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1.
Artigo em Inglês | MEDLINE | ID: mdl-32505603

RESUMO

OBJECTIVE: Resuscitation after cardiac surgery needs to address multiple pathophysiological processes that are associated with significant morbidity and mortality. Functional microcirculatory derangements despite normal systemic hemodynamics have been previously described but must be tied to clinical outcomes. The authors hypothesized that microcirculatory dysfunction after cardiac surgery would include impaired capillary blood flow and impaired diffusive capacity and that subjects with the lowest quartile of perfused vessel density would have an increased postoperative lactate level and acute organ injury scores. DESIGN: Prospective, observational study. SETTING: A single, tertiary university cardiovascular surgical intensive care unit. PARTICIPANTS: 25 adults undergoing elective cardiac surgery requiring cardiopulmonary bypass. INTERVENTION: Sublingual microcirculation was imaged using incident dark field microscopy before and 2 to 4 hours after surgery in the intensive care unit. MEASUREMENTS AND MAIN RESULTS: Compared with baseline measurements, postoperative vessel-by-vessel microvascular flow index (2.9 [2.8-2.9] v 2.5 [2.4-2.7], p < 0.0001) and perfused vessel density were significantly impaired (20.7 [19.3-22.9] v 16.3 [12.8-17.9], p < 0.0001). The lowest quartile of perfused vessel density (<12.8 mm/mm2) was associated with a significantly increased postoperative lactate level (6.0 ± 2.9 v 1.8 ± 1.2, p < 0.05), peak lactate level (7.6 ± 2.8 v 2.8 ± 1.5, p = 0.03), and sequential organ failure assessment (SOFA) score at 24 and 48 hours. CONCLUSION: In patients undergoing cardiac surgery, there was a significant decrease in postoperative microcirculatory convective blood flow and diffusive capacity during early postoperative resuscitation. Severely impaired perfused vessel density, represented by the lowest quartile of distribution, is significantly related to hyperlactatemia and early organ injury.

2.
Chest ; 2020 Jun 18.
Artigo em Inglês | MEDLINE | ID: mdl-32565271

RESUMO

BACKGROUND: Thoracic transplantation is considered for patients with Eisenmenger's syndrome (ES) who have refractory right ventricular failure despite optimal therapy for pulmonary arterial hypertension. We compared the outcomes of bilateral lung transplant (BLT) with cardiac defect repair versus combined heart-lung transplant (HLT). RESEARCH QUESTION: Which is the most effective thoracic transplant strategy in patients with ES? STUDY DESIGN AND METHODS: We identified patients with ES who underwent thoracic transplantation from 1987 to 2018 from the UNOS database. Survival curves were estimated using the Kaplan-Meyer method and compared using the log-rank test. RESULTS: During the study period, 442 adults with ES underwent thoracic transplantation (316 HLT and 126 BLT). After BLT, overall survival 1, 5 and 10 years posttransplant was 63.1%, 38.5% and 30.2%. After HLT, overall survival 1, 5 and 10 years posttransplant was 68.0%, 47.3% and 30.5% (p=0.6). When survival analysis was stratified by type of defect, patients with an atrial septal defect (ASD) had better survival after BLT than after HLT (88.3% vs 63.2% 1-year-posttransplant, p<0.01; 71.1% vs 49.8% 3-years-posttransplant, p<0.01, 37.4% vs 29.9% 10-years-posttransplant, p=0.08). Patients with a ventricular septal defect (VSD) exhibited better survival after HLT than after BLT (78.2% vs 49.6% 1-year-posttransplant, p<0.01; 55.6% vs 34.3% 5-years-posttransplant, p<0.01; 35.7% vs 26.5% 10-years-posttransplant, p=0.03). The most common cause of mortality in patients with VSD undergoing BLT was cardiac ventricular failure. INTERPRETATION: This study suggests that the best transplant option for patients with VSD remains HLT which prevents subsequent development of ventricular failure. BLT with cardiac defect repair should be considered as the first-line treatment option in patients with ES due to an uncorrected ASD. These patients can be considered to have isolated and reversible right ventricular failure akin to patients with advanced pulmonary arterial hypertension.

