Postoperative Cardiogenic Shock Research Articles

Effectiveness of VA-ECMO plus intra-aortic balloon pump for cardiac shock in patients with type A aortic dissection: a case series

Limited reports exist on the utilization of venoarterial extracorporeal membrane oxygenation (VA-ECMO) following aortic dissection surgery, possibly due to concerns regarding complications. This case series aimed to evaluate the effectiveness and safety of using VA-ECMO in combination with intra-aortic balloon pump (IABP) for managing postoperative cardiogenic shock in patients with type A aortic dissection (AAD). The study included nine patients with an average age of 57.0 ± 9.5 years. The patients underwent various surgical procedures, including coronary artery bypass grafting (CABG) and aortic root reconstruction. The results showed that the combined use of VA-ECMO and IABP was feasible and effective in managing postoperative cardiogenic shock in AAD patients. However, the in-hospital mortality rate was high, with six out of nine patients succumbing to the condition. Among the patients who received VA-ECMO plus IABP in the operating room, four were successfully weaned from VA-ECMO, and three survived with a mean follow-up of 20 months. The study also highlighted the potential risks of renal complications associated with VA-ECMO and IABP. The findings suggest that the combined therapy of VA-ECMO and IABP may be beneficial for patients who have difficulty weaning from cardiopulmonary bypass (CPB) after AAD surgery.

Management and clinical outcomes of cardiogenic shock in King Abdulaziz University Hospital: A retrospective study.

To assess frequencies of various management approaches in cardiogenic shock (CS) and their clinical outcomes. Cardiogenic shock is a state of organ hypoperfusion and hypoxia caused by cardiac failure. In this retrospective record review, we assessed the presentations, vital signs, laboratory readings, and treatments for 188 consecutive CS inpatients from 2010-2021. Patients were labeled as "ischemic CS" or "non-ischemic CS" based on the occurrence of myocardial infarction as the precipitating cause, and "post-operative CS" if they had undergone cardiac surgery. In-hospital mortality was the primary endpoint of the study. We identified 118 (62.8%) ischemic, 64 (34%) non-ischemic, and 6 (3.2%) postoperative CS patients. The study population had a high mortality rate (85.1%). Logistic regression analysis revealed that dopamine (p=0.040) and epinephrine (p=0.001) were independent predictors of mortality, while dobutamine (p=0.004) and digoxin (p=0.044) associated with increased survival. No significant association with mortality was found between either PCI or IABP. No significant difference in mortality was observed between CS subgroups. Variations in outcomes occurred with different medications. Mortality was higher in patients receiving dopamine or epinephrine and lower in those receiving dobutamine or digoxin. Implementation of clinical trials for investigation of the mortality benefit observed with dobutamine can serve towards formulation of new guidelines for improvement of CS mortality rates.

Comparison between Intra-Aortic Balloon Pump and Levosimendan as Treatment Modalities for Cardiogenic Shock Post Cardiac Surgery

Purpose: Post cardiac surgery cardiogenic shock is one of the major life threatening complications of open heart surgeries. Two modalities are widely used to improve the cardiac output and overcome the acute postoperative complication beside other conventional treatment including mechanical ventilator, inotropes and vasopressors. Those modalities are levosimendan and Intra-aortic balloon pump. The purpose of this study is to investigate the prognosis of levosimendan vs IABP in patients who developed cardiogenic shock post cardiac surgery.
 Methodology: This was a prospective observational study conducted as national heart institute, Egypt on 50 patients who developed cardiogenic shock post cardiac surgery and managed by either levosimendan or Intra-aortic balloon Pump (IABP) beside other conventional therapies. Patients were then divided into two groups according to the modality used. Group I: patients who were managed by levosimendan and group II: patients who were managed by IABP. Two groups were then compared according to baseline preoperative characteristics and in-hospital course and one month follow up post discharge echocardiography.
 Findings: No significant difference regarding between in-hospital mortality between levosimendan, 44% and IABP, 52% P value 0.5. Levosimendan was associated with significantly shorter ICU stay, 5.56±2.85 compared to IABP, 8±3.34 days (P value 0.02). Levosimendan seems to be a better option than IABP or at least equivalent to it in postoperative cardiogenic shock.
 Recommendations: Levosimendan is an alternative cost effective modality for patients with post-operative low cardiac output syndrome especially when IABP isn’t available.

N-Terminal of the Prohormone Brain Natriuretic Peptide Predicts Postoperative Cardiogenic Shock Requiring Extracorporeal Membrane Oxygenation.

