Extracorporeal Support System Research Articles

Dengue-related acute liver failure-A scoping review.

Infection by dengue virus is common in tropical countries. Hepatic involvement in dengue can range from asymptomatic elevation of transaminases to life-threatening acute liver failure (ALF). Dengue-related ALF (DALF) is responsible for significant morbidity and mortality, especially in Southeast Asia. However, there is a scarcity of literature on DALF, necessitating a thorough examination of its clinical determinants and management strategies. All relevant studies related to DALF were reviewed until December 2023. Case reports, case series and studies reporting ALF in dengue infection were included. Demographics, clinical profiles, management and outcomes of DALF cases were analyzed, which revealed a predominance of DALF incidence in pediatric patients (1.1% to 15.8%) and an upward trend over the years, particularly in India. The proportion of ALF cases attributable to dengue was also higher among pediatric ALF patients (6.7% to 34.3%). Age ≤ 40years, persistent nausea, vomiting and elevated serum bilirubin and alkaline phosphatase (ALP) with aspartate aminotransferase (AST) > 1000IU/mL within the first five days of illness, more than 10% of atypical lymphocytes in peripheral blood, platelet count of < 50,000/cu·mm, severe hepatitis at presentation and baseline model for end-stage liver disease (MELD) > 15 were the risk factors for the development of DALF. Histopathological features of DALF included multi-lobular hepatic necrosis, steatosis and occasional cholestasis. Mortality in DALF ranged from 0% to 80%; admission pH and lactate strongly predicted mortality, while mortality was found to be significantly higher in patients with cirrhosis. N-Acetyl cysteine (NAC) has been used as a treatment modality with varying results. There is limited evidence regarding the use of extra-corporeal support systems, while candidate selection for liver transplantation (LT) in DALF remains poorly defined.

Development and First Clinical Use of an Extracorporeal Artificial Multiorgan System in Acute-on-Chronic Liver Failure Patients.

Multiple organ failure (MOF) is a common and deadly condition. Patients with liver cirrhosis with acute-on-chronic liver failure (AOCLF) are particularly susceptible. Excess fluid accumulation in tissues makes routine hemodialysis generally ineffective because of cardiovascular instability. Patients with three or more organ failures face a mortality rate of more than 90%. Many cannot survive liver transplantation. Extracorporeal support systems like MARS (Baxter, Deerfield, IL) and Prometheus (Bad Homburg, Germany) have shown promise but fall short in bridging patients to transplantation. A novel Artificial Multi-organ Replacement System (AMOR) was developed at the University of Washington Medical Center. AMOR removes protein-bound toxins through a combination of albumin dialysis, a charcoal sorbent column, and a novel rinsing method to prevent sorbent column saturation. It removes excess fluid through hemodialysis. Ten AOCLF patients with over three organ failures were treated by the AMOR system. All patients showed significant clinical improvement. Fifty percent of the cohort received liver transplants or recovered liver function. AMOR was successful in removing large amounts of excess body fluid, which regular hemodialysis could not. AMOR is cost-effective and user-friendly. It removes excess fluid, supporting the other vital organs such as liver, kidneys, lungs, and heart. This pilot study's results encourage further exploration of AMOR for treating MOF patients.

Impact of extracorporeal circulation support systems on blood product resources during the course of intensive care unit treatment