4.
Ann Thorac Surg ; 2020 Apr 30.
Artigo em Inglês | MEDLINE | ID: mdl-32360877

RESUMO

BACKGROUND: No clinically validated tool exists to predict in-hospital mortality in patients requiring extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation. We generated a quantitative risk assessment tool for these patients. METHODS: Of 822 patients in the United Network for Organ Sharing (UNOS) database who required ECMO as bridge to lung transplant between 2004-2018, 630 were included in the analysis after exclusion for age <18 years, prior transplant or treatment before 2004. Recipient-specific variables associated with post-transplant in-hospital mortality were incorporated into a multivariable logistic regression model in an automated stepwise fashion. Linear prediction was used to construct the Recipient Stratification Risk Analysis in Bridging Patients to Lung Transplant on ECMO (STABLE) score. K-fold cross-validation provided an unbiased estimate of out-of-sample performance. After further exclusion for University of Pennsylvania patients, remaining cohort was used for external score validation. iOS application was developed to aid clinical use. RESULTS: Six recipient-specific, pretransplant variables were translated into a 24-point score. STABLE scores in the UNOS dataset ranged from 0-21, and each point increased the odds of in-hospital mortality by 22.0% (95% confidence interval, [95%CI]: 1.14 - 1.29, p<0.001). K-fold cross-validation yielded a receiver operating characteristic area under the curve (AUC) of 86.2%. Validation of the STABLE score using our institutional database yielded an AUC of 89%. CONCLUSIONS: The STABLE score is a novel, internally cross-validated tool for risk stratification of patients on ECMO as a bridge to transplant. Its predictive power and accuracy may aid clinical decision-making and improve post-transplant outcomes.

5.
Heart Rhythm ; 17(7): 1132-1138, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32112873

RESUMO

BACKGROUND: Postoperative bradycardia can complicate orthotopic heart transplantation (OHT). Previous studies suggested donor age and surgical technique as possible risk factors. However, risk factors in the era of bicaval anastomosis have not been elucidated. OBJECTIVE: We sought to examine the association between donor/recipient characteristics with need for chronotropic support and permanent pacemaker (PPM) implantation in patients with OHT. METHODS: All patients treated with OHT between January 2003 and January 2018 at the Hospital of the University of Pennsylvania were retrospectively evaluated until June 2018. Chronotropic support was given upon postoperative inability to increase the heart rate to patient's demands and included disproportionate bradycardia and junctional rhythm. RESULTS: A total of 820 patients (mean age 51.3 ± 12.6 years; 607, 74% men) underwent 826 OHT procedures (787 patients, 95.3% bicaval anastomosis). Patients who were exposed to amiodarone (odds ratio [OR] 2.30; 95% confidence interval [CI] 1.58-3.34; P < .001) and have older donor (OR 1.02; 95% CI 1.01-1.04; P = .001) were more likely to develop need for chronotropic support. In multivariable analysis, recipient age (OR 1.03; 95% CI 1.00-1.06; P = .04) and biatrial anastomosis (OR 6.12; 95% CI 2.48-15.09) were significantly associated with PPM implantation within 6 months of OHT. No association was found between pre-OHT amiodarone use and PPM implantation. No risk factors assessed were associated with PPM implantation 6 months post-OHT. CONCLUSION: Surgical technique and donor age were the main risk factors for the need for chronotropic support post-OHT, whereas surgical technique and recipient age were risk factors for early PPM implantation.

