Single center experience with patients on veno arterial ECMO due to postcardiotomy right ventricular failure.

OBJECTIVES: Right ventricular (RV) failure is associated with poor outcome and increased mortality in cardiac surgery. Aim of our study was to analyze the outcome of veno arterial extracorporeal membrane oxygenation (va ECMO) therapy in patients with isolated RV failure in postcardiotomy cardiogenic shock (PCS) and to evaluate risk factors associated with 30-day-mortality. METHODS: Between August 2006 until August 2016, 64 consecutive patients with va ECMO therapy due to fulminant RV failure in PCS were identified and included in this retrospective observation. Further, outcome data and a comparison of va ECMO survivors and nonsurvivors was conducted. RESULTS: The mean age of the patient cohort was 63 ± 14 years. Patients were treated with va ECMO for 79 ± 61 hours. Twenty-eight patients (44%) were successfully weaned off ECMO support. Overall 30-day-mortality was 88% (56/64). Hemoglobin concentration before ECMO implantation, maximum rise of muscle-brain type creatine kinase during ECMO therapy, as well as lactic acid concentration 24 hours after initiation of va ECMO therapy were predictive for 30-day mortality. CONCLUSION: ECMO therapy in RV failure due to PCS is shown to be associated with an excessive mortality. Regarding our data, va ECMO might only be an appropriate short-term mechanical assist device separating patients form cardiopulmonary bypass with an acceptable weaning rate. Particularly, in case of failed hemodynamic recovery of the right heart on va ECMO, direct RV bypass systems might function as a bailout option. Additionally, cardiac enzymes and lactic acid might provide valuable information in meeting therapy-related decisions.

Rosuvastatin reloading before cardiac surgery with cardiopulmonary bypass.

BACKGROUND/PURPOSE: Recent evidence suggests that statin-mediated cardioprotection after chronic statin therapy decreases over time and can be reactivated by preprocedural high-dose statin reloading therapy. We tested in a porcine cardiopulmonary bypass (CPB) model whether statin-related cardioprotection is further enhanced by a preoperative rosuvastatin reloading therapy. METHODS: Control (n = 6), rosuvastatin-pretreated (n = 6; 20 mg/day for 7 days p.o.) and rosuvastatin-reloaded (n = 6; p.o. treatment plus 0.10 mg/kg/h i.v. during surgery) pigs (Deutsche Landrasse) were subjected to CPB for 2 h with 1 h of cardioplegic cardiac arrest. Systemic hemodynamics, cardiac index (CI), coronary blood flow (CBF) and left ventricular (LV) function [pressure-volume area (PVA), preload recruitable stroke work (PRSW)] were determined before and 4 h after CPB. Myocardial expression (PCR) and protein content (Western blot) of endothelial NO synthase (eNOS) and phosphatase and tensin homolog deleted on chromosome ten (PTEN) were measured, and right coronary relaxation was assessed postmortem. All data are given as mean ± SD. RESULTS: Preoperative plasma LDL, HDL and cholesterol did not differ between treatment groups. Compared to control, oral treatment improved post-CPB CI, CBF, first derivative of maximal LV-pressure (LVdp/dt) and PVA (p < 0.05). Significant enhancement was achieved with perioperative reloading therapy (CI: 5.2 ± 1.0 vs. 3.9 ± 1.5 l/min/m(2); CBF: 76 ± 32 vs. 43 ± 8 ml/min; LVdp/dt: 1,980 ± 333 vs. 1,249 ± 461 mm Hg/s; PVA: 6,954 ± 941 vs. 3,252 ± 1,822 mm Hg·ml; p < 0.05) with improved in vitro NO-dependent coronary relaxation (102 ± 10 vs. 79 ± 14%; p = 0.003). Irrespective of recapture therapy statin pretreatment augmented myocardial eNOS and PTEN (p < 0.05), but failed to increase cardiac eNOS or PTEN expression after CPB. CONCLUSIONS: Periprocedural statin reloading therapy enhances myocardial and coronary function after cardiac surgery with CPB and may therefore provide a valuable therapeutic approach for the reduction of myocardial ischemia-reperfusion injury.

Endothelial and Hemodynamic Function in a Large Animal Model in Relation to Different Extracorporeal Membrane Oxygenation Cannulation Strategies and Intra-Aortic Balloon Pumping.

BACKGROUND: The use of simultaneous veno-arterial extracorporeal membrane oxygenation (ECMO) with or without an Intra-Aortic Balloon Pump (IABP) is a widely used tool for mechanical hemodynamic support. Endothelial function, especially in relation to different cannulation techniques, is rarely investigated in the setting of extracorporeal life support (ECLS). In this study, we analyzed endothelial function in relation to hemodynamic and laboratory parameters for central and peripheral ECMO, with or without concomitant IABP support in a large animal model to gain a better understanding of the underlying basic mechanisms. METHODS: In this large animal model, healthy female pigs with preserved ejection fraction were divided into the following groups related to cannulation strategy for ECMO and simultaneous IBAP support: control (no ECMO, no IABP), peripheral ECMO (pECMO), central ECMO (cECMO), pECMO and IABP or cECMO and IABP. During the experimental setting, the blood flow in the ascending aorta, left coronary artery and arteria carotis was measured. Afterwards, endothelial function was investigated after harvesting the right coronary artery, arteria carotis and renal artery. In addition, laboratory markers, such as creatine kinase (CK), creatine kinase muscle-brain (CK-MB), troponin, creatinine and endothelin were analyzed. RESULTS: The blood flow in the ascending aorta and the left coronary artery was significantly lower in all discussed experimental settings compared to the control group. Of note, the cECMO cannulation strategy generated favorable hemodynamic circumstances with higher blood flow in the coronary arteries than pECMO regardless of flow circumstances in the ascending aorta. The concomitant usage of IABP did not result in an improvement of the coronary blood flow, but partially showed a negative impact on the endothelial function of coronary arteries in comparison to the control. These findings correlate to higher CK/CK-MB levels in the setting of cECMO + IABP and pECMO + IABP. CONCLUSIONS: The usage of mechanical circulatory support with concomitant ECMO and IABP in a large animal model might have an influence on the endothelial function of coronary arteries while not improving the coronary artery perfusion in healthy hearts with preserved ejection.

