Interhospital Transport of Children Requiring Extracorporeal Membrane Oxygenation Support for Cardiac Dysfunction

Objective. Many centers are able to emergently deploy extracorporeal membrane oxygenation (ECMO) as support in children with refractory hemodynamic instability, but may be limited in their ability to provide prolonged circulatory support or cardiac transplantation. Such patients may require interhospital transport while on ECMO (cardiac mobile [CM]‐ECMO) for additional hemodynamic support or therapy. There are only three centers in the United States that routinely perform CM‐ECMO. Our center has a 20‐year experience in carrying out such transports. The purpose of this study was twofold: (1) to review our experience with pediatric cardiac patients undergoing CM‐ECMO and (2) identify risk factors for a composite outcome (defined as either cardiac transplantation or death) among children undergoing CM‐ECMO. Design. Retrospective case series. Setting. Cardiovascular intensive care and pediatric transport system. Patients. Children (n = 37) from 0–18 years undergoing CM‐ECMO transports (n = 38) between January 1990 and September 2005. Interventions. None. Measurements and Main Results. A total of 38 CM‐ECMO transports were performed for congenital heart disease (n = 22), cardiomyopathy (n = 11), and sepsis with myocardial dysfunction (n = 4). There were 18 survivors to hospital discharge. Twenty‐two patients were transported a distance of more than 300 miles from our institution. Ten patients were previously cannulated and on ECMO prior to transport. Thirty‐five patients were transported by air and two by ground. Six patients underwent cardiac transplantation, all of whom survived to discharge. After adjusting for other covariates post‐CM‐ECMO renal support was the only variable associated with the composite outcome of death/need for cardiac transplant (odds ratio = 13.2; 95% confidence interval, 1.60–108.90; P= 0.003). There were two minor complications (equipment failure/dysfunction) and no major complications or deaths during transport. Conclusions. Air and ground CM‐ECMO transport of pediatric patients with refractory myocardial dysfunction is safe and effective. In our study cohort, the need for post‐CM‐ECMO renal support was associated with the composite outcome of death/need for cardiac transplant.     

体外膜肺氧合在心脏移植术后移植物衰竭支持治疗中的应用

目的:总结心脏移植术后早期移植物衰竭体外膜肺氧合(extracorporeal membrane oxygena-tion,ECMO)支持治疗的临床经验。方法:自2008年1月至2011年12月,阜外医院共进行心脏移植181例,其中16例患者在心脏移植术后使用ECMO进行循环支持治疗。记录ECMO运行期间相关参数、机械辅助时间、并发症等指标。观察ECMO建立时、辅助24 h和撤机时患者血浆乳酸值,ECMO辅助前和ECMO辅助24 h多巴胺及肾上腺素的用量。结果:16例心脏移植围手术期接受ECMO支持治疗的患者中脱机14例(87.5%),存活出院13例(81.3%)。其中2例因心脏功能无改善不能脱机放弃治疗,1例脱机后发生慢性排斥反应,出现多器官功能衰竭(MOF)死亡。所有患者均采用动脉—静脉(A-V)ECMO辅助方式,患者ECMO前、ECMO运行24 h和停止ECMO时血浆乳酸值分别为:(8.36±3.41)、(2.42±1.53)、(2.25±2.17)mmol/L。运行24 h及停止ECMO时,血浆乳酸值较安装前明显下降(P<0.05)。ECMO前和运行24 h多巴胺用量分别为:(7.38±3.42)和(5.29±1.93)μg.min-1.kg-1,两者之间比较,差异无统计学意义(P>0.05)。ECMO前和运行24 h肾上腺素用量分别为:(0.17±0.11)和(0.02±0.03)μg.min-1.kg-1,运行24 h较ECMO前肾上腺素用量明显减小(P<0.05)。结论:ECMO是一种有效的循环呼吸衰竭辅助支持疗法,能明显降低终末期心脏病患者心脏移植术后早期病死率。     

机械循环辅助装置治疗围手术期急性心肺功能衰竭

目的:观察心室辅助(VAD)、体外膜式氧合(ECMO)及主动脉内气囊反搏(IABP)等机械循环辅助装置治疗围手术期急性心肺功能衰竭的疗效。方法:回顾2005年1月至2006年12月我院心脏外科监护病房224例围手术期进行循环辅助患者临床资料,VAD4例、ECMO47例及IABP173例。结果:VAD死亡2例(50%),ECMO死亡23例(48.9%),IABP死亡49例(28.3%)。并发症为感染27例、肾功能衰竭需要透析26例、出血23例、下肢缺血15例及脑并发症7例。结论:机械辅助是救治围手术期急性心肺功能衰竭的有效方法,应根据患者病情选择适合的辅助方式并及早放置,防治并发症对提高成功率非常重要。     