7.
J Heart Lung Transplant ; 38(11): 1125-1143, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31522913

RESUMO

Cardiogenic shock, cardiac arrest, acute respiratory failure, or a combination of such events, are all potential complications after cardiac surgery which lead to high mortality. Use of extracorporeal temporary cardio-circulatory and respiratory support for progressive clinical deterioration can facilitate bridging the patient to recovery or to more durable support. Over the last decade, extracorporeal membrane oxygenation (ECMO) has emerged as the preferred temporary artificial support system in such circumstances. Many factors have contributed to widespread ECMO use, including the relative ease of implantation, effectiveness, versatility, low cost relative to alternative devices, and potential for full, not just partial circulatory support. While there have been numerous publications detailing the short and midterm outcomes of ECMO support, specific reports about post-cardiotomy ECMO (PC-ECMO), are limited, single-center experiences. Etiology of cardiorespiratory failure leading to ECMO implantation, associated ECMO complications, and overall patient outcomes may be unique to the PC-ECMO population. Despite the rise in PC-ECMO use over the past decade, short-term survival has not improved. This report, therefore, aims to present a comprehensive overview of the literature with respect to the prevalence of ECMO use, patient characteristics, ECMO management, and in-hospital and early post-discharge patient outcomes for those treated for post-cardiotomy heart, lung, or heart-lung failure.

8.
J Heart Lung Transplant ; 38(11): 1144-1161, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31421976

RESUMO

Veno-arterial extracorporeal membrane oxygenation (ECMO) is established therapy for short-term circulatory support for children with life-treating cardiorespiratory dysfunction. In children with congenital heart disease (CHD), ECMO is commonly used to support patients with post-cardiotomy shock or complications including intractable arrhythmias, cardiac arrest, and acute respiratory failure. Cannulation configurations include central, when the right atrium and aorta are utilized in patients with recent sternotomy, or peripheral, when cannulation of the neck or femoral vessels are used in non-operative patients. ECMO can be used to support any form of cardiac disease, including univentricular palliated circulation. Although veno-arterial ECMO is commonly used to support children with CHD, veno-venous ECMO has been used in selected patients with hypoxemia or ventilatory failure in the presence of good cardiac function. ECMO use and outcomes in the CHD population are mainly informed by single-center studies and reports from collated registry data. Significant knowledge gaps remain, including optimal patient selection, timing of ECMO deployment, duration of support, anti-coagulation, complications, and the impact of these factors on short- and long-term outcomes. This report, therefore, aims to present a comprehensive overview of the available literature informing patient selection, ECMO management, and in-hospital and early post-discharge outcomes in pediatric patients treated with ECMO for post-cardiotomy cardiorespiratory failure.

10.
J Card Fail ; 2019 Mar 18.
Artigo em Inglês | MEDLINE | ID: mdl-30898599

RESUMO

BACKGROUND: Heart transplant volume varies significantly among centers. We hypothesized that centers where the transplant team routinely accepts organs previously declined by other centers and where operating room availability is unrestricted have higher transplant volumes. METHODS AND RESULTS: We used the potential transplant recipient sequence number in the United Network for Organ Sharing database as a surrogate for graft acceptance threshold and the number of transplantations occurring on weekends and 8 major holidays as a marker of center resource availability. Centers were classified as low-, medium-, or high-volume if the average annual number of transplants were, respectively, <10, 10-30, or >30 over a 10-year period. From July 12, 2006, to December 31, 2015, 19,054 transplants were performed by 142 centers. There were 59 low-volume centers, 69 medium-volume centers, and 14 high-volume centers with median potential transplant recipient sequence numbers for transplanted candidates of 7 (interquartile range 3-11), 7 (5-10), and 15 (7-40), respectively (P = .002). The median proportion of off-hours transplantations performed by medium-volume centers was 28% (25%-31%) compared with 32% (29%-33%) by high-volume centers (P = .009). Five-year survival was equivalent among all centers (P = .053). CONCLUSIONS: Transplants for candidates with high sequence numbers and unrestricted operating room availability are associated with increased center volume without sacrificing post-transplantation survival.

