Traumatic respiratory failure and veno-venous extracorporeal membrane oxygenation support.

BACKGROUND: Respiratory failure (RF) is a common cause of death and morbid complication in trauma patients. Extracorporeal membrane oxygenation (ECMO) is increasingly used in adults with RF refractory to invasive mechanical ventilation. However, use of ECMO remains limited for this patient population as they often have contraindications for anticoagulation. STUDY DESIGN: Medical records were retroactively searched for all adult patients who were admitted to the trauma service and received veno-venous ECMO (VV ECMO) support between June 2015 and August 2018. Survival to discharge and ECMO-related complications were collected and analyzed. RESULTS: Fifteen patients from a large Level I trauma center met the criteria. The median PaO2/FiO2 ratio was 53.0 (IQR, 27.0-76.0), median injury severity score was 34.0 (IQR, 27.0-43.0), and the median duration of ECMO support was 11 days (IQR, 7.5-20.0). For this cohort, the survival-to-discharge rate was 87% (13/15). The incidence of neurologic complications was 13%, and deep vein thrombosis was reported in two cases (13%). CONCLUSIONS: Survival rates of trauma patients in this study are equivalent to, or may exceed, those of non-trauma patients who receive ECMO support for other types of RF. With the employment of a multidisciplinary team assessment and proper patient selection, early cannulation, traumatic RF may be safely supported with VV ECMO in experienced centers.

The use of a sentinel cerebral protection system during Impella CP removal in a patient with left ventricular thrombus.

Percutaneous mechanical circulatory support (pMCS) devices are commonly being utilized for hemodynamic support in patients undergoing high-risk percutaneous coronary interventions or stabilization for those in cardiogenic shock. Left ventricular (LV) to ascending aorta (Ao) rotodynamic pumps such as the Impella devices allow for rapid hemodynamic stabilization or support in such instances. The use of such devices is contraindicated in patients with known LV thrombus. However, it remains unclear on how to manage patients who develop an LV thrombus while on prolonged Impella support. While there are currently no cerebral embolic protection devices (CEPDs) approved for use in conjunction with LV to Ao pMCS devices or other short-term mechanical support devices, there is a theoretical benefit for the use of such technology in the right circumstances. We present a case describing the use of the sentinel cerebral protection system (SCPS) in a patient who developed LV thrombus while on Impella CP support. The use of the SCPS in this patient suggests a potential role for CEPD in prevention of thromboembolism while on Impella support.

Risk of pump thrombosis and stroke in patients with continuous-flow left ventricular assist devices and gastrointestinal bleeding.

Gastrointestinal (GI) bleeding is a common complication following the placement of continuous-flow left ventricular assist devices (LVADs) in patients with advanced heart failure. Secondary events arising as a result of GI bleeding have not been well-described. Furthermore, attribution of these events to bleeding is complicated by the interruption or de-intensification of antithrombotic therapy, while bleeding is controlled. The purpose of this study was to assess the incidence of pump thrombosis and ischemic stroke in patients with LVADs who experience GI bleeding, while on support. This was a single-center, retrospective, observational cohort study of consecutive patients with LVADs implanted from January 2012 to June 2018. Patients were assigned to comparator groups based on whether they experienced GI bleeding while on LVAD support. The primary endpoint assessed was the composite of pump thrombosis or ischemic stroke. Secondary endpoints assessed included incidence of pump thrombosis or ischemic stroke. A total of 250 patients were included after screening for exclusion criteria, 101 (40.4%) in the GI bleeding group, and 149 (59.6%) in the non-bleeding group. The incidence of pump thrombosis or ischemic stroke was not significantly greater in patients experiencing GI bleeding [23 (22.8%) vs. 21 (14.1%); P = .09]; however, the incidence of ischemic stroke alone was significantly greater [17 (16.8%) vs. 10 (6.7%); P = .01]. We conclude that GI bleeding in LVAD patients may be associated with a greater risk of ischemic stroke.

Determinants of survival following hospitalization for acute heart failure.

Heart failure constitutes a major public health concern in the United States and is one of the leading causes of hospitalization, readmission, and death. Due to an aging U.S. population, it is estimated that the prevalence of heart failure will increase by 25% over the coming decades, affecting approximately 3.5% of the population by the year 2030. The ability to discriminate patients admitted with acute heart failure syndromes who are at increased risk for poor post-hospitalization outcomes is thus critical to guide therapeutic decision making for healthcare providers. This review paper will discuss clinical, hemodynamic, as well as biochemical markers that have been demonstrated to predict post-discharge outcomes among patients hospitalized with acute heart failure.

