Extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock after valve replacement.

BACKGROUND: Limited data evaluated the outcomes of extracorporeal membrane oxygenation (ECMO) in patients with prosthetic valves. This study aimed to compare the outcomes of ECMO support for postcardiotomy cardiogenic shock in patients with mechanical versus bioprosthetic valves. METHODS: This retrospective study included patients with ECMO support for postcardiotomy cardiogenic shock after valve replacement. Patients were grouped into bioprosthetic (n = 49) and mechanical valve (n = 22) groups. RESULTS: There were no differences in ECMO duration, inotropic support, intra-aortic balloon pump (IABP), stroke, duration of ICU, and hospital stay between groups. Postoperative thrombosis occurred in 2 patients with bioprosthetic valves (5.41%) and 2 with mechanical valves (14.29%), p = .30. All patients with thrombosis had central ECMO cannulation, concomitant IABP, and inotropic support during ECMO. All thrombi were related to the mitral valve. Three patients with thrombi had hospital mortality.Survival at 6, 12, and 36 months for bioprosthetic valve patients was 30.88%, 28.55%, and 25.34% and for mechanical valves was 36.36% for all time intervals (Log-rank p = .93). One patient had bioprosthetic aortic valve endocarditis after 1 year. Three patients with bioprosthetic valves had structural valve degeneration after 1, 2, and 5 years. CONCLUSIONS: Outcomes of ECMO in patients with prosthetic valves are comparable between bioprosthetic and mechanical valves. Thrombosis might occur in both valve types and was associated with high mortality. ECMO could affect the long-term durability of the bioprosthetic valves.

Venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock: The impact of cannulation strategy on survival.

BACKGROUND: The optimal venoarterial extracorporeal membrane oxygenation (VA ECMO) cannulation strategy in patients with postcardiotomy cardiogenic shock is still debatable. Studies evaluating the effect of cannulation strategy on long-term survival are scarce. OBJECTIVES: We investigated the impact of central versus peripheral cannulation strategy for ECMO insertion on hospital outcomes and survival in postcardiotomy cardiogenic shock patients. METHODS: This retrospective study involved 101 patients who had either central or peripheral ECMO due to postcardiotomy shock between June 2009 and December 2020. Study endpoints were limb ischemia, bleeding, blood transfusion, wound infection, and overall survival. RESULTS: Eighty-four patients received central (c) ECMO, and 17 patients had peripheral (p) ECMO. In the group of pECMO, limb ischemia was significantly higher (5 [29.41%] vs 6 [7.14%]; p = .01). Other endpoints were similar in both groups. Thirty-day mortality was nonsignificantly different between both cohorts (cECMO 34 [41.67%] vs pECMO 10 [58.82%]; p = .29). However, overall survival was better with cECMO (Log-rank p = .02). Patients' age [HR: 1.04 (95% CI: 1.02-1.06); p = .001], pECMO [HR: 1.98 (95% CI: 1.11-3.55), p = .002] and presence of infective endocarditis [HR: 3.54 (95% CI: 1.52-8.24), p = .03] were significant predictors of overall mortality. CONCLUSIONS: Peripheral ECMO was associated with an increased risk of limb ischemia; however, bleeding, blood transfusion, infection, and 30-day mortality were comparable to central ECMO. Central cannulation was associated with a better 1-year survival rate. Therefore, central cannulation might be the preferred strategy for patients with postcardiotomy cardiogenic shock.

Age-Specific Outcomes of Bioprosthetic vs. Mechanical Aortic Valve Replacement: Balancing Reoperation Risk with Anticoagulation Burden.