Aims: Heart valve surgery is associated with a risk of serious postoperative complications including postoperative cardiogenic shock (described as postcardiotomy shock (PCS)). The indication for extracorporeal membrane oxygenation (ECMO) is cardiogenic shock, which is resistant to optimal causal and pharmacological treatment, including the supply of catecholamines and/or an intra-aortic balloon pump (IABP). The aim of this study was to assess the usefulness of the selected preoperative biomarkers in the prediction of postoperative cardiogenic shock requiring ECMO in patients undergoing heart valve surgery. Methods: A prospective study was conducted on a group of consecutive patients with significant valvular heart disease that underwent elective valve surgery. The primary endpoint at the intra-hospital follow-up was postoperative cardiogenic shock requiring ECMO. Univariate analysis, followed by multivariate regression analysis, were performed. Results: The study included 610 patients. The primary endpoint occurred in 15 patients. At multivariate analysis, the preoperative N-terminal of the prohormone brain natriuretic peptide (NT-proBNP) level (OR 1.022; 95% CI 1.011–1.034; p = 0.001) remained an independent predictor of the primary endpoint. Conclusions: An elevated NT-proBNP level was associated with a higher risk of postoperative cardiogenic shock requiring the use of ECMO.

Preventive Impella® Support in High-Risk Patients Undergoing Cardiac Surgery

Background: Patients with severely reduced LV-EF ≤ 30% undergoing CABG have a high risk for postoperative cardiogenic shock. The optimal timing of an adequate hemodynamic support has an impact on short- and midterm mortality after CABG. This study aimed to assess the prophylactic use of the Impella pump in high-risk patients undergoing elective cardiac surgery. Methods: In this single-center retrospective study, 14 patients with LV-EF (≤30%) undergoing cardiac surgery received a prophylactic, perioperative Impella (5.0, 5.5) support between 2020 and 2022. Results: The mean age at surgery was 64.2 ± 2.6 years, the mean preoperative LV-EF was 20.7% ± 1.56%. The duration of Impella support was 4 (3–7.8) days and the 30-day survival rate was 92.85%. Acute renal failure occurred in four patients who were dialyzed on average for 1.2 ± 0.7 days. Mechanical ventilation was needed for 1.75 (0.9–2.7) days. Time to inotrope/vasopressor independence was 2 (0.97–7.25) days with a highest lactate level (24 h postoperatively) of 3.8 ± 0.6 mmol/l. Postoperative LV-EF showed a significant improvement when compared to preoperative LV-EF (29.1% ± 2.6% vs. 20.7% ± 1.56% (p = 0.022)). Conclusion: The prophylactic Impella application seems to be a safe approach to improve the outcomes of this patient population.

P42: Institutional Review of Temporary Circulatory Support Configurations for Cardiogenic Shock

Patients experiencing cardiogenic shock continue to suffer a high mortality risk despite advances and innovation in temporary mechanical circulatory support (MCS). Providers now have many tools in the armamentarium to support patients in varied etiologies of cardiogenic shock ranging from acute coronary syndrome, non-ischemic cardiomyopathy (nICM) with end-stage heart failure and postoperative-cardiotomy biventricular dysfunction. Although instituting VA-ECMO rapidly restores circulation and perfusion in cardiopulmonary failure, alternative MCS configurations may be preferred depending on the unique etiology for cardiac decompensation. A retrospective observational review was performed on our institutional data for patients in cardiogenic shock requiring MCS stratifying into those receiving ECMO only versus VA ECMO and Impella (Ecpella) support. An analysis was conducted to evaluate whether metrics including ICU length of stay, days on CRRT ECMO and mechanical ventilation are affected by the MCS configuration in specific etiologies of cardiogenic shock. Charts were reviewed from present time to 2017 with inclusion criteria of patients having documentation of VA ECMO support. Patients who had ECMO for non-cardiac intraoperative arrests, septic shock or ARDS respiratory failure were excluded. 202 patient chart were included into the analysis in which patients received VA ECMO only or Ecpella support. Figure 1 delineates grouping into cohorts: ischemic cardiomyopathy (ICM) including acute coronary syndrome, non-ischemic cardiomyopathy (nICM), and postoperative cardiogenic shock. Data analyzed included duration of days on ECMO, CRRT and mechanical ventilation as well as ICU length of stay (LOS). Statistical analysis was performed using independent t-test to report significance between sample groups. The composite and stratified averages for the metrics in patients who survived are shown in tables 1 and 2. Although not statistically significant, the patients supported by Ecpella in the nICM cohort had reduced days on devices as well as ICU LOS. In contrast, patients receiving ECMO only in the ICM cohort had shorter days on devices and ICU LOS. The postoperative cardiogenic shock cohort did not appear to have any significant trends in the analyzed metrics. Composite mortality rate was 0.63 vs 0.72 in the ECMO only vs Ecpella group. nICM patients appear to benefit from ventricular unloading with impella support during MCS that allows for improved end-organ recovery as evident by shorter days on supportive devices while awaiting myocardial recovery versus bridge to durable therapy. In contrast, prompt restoration of perfusion in ICM patients with ECMO alone may facilitate and expedite myocardial recovery, obviating the need for a left ventricular decompression device. Further studies are necessary to confirm whether pathophysiologic differences of cardiogenic shock in nICM vs ICM cause recovery to be more receptive to particular MCS configurations.