Management of out-of hospital cardiac arrest patients with extracorporeal cardiopulmonary resuscitation in 2021.

INTRODUCTION: Over the last decade, eCPR programs have become more and more popular, at least amongst high-volume centers. Despite its rise in popularity and promising outcome, strategies concerning pre- and post-implantation of VA-ECMO remain at least debatable. Besides, integrating the appropriate set-up, managing anticoagulation, implementing LV-venting, and predicting neurological outcome play important roles in caring for thise highly selective patient-collective. We sought to present our institutional´s techniques for establishing an eCPR program and managing patients peri- and post implantation in eCPR-runs. AREAS COVERED: This manuscript covers the majority of clinical concerns and parameters for establishing an eCPR program and its recent advantages. We will describe a safe way of cannulation, setting anticoagulation goals, strategies for LV-venting and ICU-treatment. Also included, an elaboration on neurological and cardiac prognostication. EXPERT OPINION: We advocate ultrasound-guided cannula placement in eCPR patients. Also, we emphasize the importance of using stiffer wires and smaller arterial cannula sizes due to the different physiological parameters of OHCA patients. After cannulation, we aim for lower flow goals, the concept of 'partial VA-ECMO,' and lower anticoagulatory targets. LV-venting with Impella should remain an individual case to case decision.

High levels of cell-free DNA accurately predict late acute kidney injury in patients after cardiac surgery.

Use of cardiopulmonary bypass in cardiac surgery triggers systemic inflammation by neutrophil activation leading to neutrophil extracellular traps (NETs) release. Hence, nuclear DNA released by necrotic and apoptotic cells might contribute to an increase in circulating cell-free DNA (cfDNA). cfDNA/NETs might induce endothelial damage and organ dysfunction. This study focuses on the accuracy of cfDNA to predict acute kidney injury (AKI) after on-pump surgery. 58 cardiac patients undergoing on-pump surgery were prospectively enrolled. Blood samples were taken preoperatively, immediately after surgery, at day 1, 2, 3 and 5 from patients with (n = 21) or without (n = 37) postoperative AKI development. Levels of cfDNA, neutrophil gelatinase-associated lipocalin (NGAL) and creatinine in patients' plasma were quantified. ROC curves were used to assess the predictive value of the biomarkers for AKI. Further baseline characteristics and perioperative variables were analyzed.cfDNA and NGAL levels highly increased in AKI patients and significant intergroup differences (vs. non-AKI) were found until day 3 and day 5 after surgery, respectively. cfDNA levels were significantly elevated in patients who developed late AKI (>24 hours), but not in those with AKI development during the first 24 hours (early AKI). NGAL and creatinine, which were highest in patients with early AKI, accurately predicted during the first 24 postoperative hours (early AKI). At day 3, at a threshold of 260.53 ng/ml cfDNA was the best predictor for AKI (AUC = 0.804) compared to NGAL (AUC = 0.699) and creatinine (AUC = 0.688). NGAL, but not cfDNA, was strongly associated with AKI stages and mortality. Monitoring of cfDNA levels from the first postoperative day might represent a valuable tool to predict late AKI after on-pump surgery.

Prophylactic intraoperative tranexamic acid administration and postoperative blood loss after transapical aortic valve implantation.

OBJECTIVES: Antifibrinolytics are widely used in cardiac surgery to save blood perioperatively. In the present study we evaluated the hemostatic effects of tranexamic acid (TXA) to decrease bleeding tendency and transfusion requirements in high-risk patients following transapical aortic valve implantation (TA-AVI). METHODS: A retrospective analysis was performed on aortic stenosis patients undergoing TA-AVI with or without intraoperative TXA administration to determine postoperative blood loss and transfusion requirements. From January 2009 to August 2010 in total 92 patients were treated without intraoperative TXA administration, from August 2010 to July 2011 54 patients received TXA intraoperatively. RESULTS: Early postoperative (24 h) blood loss was significantly lower in TXA-group than in non-TXA group (327 ± 274 mL vs. 481.1 ± 318.8 mL; p = 0.003). In the TXA group 53.7% of patients received allogeneic blood products during the hospital stay as compared to 72.8% in the non-TXA group (p = 0.242). TXA group required fewer transfusions (2.1 ± 1.9 vs. 2.9 ± 3.5 Units; p = 0.046) and had no increased incidence of thrombotic or neurological complications. There was no significant difference in the length of ICU, hospital stay, or 30-day mortality. Administration of tranexamic acid was found to be significantly associated with lower blood loss postoperatively (p = 0.002). Furthermore, there was a significant correlation between the postoperative blood loss (p = 0.036) and red blood cell transfusion (p = 0.001) with 30-day mortality. CONCLUSION: Low dose prophylactic intraoperative administration of tranexamic acid appears to be effective in reducing postoperative bleeding and the need for allogeneic blood products following TA-AVI.