11.
Congenit Heart Dis ; 13(4): 492-498, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29603626

RESUMO

BACKGROUND: Heart failure (HF) is the leading cause of death in adults with congenital heart disease (ACHD). Identification of disease progression and timing of referral for advanced therapies is often delayed. However, increased awareness and understanding of ACHD and improvements in the approach to treatment have led to improved outcomes. Pulmonary hypertension (PH) is a common barrier to HT. In ACHD, the approach to PH and HT is quite complicated, given the anatomic heterogeneity and lower prevalence and experience. However, in some cases, PH is a result of elevated systemic filling pressures and low output. METHODS: We describe the approach used to successfully transplant an ACHD patient with severe pre-HT PH performing HT alone. We review the literature and describe the one patient's journey from primarily palliative, to a combined heart-lung transplant candidate, to successful HT patient. RESULTS: We discuss the methodology used to successfully transplant a patient, with significantly elevated pulmonary pressures and an initial pulmonary vascular resistance (PVR) > 13 Wood units. CONCLUSIONS: There are a number of complexities associated with the ACHD population and it is of utmost importance to carefully identify the underlying hemodynamic milieu and inform the appropriate treatment course in order to have successful transplant outcomes.


Assuntos
Cardiopatias Congênitas/complicações , Insuficiência Cardíaca , Transplante de Coração , Hemodinâmica/fisiologia , Hipertensão Pulmonar/complicações , Transplante de Pulmão , Adulto , Cardiopatias Congênitas/fisiopatologia , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/cirurgia , Humanos , Hipertensão Pulmonar/fisiopatologia
12.
Lancet Respir Med ; 6(5): 357-367, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29650408

RESUMO

BACKGROUND: Severe primary graft dysfunction (PGD) of grade 3 (PGD3) is a common serious complication following lung transplantation. We aimed to assess physiological donor lung preservation using the Organ Care System (OCS) Lung device compared with cold static storage. METHODS: In this non-inferiority, randomised, controlled, open-label, phase 3 trial (INSPIRE) recipients were aged 18 years or older and were registered as standard criteria primary double lung transplant candidates. Eligible donors were younger than 65 years old with a ratio of partial pressure of oxygen in arterial blood to the fraction of inspired oxygen of more than 300 mm Hg. Transplant recipients were randomly assigned (1:1) with permuted blocks, stratified by centre, to receive standard criteria donor lungs preserved in the OCS Lung device (OCS arm) or cold storage at 4°C (control arm). The composite primary effectiveness endpoint was absence of PGD3 within the first 72 h after transplant and 30-day survival in the per-protocol population, with a stringent 4% non-inferiority margin. Superiority was tested upon meeting non-inferiority. The primary safety endpoint was the mean number of lung graft-related serious adverse events within 30 days of transplant. We did analyses in the per-protocol and intention-to-treat populations. This trial is registered with ClinicalTrials.gov, number NCT01630434. FINDINGS: Between Nov 17, 2011, and Nov 24, 2014, we randomly assigned 370 patients, and 320 (86%) underwent transplantation (n=151 OCS and n=169 control); follow-up was completed in Nov 24, 2016. The primary endpoint was met in 112 (79·4%) of 141 patients (95% CI 71·8 to 85·8) in the OCS group compared with 116 (70·3%) of 165 patients (62·7 to 77·2) in the control group (non-inferiority point estimate -9·1%; 95% CI -∞ to -1·0; p=0·0038; and superiority test p=0·068). Patient survival at day 30 post-transplant was 135 (95·7%) of 141 patients (95% CI 91·0-98·4) in the OCS group and 165 patients (100%; 97·8-100·0) in the control group (p=0·0090) and at 12 months was 126 (89·4%) of 141 patients (83·1-93·9) for the OCS group compared with 146 (88·1%) of 165 patients (81·8-92·8) for the control group. Incidence of PGD3 within 72 h was reported in 25 (17·7%) of 141 patients in the OCS group (95% CI 11·8 to 25·1) and 49 (29·7%) of 165 patients in the control group (22·8 to 37·3; superiority test p=0·015). The primary safety endpoint was met (0·23 lung graft-related serious adverse events in the OCS group compared with 0·28 events in the control group [point estimate -0·045%; 95% CI -∞ to 0·047; non-inferiority test p=0·020]). In the intention-to-treat population, causes of death at 30 days and in hospital were lung graft failure or lung infection (n=2 for OCS vs n=7 for control), cardiac causes (n=4 vs n=1), vascular or stroke (n=3 vs n=0), metabolic coma (n=0 vs n=2), and generalised sepsis (n=0 vs n=1). INTERPRETATION: The INSPIRE trial met its primary effectiveness and safety endpoints. Although no short-term survival benefit was reported, further research is needed to see whether the reduced incidence of PGD3 within 72 h of a transplant might translate into earlier recovery and improved long-term outcomes after lung transplantation. FUNDING: TransMedics Inc.