Veno-Arterial Extracorporeal Membrane Oxygenation for Patients Undergoing Heart Transplantation: A 7-Year Experience.

Objective: Primary graft dysfunction (PGD) is the leading cause of early death after heart transplantation. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide temporary mechanical circulatory support and time for functional recovery of the transplanted heart. The purpose of this study was to analyze the timing and prognoses of VA-ECMO in patients with severe PGD after heart transplantation.Methods: A total of 130 patients underwent heart transplantation at the Zhongshan Hospital Affiliated with Fudan University between January 2014 and December 2020. All patients received basiliximab immunoinduction and a classic double vena cava anastomosis orthotopic heart transplantation. Among them, 29 patients (22.3%) developed severe PGD in the early postoperative period. VA-ECMO was performed in patients with difficulty weaning from cardiopulmonary bypass (CPB) or postoperative refractory cardiogenic shock. Patients were divided into two groups according to whether or not they were successfully weaned from VA-ECMO (patients who survived for 48 h after weaning and did not need VA-ECMO assistance again). The perioperative clinical data were recorded, and all patients were followed up until discharge. Early outcomes were compared between groups.Results: A total of 29 patients with VA-ECMO support after heart transplantation were included in this study. The proportion of patients receiving VA-ECMO was 22.3% (29/130). Nineteen patients (65.5%) needed VA-ECMO due to difficulty with weaning from CPB, and 10 patients required VA-ECMO for postoperative cardiogenic shock. Nineteen patients (65.5%) were successfully weaned from VA-ECMO. Overall, in-hospital mortality of VA-ECMO support patients was 55.2%. The main causes of death were ventricular fibrillation (four cases), major bleeding (three cases), infection (four cases), and graft failure (five cases).Conclusion: Despite advances in heart transplantation, severe PGD remains a lethal complication after heart transplantation. At present, the treatment for severe PGD after heart transplantation is a challenge. VA-ECMO provides an effective treatment for severe PGD after heart transplantation, which can promote graft function recovery.

Impact of socioeconomic deprivation on incidence and outcomes of acute type A aortic dissection repair in New Zealand.

Socioeconomic deprivation (SED) has been associated with increased 30-day mortality and reduced long-term survival after surgical repair of acute type A aortic dissection (ATAAD). The study aimedto determine the incidence rate ratio of ATAAD in New Zealand population with higher and lower SED indices and to evaluate any association between SED and outcomes after ATAAD repair. This was a retrospective cohort study. Patients who underwent ATAAD repair from March 2003 to May 2020 were identified. Overseas patients, those with chronic aortic dissection, and those who died in hospital before the operation were excluded. The total number of New Zealand residents was estimated based on the national 2018 Census. A total of 363 ATAAD patients met the eligibility criteria. The incidence of ATAAD was 70% greater in those who were more socioeconomically deprived (higher SED) compared with less socioeconomically deprived (lower SED) New Zealanders (odds ratio = 1.7; 95% confidence interval [CI] = 1.4-2.1; p < .0005). Postoperative cardiogenic shock, renal failure, pulmonary embolism, and respiratory failure were more common in the higher than in the lower SED group. Both groups had similar operative and in-hospital mortality and time intervals in the intensive care unit and hospital. Both groups had similar freedom from reoperation (hazards ratio [HR] = 1.1; 95% CI = 0.5-2.6; p = .746) and long-term survival (HR = 0.73; 95% CI = 0.5-1.1; p = .115). The incidence of ATAAD is greater in more socioeconomically deprived New Zealand residents. Following ATAAD repair, SED is not associated with worse short- or long-term outcomes in the universal health care system.

