Acute Biventricular Failure Research Articles

Life-saving VA-ECMO treatment for pericardial decompression syndrome with acute biventricular failure: a case report

Life-saving VA-ECMO treatment for pericardial decompression syndrome with acute biventricular failure: a case report

Modelling chemotherapy-induced cardiotoxicity with live myocardial slices: from bedside to bench and back again

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Netherlands Heart Institute & Dutch Heart Foundation (Dekker Senior Clinical Scientist 2019) Introduction Cancer therapy related cardiac dysfunction (CTRCD) is a common side-effect of many oncological regimens. The prevention, diagnosis and treatment of CTRCD requires a well-orchestrated management by a multidisciplinary team composed by oncologists, cardiologists, radiologists, but less often translational scientists. Purpose In this work, we investigated the translational potential of live myocardial slices derived from a patient presenting with acute biventricular failure, with no history of cardiovascular disease, who had previously received neo-adjuvant chemotherapy containing doxorubicin (240 mg/m2) and trastuzumab, for the treatment of a breast carcinoma. In contrast to anthracycline cardiotoxicity, which is often permanent, cardiac dysfunction caused by trastuzumab is commonly reversible after cessation of treatment. Herein, we provide a novel side-by-side comparison of myocardial function ex vivo and clinical outcomes in the patient. Methods After several days on extracorporeal life support and inotropic therapy, the patient’s cardiac function did not improve. The patient was ultimately implanted with a left- and right-ventricular assist device (LVAD and RVAD, respectively). Live myocardial slices were produced from the apical biopsy obtained during LVAD implantation and cultured in a biomimetic system under physiological mechanical and electrical conditions. Slices were subsequently exposed to doxorubicin, trastuzumab or vehicle (0.1% DMSO) for a continued period of 7 days. Contractile force was recorded continuously, and a custom-made stimulation protocol applied every 24h. To evaluate responsiveness to inotropes, slices were incubated with milrinone before culture termination. Calcium transients and action potentials were determined optically using calcium and voltage-sensitive dyes. Results Continued exposure to either doxorubicin or trastuzumab limited the recovery of contractility in myocardial slices. In contrast, vehicle controls showed a robust recovery and development of stronger contractile forces. Doxorubicin-treated slices were less responsive to stimulation, displayed increased stimulation threshold and were less able to follow pacing at higher frequencies. Optical mapping revealed that exposure to doxorubicin led to the development of abnormal calcium handling. In parallel to the ex vivo findings, RVAD/LVAD-mediated cardiac unloading and the absence of any chemotherapy drug, resulted in a significant recovery of right-ventricular function, enabling RVAD removal within 2 weeks. Conclusions The complex nature of chemotherapy-induced cardiotoxicity imposes numerous challenges in clinical decision-making. In this unique case, patient care could be paralleled by concomitant state-of-the-art ex vivo tissue culture. We observed that myocardial tissue slices could partially recapitulate clinical observations, highlightings the promising synergy between translational science and personalized patient care.

(1136) - Fulminant Lymphocytic Myocarditis with Acute Biventricular Failure: The Role of Mechanical Circulatory Support

(1136) - Fulminant Lymphocytic Myocarditis with Acute Biventricular Failure: The Role of Mechanical Circulatory Support

Test Bench for Right Ventricular Failure Reversibility: The Hybrid BiVAD Concept.

When heart transplantation and myocardial recovery are unlikely, patients presenting with biventricular cardiogenic shock initially treated with extracorporeal membrane oxygenation (ECMO) may benefit from a mechanical support upgrade. In this scenario, a micro-invasive approach is proposed: the combination of the double-lumen ProtekDuo cannula (Livanova, London, UK) and the Impella 5.5 (Abiomed, Danvers, MA) trans-aortic pump that translates into a hybrid BiVAD. All consecutive ECMO patients presenting with biventricular cardiogenic shock and ineligibility to heart transplantation from August 2022 were prospectively enrolled. The clinical course, procedural details, and in-hospital events were collected via electronic medical records. A total of three patients, who were temporarily not eligible for heart transplantation or durable LVAD due to severe acute pneumonia and right ventricular (RV) dysfunction, were implanted with a hybrid BiVAD. This strategy provided high-flow biventricular support while pulmonary function ameliorated. Moreover, by differentially sustaining the systemic and pulmonary circulation, it allowed for a more adequate reassessment of RV function. All the patients were considered eligible for isolated durable LVAD and underwent less invasive LVAD implantation paired with a planned postoperative RVAD. In all cases, RV function gradually recovered and the RVAD was successfully removed. The Hybrid BiVAD represents an up-to-date micro-invasive mechanical treatment of acute biventricular failure beyond ECMO. Its rationale relies on more physiological circulation across the lungs, the complete biventricular unloading, and the possibility of including an oxygenator in the circuit. Finally, the independent and differential control of pulmonary and systemic flows allows for more accurate RV function evaluation for isolated durable LVAD eligibility reassessment.

