also maintain the target temperature and reverse the therapeutic hypothermia. For out-of-hospital cardiac arrest, there are devices that allow starting of therapeutic hypothermia on the field (prehospital hypothermia). On hospital arrival, these prehospital devices can be quickly and easily replaced with other devices more suitable for the management of therapeutic hypothermia in ICUs (in-hospital hypothermia). Some studies have compared surface and endovascular devices and found no substantial differences in neurologic outcome or survival at hospital discharge. On a clinical ground, the knowledge of the technical aspects of therapeutic hypothermia (such as characteristics of devices) is mandatory for clinicians who have to perform therapeutic hypothermia in cardiac arrest patients because the timing of therapeutic hypothermia, the choice of the device for the single patients, and avoidance of temperature fluctuation have shown to affect outcome in these patients (also in terms of reducing the incidence of complications).

Right ventricle dilation as a prognostic factor in refractory acute respiratory distress syndrome requiring veno-venous extracorporeal membrane oxygenation.

BACKGROUND: The aim of this study was to assess the incidence and prognostic role of echocardiographic abnormalities in consecutive patients with refractory acute respiratory distress syndrome (ARDS) before veno-venous extracorporeal membrane oxygenation (VV-ECMO). METHODS: In this study 74 consecutive patients with refractory ARDS underwent echocardiography (transthoracic, transesophageal or both, according to the best acoustic window). Baseline characteristics were collected for all patients and the simplified acute physiology score was calculated. At echocardiography the following parameters were considered: left ventricle (LV) ejection fraction, right ventricle (RV) size and function (by means of tricuspid annular plane excursion [TAPSE]) and systolic pulmonary arterial pressure. RESULTS: At echocardiography, 25 patients showed normal findings (33.8%), 32 patients exhibited isolated pulmonary hypertension (43.2%) and the remaining 17 patients showed RV dilation and pulmonary hypertension (23%). A reduced LVEF (<50%) was observed in 14 patients (18.9%), while RV dysfunction (as indicated by TAPSE<16 mm) was documented in 21 patients (28.4%). The in-Intensive Care Unit [ICU] mortality rate was 41.8%. At stepwise regression analysis the following variables were independent predictor for in-ICU mortality (when adjusted for TAPSE<16 mm): RV end diastolic area/LV end diastolic area (OR 0.21, 95%CI 0.062-0.709, P=0.012), Body Mass Index (BMI) (OR 0.87, 95%CI 0.802-0.958, P=0.004) CONCLUSIONS: In consecutive patients with refractory ARDS, echocardiographic alterations were common, mainly represented by systolic pulmonary hypertension associated or not with RV dilatation. Moreover, RV dilatation and BMI were independent predictors of in-ICU mortality. On clinical grounds, our findings strongly suggest that echocardiography helps to risk stratifying patients with refractory ARDS requiring VV-ECMO.

Clinical significance of echocardiography in patients supported by venous-venous extracorporeal membrane oxygenation.

Although there are extensive published data regarding venous-arterial (VA) ECMO, particularly in the pediatric population, there is a paucity of data (mainly including case reports and observational studies) delineating the role of echocardiography in the management of adult patients supported by venous-venous (VV) ECMO. The present review is aimed at specifically addressing the rationale for echocardiography use in patients supported by VV-ECMO and at summarizing the available evidence on this topic. Based on the available evidence and on the experience of our group, practical considerations on the use of echocardiography in adult patients on VV-ECMO support are reported. To date, echocardiography is mainly used for selecting the type of ECMO (VA vs VV), monitoring cannulation and the early detection of complications, but it is underused in patients supported by VV-ECMO. Nevertheless, in these patients, this methodology can provide useful information in monitoring cardiac function, cannula positioning, pericardial fluid (for early detection of tamponade) during ECMO support, and therefore it can contribute to the integrated assessment and management of these complex patients. There is a clinical need to elaborate shared protocols for echocardiography use during VV ECMO support, particularly at this time when advanced echocardiography is gaining interest among intensivists.

Cardiovascular effects of mild hypothermia in post-cardiac arrest patients by beat-to-beat monitoring. A single centre pilot study.