Assuntos
Transplante de Pulmão/métodos , Preservação de Órgãos/instrumentação , Disfunção Primária do Enxerto/prevenção & controle , Adulto , Criopreservação/métodos , Feminino , Humanos , Transplante de Pulmão/efeitos adversos , Masculino , Pessoa de Meia-Idade , Soluções para Preservação de Órgãos , Estudos Prospectivos , Fatores de Risco , Análise de Sobrevida , Resultado do Tratamento
14.
J Heart Lung Transplant ; 37(5): 548-563, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29550149

RESUMO

Airway complications remain a major cause of morbidity and mortality after cardiothoracic transplantation. The reported incidence of airway ischemic complications varies widely, contributed to by the lack of a universally accepted grading system and standardized definitions. Furthermore, the majority of the existing classification systems fail to integrate the wide range of possible bronchial complications that may develop after lung transplant. Hence, a Working Group was created by the International Society for Heart and Lung Transplantation with the aim of elaborating a universal definition of adult and pediatric airway complications and grading system. One such area of focus is to understand the problem in the context of a more standardized consensus of classifying airway ischemia. This consensus definition will have major clinical, therapeutics, and research implications.


Assuntos
Transplante de Pulmão , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/terapia , Doenças Respiratórias/diagnóstico , Doenças Respiratórias/terapia , Adulto , Criança , Humanos , Complicações Pós-Operatórias/classificação , Complicações Pós-Operatórias/etiologia , Doenças Respiratórias/classificação , Doenças Respiratórias/etiologia , Fatores de Risco
15.
J Heart Lung Transplant ; 37(6): 755-762, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29477456

RESUMO

BACKGROUND: Delirium significantly affects post-operative outcomes, but the incidence, risk factors, and long-term impact of delirium in lung transplant recipients have not been well studied. METHODS: We analyzed 155 lung transplant recipients enrolled in the Lung Transplant Outcomes Group (LTOG) cohort at a single center. We determined delirium incidence by structured chart review, identified risk factors for delirium, determined whether plasma concentrations of 2 cerebral injury markers (neuron-specific enolase [NSE] and glial fibrillary acidic protein [GFAP]) were associated with delirium, and determined the association of post-operative delirium with 1-year survival. RESULTS: Fifty-seven (36.8%) patients developed post-operative delirium. Independent risk factors for delirium included pre-transplant benzodiazepine prescription (relative risk [RR] 1.82; 95% confidence interval [CI] 1.08 to 3.07; p = 0.025), total ischemic time (RR 1.10 per 30-minute increase; 95% CI 1.01 to 1.21; p = 0.027), duration of time with intra-operative mean arterial pressure <60 mm Hg (RR 1.07 per 15-minute increase; 95% CI 1.00 to 1.14; p = 0.041), and Grade 3 primary graft dysfunction (RR 2.13; 95% CI 1.27 to 3.58; p = 0.004). Ninety-one (58.7%) patients had plasma available at 24 hours. Plasma GFAP was inconsistently detected, whereas NSE was universally detectable, with higher NSE concentrations associated with delirium (risk difference 15.1% comparing 75th and 25th percentiles; 95% CI 2.5 to 27.7; p = 0.026). One-year mortality appeared higher among delirious patients, 12.3% compared with 7.1%, but the difference was not significant (p = 0.28). CONCLUSIONS: Post-operative delirium is common in lung transplant recipients, and several potentially modifiable risk factors deserve further study to determine their associated mechanisms and predictive values.