Heparin-binding protein measurement improves the prediction of myocardial injury-related cardiogenic shock

BackgroundHeparin-binding protein (HBP), a potent inducer of increased vascular permeability, is a potentially useful biomarker for predicting outcomes in patients with postoperative myocardial injury-related cardiogenic shock (MIRCS). We aimed to evaluate and validate HBP as a prognostic biomarker for postoperative MIRCS.MethodsWe performed a case-control study in 792 patients undergoing cardiac surgery from January 1, 2016, to August 1, 2019, including 172 patients with postoperative MIRCS and 620 age- and sex-matched controls. The association between HBP and MIRCS was determined by multivariate logistic regression analysis. Receiver operating characteristic curves (ROCs) with area under the curve (AUC) were performed to calculate the cut-off value, sensitivity and specificity. The association between HBP and cardiac troponin T (cTnT) was determined by multivariable linear regression analysis. Blood samples were drawn from the coronary sinus and arterial line of the cardiopulmonary bypass (CPB) before aortic cross-clamping (time point 1) and 5 min after aortic declamping (time point 2).ResultsBefore aortic cross-clamping, coronary sinus HBP (HBPCS1) showed no differences between the two groups. However, after declamping, the MIRCS group had a significantly higher sinus HBP level (HBPCS2) than did the control group. HBPCS2 predicted MIRCS with an AUC of 0.85 (95% CI: 0.81–0.89, cut-off: 220 ng/ml, sensitivity: 92% and specificity: 70%). After adjusting for confounding factors, we found that HBP was an independent risk factor for MIRCS (OR: 7.65, 95% CI: 4.86–12.06, P < 0.01) and was positively associated with cTnT (β > 0, P < 0.01).ConclusionsElevated levels of coronary sinus HBP were useful biomarkers for predicting MIRCS after cardiac surgery.

Reply to “Central Venous-Arterial CO2 Difference in Cardiac Surgery Patients—A Parameter in Relationship to Cardiac Output and Altered Microcirculatory Blood Flow”

Reply: Dr Zante Bjoern and Dr Stefan Kluge, Thanks for your letter entitled “Central venous-arterial CO2 difference in cardiac surgery patients—A parameter in relationship to cardiac output and altered microcirculatory blood flow.” The comments that Dr Zante Bjoern and Dr Stefan Kluge raised were very important and valuable. They commented “alterations in microcirculatory blood flow may further affect P(v-a)CO2. These alterations appear characterized by increased heterogeneity of perfused and non-perfused capillaries, which may result in increased P(v-a)CO2 even when cardiac output is sufficient.” We totally agreed with their comments. In the previous study, the P(v-a)CO2 values ranging between 2 mm Hg and 6 mm Hg may reflect un-normal conditions (1). Experimental studies in which blood flow was progressively reduced, an elevation in P(v-a)CO2 following the reduction in oxygen delivery (DO2) was reported, while a constant oxygen consumption (VO2) was measured. When DO2 was more diminished under its critical value, a drop in VO2 was noticed, insinuating O2 supply dependency and occurrence of anaerobic metabolism. The progressively increasing value of P(v-a) CO2 observed before DO2 achieving the critical point, was amplified by an acute rise in P(v-a)CO2, then DO2 declined below that point (2). From the analysis of the data of these experimental studies, it can be reasonably supposed that an abrupt increase in P(v-a)CO2 should not be easily attributed to the outset of hypoxia but rather to an additional decrease in cardiac output (3). Since the association between P(v-a)CO2 and cardiac output is curvilinear (Fick equation), an enormous rise in P(v-a)CO2 must be noticed for a reduction in cardiac output in its lowest scale. In our study (4), we focused on the association between P(v-a)CO2 and poor outcomes after cardiac surgery, and demonstrated that there is a negative correlation between P(v-a)CO2 and cardiac index. It was entirely consistent with the Fick equation. It is also similar to a recent study (5), while another study (6) that reported P(v-a)CO2 and outcome were unrelated defined more complications. The best cutoff of the P(v-a)CO2 was 7.12 mm Hg in our study which had exceeded the cutoff of “un-normal condition” (1). Therefore, the P(v-a)CO2 may provide an alternative to predict poor outcomes of patients with postoperative cardiogenic shock. However, a cutoff of 7.12 mm Hg might misinterpret pathophysiological alterations in extracorporeal circulation (ECC)-treated patients. It may be caused by the poor outcomes which were widely identified. The poor outcomes in our study were identified as sudden death, cardiac arrest, use of extracorporeal membrane oxygenation, and high vasoactive inotropic agents score. The cut-off values might be changed in different postoperative situations. As Dr Zante Bjoern and Dr Stefan Kluge mentioned “P(v-a)CO2 may be altered in cardiac surgery patients especially after ECC use due to impaired microcirculation and/or a discrepancy of blood flow and/or altered metabolic conditions,” the cut-off value of P(v-a)CO2 might be increased or decreased in patients with using ECC postoperatively. Our study was conducted at a single institution as a retrospective observational study. We regret that we could not investigate P(v-a)CO2 value for every single postoperative complication. Thus, we recommend further high-quality trials to answer questions about the best cutoff of P(v-a)CO2 or P(v-a)CO2 combined with lactate in different situations after cardiac surgery, especially in ECC-treated patients.

