Preoperative Extracorporeal Life Support Research Articles

Emergency arterial switch: Rescue therapy for life-threatening hypoxemia in infants with transposition of great arteries with intact intraventricular septum

ObjectiveA small percentage of infants with d-loop transposition of the great arteries with intact intraventricular septum have life-threatening refractory hypoxemia often due to coexistent persistent pulmonary hypertension of the newborn. In this case series we describe the outcomes of a “rescue” emergency arterial switch operation (ASO). MethodsWe undertook a retrospective medical record analysis of infants with d-loop transposition of the great arteries with intact intraventricular septum who underwent an ASO in New Zealand from January 1, 1996, to April 30, 2017. Data were compared for those who received an emergency ASO and those with a nonemergency ASO for descriptive purposes. An emergency ASO was defined as one that was undertaken for life-threatening refractory hypoxemia when the only alternative stabilization strategy was preoperative extracorporeal life support. Primary outcome measures were 30-day postoperative mortality and abnormal neurodevelopmental outcome in the survivors. Secondary outcomes were low cardiac output, arrhythmia, renal dysfunction, postoperative seizures, and length of stay. Other known risk factors for morbidity and mortality were also assessed. ResultsTwo hundred seventy-two infants underwent an ASO with 25 (9%) who received an emergency ASO. No infants received preoperative extracorporeal life support. The emergency group had greater 30-day postoperative mortality (8.0% vs 0.4%; P = .01) with no difference in abnormal neurodevelopmental outcome among the survivors (17.4% vs 13.8%; P = .35). The emergency group had more therapies for low cardiac output syndrome, more postoperative seizures, and a longer length of stay. ConclusionsAn emergency ASO is a definitive rescue therapy that can be undertaken with acceptable mortality and neurodevelopmental outcome with consideration of the preoperative clinical state.

Early Results after Lung Transplantation in Patients Bridged with Extracorporeal Life Support: Experience from a 7-year Period

Purpose Extracorporeal life support (ECLS) is being increasingly used in selected patients with end-stage pulmonary disease as a bridge to transplantation (BTT). In this study, we present our experience using preoperative ECLS in lung transplantation (LTx) and evaluate its impact on early outcome and survival. Methods We have performed a single-center retrospective analysis of all adult patients who were consecutively bridged to LTx using ECLS at Harefield Hospital between January 2012 and December 2018. Data were extracted from our institutional electronic medical records. Patients’ preoperative characteristics, use of perioperative ECLS, early postoperative results and in-hospital complications were analysed. Primary endpoint was 30-day mortality. Secondary endpoints were early postoperative outcomes. Results In total, 28 LTx recipients (53.6% males, mean age 32.6±10.6 years) were bridged to bilateral sequential single LTx with ECLS. The most common diagnoses were cystic fibrosis (75%), pulmonary artery hypertension (10.7%), fibrotic lung disease (7.1%), alpha-1 antitrypsin deficiency (3.6%) and others (3.6%). ECLS strategies included venovenous (VV) extracorporeal membrane oxygenation (ECMO; 71.4%), venoarterial (VA) ECMO (17.9%) and Novalung Interventional Lung Assist (iLA) device (10.7%). Median duration of bridging was 6 (range 2-53) days. Sixteen (57.1%) patients were awake and nonintubated during ECLS. Intraoperatively, 13 patients (46.4%) required cardiopulmonary bypass. Eleven patients stayed on VV ECMO, one on VA ECMO and 3 were converted to VA ECMO. Postoperatively, ECLS was utilized in 15 (53.6%) patients (6 VA ECMO/7 VV ECMO/2 Novalung). 30-day mortality was 21.4%. Median intensive care unit stay after LTx was 20 days. We have observed a delayed chest closure in 9 (32.1%) patients, surgical re-exploration for bleeding in 12 (42.9%) and renal failure requiring renal replacement therapy in 18 (64.3%). Conclusion We have performed a descriptive analysis of early postoperative outcomes of LTx in patients bridge with ECLS in a tertiary center over a 7-year period. Overall, we have demonstrated that, even if associated with high rate of early postoperative complications, ECLS as a BTT can be successfully used in selected patients with end-stage respiratory failure in a high-urgency setting.