Examination of hyperlucent foci and clinical outcomes in pediatric cardiac patients on extracorporeal membrane oxygenation

Background: A number of cardiac patients on venoarterial extracorporeal membrane oxygenation (VA‐ECMO) at our institution were found to have hyperlucent foci evident on echocardiography. However, the clinical significance of these findings is not known. Methods: To investigate this phenomenon further we undertook a retrospective analysis to determine the prevalence and clinical implications of hyperlucent foci in children supported with VA‐ECMO. Results: From January 2002 to September 2009 49 subjects were supported with VA‐ECMO. Of these, 12 (24%) were found to have hyperlucent foci. Foci were multifocal in six subjects (50%) and the most common location was left ventricular wall. No association was noted between primary cardiac diagnoses, or for inciting reason for placement on ECMO (extracorporeal cardiopulmonary resuscitation vs. transition from cardiopulmonary bypass to ECMO). There was no association between the presence of the foci and death in less than 14 days following decannulation from ECMO, hospital survival 42% versus 43%, P = 0.1. Among subjects who survived at least 14 days after ECMO decannulation hyperlucent foci resolved in 5 of 7. Conclusions: Hyperlucent foci can be seen in children supported by VA‐ECMO. They do not portend a poorer prognosis. Among hospital survivors resolution is the norm. (Echocardiography 2011;28:358‐362)     

Epidemiology of blood stream infection in adult extracorporeal membrane oxygenation patients: A cohort study

PurposeThe purpose of our study was to characterize the epidemiology of blood stream infection (BSI) in adult extracorporeal membrane oxygenation (ECMO) patients at a single tertiary care academic medical center with standardized post-cannulation antibiotic prophylaxis practices.MethodsA single-center retrospective cohort study was performed over a five-year period. BSI incidence was characterized and patients who developed BSI during ECMO were compared with those who did not.ResultsNineteen of 145 VV ECMO patients (13.1%) developed BSI while 7 of 123 VA ECMO patients (5.7%) developed BSI. When accounting for total ECMO days, the incidence rate was 8 BSIs per 1,000 ECMO days for both VV and VA ECMO patients. VV ECMO patients with BSI had longer ECMO runs and more red blood cell transfusion (both p<0.05). VA ECMO patients who developed BSI had longer ECMO runs and more platelet transfusion (both p<0.05). In VV ECMO patients there was an association between renal failure and BSI and in VA ECMO patients there was an association between hepatic failure and BSI.ConclusionsBSIs are common in ECMO patients even with post-cannulation antimicrobial prophylaxis and are associated with ECMO duration, blood transfusion, and organ failure. Further work is needed to clarify the optimal duration and type of antimicrobial prophylaxis, as well as surveillance strategies for BSIs during adult ECMO.     

Outcome for biliary atresia patients treated at a low-volume centre

Objectives: The importance of case load for treatment of extrahepatic biliary atresia (BA) is debated. The aim of this study was to register results of BA treatment in a small volume centre.

Methods: Retrospective chart review study of patients with BA treated from 2000 to 2017. The institutional review board approved the study.

Results: Forty-five babies were identified of which 42 (93%) are alive. Forty-one patients had a Kasai portoenterostomy (PE), two had a hepaticojejunostomy and two had a primary liver transplantation. The age at PE/hepaticojejunostomy was median 63 (4–145 days). Seven surgeons performed the operations, and the median duration of the diagnostic work-up was 8 (3–24) days. Clearance of jaundice was achieved in 23/43 (53%) babies, and 3- and 5-year native liver survival was 47% and 40%, respectively. Clearance of jaundice post-PE/hepaticojejunostomy was a strong predictor of native liver survival (adjusted OR: 0.027; 95%; p?=?.009). Plasma level of conjugated bilirubin at time of referral was also a significant predictor of native liver survival (adjusted OR: 1.053; p?=?.017).

Conclusion: A small volume centre may achieve satisfactory results for BA patients. The study has, however, identified factors that may further improve results; earlier referral, optimizing diagnostic work-up and establishing one dedicated surgical team.     