Abstract Background Extracorporeal circulatory support systems necessitate careful blood product management due to the large cannulas and exposure of blood components to artificial surfaces in the circuits. Blood component derangements can occur during implantation and the operational period of these systems, posing a significant complication. To enhance patient safety and bolster the body's own blood reserves, accurate characterization of the extent of necessary blood product substitution is imperative. Methods We analyzed data from consecutive patients who received extracorporeal circulatory support systems (Impella, veno-arterial extracorporeal membrane oxygenation (VA-ECMO), or ECMella) over a 5-year period (2016-2021). We obtained information on blood product usage, costs, and various clinical parameters. We assessed the vascular access site according to the Bleeding Academic Research Consortium (BARC) and Global Utilization of Streptokinase and tPA for Occluded Coronary Arteries (GUSTO) criteria, and hemolysis was evaluated using serum free hemoglobin (fHb). Results We studied 370 patients (Table 1) who received extracorporeal circulatory support systems (Impella, VA-ECMO, and ECMella) from 2016 to 2021. The median number of RBC transfusions was 7 (3 - 12) for the entire cohort, with ECMella patients requiring the highest amount (12.5 (6.7 - 27.5)) and VA-ECMO patients requiring the most within the first 24 hours (57%, p &amp;lt; 0.05). Hemolysis was present in all groups, with Impella patients having the highest levels (49.8 µmol / L (21.3 – 113.1), p &amp;lt; 0.01). ECMella patients required the highest overall blood product substitution (Figure 1) and incurred the highest associated costs (1642.4 EUR (1079.1 – 3660.3), p &amp;lt; 0.01). Bleeding complications in the groin area were moderate in 45% of patients, with VA-ECMO patients having the highest incidence (58%, p &amp;lt; 0.05). Type 3a bleeding according to the BARC criteria was most common (31.7%). Conclusion Although extracorporeal circulatory support systems have made technical advances, significant resources are still required during the operational period to maintain coagulation homeostasis, particularly in ECMella patients. Complications at the insertion site are also common, with bleeding being expected, especially in emergency situations when a VA-ECMO is used. To ensure patient safety, interdisciplinary teams should establish standardized follow-up protocols to detect peripheral complications early.

Acute-On-Chronic Liver Failure: Current Interventional Treatment Options and Future Challenges.

Acute-on-chronic liver failure (ACLF) is a frequent complication in patients with liver cirrhosis that has high short-term mortality. It is characterized by acute decompensation (AD) of liver cirrhosis, intra- and extrahepatic organ failure, and severe systemic inflammation (SI). In the recent past, several studies have investigated the management of this group of patients. Identification and treatment of precipitants of decompensation and ACLF play an important role, and management of the respective intra- and extrahepatic organ failures is essential. However, no specific treatment for ACLF has been established to date, and the only curative treatment option currently available for these patients is liver transplantation (LT). It has been shown that ACLF patients are at severe risk of waitlist mortality, and post-LT survival rates are high, making ACLF patients suitable candidates for LT. However, only a limited number of patients are eligible for LT due to related contraindications such as uncontrolled infections. In this case, bridging strategies (e.g., extracorporeal organ support systems) are required. Further therapeutic approaches have recently been developed and evaluated. Thus, this review focuses on current management and potential future treatment options.

Use of a surgically implanted, nondischargeable, extracorporeal continuous flow circulatory support system as a bridge to heart transplant

Introduction and objectivesWe aimed to describe the clinical outcomes of the use of the CentriMag acute circulatory support system as a bridge to emergency heart transplantation (HTx). MethodsWe conducted a descriptive analysis of the clinical outcomes of consecutive HTx candidates included in a multicenter retrospective registry who were treated with the CentriMag device, configured either for left ventricular support (LVS) or biventricular support (BVS). All patients were listed for high-priority HTx. The study assessed the period 2010 to 2020 and involved 16 transplant centers around Spain. We excluded patients treated with isolated right ventricular support or venoarterial extracorporeal membrane oxygenation without LVS. The primary endpoint was 1-year post-HTx survival. ResultsThe study population comprised 213 emergency HTx candidates bridged on CentriMag LVS and 145 on CentriMag BVS. Overall, 303 (84.6%) patients received a transplant and 53 (14.8%) died without having an organ donor during the index hospitalization. Median time on the device was 15 days, with 66 (18.6%) patients being supported for> 30 days. One-year posttransplant survival was 77.6%. Univariable and multivariable analyses showed no statistically significant differences in pre- or post-HTx survival in patients managed with BVS vs LVS. Patients managed with BVS had higher rates of bleeding, need for transfusion, hemolysis and renal failure than patients managed with LVS, while the latter group showed a higher incidence of ischemic stroke. ConclusionsIn a setting of candidate prioritization with short waiting list times, bridging to HTx with the CentriMag system was feasible and resulted in acceptable on-support and posttransplant outcomes.