P312 Early changes of left ventricular myocardial work performance in patients undergoing coronary artery bypass surgery: off-pump vs. on-pump

Abstract Background Coronary-artery bypass grafting (CABG) without the use of cardio-pulmonary bypass (CPB) was introduced to avoid the potential damaging effects of fpreign surfaces. Nevertheless, the value of off-pump CABG (OPCAB) remains controversial. Regional myocardial work has been shown to reflect regional metabolic demand and provide a more comprehensive assessment of myocardial function. Recently a novel non-invasive method for assessing regional MW by LV pressure–strain loop analysis has been described. Purpose To detect changes of MW after CABG comparing off- and on-pump techniques. Methods We prospectively evaluated 93 patients undergoing CABG (50 on- vs. 43 off-pump). Patients underwent transthoracic echocardiography exams prior to and one week after surgery as well as concurrently systolic arterial blood pressure measurements at rest. Besides conventional echocardiography parameters, wemeasured global longitudinal strain (GLS), global work index (GWI) and global work efficiency (GWE). Results All patients survived surgery. Patients in the OPCAB group had significantly higher EuroSCORE II (3.3% vs. 1.1%, p &amp;lt; 0.001). Preoperatively, OPCABgroup had significantly lower EF (50.1 vs. 55.7%, p = 0.004), lower GWI (1411 vs. 1650mmHg%, p = 0.039) and lower GWE (86.7 vs. 91.6%, p = 0.017). GLS did not differ significantly between off- and on-pump groupspreoperatively. However, postoperatively GLS, MWI, MWE and EF decreased significantly within the on-pump group (p &amp;lt; 0.001, p &amp;lt; 0.001, p &amp;lt; 0.001 and p = 0.002, respectively). In the OPCAB group only GWI and GLSdecreased significantly (p = 0.028 and p = 0.017, respectively). Due to the fact, that mean differences between all pre- and postoperative values were higher in the on-pump group, no significant differences in systolic LV-function (sLVF) could be detected between on- and off-pump patients postoperatively. During the early postoperative phase, no correlation between GWI and GWE and clinical outcomes could be detected, onlylower preoperative-GWI values showed a weak correlation with the incidence of postoperative cardiogenic shock (r= -0.27, p = 0.029). Conclusion Despite having worse preoperative sLVF in the off-pump group determined by EF, GLS, GWI and GWE, the decrease in sLVF parameters was significantly higher in the on-pump group, leading to an equal distribution of LV-function parameters between off- and on-pump patients postoperatively. Our results suggest that off-pump CABG provides a better preservation of LV-function.

High Central Venous-to-Arterial CO2 Difference is Associated With Poor Outcomes in Patients After Cardiac Surgery: A Propensity Score Analysis.

In contrast to arterial lactate, previous studies have proposed central venous-to-arterial CO2 difference (P (v-a)CO2) as a more useful guide for categorizing patients at risk of developing septic shock. It is worthwhile studying P (v-a)CO2 in determining whether it could serve as a useful predictor for poor postoperative outcomes in patients undergoing cardiac surgery. We investigated the ability of P(v-a)CO2 to predict poor outcomes of patients with postoperative cardiogenic shock. In total, 1,672 patients were enrolled in this study from January 1, 2014 to June 1, 2017. Of these patients, 143 exhibited complicated and poor outcomes. To address any bias, we derived a propensity score predicting the functions of P(v-a)CO2 on poor outcomes and matched 114 cases to 114 controls with a similar risk profile. In this cohort study, poor outcomes were defined as the occurrence of any adverse complications, including sudden death, cardiac arrest, extracorporeal membrane oxygenation, oliguria, and the administration of a large amount of vasoactive-inotropic drugs. In propensity-matched patients, significant differences in P(v-a)CO2 (6.11 ± 2.94 mm Hg vs. 11.21 ± 5.22 mm Hg, P < 0.001) were noted between the control group and poor outcome group. The area under the receiver operating characteristic curve of P(v-a)CO2 (AUC: 0.837, 95% CI: 0.782-0.892) for the detection of poor outcomes was significantly better compared to that of the central venous oxygen saturation and arterial lactate. Additionally, there was a negative correlation between cardiac index and P(v-a)CO2 (R= -0.68, P < 0.001). We have shown a correlation between P(v-a)CO2 to cardiac output which may be used as an alternative metric to predict the poor outcomes of patients with postoperative cardiogenic shock.