BACKGROUND: The choice of prosthesis for aortic valve replacement (AVR) remains challenging. The risk of anticoagulation complications vs. the risk of aortic valve reintervention should be weighed. This study compared the outcomes of bioprosthetic vs. mechanical AVR in patients older and younger than 50. METHODS: This retrospective study was conducted from 2009 to 2019 and involved 292 adult patients who underwent isolated AVR. The patients were divided according to their age (above 50 years or 50 years and younger) and the type of valves used in each age group. The outcomes of bioprosthetic valves (Groups 1a (>50 years) and 1b (≤50 years)) were compared with those of mechanical valves (Groups 2a (>50 years) and 2b (≤50 years)) in each age group. RESULTS: The groups had nearly equal rates of preexisting comorbidities except for Group 1b, in which the rate of hypertension was greater (32.6% vs. 14.7%; p = 0.025). This group also had higher rates of old stroke (8.7% vs. 0%, p = 0.011) and higher creatinine clearance (127.62 (108.82-150.23) vs. 110.02 (84.87-144.49) mL/min; p = 0.026) than Group 1b. Patients in Group 1a were significantly older than Group 2a (64 (58-71) vs. 58 (54-67) years; p = 0.002). There was no significant difference in the NYHA class between the groups. The preoperative ejection fraction and other echocardiographic parameters did not differ significantly between the groups. Re-exploration for bleeding was more common in patients older than 50 years who underwent mechanical valve replacement (p = 0.021). There was no difference in other postoperative complications between the groups. The groups had no differences in survival, stroke, or bleeding rates. Aortic valve reintervention was significantly greater in patients ≤ 50 years old with bioprosthetic valves. There were no differences between groups in the changes in left ventricular mass, ejection fraction, or peak aortic valve pressure during the 5-year follow-up. CONCLUSIONS: The outcomes of mechanical and bioprosthetic valve replacement were comparable in patients older than 50 years. Using bioprosthetic valves in patients younger than 50 years was associated with a greater rate of valve reintervention, with no beneficial effect on the risk of bleeding or stroke.

Surgical vs Transcatheter Aortic Valve Replacement in Patients With a Low Ejection Fraction.

Currently, there is no preference for surgical (SAVR) vs transcatheter (TAVR) aortic valve replacement in patients with low ejection fraction (EF). The present study retrospectively compared the outcomes of SAVR vs TAVR in patients with EF ≤40% (70 SAVR and 117 TAVR patients). Study outcomes were survival and the composite endpoint of stroke, aortic valve reintervention, and heart failure readmission. The patients who had TAVR were older (median: 75 (25-75th percentiles: 69-81) vs 51 (39-66) years old; P < .001) with higher EuroSCORE II (4.95 (2.99-9.85) vs 2 (1.5-3.25); P < .001). Postoperative renal impairment was more common with SAVR (8 (12.5%) vs 4 (3.42%); P = .03), and they had longer hospital stay [9 (7-15) vs 4 (2-8) days; P < .001). There was no difference between groups in stroke, reintervention, and readmission (Sub-distributional Hazard ratio: .95 (.37-2.45); P = .92). Survival at 1 and 5 years was 95% and 91% with SAVR and 89% and 63% with TAVR. Adjusted survival was comparable between groups. EF improved significantly (ß: .28 (.23-.33); P < 0.001) with no difference between groups (P = .85). In conclusion, TAVR could be as safe as SAVR in patients with low EF.

Concomitant intra-aortic balloon pump and veno-arterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock.

We aimed to compare the outcomes of ECMO with and without IABP for postcardiotomy cardiogenic shock. The study included 103 patients who needed ECMO for postcardiotomy cardiogenic shock. Patients were grouped according to the use of IABP into ECMO without IABP (n = 43) and ECMO with IABP (n = 60). The study endpoints were hospital complications, successful weaning, and survival. Patients with IABP had lower preoperative ejection fraction (p = 0.002). There was no difference in stroke (p = 0.97), limb ischemic (p = 0.32), and duration of ICU stay (p = 0.11) between groups. Successful weaning was non-significantly higher with IABP (36 (60%) vs 19 (44.19%); p = 0.11). Predictors of successful weaning were inversely related to the high pre-ECMO lactate levels (OR: 0.89; p = 0.01), active endocarditis (OR: 0.06; p = 0.02), older age (OR: 0.95; p = 0.02), and aortic valve replacement (OR: 0.26; p = 0.04). There was no difference in survival between groups (p = 0.80). Our study did not support the routine use of IABP during ECMO support.

Surgical management of right coronary artery-coronary sinus fistula causing severe mitral and tricuspid regurgitation.

Coronary arteriovenous (AV) fistula is a rare congenital anomaly, mostly diagnosed incidentally during routine coronary angiography. We report a symptomatic patient with right coronary artery to coronary sinus (RCA-CS) fistula, complicated by aneurysmal dilatation and thrombosis of the CS, causing severe mitral regurgitation (MR) and tricuspid regurgitation (TR).