Relationship of Preoperative Thyroid Dysfunction to Clinical Outcomes in Pediatric Cardiac Surgery.

Thyroid function may be assessed in children before cardiac surgery because of concerns that hypothyroidism or thyrotoxicosis might adversely affect cardiac function perioperatively. However, the relationship between preoperative thyroid dysfunction and surgical outcomes is unknown. Determine the relationship between preoperative thyroid dysfunction and outcomes of pediatric cardiac surgery. Retrospective cohort study (January 2005 to July 2019). Academic pediatric hospital. All patients <19 years old who underwent cardiac surgery with cardiopulmonary bypass and had thyrotropin (TSH) measured within 14 days preoperatively. Exclusion criteria included neonates (≤30 days), preoperative extracorporeal life support, salvage operations, or transplantation procedures. Subjects were stratified by preoperative TSH concentration (mIU/L): low (<0.5), normal (0.5-5), mildly high (5.01-10), or moderately high (>10). Outcomes were compared among subjects with normal TSH (control) and each group with abnormal TSH concentrations. The primary outcome was 30-day mortality. Secondary outcomes included time to extubation, intensive care unit and hospital length of stay, and operative complications. Among 592 patients analyzed, preoperative TSH was low in 15 (2.5%), normal in 347 (58.6%), mildly high in 177 (29.9%), and moderately high in 53 (9.0%). Free thyroxine was measured in 77.4% of patients and was low in 0 to 4.4% of subjects, with no differences among TSH groups. Thirty-day mortality was similar among TSH groups. There were no differences in any secondary outcome between patients with abnormal TSH and patients with normal TSH. Preoperative mild to moderate subclinical hypothyroidism was not associated with adverse postoperative outcomes in children undergoing cardiopulmonary bypass procedures.

Surgical Treatment of Post-Infarction Left Ventricular Free-Wall Rupture: A Multicenter Study

Left ventricular free-wall rupture (LVFWR) is an uncommon but serious mechanical complication of acute myocardial infarction. Surgical repair, though challenging, is the only definitive treatment. Given the rarity of this condition, however, results after surgery are still not well established. The aim of this study was to review a multicenter experience with the surgical management of post-infarction LVFWR and analyze the associated early outcomes. Using the CAUTION (Mechanical Complications of Acute Myocardial Infarction: an International Multicenter Cohort Study) database, we identified 140 patients who were surgically treated for post-acute myocardial infarction LVFWR in 15 different centers from 2001 to 2018. The main outcome measured was operative mortality. Multivariate analysis was carried out by constructing a logistic regression model to identify predictors of postoperative mortality. The mean age of patients was 69.4 years. The oozing type of LVFWR was observed in 79 patients (56.4%), and the blowout type in 61 (43.6%). Sutured repair was used in the 61.4% of cases. The operative mortality rate was 36.4%. Low cardiac output syndrome was the main cause of perioperative death. Myocardial rerupture after surgery occurred in 10 patients (7.1%). Multivariable analysis revealed that preoperative left ventricular ejection fraction (P < .001), cardiac arrest at presentation (P= .011), female sex (P= .044), and the need for preoperative extracorporeal life support (P= .003) were independent predictors for operative mortality. Surgical repair of post-infarction LVFWR carries a high operative mortality. Female sex, preoperative left ventricular ejection fraction, cardiac arrest, and extracorporeal life support are predictors of early mortality.

Quadritherapy vs standard tritherapy immunosuppressant regimen after heart transplantation: A propensity score-matched cohort analysis.

After heart transplant, adding everolimus (EVL) to standard immunosuppressive regimen mostly relies on converting calcineurin inhibitors (CNIs) into EVL. The aim of this study was to describe the effects of combining low-dose EVL and CNIs in maintenance immunosuppression regimen (quadritherapy) and compare it with standard tritherapy associating standard-dose CNIs, mycophenolate mofetil, and corticosteroids. In the 3-year registry cohort of heart transplanted patients, those who received quadritherapy were compared with those who received tritherapy. EVL was added after 3months posttransplant. Three analyses were performed to control for confounders: propensity score matching, multivariable survival, and inverse probability score weighting analyses. Among 213 patients who were included (75 with quadritherapy), propensity score matching selected 64 unique pairs of patients with similar characteristics. In the matched cohort (n=128), quadritherapy was associated with fewer deaths (3 [4.7%] vs 17 [21.9%], P=.007) and biopsy-proven acute rejections (15 [23.4%] vs 31 [48.4%], P=.002). These results were confirmed in the overall cohort (n=213), after multivariable and inverse probability score weighting analyses. Renal function and donor-specific HLA-antibodies remained similar in both groups. Low-dose combination quadritherapy was associated with fewer deaths and rejections, compared with standard immunosuppression tritherapy.

