Extracorporeal Life Support for Cardiogenic Shock in Octogenarians: Single Center Experience.

BACKGROUND: The age limit for the use of extracorporeal membrane oxygenation (ECMO) support for post-cardiotomy cardiac failure is not defined. The aim of the study was to evaluate the outcomes of octogenarians supported with ECMO due to cardiogenic shock. METHODS: A retrospective review of consecutive elderly patients supported with ECMO during a 13-year period in a tertiary care center. Patient's demographic variables, comorbidities, perioperative data and outcomes were collected from patient medical records. Data of octogenarian patients were compared with the septuagenarian group. The main outcomes of the study was in hospital mortality, 6-month survival and 1-year survival after hospital discharge and discharge options. Multivariate logistic regression analysis was performed to identify the factors associated with hospital survival. RESULTS: Eleven patients (18.3%) in the elderly group were octogenarians (aged 80 years or above), and forty-nine (81.7%) were septuagenarians (aged 70-79 years). There were no differences except age in demographic and preoperative variables between groups. Pre ECMO SAVE, SOFA, SAPS-II and inotropic scores were significantly higher in septuagenarians than octogenarians. There was no statistically significant difference in hospital mortality, 6-month survival, 1 year survival or discharge options between groups. CONCLUSIONS: ECMO could be successfully used in selected octogenarian patients undergoing cardiac surgery to support a failing heart. An early decision to initiate ECMO therapy in elderly post-cardiotomy shock patients is associated with favorable outcomes.

A Comparison of the Catheter-Based Transapical and Surgical Treatment Modalities for Mitral Paravalvular Leak.

BACKGROUND: There is a lack of studies where the outcomes of mitral paravalvular leak treatment were compared between surgery and catheter-based closure. The aim of this study was to compare the outcomes of re-do surgery with transapical catheter-based paravalvular leak closure. METHODS: This is a retrospective observational study at a single institution; 76 patients were included. According to the treatment, two groups were formed: the "Surgical" group (49 patients after re-do surgery) and the "Catheter" group (27 patients after transapical catheter-based treatment). RESULTS: In-hospital myocardial infarction occurred in 9 (18%) cases in the "Surgical" group and none in the "Catheter" group, p = 0.018. Procedure-related life-threatening bleeding occurred in 9 (18%) patients in the "Surgical" group and none in the "Catheter" group, p = 0.018. Nine (18%) patients died in 30 days in the "Surgical" group, and none died in the "Catheter" group, p = 0.039. A mean follow-up was 3.3 years. No difference was found between the groups by the degree of residual paravalvular regurgitation either at discharge or at follow-up. During the follow-up, 19 (39%) patients died in the "Surgical" group and 2 (7%) among the "Catheter" patients. CONCLUSIONS: Transapical catheter-based closure of mitral paravalvular leak seems to be a safer treatment procedure than conventional re-do surgery, and the effectiveness of these procedures does not differ.

Evaluation of risk factors for adverse outcome in extracorporeal membrane oxygenation-supported elderly postcardiotomy patients.

BACKGROUND: Recently extracorporeal membrane oxygenation is becoming the commonly used mechanical assist device for the treatment of severe cardiogenic shock in postcardiotomy patients. Evaluation of risk factors of negative outcome would be beneficial in decision-making in the elderly patient population. METHODS: This was a retrospective single-centre analysis of elderly patients who underwent extracorporeal membrane oxygenation treatment for refractory cardiogenic shock in a tertiary care centre. Demographic data, comorbidities and perioperative parameters were collected to evaluate their impact on the outcome of extracorporeal membrane oxygenation treatment in this patient group. Logistic regression analysis of the variables was performed to identify factors predicting an adverse outcome. RESULTS: Forty consecutive elderly patients underwent extracorporeal membrane oxygenation treatment during the study period. The mean age was 76.7 ± 3.8 years, 27 (68%) were male. The mean Survival after Veno-Arterial extracorporeal membrane oxygenation score before initiating extracorporeal membrane oxygenation support was - 11 ± 6. Intra-aortic counterpulsation was used as the first-line mechanical support in 31 (77%) patients. The mean duration of extracorporeal membrane oxygenation support was 172 ± 128 hours. Twenty-four patients (56%) were successfully weaned from extracorporeal membrane oxygenation, and 8 (20%) survived to hospital discharge. Lactate level before extracorporeal membrane oxygenation initiation was the only predictor of unfavourable outcome in multivariate analysis (p < 0.05). CONCLUSION: High lactate level before initiation of extracorporeal membrane oxygenation was the most important prognostic values of an unfavourable outcome.

Anesthetic Management and Procedural Outcomes of Patients Undergoing Off-Pump Transapical Implantation of Artificial Chordae to Correct Mitral Regurgitation: Case Series of 76 Patients.

BACKGROUND: Transapical implantation of artificial chordae using the NeoChord system (NeoChord Inc, Minneapolis, MN) is an emerging beating-heart technique for correction of mitral regurgitation (MR) through a minimally invasive left minithoracotomy. The purpose of the study was to describe the anesthetic management and procedural success of patients undergoing this procedure. METHODS: All patients (n = 76) who underwent mitral valve repair with the NeoChord system in our institution from December 2011 to December 2016 were included in this observational prospective study. Balanced anesthesia with a combination of fentanyl, propofol, and sevoflurane was used in all patients. Each patient's core temperature was maintained at >36°C whenever possible. Two- and 3-dimensional transesophageal echocardiography was used in all patients to navigate the device to the posterior mitral valve leaflet (68 of 76 patients), anterior mitral valve leaflet (3 of 76 patients), or both leaflets (5 of 76 patients). After effective leaflet capture, the artificial chordae were deployed. Position and function of the artificial chordae were assessed by evaluating the degree of MR when the neochordae were tensed. After surgery, all patients were transferred to the intensive care unit. RESULTS: The mean age of the patients was 60 ± 13 years (range, 33-87 years), and the male/female ratio was 52/24. Most patients had severe MR (grade 4+ in 25 [33%] patients, grade 3+ in 51 [67%] patients). The average preoperative EuroSCORE II was 1.23% ± 1.16% (range, 0.46%-4.23%). The median duration of the procedure was 120 minutes (interquartile range [IQR] 115-145 minutes). After the procedure, 42 (56%) patients had trivial MR, 27 (36%) had grade 1+ MR, 4 (5%) had grade 2+ MR, and 2 (3%) had >2+ MR. One patient underwent conversion to conventional mitral valve repair due to perforation of the posterior mitral valve leaflet. The whole procedure was well tolerated by the patients, with hemodynamics remaining stable in the majority of the cases. Only 20 (26%) patients needed low-dose inotropic support perioperatively. All patients had an uneventful postoperative course. The median time to extubation was 4 hours (IQR, 2.6-6), and the length of intensive care unit stay was 22 hours (IQR, 21-24). Five (6.6%) patients required allogeneic blood products. CONCLUSIONS: Anesthesia for transapical NeoChord implantation can be safely performed under beating-heart conditions, with low perioperative morbidity and rare blood transfusions. Transesophageal echocardiography is crucial for the guidance, safety, and effectiveness of the procedure.