Comparison of the Mortality Rates of Surgical Techniques for Correcting Atrioventricular Disjunction

Objective: A left ventricular rupture is a rare but lethal complication of surgical mitral valve replacement. We compared the mortality rates of two different surgical techniques for the correction of atrioventricular disjunction. Methods: From January 2005 to January 2012, 720 patients underwent mitral valve replacement at our institution. Two different surgical techniques were used for the correction of atrioventricular disjunction. The techniques were: in group I, the mitral annulus was fixed with bovine pericardial strips; in group II, a 'patch' of bovine pericardium was sutured; the patch extended from the base of the lateral and medial papillary muscle, covered the posterior wall of the left ventricle, went through the posterior mitral annulus, and ended in the posterior wall of the left atrium adjacent to the mitral ring. Results: Atrioventricular disjunction occurred in 10 (1.39%) of 720 patients, out of which the group I technique was used in 6 (60%) patients, and the group II technique in 4 (40%) patients. The mortality rate for the group I technique was 100% (6 patients) with 5 deaths in the operating room and 1 death from postoperative cardiogenic shock. For the group II technique, the mortality rate was 25% (1 patient) and the death was associated with late pulmonary sepsis. Conclusion: The group II technique showed a lower mortality, and was more efficient than the group I technique.

The effects of multimedia education on postoperative delirium in patients undergoing coronary artery bypass graft: A randomized clinical trial.

Patients undergoing cardiac surgeries are at high risk of developing delirium. The present study aimed to determine the effects of multimedia education on postoperative delirium in patients undergoing a coronary artery bypass graft. This study was a randomized clinical trial. In this study, 110 patients undergoing a coronary artery bypass graft were assigned to two groups, control and intervention. Patients in the intervention group received multimedia education, and those in the control group received routine training. The inclusion criteria were experiencing the coronary artery bypass graft for the first time and non-development of post-operative cardiogenic shock or myocardial rupture. After measuring the level of consciousness, patients were examined in terms of delirium using the confusion assessment method for the ICU scale twice a day from admission to discharge from the ICU. The data were statistically analysed using χ2 test and Fisher's exact test. Patients of both groups were matched in terms of demographics. The highest incidence of delirium was observed on the first day after surgery in the intervention group (14.5%) and in the morning of the second day after surgery (29.1%) in the control group. Moreover, there was a significant difference between the two groups in the incidence of delirium in the morning of the second, third, and fourth days after surgery as it was higher in the control group over these days. Considering the lower incidence of post-operative delirium in patients who experienced multimedia education rather than control group, the use of this non-pharmaceutical method is recommended to prevent delirium in such patients. Delirium is also an acute organic brain syndrome that often leads to complicated conditions after cardiac surgeries. Fortunately, delirium is a preventable issue. The implementation of multimedia education as a non-pharmacological approach had positive effects on patients' delirium.

Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO), also known as extracorporeal life support, is the practice of using circulatory assist devices and a gas exchange system to maintain sufficient tissue oxygen delivery, supplementing pulmonary and/or cardiac function in patients whose native physiology is too severely altered to be successfully supported solely by conventional life support techniques (eg, mechanical ventilation and inotropic and vasopressor drugs). ECMO should be considered in patients who are at a high risk of death due to a potentially reversible etiology of cardiopulmonary collapse. Indications for ECMO can be broadly divided into profound respiratory failure and/or cardiogenic shock. The indications include acute respiratory distress syndrome, heart failure, postoperative cardiogenic shock, and as an adjunct to cardiopulmonary resuscitation in patients with cardiac arrest. ECMO is currently experiencing a renaissance, and familiarity with its concepts is important for all critical care practitioners. This review contains 8 figures, 8 tables and 34 references Key Words: complications, equipment, indications, management basics, outcomes

Surgery for Active Infective Endocarditis of the Aortic Valve With Infection Extending Beyond the Leaflets

The optimal aortic substitute in extensive aortic valve active infective endocarditis (AIE) continues to be debated. To determine the surgical approach in aortic valve AIE with infection extension beyond the leaflets, we evaluated the outcome of reconstructive surgery with various valve substitutes in those patients. During 2000-2013, 168 patients had surgery for extensive aortic valve AIE. Patients were categorised based on aortic valve substitute: Group A: Stented aortic valve replacement (AVR), Group B: Stented AVR with patch support, Group C: Stentless valve, Group D: Aortic allograft, and Group E: Composite valve graft. Outcome parameters were mortality, postoperative cardiogenic or septic shock, stroke, or reinfection. Stented valves with patch support were more frequently utilised in cases of native valve endocarditis (p<0.001). Postoperative complications were comparable among groups. Concomitant preoperative extension of infection in the mitral valve predicted reinfection (OR 3.6; confidence interval 1.46-8.66; p=0.005). Survival was not affected by operative group (log rank=0.6). Univariable preoperative predictors of mortality were: septic shock (hazard ratio 8.3; 95% confidence interval 3.6-19.2; p<0.001), ejection fraction (hazard ratio 0.96; 95% confidence interval 0.93-0.99; p=0.006), preoperative cardiogenic shock (hazard ratio 1.9; 95%CI 1.1-3.6, p=0.02) and concomitant mitral valve surgery (hazard ratio 1.8; 95% confidence interval 1.2-2.5; p=0.002). Surgical treatment of extensive aortic valve infective endocarditis remains a challenge. Outcomes were not affected by the surgical complexity of aortic reconstruction procedure or valve substitute. Surgical approach should be tailored to individual patient's characteristics.

Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO), also known as extracorporeal life support, is the practice of using circulatory assist devices and a gas exchange system to maintain sufficient tissue oxygen delivery, supplementing pulmonary and/or cardiac function in patients whose native physiology is too severely altered to be successfully supported solely by conventional life support techniques (eg, mechanical ventilation and inotropic and vasopressor drugs). ECMO should be considered in patients who are at a high risk of death due to a potentially reversible etiology of cardiopulmonary collapse. Indications for ECMO can be broadly divided into profound respiratory failure and/or cardiogenic shock. The indications include acute respiratory distress syndrome, heart failure, postoperative cardiogenic shock, and as an adjunct to cardiopulmonary resuscitation in patients with cardiac arrest. ECMO is currently experiencing a renaissance, and familiarity with its concepts is important for all critical care practitioners. This review contains 8 figures, 8 tables and 34 references Key Words: complications, equipment, indications, management basics, outcomes

Predictors of cardiogenic shock in cardiac surgery patients receiving intra-aortic balloon pumps

BackgroundCardiogenic shock after cardiac surgery leads to severely increased mortality. Intra-aortic balloon pumps may be used during the preoperative period to increase coronary perfusion. The purpose of this study was to characterize predictors of postoperative cardiogenic shock in cardiac surgery patients with and without intra-aortic balloon pumps support. MethodsWe performed a retrospective analysis of our institutional database of the Society of Thoracic Surgeons for patients operated between January 2008 to July 2015. Multivariable logistic regression was used to model postoperative cardiogenic shock in both the intra-aortic balloon pumps and matched control cohorts. ResultsOverall, 4,741 cardiac surgery patients were identified during the study period, of whom 192 (4%) received a preoperative intra-aortic balloon pump. Intra-aortic balloon pumps patients had a greater prevalence of diabetes, previous cardiac surgery, congestive heart failure, and an urgent/emergent status (P < .001). Intra-aortic balloon pumps patients also had greater 30-day mortality and more postoperative cardiogenic shock (9% vs 3%, P < .001). On multivariable analysis of the matched control cohort, postoperative cardiogenic shock remained multifactorial. Among the intra-aortic balloon pumps cohort, only sex, previous percutaneous coronary intervention and preoperative arrhythmia remained significant on multivariable analysis (all P < .05). ConclusionFactors associated with cardiogenic shock among postcardiac surgery patients differ between those patients receiving intra-aortic balloon pumps and those who do not. Further analysis of the effects of prophylactic intra-aortic balloon pumps support is warranted. (Surgery 2017;160:XXX-XXX.)

Reduction of risk associated with stent implantation using prophylactic application of aortic balloon counterpulsation in high-risk patients with myocardial infarction

Objective To evaluate the effect of prophylactic intra-aortic balloon pump (IABP) on reduction of the incidence of major adverse cardiovascular events (MACE) occurred during perioperative period. Methods A total of 246 high-risk patients with AMI admitted from October 2013 through October 2016 were divided into two groups: prophylactic IABP group(n=144) and remedial IABP group(n=102). The likely complications associated with IABP were observed such as dissecting aneurysm, thrombocytopenia, lower extremity thrombosis, anemia, hematoma at puncture site. The comparison of postoperative heart failure, cardiogenic shock and refractory arrhythmia, and nosocomial death between two groups was carried out. The difference in length of time for treatment with IABP between two groups was compared. Statistical analysis of measurement data expressed in ±s using independent sample t test. Count data expressed in percentage were compared with chi-square test. Non-normal distribution data were checked with median±interquartile range. P<0.05 for the difference was concerned statistically significant. Results Gensini score was higher in prophylactic IABP group (t=2.311, P<0.05). In remedial IABP group, the operative time was longer (t=2.626, P< 0.05), the higher rate of using therapeutic medicine was significant (χ2=60.105, P<0.01), the no reflow rate was higher (χ2=19.920, P<0.01), the amount of contrast agent used was greater (t=2.437, P<0.05), the in-hospital incidence of heart failure was higher (χ2=31.638, P<0.01), the rate of nosocomial postoperative cardiogenic shock was higher (χ2=7.793, P<0.01), and the number of in-hospital death increased (χ2=4.827, P<0.05). Compared with prophylactic IABP group, higher BNP (t=7.447, P<0.05), and lower LVEF (t=3.557, P<0.05) were found in remedial IABP group. Conculsion Prophylactic employment of IABP for the treatment of high-risk AMI patients effectively improved the survival rate and reduced peri-opearative MACE. Key words: Intra-aortic ballon pump; Acute myocardial infarction; Percutaneous coronary intervention; Major adverse cardiovascular events; Heart failure; Cardiac shock