Extracorporeal membrane oxygenation: experience in an adult medical ICU

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a technology that can provide extracorporeal gas exchange to patients with severe pulmonary or cardiac dysfunction. We report on our clinical experience with ECMO in critically ill patients. METHODS: We performed a retrospective analysis of 23 patients treated with ECMO in a medical intensive care unit in a tertiary referral academic centre. RESULTS: 13 patients were considered immunocompetent and 10 were immunocompromised when extracorporeal membrane oxygenation was started. 16 patients presented with acute respiratory distress syndrome (ARDS), 2 patients had intractable cardiac failure, and 5 patients had combined respiratory and cardiac failure. In 16 patients, a veno-venous bypass was constructed; in 7 patients, the initial bypass was venoarterial. 11 patients survived. In 2 patients technical complications were fatal. CONCLUSIONS: Our data indicate that patients with community-acquired pneumonia and no underlying disease will benefit most from this technique. However, long-term survival is possible in immunocompromised patients. Venoarterial bypass can carry a higher risk for technical complications. Increasing experience apparently also reduces the risk of technical complications.     

Kinetics of procalcitonin in cardiogenic shock and in septic shock. Preliminary data

Abstract

Background: In cardiac acute patients, data on procalcitonin (PCT) are controversial and the clinical interpretation of absolute PCT values represents a major challenge since they may be influenced by several factors. No data are so far available on the dynamics of PCT levels in patients with cardiogenic shock. Aims: to evaluate the serum evolution of PCT during intensive cardiac care unit (ICCU) staying in a group of 24 patients with cardiogenic shock (CS) following ST-elevation myocardial infarction (STEMI) submitted to primary percutaneous intervention (PCI) with no laboratory or clinical sign of infection. Furthermore we assessed the kinetics of PCT in a series of 24 patients with septic shock. Results: In septic shock, no significant difference was detectable in PCT kinetics between survivors (R2 = 0.90; P = 0.051) and non-survivors (R2 = 0.63; P = 0.204). In cardiogenic shock, survivors exhibited a significant reduction in PCT values (R2 = 0.94; P = 0.032) while non survivors did not (R2 = 0.68; P = 0.178). Conclusions: differently from septic shock, cardiogenic shock following STEMI was associated with heterogeneous patterns of temporal PCT variations since only patients who survived exhibited a significant PCT reduction during ICCU stay. Our findings support the contention that the ‘dynamic’ approach may be more reliable that the static one especially in cardiogenic shock.     

Alveolar and serum concentrations of imipenem in two lung transplant recipients supported with extracorporeal membrane oxygenation

Venovenous extracorporeal membrane oxygenation (ECMO) is increasingly used in patients with respiratory failure who fail conventional treatment. Postoperative pneumonia is the most common infection after lung transplantation (40%). Imipenem is frequently used for empirical treatment of nosocomial pneumonia in the intensive care unit. Nevertheless, few data are available on the impact of ECMO on pharmacokinetics, and no data on imipenem dosing during ECMO. Currently, no guidelines exist for antibiotic dosing during ECMO support. We report the cases of 2 patients supported with venovenous ECMO for refractory acute respiratory distress syndrome following single lung transplantation for pulmonary fibrosis, treated empirically with 1 g of imipenem intravenously every 6 h. Enterobacter cloacae was isolated from the respiratory sample of Patient 1 and Klebsiella pneumoniae was isolated from the respiratory sample of Patient 2. Minimum inhibitory concentrations of the 2 isolated strains were 0.125 and 0.25 mg/L, respectively. Both patients were still alive on day 28. This is the first report, to our knowledge, of imipenem concentrations in lung transplantation patients supported with ECMO. This study confirms high variability in imipenem trough concentrations in patients on ECMO and with preserved renal function. An elevated dosing regimen (4 g/24 h) is more likely to optimize drug exposure, and therapeutic drug monitoring is recommended, where available. Population pharmacokinetic studies are indicated to develop evidence‐based dosing guidelines for ECMO patients.     

Transplantation cardiaque en super urgence (SU) avec et sans assistance circulatoire mécanique de type extracorporeal membrane oxygenation (ECMO)

Objective

Severely impaired patients may wait in France on a special and temporary high emergency national list (called SU). Some of these patients need mechanical circulatory support with ECMO. In order to compare two groups of patients on SU, who acceeded to heart transplantation (HT) with or without ECMO, we reviewed retrospectively 20 consecutive patients transplanted on SU between January 2004 and September 2007 in Rennes.

Patients and methods

Among them, 10 were transplanted without ECMO and 10 others were implanted with a femoro-femoral ECMO before HT.