BACKGROUND: Data on the hemodynamic and cardiovascular effects of hypothermia in patients with cardiac arrest are scarce. The aim of this study was to evaluate the hemodynamic changes induced by hypothermia by means of Most Care(®) (pressure recording analytical method, PRAM methodology), a beat-to-beat hemodynamic monitoring method. METHODS: We enrolled 20 patients with cardiac arrest (CA) consecutively admitted to our intensive cardiac care unit and treated with mild hypothermia (TH). RESULTS: While non-survivors showed no changes in haemodynamic variables throughout the study period, survivors exhibited a significant increase in systemic vascular resistance indexed during hypothermia and a trend towards lower values of heart rate and higher levels of mean arterial pressure. CONCLUSIONS: According to our data, PRAM methodology proved to be a feasible and clinically useful tool in CA patients treated with TH since it provides continuous beat-to-beat haemodynamic monitoring that is based on assessment of several haemodynamic variables. Moreover, we observed that survivors showed a different haemodynamic behaviour during hypothermia in respect to patients who died. However, further studies, performed in larger cohorts, are needed to better elucidate the haemodynamic effects of hypothermia in CA patients by means of PRAM methodology.

H3N2 Virus as Causative Agent of ARDS Requiring Extracorporeal Membrane Oxygenation Support.

Pandemic influenza virus A(H1N1) 2009 was associated with a higher risk of viral pneumonia in comparison with seasonal influenza viruses. The influenza season 2011-2012 was characterized by the prevalent circulation of influenza A(H3N2) viruses. Whereas most H3N2 patients experienced mild, self-limited influenza-like illness, some patients were at increased risk for influenza complications because of age or underlying medical conditions. Cases presented were patients admitted to the Intensive Care Unit (ICU) of ECMO referral center (Careggi Teaching Hospital, Florence, Italy). Despite extracorporeal membrane oxygenation treatment (ECMO), one patient with H3N2-induced ARDS did not survive. Our experience suggests that viral aetiology is becoming more important and hospitals should be able to perform a fast differential diagnosis between bacterial and viral aetiology.

Dynamic behaviour of lactate values during mild hypothermia in patients with cardiac arrest.

BACKGROUND AND METHODS: The present investigation was aimed at assessing the dynamic behaviour of lactate values during hypothermia in 33 patients with cardiac arrest. RESULTS: Fifteen patients died during intensive care stay (15/33, 45.5%). When compared to survivors, they were older (survivors 50.7 ± 14.7 vs. non-survivors 70.1 ± 10.4 years, p<0.001) and exhibited a significantly higher APACHE score (survivors 21.9 ± 3.9 vs. non-survivors 27.5 ± 4.6, p<0.001). A higher incidence of non-shockable rhythms was observed in non-survivors (p=0.026) who showed a longer collapse-recovery of spontaneous circulation time (p=0.01). During hypothermia, lactate values showed a progressive and significant decrease despite no significant change in mean arterial pressure and central venous pressure (i.e. independently of blood pressure values and volaemia). Lactate values when measured during hypothermia were related to in-intensive cardiac care unit (in-ICCU) death. CONCLUSION: In our series, lactate values measured during hypothermia hold a prognostic role in these patients since they are related to in-ICCU death.

Venous-arterial extracorporeal membrane oxygenation for refractory cardiac arrest: a clinical challenge.

Guidelines stated that extracorporeal membrane oxygenation (ECMO) may improve outcomes after refractory cardiac arrest (CA) in cases of cardiogenic shock and witnessed arrest, where there is an underlying circulatory disease amenable to immediate corrective intervention. Due to the lack of randomized trials, available data are supported by small series and observational studies, being therefore characterized by heterogeneity and controversial results. In clinical practice, using ECMO involves quite a challenging medical decision in a setting where the patient is extremely vulnerable and completely dependent on the medical team's judgment. The present review focuses on examining existing evidence concerning inclusion and exclusion criteria, and outcomes (in-hospital and long-term mortality rates and neurological recovery) in studies performed in patients with refractory CA treated with ECMO. Discrepancies can be related to heterogeneity in study population, to differences in local health system organization in respect of the management of patients with CA, as well as to the fact that most investigations are retrospective. In the real world, patient selection occurs individually within each center based on their previous experience and expertise with a specific patient population and disease spectrum. Available evidence strongly suggests that in CA patients, ECMO is a highly costly intervention and optimal utilization requires a dedicated local health-care organization and expertise in the field (both for the technical implementation of the device and for the intensive care management of these patients). A careful selection of patients guarantees optimal utilization of resources and a better outcome.

In-hospital refractory cardiac arrest treated with extracorporeal membrane oxygenation: a tertiary single center experience.