Defining the role for percutaneous mechanical circulatory support devices for medically refractory heart failure.

Despite significant advances in the management of heart failure, short-term mortality due to advanced heart failure and cardiogenic shock remains high. Developed over the past few decades, percutaneous circulatory support devices offer a rapid and effective approach to slow the downward spiral of hemodynamic instability in patients presenting with decompensated heart failure until a more definitive strategy is pursued or patients recover. This review will discuss the goals of percutaneous circulatory support, the types of devices currently available, and the most recent clinical datasets examining the utility of these devices.

Left Ventricular Assist Device Support and Longitudinal Sleeve Gastrectomy Combined With Diet in Bridge to Heart Transplant.

Combining left ventricular assist device (LVAD) implantation and longitudinal sleeve gastrectomy may enable patients with morbid obesity to lose enough weight for heart transplant eligibility. In a retrospective study, we evaluated long-term outcomes of patients with body mass indexes ≥35 who underwent LVAD implantation and longitudinal sleeve gastrectomy during the same hospitalization (from January 2013 through July 2018) and then adhered to a dietary protocol. We included 22 patients (mean age, 49.9 ± 12.5 yr; mean preoperative body mass index, 43.3 ± 6.2). Eighteen months after gastrectomy, all 22 patients were alive, and 16 (73%) achieved a body mass index of less than 35. Myocardial recovery in 2 patients enabled LVAD removal. As of October 2020, 10 patients (45.5%) had undergone heart transplantation, 5 (22.3%) were waitlisted, 5 (22.3%) still had a body mass index ≥35, and 2 (9%) had died. With LVAD support, longitudinal sleeve gastrectomy, and dietary protocols, most of our patients with morbid obesity and advanced heart failure lost enough weight for transplant eligibility. Support from physicians and dietitians can maximize positive results in these patients.

Integrating Interventional Cardiology and Heart Failure Management for Cardiogenic Shock.

Cardiogenic shock remains one of the most common causes of in-hospital death. Recent data have identified an overall increase in patient complexity, with cardiogenic shock in the setting of acute myocardial infarction. The use of percutaneous acute mechanical circulatory support (AMCS) has steadily grown in the past decade. Guidelines and consensus statements addressing proper patient selection, timing of AMCS implantation, device choice, and postimplantation protocol are appearing. The emerging role of interventional heart failure specialists within the heart team includes integration and understanding of advanced hemodynamic and cathether-based therapies, with the goal of improving outcomes.

Heart Failure With Preserved Ejection Fraction: What Is in a Name?

Evidence-based management of heart failure (HF) with preserved left ventricular ejection fraction (LVEF; HFpEF) remains a major gap in the care of patients with HF. Clinical trials directed toward the population with HFpEF have been disappointing, although renin-angiotensin-aldosterone system blockade appears to prevent HF in populations predisposed to HFpEF. This paradox may partly be because of inhomogeneity within the HF populations studied. Although the term HFpEF is often used to imply a specific diagnosis, in fact this constellation may be due to a large variety of disease states with different underlying pathophysiologic mechanisms. Furthermore, in patients with HF, regardless of LVEF, myocardial dysfunction is common during both systole and diastole, and LVEF is influenced at least as much by the pattern of left ventricular remodeling as it is by myocardial contractility. The most common clinical-pathologic syndrome responsible for HFpEF is strongly associated with hypertension, with the metabolic syndrome, and with older age. Recent findings support that this condition is mediated via endothelial dysfunction, inflammation, oxidative stress, myocyte hypertrophy, and altered collagen turnover. We, therefore, propose the terms "metabolic HF" and "senile HF" to describe this specific disease state. The search for therapies designed to prevent, halt, or reverse HF should more strongly focus on populations carefully selected to represent specific underlying cardiovascular disease states.

Impact of diagnosing metabolic syndrome on risk perception.

OBJECTIVES: To determine the effect of using the diagnosis of metabolic syndrome (MetSx) on risk perception. METHODS: We randomized 74 participants to receive either the diagnosis of MetSx or the diagnosis of individual cardiovascular risk factors. The MetSx group was subdivided into those receiving written patient education material or written patient education plus educational videos. RESULTS: At 6 weeks, participants receiving the diagnosis of MetSx were more likely to increase their health concerns, perceived risk of myocardial infarction, and their motivation toward health behavior. CONCLUSION: Sharing the diagnosis of MetSx increases risk perception and motivation toward a healthier behavior.