Results

(1) Considering the group SU without pretransplantation ECMO: 2 years survival rate was 70%. Mean hospital stay was 26.4 days. Three patients were implanted with ECMO for graft dysfunction during postoperative course, without inherent complication. None graft dysfunction occurred after initial hospitalization; (2) considering the group SU with pretransplantation ECMO: 2 years survival rate was 90% (one early death). Mean hospital stay was 45 days with multiple complications due to the ECMO (leg's ischemia: n =2; lung oedema: n =1; lymphorrhea: n =3, low flow requiring change of canulae: n =1). None graft dysfunction occurred after initial hospitalization.

Conclusion

Althought we didn’t reach statistical significance, it seems that ECMO for patients in SU may be useful as bridge to transplant but with a higher morbidity than for similar patients transplanted without ECMO. Additional data from other transplant centers are needed to confirm our findings.     

Comparison of ECMO vs ECpella in Patients With Non-Post-Pericardiotomy Cardiogenic Shock: An Updated Meta-Analysis

IntroductionThe impact of Impella and ECMO (ECPELLA) in cardiogenic shock (CS) remains to be defined. The aim of this meta-analysis is to evaluate the benefit of ECPELLA compared to VA-ECMO in patients with non post-pericardiotomy CS.MethodsAll studies reporting short term outcomes of ECpella or VA ECMO in non post-pericardiotomy CS were included. The primary endpoint was 30-day mortality. Vascular and bleeding complications and LVAD implantation/heart transplant within 30-days were assessed as secondary outcomes.ResultsOf 407 studies identified, 13 observational studies (13,682 patients, 13,270 with ECMO and 412 with ECpella) were included in this analysis. 30-day mortality was 55.8% (51.6–59.9) in the VA-ECMO group and 58.3% (53.5–63.0) in the ECpella group. At meta-regression analysis the implantation of IABP did not affect mortality in the ECMO group. The rate of major bleeding in patients on VA-ECMO and ECpella support were 21.3% (16.9–26.5) and 33.1% (25.9–41.2) respectively, while the rates of the composite outcome of LVAD implantation and heart transplantation within 30-days in patients on VA-ECMO and ECpella support were 14.4% (9.0–22.2) and 10.8%. When directly compared in 3 studies, ECpella showed a positive effect on 30-day mortality compared to ECMO (OR: 1.81: 1.039–3.159).ConclusionOur data suggest that ECpella may reduce 30-day mortality and increase left ventricle recovery, despite increased of bleeding rates.     

Identification of prognostic markers in transthyretin and AL cardiac amyloidosis*

Abstract

Background: The prognosis of amyloidosis is known to depend heavily on cardiac function and may be improved by identifying patients at highest risk for adverse cardiac events.

Aims: Identify predictors of mortality in patients with cardiac light-chain amyloidosis (AL), hereditary transthyretin amyloidosis (m-TTR), or wild-type transthyretin amyloidosis (WT-TTR) to prompt physician to refer these patients to dedicated centers.

Methods and results: Observational study. About 266 patients referred for suspected cardiac amyloidosis (CA) in two French university centers were included. About 198 patients had CA (AL?=?118, m-TTR?=?57, and WT-TTR?=?23). Their median (25th–75th percentile) age, NT-proBNP left ventricular ejection fraction were, respectively, 68 years (59–76), 2339?pg mL^?1 (424–5974), and 60% (48–66). About 31% were in NYHA class III–IV. Interventricular septal thickness was greater in the m-TTR and WT-TTR groups than in the AL group (p?<?0.0001). Median follow-up in survivor was 26 months (15–44) and 87 (44%) patients died. By multivariate analysis, independent predictors of mortality for AL amyloidosis were the following: age, cardiac output and NT-proBNP; for TTR amyloidosis was: NT-proBNP. When all amyloidosis were combined NT-proBNP, low cardiac output and pericardial effusion were independently associated with mortality.

Conclusion: NT-proBNP is a strong prognosticator in the three types of cardiac amyloidosis. High NT-proBNP, low cardiac output, and pericardial effusion at the time of screening should prompt physician to refer the patients to amyloidosis referral center.     

Temporal trends in liver transplant centre volume in the USA

Background:

Although prior studies have suggested an inverse association between liver transplant centre volume and postoperative patient mortality, more recent analyses have failed to confirm this association. To date, all studies of the relationship between centre volume and outcomes in liver transplantation have been cross-sectional in design.