HYBRID MODEL FOR TRAINING HYBRID EXTRACORPOREAL MEMBRANE OXYGENATION SPECIALISTS

<h3>Objectives</h3> The latest global pandemic highlighted the need to change and adapt the approach to extracorporeal membrane oxygenation (ECMO) support provision. As one of the most complex and specialised extracorporeal organ support systems, the provision of ECMO tends to be less flexible compared to other services. This abstract outlines a hybrid model of training specialised hybrid ECMO specialist staff that can form the base of running an ECMO service that can adapt to shifting demands. <h3>Design and Methods</h3> Our ECMO centre delivers regular courses for staff aiming to become ECMO specialists. The course is aimed at nurses who have completed their critical care specialisation and have worked in the critical care unit for at least six months. A two-day hybrid course provides them with theoretical knowledge, "wet labs" for hands-on skills and high-fidelity simulations of ECMO emergencies. The content of the course follows the one suggested by the guidelines published by the extracorporeal life support organisation (ELSO). All candidates must complete pre-course and post-course assessments and be signed off for essential practical competencies before working as independent ECMO specialists. In order to maintain the specialisation, they need to complete a fixed number of shifts to ensure adequate experience and exposure. <h3>Results</h3> ELSO recognises that a safe and economically sound model of ECMO provision includes not relying on ancillary services such as perfusion scientists and cardiac surgery. The preferred alternative is training and having experienced ECMO specialists at the bedside. An ECMO centre with hybrid staff that functions both as bedside critical care nurses and ECMO specialists allows for flexibility in changing demand for ECMO support. A set minimum of shifts that the ECMO specialists need to sustain the specialisation ensures that they have enough exposure to maintain safe practice. The hybrid approach to course delivery was dictated by the reality of needing to train the staff during the global pandemic. However, it has clear benefits social distancing aside. It allows for more flexibility and time to focus on practical aspects of caring for a patient on ECMO support. The option to complete theoretical studies at their own time and pace fits adult learning theory. Since the candidates are experienced critical care nurses, they are familiar with concepts of basic physiology, hence the lectures can focus specifically on the physiology of ECMO. A hybrid course design also takes into consideration the practical realities of delivering courses in circumstances requiring social distancing. Adequate progression between the pre-course and post-course tests guarantees engagement with the course material and the impact of the intervention. <h3>Conclusions</h3> As highlighted by international ECMO societies, there is a need to ensure the possibility of expanding ECMO capacity rapidly in case of emergencies. Having hybrid staff can allow the healthcare system to achieve that. Utilising hybrid training methods can help train more staff in a more economically and time-efficient way, even if options for in-person training are limited.

Extracorporeal membrane oxygenation and hemodynamics : Therapy is not only a friend of the heart

Extracorporeal support systems for the heart and lungs are employed for cardiac, pulmonary and also cardiopulmonary failure; however, neither the pure lung support by venovenous extracorporeal membrane oxygenation (vvECMO) nor the venoarterial (va) ECMO behave in ahemodynamically inert manner with respect to the patient's own cardiovascular system. The success of ECMO treatment is decisively dependent on monitoring before and during the execution and the pathophysiological understanding of the hemodynamic changes that occur during treatment. This article explicitly elucidates these "concomitant phenomena" and discusses fundamental aspects of cardiovascular physiology and the specific interplay with ECMO treatment.

Rationale and Design of JenaMACS-Acute Hemodynamic Impact of Ventricular Unloading Using the Impella CP Assist Device in Patients with Cardiogenic Shock.