Impact of preoperative extracorporeal life support on left ventricular assist device outcomes: A comparative study.

To investigate whether preoperative short-term extracorporeal life support therapy in patients undergoing continuous-flow left ventricular assist device implantation has an impact on the outcome regarding survival and adverse events. Between January 2011 and May 2018, 100 consecutive patients received HeartMate II, HeartWare, or HeartMate III for end-stage heart failure. Mean age was 64.2 ± 10.3 years. Three patient groups were identified: without preoperative extracorporeal life support (non-extracorporeal life support group, n = 80), with preoperative extracorporeal life support due to postcardiotomy shock after conventional cardiac surgery (postcardiotomy shock group, n = 9), and with preoperative extracorporeal life support without previous surgery (non-postcardiotomy shock group, n = 11). The primary endpoint was overall survival after device implantation. Secondary endpoints were adverse events during the follow-up period. Survival was significantly different between the groups (p < 0.05): 30-day, 6-month, and 1-year survival rates were 85%, 68%, and 61% for non-extracorporeal life support group; 44%, 22%, and 22% for postcardiotomy shock group; and 45%, 27%, and 24% for non-postcardiotomy shock group, respectively. Furthermore, in both extracorporeal life support groups (postcardiotomy shock and non-postcardiotomy shock), there were a higher incidence (p < 0.05) of postoperative right heart failure (30% vs 66.7% vs 54.5%), acute renal failure requiring dialysis (20% vs 77.8% vs 54.5%), and respiratory failure (31.3% vs 88.9% vs 81.8%). Continuous-flow left ventricular assist device implantation with prior extracorporeal life support appears to have a worse outcome regarding survival, right heart failure, renal and respiratory dysfunction (p < 0.05). Future studies have to be done to evaluate the outcome after extracorporeal life support bridge pre-left ventricular assist device, especially as ultima ratio in postcardiotomy shock patients.

Improvement of survival in low-weight children on the Berlin Heart EXCOR ventricular assist device support†.

Publications on the paediatric Berlin Heart EXCOR ventricular assist device have revealed that low body weight <10 kg is a significant risk factor for mortality with children weighing <5 kg being at the highest risk. However, these studies are limited to implantation periods prior to 2011. Since then, progress has been made in the optimization of patient selection and management. This study investigated whether the survival of children weighing <10 kg supported with the EXCOR assist device has improved in recent years and sought to determine the risk factors for mortality. The Berlin Heart EXCOR prospective registry (n = 1832) was retrospectively reviewed between 2000 and 2017 to compare the outcomes of different weight cohorts: A (<5 kg; n = 204), B (5-10 kg; n = 633) and C (>10 kg; n = 995) in different eras [era 1: January 2000-December 2012 (n = 1089) and era 2: January 2013-June 2017 (n = 743)]. Overall survival in groups A and B significantly increased from era 1 to era 2 (group A 51% vs 65%, P < 0.001; group B 74% vs 78%, P = 0.001), whereas it remained stable in group C (78% vs 73%). In era 2, the survival of group B was not significantly different from group C. On the multivariable analysis of children weighing <5 kg, congenital heart disease, preoperative extracorporeal life support and biventricular support were independently associated with increased mortality in era 1 [hazard ratio 2.04 (95% confidence interval 1.18-3.53); 2.44 (1.36-4.37) and 1.93 (1.11-3.34), respectively] but not in era 2. Paediatric EXCOR ventricular assist device therapy has significantly improved for patients weighing <10 kg. Withholding a ventricular assist device is not justified on the basis of the body weight alone.

Liberal Right Ventricular Assist Device Extracorporeal Membrane Oxygenation Support for Right Ventricular Failure after Implantable Left Ventricular Assist Device Placement.