Recovery of RV Function Determines Outcomes of Extracorporeal Biventricular Support for Acute Biventricular Failure

<h3>Purpose</h3> Mechanical circulatory support for acute biventricular failure is challenging. Given that durable VAD is available only for LV support as bridge-to-transplantation in Japan, the treatment options for this pathology are limited to extracorporeal biventricular assist device (BiVAD) support first, which can be subsequently upgraded to durable LVAD in cases having recovery of RV function and transplant candidacy. The purpose of this study was to review the outcomes of extracorporeal BiVAD and to explore factors associated with the outcomes. <h3>Methods</h3> This study enrolled an institutional consecutive series of 39 cases who underwent extracorporeal BiVADs implantation for acute biventricular failure between April 2014 and October 2020. The etiological diagnosis was myocarditis in 27 cases, acute MI in 6 cases, and dilated cardiomyopathy (DCM) in 6 cases. The cases were assigned into the two groups according to the BiVAD support less than 7 days (n=18, Short group) or 7 days or more (n=21, Long group). The Long group consisted of 6 cases of acute MI (100%), 13 cases (48%) of myocarditis, two cases of DCM (33%). <h3>Results</h3> There was no case who deceased within 7 days after BiVAD implantation. In the Short group, extracorporeal LVAD was weaned-off in 11 cases (61%) or upgraded to durable LVAD in 6 cases after withdrawal of RV support within 7 days. The remaining one case deceased under extracorporeal LVAD. In the Long group, RV support was discontinued in 10 cases in the median support of 60 days (IQR; 24.2-76.8), while two cases were on BiVAD support at October 2020. The remaining nine cases (43%) deceased under BiVAD support in-hospital. Survival and VAD-free survival at 1 year were 79% and 56% in the Short group versus 48% and 20% in the Long group, respectively. <h3>Conclusion</h3> Outcomes of extracorporeal BiVAD support for acute biventricular failure were dependent on recovery of RV function. Targeting approach for RV function would be warranted for poor biventricular function.

CARDIOGENIC SHOCK IN THYROID STORM: A BIVENTRICULAR IMPELLA APPROACH

Acute biventricular failure in the setting of thyroid storm is rare, but is associated with a significant in-hospital mortality. Given the limited options for medical therapy, assessment for and implementation of mechanical circulatory support plays an integral role in patient outcomes. A 31 year

P1688 Rare cause of acute heart failure in patient with scleroderma

Abstract A 32-year old female patient, known to have scleroderma, presented with symptoms of recurrent attacks of palpitations, dyspnea (NYHA class III) &amp; dizziness for 3 days before presentation. No chest pain or syncope. Physical examination at presentation revealed hemodynamic instability (BP: 80/50 mmHg, HR: 200 bpm/ regular thready pulse with fine bilateral basal chest crackles. ECG revealed ventricular tachycardia (figure 1), so electrical cardioversion was immediately done upon which the reverted to multifocal atrial tachycardia with RBBB and restoration of hemodynamics and disappearance of chest crackles. She also had thickening of the fingertips’ skin, amputated tip of the right middle finger with severe associated Raynaud’s phenomenon, skin tightness of both upper and lower limbs, Buccal buckling with limited mouth opening (figure 2 and 3). Renal function and serum electrolytes were normal with elevated troponin I, creatine kinase and CK-MB serum levels. Echocardiogram showed mild concentric LV hypertrophy with normal internal dimensions and severely impaired systolic function (EF∼ 20%) with severe global hypokinesia . The RV was also dilated and impaired (TAPSE∼8 mm). Mild pericardial effusion with no chamber collapse (Figure 4, 5 and 6). Coronary angiography revealed normal epicardial coronaries. Echocardiography one month prior to presentation revealed normal LV dimensions, preserved systolic function and mild diastolic dysfunction with no resting wall motion abnormalities, upper normal RV size with preserved RV systolic function and mild elevation of pulmonary artery systolic pressure. The presence of new acute biventricular failure in the absence of CAD and elevated cardiac biomarkers are highly suggestive of acute myocarditis. Medical therapy included loop diuretics, angiotensin-converting-enzyme inhibitor, beta-blocker and aldosterone receptor antagonist. She was discharged in NYHA I-II, with normal cardiac enzymes and left ventricle ejection fraction of 30% and resolution of the pericardial effusion. Discussion Scleroderma is rarely present with impaired LV contractility but more commonly presented with diastolic dysfunction (in up to 40% of cases) (1,2). This case was presented with acute myopericarditis with severe biventricular systolic dysfunction which is very rare with scleroderma and only mentioned in few case studies, so no consensus on specific treatment. Few patients with myocarditis and scleroderma were treated with immunosuppressants along with diuretics, beta-blockers, and ACE inhibitors with most of them showed improvement clinically with recovery of systolic function after 12 months of follow up (3). We noted improvement of patient symptoms within few days of diuretics, beta-blockers, Aldosterone antagonists and ACE inhibitors. This case had baseline conduction abnormalities (RBBB with multifocal atrial tachycardia) which could be present in up to 20% of cases (4). Abstract P1688 Figure.