Introduction: Cardiogenic shock due to myocardial infarction or heart failure entails a reduction in end organ perfusion. Patients who cannot be stabilized with inotropes and who experience increasing circulatory failure are in need of an extracorporeal mechanical support system. Today, small, percutaneously implantable cardiac assist devices are available and might be a solution to reduce mortality and complications. A temporary, ventricular, continuous flow propeller pump using magnetic levitation (Impella®) has been approved for that purpose. Methods and Study Design: JenaMACS (Jena Mechanical Assist Circulatory Support) is a monocenter, proof-of-concept study to determine whether treatment with an Impella CP® leads to improvement of hemodynamic parameters in patients with cardiogenic shock requiring extracorporeal, hemodynamic support. The primary outcomes of JenaMACS are changes in hemodynamic parameters measured by pulmonary artery catheterization and changes in echocardiographic parameters of left and right heart function before and after Impella® implantation at different support levels after 24 h of support. Secondary outcome measures are hemodynamic and echocardiographic changes over time as well as clinical endpoints such as mortality or time to hemodynamic stabilization. Further, laboratory and clinical safety endpoints including severe bleeding, stroke, neurological outcome, peripheral ischemic complications and occurrence of sepsis will be assessed. JenaMACS addresses essential questions of extracorporeal, mechanical, cardiac support with an Impella CP® device in patients with cardiogenic shock. Knowledge of the acute and subacute hemodynamic and echocardiographic effects may help to optimize therapy and improve the outcome in those patients. Conclusion: The JenaMACS study will address essential questions of extracorporeal, mechanical, cardiac support with an Impella CP® assist device in patients with cardiogenic shock. Knowledge of the acute and subacute hemodynamic and echocardiographic effects may help to optimize therapy and may improve outcome in those patients. Ethics and Dissemination: The protocol was approved by the institutional review board and ethics committee of the University Hospital of Jena. Written informed consent will be obtained from all participants of the study. The results of this study will be published in a renowned international medical journal, irrespective of the outcomes of the study. Strengths and Limitations: JenaMACS is an innovative approach to characterize the effect of additional left ventricular mechanical unloading during cardiogenic shock via a minimally invasive cardiac assist system (Impella CP®) 24 h after onset and will provide valuable data for acute interventional strategies or future prospective trials. However, JenaMACS, due to its proof-of-concept design, is limited by its single center protocol, with a small sample size and without a comparison group.

Effect of Thoraco-Abdominal Normothermic Regional Perfusion on Pulmonary Grafts in a Porcine Model of Warm Ischemic Injury

<h3>Purpose</h3> Thoraco-abdominal normothermic regional perfusion (TA-NRP) is a novel technique to recover organs from donors after circulatory death (DCD). By restarting regional circulation with an extracorporeal support system, the effects of warm ischemia can be mitigated and suitability for transplantation of the organs can be assessed. Little is known of the potential injury of TA-NRP on the pulmonary graft. We developed a porcine model of DCD TA-NRP and compared the potential injury on the pulmonary graft with lungs subjected to a short warm ischemic interval without TA-NRP. <h3>Methods</h3> 15 minutes after circulatory arrest (n=7), TA-NRP was initiated via central cannulation with clamped supra-aortic vessels. Lungs were ventilated at the start of TA-NRP (tidal volume 8 mL/kg, FiO2 at 40%, PEEP of 5cmH2O, respiratory rate of 15). After 60 minutes, TA-NRP was weaned and lungs were explanted. Control lungs (n=4, CTRL) were subjected to 15 minutes warm ischemia and explanted. We performed histological analysis and ex-vivo CT imaging. <h3>Results</h3> CT density of the TA-NRP lungs were comparable between CTRL and TA-NRP, indicating similar levels of water accumulation. Data are expressed in figure 1. In addition, histological assessment (scoring for interstitial and alveolar edema, hemorrhage, interstitial cell infiltration, intra-alveolar neutrophil infiltration and hyaline membrane) of CTRL versus TA-NRP did not differ. <h3>Conclusion</h3> In our porcine DCD model, TA-NRP did not affect lung quality compared to lungs only subjected to 15 minutes of warm ischemia. As it is known that lungs are more resistant to warm ischemia than other organs and that the outcome of DCD lung donation without TA-NRP is comparable to DBD lung donation, our findings open perspectives to further explore the potential of TA-NRP in lung transplantation.

Pharmacokinetics of Antibiotics in Pediatric Intensive Care: Fostering Variability to Attain Precision Medicine.

Children show important developmental and maturational changes, which may contribute greatly to pharmacokinetic (PK) variability observed in pediatric patients. These PK alterations are further enhanced by disease-related, non-maturational factors. Specific to the intensive care setting, such factors include critical illness, inflammatory status, augmented renal clearance (ARC), as well as therapeutic interventions (e.g., extracorporeal organ support systems or whole-body hypothermia [WBH]). This narrative review illustrates the relevance of both maturational and non-maturational changes in absorption, distribution, metabolism, and excretion (ADME) applied to antibiotics. It hereby provides a focused assessment of the available literature on the impact of critical illness—in general, and in specific subpopulations (ARC, extracorporeal organ support systems, WBH)—on PK and potential underexposure in children and neonates. Overall, literature discussing antibiotic PK alterations in pediatric intensive care is scarce. Most studies describe antibiotics commonly monitored in clinical practice such as vancomycin and aminoglycosides. Because of the large PK variability, therapeutic drug monitoring, further extended to other antibiotics, and integration of model-informed precision dosing in clinical practice are suggested to optimise antibiotic dose and exposure in each newborn, infant, or child during intensive care.