Refractory right ventricular failure (RVF) after implantation of left ventricular assist device (LVAD) is a dramatic complication. The addition of right ventricular assist device (RVAD) may improve RV recovery and lead to improve outcomes. From February 2012 to September 2014, 44 patients received a HeartMate II. These patients were retrospectively compared in two groups according to early liberal implantation of an extracorporeal membrane oxygenation (ECMO) used as a RVAD established between a femoral vein and the pulmonary artery. Of the 44 patients, 22 required addition of a temporary RVAD (t-RVAD group). Patients are sicker in the t-RVAD group with significantly higher rate of preoperative extracorporeal life support (46% vs. 9%; p = 0.016) or any mechanical circulatory support (55% vs. 14%; p = 0.01), more preoperative hemofiltration (23% vs. 0%; p = 0.048), and more inotrope support by dobutamine (68.2% vs. 27.3%; p = 0.015). Likewise Michigan risk score was significantly higher in t-RVAD group (2.61 ± 2.2 vs. 1.0 ± 1.6 pts; p = 0.013) and INTERMACS clinical profile (2.1 ± 0.6 vs. 3.4 ± 1.3 pts; p = 0.0001). Despite severity of preimplant conditions in t-RVAD group, clinical outcomes did not differ in both groups with similar survival rate at 6 months (60.4 ± 12 vs. 71.4 ± 9.9%; p = 0.585). Early and liberal use of temporary RVAD in patients with risk factors of RVF could improve the prognostic after LVAD implantation.

Successful support of biventricular heart failure patients by new EXCOR® Adult pumps with bileaflet valves: a prospective study.

The Berlin Heart EXCOR® Adult biventricular assist device (BiVAD) is an approved mechanical circulatory support for patients with end-stage biventricular heart failure. In this prospective post-market clinical follow-up study, we present the first clinical experience of the new EXCOR® Adult pump with bileaflet (BL) valves in Europe. After CE-mark approval in August 2014, a total of 12 patients were enrolled with a mean age of 44years ± 11 (range 21-58years). The majority of patients (n = 11) were in INTERMACS level 1 or 2. Eight patients had a median pre-operative extracorporeal life support (ECLS) of 6days (range 1-37days). Primary end point was survival, either to heart transplantation (HTx), recovery or alive at 12months on device, whichever occurred first. Secondary end point was the number of adverse events throughout EXCOR® BiVAD support. Median support time up to last follow-up on EXCOR® BiVAD device was 248days (range 57-381days) and patient survival at 1year was 92%. Half of the EXCOR® BiVAD patients (n = 6) were transplanted and five patients were still on support at 1year post-implantation. Complications during EXCOR® BiVAD support were thoracic bleeding, exit site infection and ischemic cerebrovascular incidents in three cases, respectively. The new EXCOR® Adult pump with BL provides pulsatile high cardiac output with excellent outcome and successful bridging to HTx, particularly in critically ill patients with INTERMACS level 1 or 2at the time of implantation.

Central Extracorporeal Life Support With Left Ventricular Decompression to Berlin Heart Excor: A Reliable "Bridge to Bridge" Strategy in Crash and Burn Patients.