Clipping Barlow&rsquo;s mitral valve to rescue a patient with acute biventricular failure.

Percutaneous edge-to-edge mitral repair with the MitraClip device is an alternative therapy for patients with severe mitral regurgitation. Given that Barlow's disease is characterised by multiple prolapsed segments and multiple regurgitant jets, the MitraClip is not recommended. Herein, we present the case of a 42-year-old gentleman who suffered acute biventricular failure due to a primary chordae rupture of Barlow's mitral valve. Because of prohibitive surgical risk, he was successfully rescued using transcatheter edge-to-edge mitral repair. Our critical case may demonstrate the feasibility of MitraClip use as a rescue therapy for patients with acute severe mitral regurgitation.

Anaphylactic shock versus Kounis syndrome in cardiac surgery: Differential diagnosis

Although Kounis syndrome was described almost 3 decades ago, there has been a notable increase in the reports of cases of acute coronary syndromes developed in the context of allergic reactions, also known as Kounis syndrome. This article discusses the diagnostic possibility in the face of an acute biventricular failure in the course of an anaphylactic reaction during the intra-operative period of a cardiac valve surgery.

Case Report: Acute Biventricular failure and Cardiopulmonary arrest due to Acute Fulminant myocarditis in Young patient

Case Report: Acute Biventricular failure and Cardiopulmonary arrest due to Acute Fulminant myocarditis in Young patient

Сardiovascular autonomic neuropathy as a diabetes complication

The article deals with one of the possible complications of diabetes mellitus - cardiovascular autonomic neuropathy as a variant of diabetic neuropathy. The basic pathogenic mechanisms of development of this condition and clinical manifestations depending on the patient’s age, duration and degree of diabetes compensation, are described. Diagnostic criteria for heart involvement in diabetes mellitus are discussed in detail, from asymptomatic course to sudden patient’s death, from instrumental findings to acute biventricular failure development. The main findings from patient’s work-up (ECG, echocardiography) are named. The principles of prevention and treatment of heart disease in diabetes mellitus are provided. Theory is accompanied by our own clinical observation and is illustrated with ECG. In the clinical case tactics of treatment and prevention of diabetic cardiopathy are suggested.

HVAD continuous flow assist device for ischemic ventricular septal rupture

HVAD continuous flow assist device for ischemic ventricular septal rupture

Acute Biventricular Failure as a Sequela of Multiple Autoimmune Disorders

In this case, uncharacteristic clinical and laboratory findings led to an unanticipated diagnosis for a 24-year-old woman admitted for new-onset heart failure with features suggesting cardiac tamponade. Concomitant diagnosis of progressive mixed connective tissue disease associated with severe hypothyroidism was made. Despite early recognition (based on clinical and pathologic features) and rapid management (with glucocorticoids, thyroxine, metoprolol, lisinopril, furosemide, and milrinone), she deteriorated and died within 4 weeks.