Patient transport and networks for use of extracorporeal life support

Neue Technologien und die kontinuierliche Weiterentwicklung extrakorporaler Unterstützungssysteme haben das Anwendungsspektrum des Extracorporeal Life Support (ECLS) in den letzten Jahren erweitert. Neben dem Einsatz im kardiogenen Schock oder unter Reanimation nehmen die Anfragen zur Übernahme instabiler Patienten aus peripheren Krankenhäusern zu. Durch organisatorische Herausforderungen wie die Etablierung von Netzwerken und ein strukturiertes Teamtraining aller Beteiligten ergibt sich eine rasche Verfügbarkeit des ECLS-Teams, um schnell beim zu versorgenden Patienten einzutreffen.

Development of Inspired Therapeutics Pediatric VAD: Benchtop Evaluation of Impeller Performance and Torques for MagLev Motor Design.

Despite the availability of first-generation extracorporeal mechanical circulatory support (MCS) systems that are widely used throughout the world, there is a need for the next generation of smaller, more portable devices (designed without cables and a minimal number of connectors) that can be used in all in-hospital and transport settings to support patients in heart failure. Moreover, a system that can be universally used for all indications for use including cardiopulmonary bypass (CPB), uni- or biventricular support (VAD), extracorporeal membrane oxygenation (ECMO) and respiratory assist that is suitable for use for adult, neonate, and pediatric patients is desirable. Providing a single, well designed, universal technology could reduce the incidence of human errors by limiting the need for training of hospital staff on a single system for a variety of indications throughout the hospital rather than having to train on multiple complex systems. The objective of this manuscript is to describe preliminary research to develop the first prototype pump for use as a ventricular assist device for pediatric patients with the Inspired Universal MCS technology. The Inspired VAD Universal System is an innovative extracorporeal blood pumping system utilizing novel MagLev technology in a single portable integrated motor/controller unit which can power a variety of different disposable pump modules intended for neonate, pediatric, and adult ventricular and respiratory assistance. A prototype of the Inspired Pediatric VAD was constructed to determine the hemodynamic requirements for pediatric applications. The magnitude/range of hydraulic torque of the internal impeller was quantified. The hydrodynamic performance of the prototype pump was benchmarked using a static mock flow loop model containing a heated blood analogue solution to test the pump over a range of rotational speeds (500-6000 RPM), flow rates (0-3.5L/min), and pressures (0 to ~420 mmHg). The device was initially powered by a shaft-driven DC motor in lieu of a full MagLev design, which was also used to calculate the fluid torque acting on the impeller. The pediatric VAD produced flows as high as 4.27L/min against a pressure of 127 mmHg at 6000 RPM and the generated pressure and flow values fell within the desired design specifications. The empirically determined performance and torque values establish the requirements for the magnetically levitated motor design to be used in the Inspired Universal MagLev System. This next step in our research and development is to fabricate a fully integrated and functional magnetically levitated pump, motor and controller system that meets the product requirement specifications and achieves a state of readiness for acute ovine animal studies to verify safety and performance of the system.

From activated charcoal to selective plasma exchange: A retrospective analysis of mushroom poisoning cases treated in the intensive care unit

Introduction: This study aims to evaluate presenting symptoms, clinical and laboratory findings, and treatment modalities of adult patients presenting with mushroom poisoning treated in the intensive care unit (ICU) with special consideration of extracorporeal liver support systems.&#x0D; Materials and methods: Records of patients with mushroom poisoning treated in the ICU between January 2007 and December 2014 were analyzed retrospectively.&#x0D; Results: Sixteen adult patients were treated in the ICU for mushroom poisoning during the designated study period. Presentation to the hospital was most common during October of each year. Average time from ingestion of mushrooms to first symptoms was 17.81 hours, and to ICU admission was 2.38 days. The most common symptoms were nausea, vomiting and diarrhea. The most common laboratory finding was elevation of liver transaminases. In cases with elevated liver transaminases, penicillin G, silibinin and N-acetyl cysteine were used. Extracorporeal support systems were used in 9 cases. Two cases underwent emergency liver transplantation.&#x0D; Conclusion: Liver transplantation is the most definitive and effective treatment in indicated cases of mushroom poisoning. Extracorporeal support systems should be considered in the early period both as a treatmet modality on their own or to save time until the definitive treatment is possible. The question of which extracorporeal detoxification technique to use is difficult to answer and controlled clinical trials which compare their efficacy are needed.