Assuntos
Delírio/epidemiologia , Transplante de Pulmão , Complicações Pós-Operatórias/epidemiologia , Idoso , Estudos de Coortes , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco
16.
J Cardiothorac Surg ; 13(1): 22, 2018 Feb 13.
Artigo em Inglês | MEDLINE | ID: mdl-29433532

RESUMO

BACKGROUND: Continuous-flow left ventricular assist devices (CF-LVAD) have become the standard of care for patients with end stage heart failure. Device reliability has increased, bringing the potential for VAD, compared to transplant, into debate. However, complications continue to limit VADs as first line therapy. Bleeding is a major morbidity. A debate exists as to the difference in bleeding profile between the major centrifugal and axial flow devices. We hypothesized that there would be similar adverse bleeding event profiles between the 2 major CF-LVADs. METHODS: We retrospectively investigated isolated CF LVADs performed at our institution between July 2010 and July 2015: HeartMateII (HMII, n = 105) and HeartWare (HVAD, n = 34). We reviewed demographic, perioperative and short- and long-term outcomes. RESULTS: There was no significant difference in demographics or comorbidities. There was a low incidence of gastrointestinal (GI) bleed 3.9% in HMII and 2.9% in HVAD (p = 0.78). Preoperatively, the cohorts did not differ in coagulation measures (p = 0.95). Within the post-operative period, there was no difference in product transfusion: red blood cells (p = 0.10), fresh frozen plasma (p = 0.19), and platelets (p = 0.89). Post-operatively, a higher but not significantly different number of HMII patients returned to the operating room for bleeding (n = 27) compared to HVAD (n = 6, p = 0.35). There was no difference in rates of stroke (p = 0.65), re-intubation (p = 0.60), driveline infection (p = 0.05), and GI bleeding (p = 0.31). The patients had equivalent ICU LOS (p = 0.86) and index hospitalization LOS (p = 0.59). CONCLUSION: We found no difference in the rate of bleeding complications between the current commercially available axial and centrifugal flow devices.


Assuntos
Hemorragia Gastrointestinal/etiologia , Insuficiência Cardíaca/cirurgia , Coração Auxiliar/efeitos adversos , Complicações Pós-Operatórias , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Estudos Retrospectivos , Acidente Vascular Cerebral/etiologia , Infecção da Ferida Cirúrgica/etiologia
17.
Ann Transl Med ; 5(20): 398, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29152498

RESUMO

Increased experience with extracorporeal life support (ECLS) as a mode of cardiac support has expanded its use to diverse patient populations including patients requiring a bridge to heart transplantation and patients requiring posttransplant support for primary graft dysfunction (PGD). The use of ECLS is associated with acceptable outcomes in well-selected patients. While outcomes with the use of extracorporeal membrane oxygenation (ECMO) as a bridge to heart transplant have been variable, several series have confirmed the safe use of ECLS to stabilize patients prior to left ventricular assist device (LVAD) implantation. These patients are then considered later, when in stable condition, for heart transplant. When ECLS is used prior to heart transplant, mortality is greatest during the first 6 months posttransplant. Patients who are alive 6 months after transplant appear to have similar survival rates as patients who were not supported with ECLS prior to transplant. ECLS support is a reliable therapeutic option for severe PGD and early graft failure after heart transplantation. In patients who require support for severe PGD, venoarterial-ECMO appears to result in better clinical outcomes than LVAD support. ECLS use for PGD after heart transplant continues to be the first line of support. Further studies are necessary to understand the optimal role of ECLS in heart transplantation.