The aim of this study was to compare patients with severe biventricular heart failure who underwent Berlin Heart Excor implantation with (cardiogenic shock [CS] status) or without the need for preoperative extracorporeal life support (ECLS) as a bridge to long-term device. A total of 40 consecutive patients with severe biventricular heart failure underwent Berlin Heart Excor implantation with (CS status, n=20, 50%) or without (control, n=20, 50%) the need for preoperative ECLS as a bridge to long-term device from March 2007 to May 2015 at our institution. Demographics and preoperative baseline characteristics as well as early and long-term outcomes including mortality and complication rates were retrospectively compared between the two groups. There were no statistically significant differences in terms of demographics and most preoperative clinical characteristics. The mean age in the ECLS (CS group) and control group was 43.5±19.4 and 41.3±16.4 (P=0.705), whereas 20 and 25% of patients were females (P=1.000). However, patients from the ECLS group had preoperatively higher lactate (P=0.037), aspartate aminotransferase (P<0.001), and alanine aminotransferase (P<0.001) levels, all of them significantly decreased after surgery (P=0.004, P=0.017, and P=0.001, respectively) and did not show any statistical differences to the corresponding values from the control group (P=0.597, P=0.491, and P=0.339, respectively). Postoperatively, patients from the control and ECLS groups had statistically similar incidences of liver failure (30 vs. 35%, P=0.736), renal failure (45 vs. 70%, P=0.110), need for reopening (35 vs. 60%, P=0.113), major cerebrovascular events (35 vs. 30%, P=0.736), sepsis (10 vs. 25%, P=0.407), wound infection (20 vs. 30%, P=0.716), abdominal ischemia requiring surgery (28.6 vs. 36.8%, P=0.719), and acute respiratory distress syndrome (25 vs. 35.3%, P=1.000). The proportion of patients who were bridged to transplantation was statistically similar between the ECLS and the control groups (40 vs. 52.6%, P=0.429). Furthermore, there were no statistically significant differences in terms of early (Breslow [generalized Wilcoxon] P=0.907) and long-term (log-rank [Mantel-Cox] P=0.787) overall cumulative survival accounting for 30-day survival of 75 versus 75%, 6-month survival of 60 versus 55%, 1-year survival of 54 versus 40%, and 7-year survial of 47 versus 40% in the control and ECLS groups, respectively. ECLS in critical CS as a bridge to implantation of the Berlin Heart Excor ventricular assist device is safe and is associated with improvement in end-organ function leading to similar excellent early and long-term survival and incidences of major complications as in patients without the need for preoperative ECLS support.

(620) - Lung Transplant Recipient Survival Following Urgent Inpatient Candidacy Evaluation

of preoperative extracorporeal life support (ECLS). With such criteria, 42 patients had an initial indication for HLT, but only 30 received HLT (Gr 1 HLT/HLT); 32 patients received DLT as initially indicated (Gr 2 DLT/DLT). Twelve patients initially planned for HLT received DLT (Gr 3 HLT/DLT). ICU and long-term mortality rated were recorded. Need for post operative ECLS and course of organ failure (defined by the SOFA score) were also recorded. Results: ICU survival rates were not different between the 3 groups (gr 1 77%; gr 2 78%, gr 3 92%), as the 3-years survival rates (gr 1 57%; gr 2 62%; gr 3 58%). Number of patients with a postoperative ECLS were similar among groups 1, 2, 3 (27%, 25%, 33%, respectively). Median duration of inotropic support was significantly longer in gr 3 compared to gr 1 and gr 2 (13 days vs 4 days, p= 0.01). Course of organ failure was different during the first postoperative 7 days: SOFA score was significantly higher for gr 3 compared to gr 1 and gr 2 (p= 0.04). Finally, nosocomial infections, surgical complications, and immunologic events were not different between the 3 groups. Conclusion: Despite a more complicated ICU course, for selected PH patients initially scheduled for HLT, DLT is a valuable option with good early and long-term results.

Short-Term Ventricular Assist Device as a Bridge to Decision in Cardiogenic Shock: Is It a Justified Strategy?

Low cardiac output syndrome is associated with significant mortality. In patients with refractory low cardiac output left ventricular assist devices (VAD) are used to re-establish cardiac output and to prevent death. However, long-term LVAD implantation in these is complicated by a high rate of right heart failure and mortality. Therefore, our strategy is to implant a short-term VAD (left or biventricular) as a bridge to decission. We retrospectively analysed data from 66 patients who received a short-term LVAD support prior to implantation of a long-term LVAD or HTx between 2003 and 2014. We performed short-term LVAD (CentriMag; Thoratec) implantation via median sternotomy with percutaneous cannulas. Patients were included regardless of perioperative status and severity of heart failure. Patients suffering postcardiotomy cardiogenic shock, receiving isolated RVAD as well as posttransplant patients were excluded from this study. Mean duration of support in the survivor group was 35 ± 25 days versus 25 ± 25 days in the nonsurvivor group (n.s.), range from 1 to 109 days. The overall survival on support was 40 (60%) patients. In the survivor group 12 patients could be successfully weaned from the system, 12 patients received a heart transplant and in 16 a long-term VAD was implanted. In the nonsurvivor group the rate of preoperative extracorporeal life support, the rate of postoperative renal failure and multiorgan failure was significantly higher. Thanks to its capacity for full ventricular support, short-term univentricular or biventricular LevotronixCentriMag VAD currently represents an ideal solution for bridge-to-decision.

