First results of the 'Deutsches Herzzentrum der Charite' paediatric impella cohort.

Cardiogenic Shock: Searching for a Better Lifeboat.

ELSO Interim Guidelines for Venoarterial Extracorporeal Membrane Oxygenation in Adult Cardiac Patients.

Predictive factors of cardiogenic shock in children with supraventricular tachycardia

Cardiogenic shock which corresponds to an acute state of circulatory failure due to impairment of myocardial contractility is a very rare disease in children, even more than in adults. To date, no international recommendations regarding its management in critically ill children are available. An experts’ recommendations in adult population have recently been made (Levy et al. Ann Intensive Care 5(1):52, 2015; Levy et al. Ann Intensive Care 5(1):26, 2015). We present herein recommendations for the management of cardiogenic shock in children, developed with the grading of recommendations’ assessment, development, and evaluation system by an expert group of the Groupe Francophone de Réanimation et Urgences Pédiatriques (French Group for Pediatric Intensive Care and Emergencies). The recommendations cover four major fields of application such as: recognition of early signs of shock and the patient pathway, management principles and therapeutic goals, monitoring hemodynamic and biological variables, and circulatory support (indications, techniques, organization, and transfer criteria). Major principle care for children with cardiogenic shock is primarily based on clinical and echocardiographic assessment. There are few drugs reported as effective in childhood in the medical literature. The use of circulatory support should be facilitated in terms of organization and reflected in the centers that support these children. Children with cardiogenic shock are vulnerable and should be followed regularly by intensivist cardiologists and pediatricians. The experts emphasize the multidisciplinary nature of management of children with cardiogenic shock and the importance of effective communication between emergency medical assistance teams (SAMU), mobile pediatric emergency units (SMUR), pediatric emergency departments, pediatric cardiology and cardiac surgery departments, and pediatric intensive care units.Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-016-0111-2) contains supplementary material, which is available to authorized users.

Optimal ECLS Support in Mixed Cardiogenic and Septic Shock

Cardiogenic shock is caused by dysfunction of the cardiac pump, resulting in multiple organ failure and metabolic disturbances.Because of its rapid onset, various manifestations, rapid progress and high mortality rate, it becomes one of the critical diseases in pediatrics.Early diagnosis and active treatment is the key to improve prognosis.The application of hemodynamic monitoring and mechanical circulatory assist devices play an increasingly important role in the treatment of cardiogenic shock in children. Key words: Cardiogenic shock; Diagnosis; Treatment; Mechanical circulatory assist; Children,

PCJ6-23 - Predictive factors of cardiogenic shock in children with supraventricular tachycardia

Cardiogenic Shock in Children: Clinical Presentation and Outcomes

Pediatric Implantable Ventricular Assist Devices in the State of Texas: A 14 Year Review

Background and aimThis study aimed to assess right ventricular (RV) function during cardiogenic shock due to acute left ventricular (LV) failure, including during LV unloading with Impella CP and an added moderate dose of norepinephrine.MethodsCardiogenic shock was induced by injecting microspheres in the left main coronary artery in 18 adult Danish Landrace pigs. Conductance catheters were placed in both ventricles and pressure-volume loops were recorded simultaneously.ResultsCardiogenic shock due to LV failure also impaired RV performance, which was partially restored during haemodynamic support with Impella CP, as demonstrated by changes in the ventriculo-arterial coupling (Ea/Ees ratio) (baseline (median [Q1;Q3]) 1.2 [1.1;1.6]), cardiogenic shock (3.0 [2.4;4.5]), Impella CP (2.1 [1.3;2.7]) (pBaseline vs CS < 0.0001, pCS vs Impella = 0.001)). Impella CP support also improved RV stroke work (SW) (cardiogenic shock 333 [263;530] vs Impella CP (830 [717;1121]) (p < 0.001). Moderate norepinephrine infusion concomitant with Impella CP further improved RV SW (Impella CP (818 [751;1065]) vs Impella CP+moderate norepinephrine (1231 [1142;1335]) (p = 0.01)) but at the expense of an increase in LV SW (Impella CP (858 [555;1392]) vs Impella CP+moderate norepinephrine (2101 [1024;2613]) (p = 0.04)).ConclusionsThe Impella CP provided efficient LV unloading, improved RV function, and end-organ perfusion. Moderate doses of norepinephrine during Impella support further improved RV function, but at the expense of an increase in SW of the failing LV.