558 Comparative Study between Cavopulmonary Anastomosis Associated with Left Ventricular Assist Device Support and Biventricular Circulatory Assistance in Acute Biventricular Failure

558 Comparative Study between Cavopulmonary Anastomosis Associated with Left Ventricular Assist Device Support and Biventricular Circulatory Assistance in Acute Biventricular Failure

Thoratec paracorporeal biventricular assist device therapy: the Freiburg experience

The treatment of severe biventricular (BV) contractile failure using mechanical circulatory support is challenging. We analyzed our center's results following implantation of a biventricular assist device (BVAD). We implanted 39 BVADs between September 2001 and January 2009. All patients were qualified candidates for heart transplantation, without an organ available at time of BVAD implantation. Fifteen patients without a history of chronic cardiomyopathy suffered from acute BV failure (group 1), whereas the other 24 suffered from severe chronic cardiomyopathy (group 2). The indication for BVAD implantation was determined in reference to echocardiography, the degree of end-organ damage, and whether the patient qualified for a heart transplant or was a candidate for bridge to recovery. Both groups were similar regarding their preoperative hemodynamics, intraoperative and early postoperative findings, and adverse events. Patients in group 1 were younger (mean age 37±17 years) than those in group 2 (51±12 years). Mean duration of support in group 1 was 137±109 days, and 65±61 days in group 2. In group 1, 33% (5/15) were weaned off the device and 53% (8/15) underwent heart transplantation, whereas 8/24 patients (42%) in the chronic group were transplanted. Group 1's mortality on the device was lower than that of group 2 (13% vs 67%). Furthermore, 11 patients of group 1 survived for 1 year compared with four in group 2 (73% vs 17%). Implantation of a BVAD in patients with chronic heart failure and acute decompensation is associated with a high mortality and morbidity rate. By contrast, BVAD implantation can achieve excellent results in patients with acute BV failure without a history of chronic cardiomyopathy, even if they are in cardiogenic shock upon admission.

185: Cavopulmonary Anastomosis Improves Left Ventricular Assist Device Support in Acute Biventricular Failure

185: Cavopulmonary Anastomosis Improves Left Ventricular Assist Device Support in Acute Biventricular Failure

Cardiovascular Collapse During Living-Directed Orthotopic Liver Transplantation Associated With the Transfusion of Contaminated Red Blood Cells

LOOD TRANSFUSION HAS many documented risks. Anesthesiologists administer more than half of the transfusions in the United States. In 2004, about 22 million blood components were transfused in the United States. Patients undergoing liver transplant often require multiple blood components. A fatal complication of transfusion during liver transplantation because of Klebsiella contamination of a unit of red blood cells is reported. CASE REPORT A 53-year-old man with end-stage liver disease secondary to hepatitis C virus and alcoholic cirrhosis presented for living-directed orthotopic liver transplantation (OLTx). Physical examination revealed a 109-kg man with blood pressure of 101/70 mmHg, heart rate of 72 beats/min, and respiratory rate of 18 beats/min. The patient was mildly jaundiced and appeared chronically ill. Secondary to his cirrhosis, he also had ascites, hepatic encephalopathy, and esophageal varices. The patient had undergone a splenectomy many years ago after a motor vehicle accident. His end-stage liver disease score was 17. The patient’s younger brother was in excellent health and would serve as the liver donor. General anesthesia was induced with sodium thiopental and fentanyl, and endotracheal intubation was facilitated by rocuronium. Anesthesia was maintained with isoflurane, fentanyl, and pancuronium. Femoral and radial artery catheters were placed, and pulmonary artery catheterization was performed with an oximetric catheter using the right internal jugular vein. Vital signs before incision were unremarkable. The patient’s abdomen was opened through a bilateral subcostal incision, and multiple dense adhesions were encountered. With portal hypertension, the subsequent adhesionolysis was associated with significant blood loss, and the patient received 16 U of packed red blood cells (PRBCs) and 38 U of fresh frozen plasma. Eventually, the porta hepatis was isolated, and the hepatectomy was completed without incident. After hepatectomy, a temporary end-to-side portocaval shunt was constructed to decompress the portal venous system while work on the right lobe liver graft was completed. Hemostasis at this point in the procedure was excellent, and the patient’s hemodynamic status was unremarkable with blood pressure of 100/70 mmHg, heart rate of 90 beats/min, and pulmonary artery pressure of 28/15 mmHg. Significant laboratory studies revealed a hemoglobin of 6.1 g/dL, and the patient was transfused an additional unit of PRBCs. During the administration of this last unit of PRBCs, the patient became abruptly tachycardic with profound systemic hypotension (to 40/20 mmHg) and pronounced pulmonary hypertension (to 70/40 mmHg) consistent with acute biventricular failure and massive peripheral vasodilatation. On examination, the patient also had a mottled appearance. After several seconds, the patient’s heart rate slowed, and he became asystolic. The blood transfusion was stopped, and resuscitation was initiated with epinephrine. The patient did not respond to a total of 3 mg of epinephrine and 20 units of vasopressin administered over approximately 3 minutes so a midline sternotomy was urgently performed and the patient was placed on cardiopulmonary bypass (CPB). The authors estimate that the patient was without perfusion for 15 minutes. Despite flow of greater than 6 L/min and aggressive pharmacologic support including norepinephrine, 15 g/min, and vasopressin, 0.04 U/min for 5 hours, the patient remained profoundly hypotensive and acidotic (final pH 7.0, base deficit 18) despite treatment with sodium bicarbonate. The patient died secondary to refractory hypotension and the inability to establish a cardiac rhythm. A culture of the blood remaining in the unit of PRBCs at the time of the patient’s cardiovascular collapse revealed Klebsiella pneumoniae in less than 14 hours. An endotoxin assay on the donor blood was markedly positive at 632 EU/mL. A culture of the patient’s blood also revealed K pneumoniae. A transfusion of pooled platelets at another hospital that included the platelet concentrate derived from the same donor unit resulted in a transfusion reaction of an increase in temperature greater than 3°C. Although the fever was attributed to the platelet transfusion, no further evaluation of the platelets was performed. Unfortunately, the platelets were not cultured. The local collection facility contacted the donor who did not report any recent infections and remained asymptomatic. No other follow-up studies were performed on the donor.