Argatroban dosing requirements in extracorporeal life support and other critically ill populations

Argatroban is a parenteral direct thrombin inhibitor that requires close monitoring to ensure safety and efficacy. Limited data exist to describe its effect in critically ill patients. This was a retrospective, single-center, cohort study that aimed to compare argatroban dosing requirements in those receiving extracorporeal life support (ECLS), continuous renal replacement therapy (CRRT), or neither. Organ dysfunction was assessed using a modified version of the Sequential Organ Failure Assessment (modSOFA) that incorporated the use of extracorporeal support systems. Eighty patients were included in the study (n = 20, 20, 40 in the ECLS, CRRT, and support-free groups, respectively). The majority of patients were Child-Pugh classification B (73%). Median modSOFA scores were higher in the ECLS (16.5) and CRRT (15.5) groups than in the support-free group (7.5) (P < .001). There was no difference in the primary outcome of first therapeutic argatroban dose between the three groups (0.5 μg/kg/min for each; IQRs 0.25–0.50, 0.11–0.50, and 0.25–0.50, respectively; P = .455). The ECLS group had the lowest mean (0.39 μg/kg/min), minimum (0.20 μg/kg/min), and final (0.43 μg/kg/min) doses. ECLS patients had more supratherapeutic aPTTs and dose changes overall, supporting the need for more frequent anticoagulation monitoring or dose reductions in this population. Total modSOFA score demonstrated a moderate inverse correlation with first therapeutic dose (dose = 0.54 – (modSOFA score × 0.012); R = −0.342, P = .002). Overall, initial argatroban doses of 0.3–0.5 μg/kg/min appear to achieve therapeutic aPTT values in the studied populations.

A Post Market Surveillance Study of the Hemovent Extracorporeal Cardiopulmonary Support System of Cardiac and Respiratory Support: The MOBYBOX Trial

A Post Market Surveillance Study of the Hemovent Extracorporeal Cardiopulmonary Support System of Cardiac and Respiratory Support: The MOBYBOX Trial

Using Patient Feedback to Drive Psychological Care in Awake Extracorporeal Life Support

Purpose The use of awake extracorporeal circulatory support (AECLS) systems, as a means of bridging to lung transplantation, was initiated in the UK at Harefield Hospital in 2011. This centre remains the only UK centre using this approach. Being awake whilst being bridged enables patients to optimize their physical health status pre transplant surgery by engaging in physiotherapy. When the programme was initiated, little was known about the impact of such an approach on the patient's psychological well-being and what psychological support might be beneficial. The aim was to understand the psychological needs of this patient cohort and employ patient feedback to enhance the care delivered to future patients undergoing AECLS. Methods The psychologist collated feedback from the experiences of patients and their relatives of AECLS in the intensive care unit. A framework for the psychological support of this cohort was developed. Engaging key stakeholders, including the physicians, surgical and nursing teams was important. Results The framework for psychological support in AECLS is supported by the team. All patients undergoing AECLS as a bridge to lung transplantation receive regular psychological support. The unit allows open visiting hours for this patient cohort in order to maximize the opportunities for social support and non- clinical activities. The team support “sunshine therapy”, where possible, to facilitate a change in environment for these patients. Children are actively encouraged to visit their parent on AECLS and pleasurable activities, such as film watching and painting, are supported with the patient and their children. The prophylactic use of a mood stabilizing medication is discussed with every patient being bridged on AECLS. Conclusion Bridging to lung transplantation via AECLS continues to evolve as a strategy in the UK. Attention to the psychological support required for these patients is paramount in ensuring they are able to engage in the process, thus optimizing their physical health status pre transplant surgery. With good psychological support, patient distress can be minimized at what is clearly a stressful time for them and their family. Patient experience feedback is a valid tool for driving the development of effective psychological care.