The role of cardiopulmonary bypass in lung transplantation.

The risk-benefit for utilizing cardio-pulmonary bypass (CPB) in lung transplantation (LTx) remains debatable. This study compares outcomes after LTx utilizing different CPB strategies - elective CPB vs. off-pump vs. off-pump with unplanned conversion to CPB. A total of 302 LTx performed over seven yr were divided into three groups: "off-pump" group (n = 86), "elective on-pump" group (n = 162), and "conversion" group (n = 54). The preoperative donor and recipient demographics and baseline characteristics and the postoperative outcomes were analyzed; 1:1 propensity score matching was used to identify patients operated upon using elective CPB who had risk profiles similar to those operated upon off-pump (propensity-matching 1) as well as those emergently converted from off-pump to CPB (propensity-matching 2). Preoperative group demographic characteristics were comparable; however, the "off-pump" patient group was significantly older. The "conversion" group had a significantly greater number of patients with primary pulmonary hypertension, pulmonary fibrosis, preoperative mechanical ventilation, and preoperative extracorporeal life support (ECLS). Postoperatively, patients from the "conversion" group had significantly poorer PaO2 /FiO2 ratios upon arrival in intensive care unit (ICU) and at 24, 48, and 72 h postoperatively, and they required more prolonged ventilation, longer ICU admission, and they experienced an increased need for ECLS than the other groups. Overall, cumulative survival at one, two, and three yr was significantly worse in patients from the "conversion" group compared to the "off-pump" and "elective on-pump" groups - 61.9% vs. 94.4% vs. 86.9%, 54.4% vs. 90.6% vs. 79.5% and 39.8% vs. 78.1% vs. 74.3%, respectively (p < 0.001). The "off-pump" group had significantly better PaO2 /FiO2 ratios, and a significantly shorter duration of ventilation, ICU stay, and hospital length of stay when compared to the propensity-matched "elective on-pump" group. There were no statistically significant differences in postoperative outcomes and overall survival between the "converted" group and the propensity-matched "elective on-pump" group. Despite segregation of unplanned CPB conversion cases from elective on-pump cases, patients with comparable preoperative demographic/risk profiles demonstrated better early postoperative outcomes and, possibly, an improved early survival with an off-pump strategy. A considerable proportion of high-risk patients require intraoperative conversion from off-pump to CPB, and this seems associated with suboptimal outcomes; however, there is no significant benefit to employing an elective on-pump strategy over emergent conversion in the high-risk group.

Outcome of Extracorporeal Membrane Oxygenation as a Bridge To Lung Transplantation: An Institutional Experience and Literature Review.

Extracorporeal life support (ECLS) as a bridge to lung transplantation (LuTx) is a promising option for patients with end-stage lung disease on the transplant waiting list. We investigated the outcome of patients bridged to lung transplantation on ECLS technologies, mainly extracorporeal membrane oxygenation (ECMO). Between January 2007 and October 2013, ECLS was implanted in 30 patients with intention to bridge to LuTx. Twenty-six patients (26/30) were successfully bridged to LuTx on ECLS. The most common diagnosis was cystic fibrosis (N = 12). Venovenous ECMO was used in 10, venoarterial in 4, interventional lung assist in 5, and stepwise combination of them in 7 recipients. Two patients weaned from ECMO, and 2 patients died on ECMO on the waiting list. Median duration of ECLS was 21 days (1-81 years). Six patients were awake and spontaneously breathing during ECLS support. Thirty-day, 1-year, and 2-year survivals were 89%, 68%, and 53%, respectively, for bridged patients and 96%, 85%, and 79%, respectively, for control group (P = 0.001). Three months conditional survivals were 89% and 69% at 1 and 2 years for ECLS group, compared to 92% and 86% for control group (P = 0.03). Cystic fibrosis recipients had 82% survival rate at 1 and 2 years. All recipients bridged to LuTx on awake ECLS (N = 6) are alive with a median follow-up of 10.8 months (range, 6-21 months). Our data show significantly lower survival in this high-risk group compared to patients transplanted without preoperative ECLS. Awake and ambulatory ECLS provides the best prognosis for these high-risk patients.