We retrospectively assessed the experience of our tertiary care center on the use of venous-arterial extracorporeal membrane oxygenation (VA-ECMO) in 16 adult patients with refractory cardiac arrest. Cardiac arrest was due to acute coronary syndrome in 10 patients (62.5%), Takotsubo Syndrome in 1 patient (6.25%), dilated cardiomyopathy in 4 (25%) patients and massive pulmonary embolism in 1 patient (6.25%). The device was implanted in the catheterization laboratory in 14 patients (87.5%), in the operating room in 1 patient (6.25%) and in the emergency department in 1 patient (6.25%). During support, 7 patients were submitted to percutaneous coronary intervention, while coronary artery bypass grafting was performed in 1 patient, and cardiac surgery for repair of left ventricular wall rupture was performed in 1 patient. The device was successfully weaned in 6 patients (37.5%), among whom 2 patients died and 4 patients (25%) were discharged alive. In our institution 2/16 (12.5%) patients treated with VA-ECMO for refractory cardiac arrest survived to hospital discharge neurologically intact, and a good neurological function was observed in 3/16 (18.8%) at six-month follow-up.

Intraaortic balloon pump: incidence and predictors of complications in the Florence registry.

BACKGROUND: The intraaortic balloon pump (IABP) is the most commonly used mechanical circulatory support for patients with acute coronary syndromes and cardiogenic shock. Nevertheless, IABP-related complications are still frequent and associated with a poor prognosis. HYPOTHESIS: To prospectively assess the incidence and predictors of complications in patients treated with IABP. METHODS: A total of 481 patients treated with IABP were prospectively enrolled in our registry (the Florence Registry). At multivariable logistic regression analysis the following variables were independent predictors for complications (when adjusted for age >75 years, eGFR and time length of IABP support): use of inotropes (OR 2.450, P < 0.017), nadir platelet count (1000/µL step; OR 0.990, P < 0.001), admission lactate (OR 1.175, P = 0.003). Nadir platelet count showed a negative correlation with length of time of IABP implantation (r-0.31; P < 0.001). A nadir platelet count cutoff value of less than 120,000 was identified using a receiver operating characteristic (ROC) curve for the development of complications (area under the curve [AUC] 0.70; P < 0.001). RESULTS: Complications were observed in the 13.1%, among whom 33 of 63 showed major bleeding. The incidence of complications was higher in patients aged >75 years (P = 0.015) and in those who had an IABP implanted for more than 24 hours (P = 0.001). Patients with complications showed an in Intensive Cardiac Care Unit (ICCU) mortality higher than patients who did not (44.4% vs 17.2%, P < 0.001). CONCLUSIONS: In consecutive patients treated with IABP support, the degree of hemodynamic impairment and the decrease in platelet count were independent predictors of complications, whose development was associated with higher in-ICCU mortality.

Implantable cardioverter defibrillator prevents sudden cardiac death in systemic sclerosis.

OBJECTIVE: Cardiac involvement means a poor prognosis in systemic sclerosis (SSc). Conduction defects and arrhythmias are frequent in patients with SSc, and may result in sudden cardiac death. We tested whether electrophysiologic studies and implantation of cardioverter defibrillators are recommended when ventricular arrhythmias are present. METHOD: A cardioverter defibrillator was implanted in 10 patients with SSc who had heart involvement. RESULT: After 36 months, analysis of the device showed several episodes of ventricular tachycardia in 3 patients, which were promptly reverted by electrical shock delivery. CONCLUSION: In patients with SSc who are affected by ventricular arrhythmias, the implantation of a cardioverter defibrillator may prevent sudden cardiac death.

Feasibility of inter-hospital transportation using extra-corporeal membrane oxygenation (ECMO) support of patients affected by severe swine-flu(H1N1)-related ARDS.

BACKGROUND: To describe the organization of an ECMO-centre from triage by telephone to the phase of inter-hospital transportation with ECMO of patients affected by H1N1-induced ARDS, describing techniques and equipment used. METHODS: From September 2009 to January 2010, 18 patients with H1N1-induced ARDS were referred to our ECMO-centre from other hospitals. Six patients had contraindications to treatment with ECMO and remained in the local hospital. Twelve patients were transported to our centre and were included in this study. Four patients were transported on ECMO (Group A) and eight on conventional ventilation (Group B). The groups were compared on the basis of adverse events during transport, clinical characteristics and outcome. RESULTS: The PaO2/FiO2 ratio was lower in the patients of Group A (46.8 vs 89.7 [median]) despite the PEEP values being higher (15.0 vs 8.5 [median]). The Murray score was higher in Group A (3.50 vs 2.75 [median]). During the transfer there were no significant complications noted in Group A, whereas two patients in Group B were reported with hypoxia (SpO2 < 90%). One patient in Group A died. All the other patients of the two groups have been discharged from hospital. CONCLUSIONS: The creation of an ECMO team, with various experts in the treatment of ARDS, assured a safe transfer of patients with severe hypoxia, over long distances, when in other cases they wouldn't have been be transportable.