Use of vasopressors and inotropics in cardiogenic shock

Vasoactive drugs and inotropic agents are important for the hemodynamic management of cardiogenic shock. In this article the use of different vasoactive and ionotropic drugs in cardiogenic shock is presented. Hemodynamic management during cardiogenic shock occurs after initial moderate volume delivery by dobutamine to increase inotropism. If adequate perfusion pressures are not achieved norepinephrine is administered. If asufficient increase in cardiac performance can still not be achieved by the treatment, administration of levosimendan or phosphodiesterase (PDE) inhibitors may be necessary. Levosimendan is superior to PDE inhibitors for patients in cardiogenic shock. The aim of hemodynamic management in cardiogenic shock is to allow the transient use of inotropics and vasopressors in the lowest necessary dose and only as long as necessary. The daily question is whether the dose can be reduced or in the case of deterioration whether the use of an extracorporeal circulatory support system should be considered. There are currently no available data on mortality that demonstrate the benefit of hemodynamic monitoring using target criteria. The advantage, however, results from the economic use of inotropics and vasopressors by certain target criteria.

Update cardiogenic shock

Although IABP support induces left ventricular unloading, these beneficial effect does not lead to improved microcirculation and survival. The use of percutaneous extracorporeal support systems (ECLS, ECMO) as well as left ventricular assist devices (pVAD) for adjunctive treatment of STEMI has increased during the recent years, but without sufficient evidence for a survival benefit. The PCI-access via the radial artery may lead to improved outcomes, especially in regard to survival. A liberal transfusion regimen for red cell packages in the perioperative phase of cardiac surgery seems to improve outcomes in regard to lower incidence of cardiogenic shock postoperatively.

17 Outcome of extra-corporeal life support for fulminant heart failure/cardiogenic shock

Background Fulminant heart failure (so called ‘crash and burn’) are associated with a grim prognosis, and the outcomes of ventricular assist device (VAD) implantation in this group are poor. Accordingly extracorporeal life support (ECLS) systems have emerged as options for stabilisation of these patients allowing for a more definitive intervention at a later stage (‘bridge to decision’ or ‘bridge to bridge’). Aim and methods To evaluate ECLS outcomes for fulminant heart failure / cardiogenic shock (CS) and to compare these with ECLS outcomes for other indications. A systematic review of all cases of ECLS for cardiac indications in one institution since program inception was undertaken. Results Between 2009 and 2015, 37 patients underwent cardiac ECLS (Cardiohelp® Maquest, Germany) for a median of 5 days range (range: 1–13 days) and a total of 193 ELCS days. Fourteen patients (37%) had CS, 16 patients (43%) had post-cardiotomy cardiogenic shock (PCCS) and 7 patients (19%) had ECLS during cardiopulmonary resuscitation (ECPR). Survival to hospital discharge was 75% and 57% among the PCCS and ECPR groups respectively. Of the 14 CS patients, 3 (21%) survived, one to hospital discharge (‘bridge to recovery’) and 2 to VAD implantation as bridge to transplantation (‘bridge to bridge’). The remaining 11 CS patients were deemed unsuitable for further intervention and did not survive. Conclusion ECLS for fulminant heart failure can be life saving. However, expectations should be tempered by the fact that overall outcomes in this group remains poor. While certain presentations, such as fulminant myocarditis, can neither be prevented nor predicted, in less acute situations timely recognition of patients who might ultimately require cardiac transplantation is desirable.

Implementing an Innovative Cardiac Assist System in a Nonuniversity Hospital--Feasibility, Complications, and First Results.

To evaluate the feasibility of implementing a cardiac assist system in a nonuniversity hospital we analyzed 18 consecutive patients treated with venoarterial membrane oxygenation. The system was used electively in 5/18 (27.8%) patients during high-risk interventions. Thirteen patients (72.2%) were treated in emergency situations. The extracorporal system could be initiated successfully in all patients. Periprocedural complications were hemolysis in 3/18 (16.7%), disseminated intravascular coagulation in 2/18 (11.1%), cerebral ischemia in 1/18 (5.6%), and local infection in 2/18 (11.1%) patients. None of these led to a discontinuation of the therapy. All electively treated patients were successfully weaned from the extracorporeal system. In 9/13 (69.2%) emergency patients the system was removed successfully. The 60-day survival rate of the emergency patients was 53.8% (7/13). Our experience confirms that an innovative extracorporeal circulatory support system can be implemented in a nonuniversity hospital at a tolerable risk and a low complication and high procedural success rate.