Cardiogenic shock (CS) and low cardiac output syndrome (LCOS) are potentially life-threatening complications of acute myocardial infarction (AMI), heart failure (HF) or cardiac surgery. While there is solid evidence for the treatment of other cardiovascular diseases of acute onset, treatment strategies in haemodynamic instability due to CS and LCOS remains less robustly supported by the given scientific literature. Therefore, we have analysed the current body of evidence for the treatment of CS or LCOS with inotropic and/or vasodilating agents. This is the second update of a Cochrane review originally published in 2014. Assessment of efficacy and safety of cardiac care with positive inotropic agents and vasodilator agents in CS or LCOS due to AMI, HF or after cardiac surgery. We conducted a search in CENTRAL, MEDLINE, Embase and CPCI-S Web of Science in October 2019. We also searched four registers of ongoing trials and scanned reference lists and contacted experts in the field to obtain further information. No language restrictions were applied. Randomised controlled trials (RCTs) enrolling patients with AMI, HF or cardiac surgery complicated by CS or LCOS. We used standard methodological procedures according to Cochrane standards. We identified 19 eligible studies including 2385 individuals (mean or median age range 56 to 73 years) and three ongoing studies. We categorised studies into 11 comparisons, all against standard cardiac care and additional other drugs or placebo. These comparisons investigated the efficacy of levosimendan versus dobutamine, enoximone or placebo; enoximone versus dobutamine, piroximone or epinephrine-nitroglycerine; epinephrine versus norepinephrine or norepinephrine-dobutamine; dopexamine versus dopamine; milrinone versus dobutamine and dopamine-milrinone versus dopamine-dobutamine. All trials were published in peer-reviewed journals, and analyses were done by the intention-to-treat (ITT) principle. Eighteen of 19 trials were small with only a few included participants. An acknowledgement of funding by the pharmaceutical industry or missing conflict of interest statements occurred in nine of 19 trials. In general, confidence in the results of analysed studies was reduced due to relevant study limitations (risk of bias), imprecision or indirectness. Domains of concern, which showed a high risk in more than 50% of included studies, encompassed performance bias (blinding of participants and personnel) and bias affecting the quality of evidence on adverse events. All comparisons revealed uncertainty on the effect of inotropic/vasodilating drugs on all-cause mortality with a low to very low quality of evidence. In detail, the findings were: levosimendan versus dobutamine (short-term mortality: RR 0.60, 95% CI 0.36 to 1.03; participants = 1701; low-quality evidence; long-term mortality: RR 0.84, 95% CI 0.63 to 1.13; participants = 1591; low-quality evidence); levosimendan versus placebo (short-term mortality: no data available; long-term mortality: RR 0.55, 95% CI 0.16 to 1.90; participants = 55; very low-quality evidence); levosimendan versus enoximone (short-term mortality: RR 0.50, 0.22 to 1.14; participants = 32; very low-quality evidence; long-term mortality: no data available); epinephrine versus norepinephrine-dobutamine (short-term mortality: RR 1.25; 95% CI 0.41 to 3.77; participants = 30; very low-quality evidence; long-term mortality: no data available); dopexamine versus dopamine (short-term mortality: no deaths in either intervention arm; participants = 70; very low-quality evidence; long-term mortality: no data available); enoximone versus dobutamine (short-term mortality RR 0.21; 95% CI 0.01 to 4.11; participants = 27; very low-quality evidence; long-term mortality: no data available); epinephrine versus norepinephrine (short-term mortality: RR 1.81, 0.89 to 3.68; participants = 57; very low-quality evidence; long-term mortality: no data available); and dopamine-milrinone versus dopamine-dobutamine (short-term mortality: RR 1.0, 95% CI 0.34 to 2.93; participants = 20; very low-quality evidence; long-term mortality: no data available). No information regarding all-cause mortality were available for the comparisons milrinone versus dobutamine, enoximone versus piroximone and enoximone versus epinephrine-nitroglycerine. At present, there are no convincing data supporting any specific inotropic or vasodilating therapy to reduce mortality in haemodynamically unstable patients with CS or LCOS. Considering the limited evidence derived from the present data due to a high risk of bias and imprecision, it should be emphasised that there is an unmet need for large-scale, well-designed randomised trials on this topic to close the gap between daily practice in critical care of cardiovascular patients and the available evidence. In light of the uncertainties in the field, partially due to the underlying methodological flaws in existing studies, future RCTs should be carefully designed to potentially overcome given limitations and ultimately define the role of inotropic agents and vasodilator strategies in CS and LCOS.