Effects and risks of hypothermia during blood purification in the treatment of postoperative cardiogenic shock in valvular heart diseases

To implement hypothermia during blood purification to investigate its effect and risk in the treatment of postoperative cardiogenic shock in valvular heart disease. A non-blinded prospective randomized controlled trial (RCT) was conducted. Patients with valvular heart disease suffering from postoperative cardiogenic shock admitted to intensive care unit (ICU) of Wuhan Asian Heart Hospital from January 2011 to December 2014 were enrolled, and they were randomly divided into normothermic continuous blood purification (CBP) group (NT group) and hypothermia CBP group (HT group) according to random number table and envelope enclosed method. The patients in both groups were given continuous renal replacement therapy (CVVH), the blood temperature in NT group was remained at 36.5-37.3 °C , and it was controlled at 34.0-35.0 °C in HT group. The data were collected before and 1, 2, 3 days after treatment, including cardiac index (CI), the oxygen supply/oxygen consumption ratio (DO₂/VO₂), acute physiology and chronic health evaluation III (APACHE III) score, multiple organ dysfunction (MODS) score. The length of ICU stay, duration of mechanical ventilation, duration of CBP, ICU mortality and the incidence of complication were recorded. A total of 95 patients were enrolled, with 47 patients in NT group, and 48 in HT group. There was no significant difference in gender, age, preoperative cardiac function, cardiothoracic ratio and type of valve replacement between two groups. Compared with those before treatment, no significant difference was found in CI, DO₂/VO₂ ratio, APACHE III score, MODS score on 1, 2, 3 days after treatment in NT group (all P > 0.05). But in HT group, DO₂/VO₂ ratio was significantly improved on 1 day after treatment (2.5 ± 0.7 vs. 1.8 ± 0.4, P < 0.05), CI (mL · s⁻¹ · m⁻²: 50.01 ± 8.34 vs. 31.67 ± 11.67), APACHE III score ( 50.6 ± 6.2 vs. 77.5 ± 5.5), and MODS score (6.0 ± 1.5 vs. 9.3 ± 3.4) were significantly improved 3 days after treatment (all P < 0.05). Compared with those in NT group, DO₂NO2 ratio in HT group was significantly increased from 1 day after treatment (2.5 ± 0.7 vs. 1.8 ± 0.4, P < 0.05), and CI (mL · s⁻¹ · m⁻²: 38.34 ± 10.00 vs. 35.01 ± 6.67), APACHE III score (68.9 ± 7.1 vs. 81.2 ± 7.3), and MODS score (8.9 ± 2.7 vs. 10.6 ± 2.4) were significantly improved from 2 days after treatment (all P < 0.05). In respect of clinical outcomes, compared with NT group, the length of ICU stay (days: 6.9 ± 3.4 vs. 12.5 ± 3.5, t = 2.024, P = 0.017) and duration of mechanical ventilation (days: 4.2 ± 1.3 vs. 7.5 ± 2.7, t = 1.895, P = 0.034) in HT group was significantly shortened, duration of CBP was also significantly shortened (days: 4.6 ± 1.4 vs. 10.5 ± 4.0, t = 2.256, P = 0.019), and ICU mortality was significantly lowered (12.50% vs. 23.40, χ² = 1.987, P = 0.024), but there was no significant difference in incidence of infection (54.17% vs. 53.19%, χ² = 0.689, P = 0.341), ventricular arrhythmia (31.25% vs. 36.17%, χ² = 0.772, P = 0.237), and muscle fibrillation (14.58% vs. 8.51%, χ² = 0.714, P = 0.346), and blood loss (mL: 617.0 ± 60.7 vs. 550.9 ± 85.2, t = 1.290, P = 0.203) between HT group and NT group. The incidence of bradycardia in HT group was significantly higher than that of the NT group (29.17% vs. 14.89%, χ² = 2.368 P = 0.029). Blood purification under hypothermia is a safe and effective therapeutic procedure for postoperative cardiogenic shock in patients with valvular heart disease, and it may improve the prognosis of postoperative patients.