Unusual Ventilation-Perfusion Scintigraphy in Adult Respiratory Distress Syndrome Secondary to Acute Lupus Myocarditis

A 40-year-old Cambodian woman with newly diagnosed systemic lupus erythematosus developed acute biventricular failure and deteriorated rapidly despite high-dose immunosuppression. Due to persistent hypoxia and elevated pulmonary pressures on echocardiogram, a Tc-99m ventilation-perfusion scan was performed. The scan suggested a high probability of pulmonary emboli. Prior to the commencement of anticoagulation, the patient had a cardiac arrest and was unable to be resuscitated. Post mortem examination confirmed myocarditis. Lung tissue showed prominent, thickened alveolar membranes and inflammation of all lobes, consistent with adult respiratory distress syndrome. There was no evidence of pulmonary emboli or vasculitis affecting the lungs. The authors show an unusual cause for a high-probability lung scan.

Potentialities and problems of a novel bilateral ventricular assist system without thoracotomy.

Mechanical cardiac assistance can be critical in saving the lives of patients with acute cardiac failure. However, currently used methods of ventricular assistance require advanced technical knowledge and equipment, and only small numbers of patients can be provided with them. Our aim was to develop new cannulas to construct a less invasive biventricular assist system that would permit easy application without thoracotomy. We prepared 2 centrifugal pumps and 4 uniquely shaped cannulas and conducted experiments to investigate the potential and problems of the system. In the first experiment, the system was attached to 6 dogs with ventricular fibrillation to confirm whether our system could maintain cardiac output. In the second experiment, the system was installed for 3 days in 3 goats, and changes in aminotransferases, BUN, creatinine, and plasma free hemoglobin levels were examined. In Experiment 1, it was demonstrated that the system was able to maintain circulation in dogs. In Experiment 2, although the flow rate of the pumps was maintained over 3 days, increased hemolysis and deteriorating renal function were observed. Although these problems need to be solved, the system was still helpful in the management of acute biventricular failure for short periods and may be clinically useful in the near future.

Effects of right ventricular failure on renal function during pneumatic left ventricular assist.

In an experiment dog model of acute biventricular failure, the effects of left ventricular (LV) assist on renal hemodynamics and function were evaluated. After the induction of severe cardiac failure by multiple ligation of the coronary arteries, LV assist with a 40 ml pneumatic pulsatile pump was initiated, and the aortic flow was maintained at control values. The right atrial pressure (RAP) rose to 21.3 mm Hg with the appearance of profound right ventricular (RV) failure. Renal arterial blood flow (RAF) decreased to about 60% of the control value after 2 h of LV assist. The urine volume decreased and renal function deteriorated progressively. RV assist decreased the RAP to 4.8 mm Hg, and the reduced RAF recovered. After 3 h of RV assist, the RAF returned to initial values and the urine volume increased, but renal function did not recover. Advanced biventricular failure with elevated RAP during LV assist reduced renal perfusion and impaired renal function and may be an indication for early RV assist.