19.
Circ Res ; 121(8): 963-969, 2017 Sep 29.
Artigo em Inglês | MEDLINE | ID: mdl-28729354

RESUMO

RATIONALE: The objective of this autopsy study was to determine whether gastrointestinal angiodysplasia develops during continuous-flow left ventricular assist device (LVAD) support. OBJECTIVE: LVAD support causes pathologic degradation of von Willebrand factor (vWF) and bleeding from gastrointestinal angiodysplasia at an alarming rate. It has been speculated that LVAD support itself may cause angiodysplasia. The relationship to abnormal vWF metabolism is unknown. We tested the hypothesis that abnormal gastrointestinal vascularity develops during continuous-flow LVAD support. METHODS AND RESULTS: Small bowel was obtained from deceased humans, cows, and sheep supported with a continuous-flow LVAD (n=9 LVAD, n=11 control). Transmural sections of jejunum were stained with fluorescein isothiocyanate-conjugated isolectin-B4 for endothelium to demarcate vascular structures and quantify intestinal vascularity. Paired plasma samples were obtained from humans before LVAD implantation and during LVAD support (n=41). vWF multimers and degradation fragments were quantified with agarose and polyacrylamide gel electrophoresis and immunoblotting. Abnormal vascular architecture was observed in the submucosa of the jejunum of human patients, cows, and sheep supported with a continuous-flow LVAD. Intestinal vascularity was significantly higher after LVAD support versus controls (5.2±1.0% versus 2.1±0.4%, P=0.004). LVAD support caused significant degradation of high-molecular-weight vWF multimers (-9±1%, P<0.0001) and accumulation of low-molecular-weight vWF multimers (+40±5%, P<0.0001) and vWF degradation fragments (+53±6%, P<0.0001). CONCLUSIONS: Abnormal intestinal vascular architecture and LVAD-associated vWF degradation were consistent findings in multiple species supported with a continuous-flow LVAD. These are the first direct evidence that LVAD support causes gastrointestinal angiodysplasia. Pathologic vWF metabolism may be a mechanistic link between LVAD support, abnormal angiogenesis, gastrointestinal angiodysplasia, and bleeding.


Assuntos
Angiodisplasia/etiologia , Coração Auxiliar/efeitos adversos , Doenças do Jejuno/etiologia , Jejuno/irrigação sanguínea , Implantação de Prótese/efeitos adversos , Implantação de Prótese/instrumentação , Função Ventricular Esquerda , Adulto , Idoso , Angiodisplasia/metabolismo , Angiodisplasia/patologia , Animais , Autopsia , Bovinos , Modelos Animais de Doenças , Hemorragia Gastrointestinal/etiologia , Humanos , Doenças do Jejuno/metabolismo , Doenças do Jejuno/patologia , Jejuno/metabolismo , Jejuno/patologia , Pessoa de Meia-Idade , Peso Molecular , Desenho de Prótese , Proteólise , Carneiro Doméstico , Fator de von Willebrand/metabolismo
20.
Circulation ; 135(24): e1115-e1134, 2017 Jun 13.
Artigo em Inglês | MEDLINE | ID: mdl-28533303

RESUMO

Cardiac arrest in patients on mechanical support is a new phenomenon brought about by the increased use of this therapy in patients with end-stage heart failure. This American Heart Association scientific statement highlights the recognition and treatment of cardiovascular collapse or cardiopulmonary arrest in an adult or pediatric patient who has a ventricular assist device or total artificial heart. Specific, expert consensus recommendations are provided for the role of external chest compressions in such patients.


Assuntos
American Heart Association , Reanimação Cardiopulmonar/normas , Parada Cardíaca/epidemiologia , Parada Cardíaca/terapia , Coração Auxiliar/normas , Adulto , Reanimação Cardiopulmonar/tendências , Criança , Serviços Médicos de Emergência/normas , Serviços Médicos de Emergência/tendências , Circulação Extracorpórea/normas , Circulação Extracorpórea/tendências , Coração Auxiliar/tendências , Humanos , Estados Unidos/epidemiologia
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