Ambulatory simultaneous venoarterial extracorporeal membrane oxygenation and temporary percutaneous left ventricular assist device bridge to heart transplantation

Meta-Analysis on Left Ventricular Unloading With Impella in Patients With Cardiogenic Shock Receiving Venoarterial Extracorporeal Membrane Oxygenation

Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an effective mechanical circulatory support for cardiac insufficiency following cardiac surgery especially cardiac surgery with extracorporeal circulation, which can quickly restore the perfusion of vital organs. However, retrograde blood flow in the aorta during VA-ECMO may lead to increased left ventricular (LV) afterload, elevated LV filling pressure, mitral insufficiency, and elevated left atrial pressure, which may subsequently result in reduced coronary blood flow and pulmonary edema, thus aggravating the patient’s condition. Therefore, LV unloading is necessary during VA-ECMO. The optimal approach for LV unloading remains undefined, but the percutaneous access has been increasingly used over time. To addresss this issue, we have attempted to use cannulation of the subclavian artery for left ventricular unloading during VA-ECMO. This study aims to describe our method and report the preliminary results in three patients. Methods: Three patients with low cardiac output syndrome after cardiac surgery. All 3 patients had difficulty weaning from cardiopulmonary bypass (CPB) due to overfilling and contractile weakness of the heart, low mean arterial pressure<80mmHg, and left atrial pressure of >20 mmHg. Decision was made to start ECMO support immediately, and LV unloading was initiated via cannulation of the subclavian artery (Table 1). Given the differences in the surgical approaches and condition of patients, three methods were used to achieve LV unloading via the subclavian artery.Methods of LV unloading with cannulation via the subclavian artery during VA-ECMO in three patients with low cardiac output syndrome after cardiac surgery: 1) VA-ECMO with LV unloading via subclavian artery; 2) femoral vein-to-subclavian artery VA-ECMO with LV unloading via a 4-branched graft; 3) LV bypass via femoral artery-subclavian artery. Results: In all patients, the subclavian artery cannula was withdrawn at postoperative days 2-3, and ECMO was successfully weaned on postoperative day 4. One patient developed cardiac tamponade within 24 hour of surgery, echocardiography showed an LVEF of 55%. During an exploratory thoracotomy, a large amount of blood clot about 500 mL was found in the pericardium and removed, and the patient recovered uneventfully. Table 2 summarizes the postoperative courses of the 3 patients with different LV unloading methods. Conclusion: This study partly illustrated that LV drainage via the subclavian artery could safely and effectively reduce the LV load, prevent VA-ECMO-related complications, and minimize the risk of trauma and infection during LV examinations. Certainly, whether the subclavian artery approach is the optimal strategy for LV unloading as well as patient risks and benefits remains to be further investigated.Figure 1. ECMO + LV unloading schematic diagram of Case 1 (femoral artery + femoral vein+ subclavian artery)Figure 2. ECMO + LV unloading schematic diagram of Case 2 (femoral artery + femoral vein + four branches aortic graft)Figure 3. LV unloading schematic diagram of Case 2 (femoral artery + subclavian artery)

Evidence for the effectiveness of left ventricular (LV) unloading in patients who received venoaterial extracorporeal membrane oxygenation (VA-ECMO) for acute myocardial infarction (AMI) or non-AMI induced cardiogenic shock (CS) is limited. The aim of the present study was to compare the effect of LV unloading in AMI-induced and non-AMI-induced CS. This is a single-centre retrospective observational study of patients with CS undergoing VA-ECMO from January 2011 to March 2019. Patients were classified as AMI-induced and non-AMI-induced CS. The association of LV unloading with 90-day mortality in both groups was analysed using Cox proportional hazard regression analysis. Of the 128 CS patients, 71 (55.5%) patients received VA-ECMO due to AMI-induced CS, and the remaining 57 (44.5%) received VA-ECMO due to non-AMI-induced CS. The modality of LV unloading was predominantly with IABP (94.5%). In the AMI-induced CS group, LV unloading did not reduce 90-day mortality (adjusted hazard ratio 1.96, 95% confidence interval 0.90-4.27, P=0.089). However, in the non-AMI-induced CS group, LV unloading combined with VA-ECMO significantly reduced 90-day mortality (adjusted hazard ratio 0.37, 95% confidence interval 0.14-0.96, P=0.041; P for interaction=0.029) as compared with those who received VA-ECMO alone. LV unloading with VA-ECMO may reduce 90-day mortality compared with VA-ECMO alone in patients with non-AMI-induced CS, but not in AMI-induced CS.