Objective:

The objective of our study was to examine temporal trends in the volume–outcomes relationship for liver transplantation.

Methods:

We used information obtained from the Scientific Registry of Transplant Recipients (SRTR) programme-specific data reports to examine the outcomes of adult liver transplant recipients stratified by annual centre volume. This relationship between centre volume and patient outcomes was assessed over three consecutive time periods from 2000 through 2007.

Results:

The overall 25% increase in adult liver transplant volume in the USA from 2000 to 2007 appeared to be distributed fairly equally among existing transplant centres. In the earliest time period of our analysis, high-volume centres achieved superior risk-adjusted 1-year patient outcomes compared with low-volume centres. By the third and most recent time period of the analysis, this discrepancy between the outcomes of high- and low-volume centres was no longer statistically apparent.

Conclusions:

The relationship between centre volume and patient outcomes for liver transplantation in the USA has become less pronounced over time, suggesting that the use of procedure volume as a marker of liver transplant centre quality cannot be justified. The performance-based review process currently utilized in the USA may have contributed to this diminishing influence of centre volume on liver transplant recipient outcomes. This type of review process should be considered as a potential alternative to the volume-based referral initiatives that have been developed for other non-transplant, complex surgical procedures.     

Predictors of extracorporeal membrane oxygenation support after surgery for adult congenital heart disease in children's hospitals

Objective: Adult congenital heart disease (ACHD) patients who undergo cardiac surgery are at risk for poor outcomes, including extracorporeal membrane oxygenation support (ECMO) and death. Prior studies have demonstrated risk factors for mortality, but have not fully examined risk factors for ECMO or death without ECMO (DWE). We sought to identify risk factors for ECMO and DWE in adults undergoing congenital heart surgery in tertiary care children’s hospitals.
Design: All adults (≥18 years) undergoing congenital heart surgery in the Pediatric Health Information System (PHIS) database between 2003 and 2014 were included. Patients were classified into three groups: ECMO‐free survival, requiring ECMO, and DWE. Univariate analyses were performed, and multinomial logistic regression models were constructed examining ECMO and DWE as independent outcomes.
Setting: Tertiary care children’s hospitals.
Results: A total of 4665 adult patients underwent ACHD surgery in 39 children’s hospitals with 51 (1.1%) patients requiring ECMO and 64 (1.4%) patients experiencing DWE. Of the 51 ECMO patients, 34 (67%) died. Increasing patient age, surgical complexity, diagnosis of single ventricle heart disease, preoperative hospitalization, and the presence of noncardiac complex chronic conditions (CCC) were risk factors for both outcomes. Additionally, low and medium hospital ACHD surgical volume was associated with an increased risk of DWE in comparison with ECMO.
Conclusions: There are overlapping but separate risk factors for ECMO support and DWE among adults undergoing congenital heart surgery in pediatric hospitals.     

体外膜肺氧合对心脏术后心肺复苏患者的应用

目的:探讨体外膜肺氧合技术(ECMO)在成年心脏手术后心肺复苏(CPR)困难患者的应用经验。方法:回顾分析2010年1月至2012年9月期间,7例心脏手术后因CPR困难应用ECMO救治的成年患者的临床资料,男性4例,女性3例,年龄42～65岁,平均(54±7)岁,其中冠状动脉旁路移植术(CABG)6例,主动脉瓣置换术1例。全部患者均经股动静脉插管建立ECMO辅助。结果:7例患者CPR时间40～65 min,平均(53±7)min,建立ECMO辅助后全部患者均恢复自主心律,ECMO辅助时间36～128 h,平均(85±26)h,监护室停留时间2～8d,平均(5±1)d。辅助24h后患者平均动脉压(MBP)、血乳酸(Lac)及正性肌力药物评分(IS)均明显改善。6例(85.7%)患者成功撤离ECMO辅助,其中3例(42.9%)存活出院,1例患者因无法脱机而死亡,3例成功脱机后因感染及中枢神经系统并发症死亡;4例患者同时应用主动脉内球囊反搏(IABP),3例进行肾替代治疗(CRRT)。结论:体外膜肺心肺复苏(ECPR)可以提供紧急生命支持,挽救部分常规方法复苏困难的心脏术后心脏骤停患者的生命。     

Causes of Death after Congenital Heart Surgery in Children

Background: This retrospective cohort study aimed to explore the causes of death in children with congenital heart disease (CHD) after cardiac surgery in one of the biggest cardiac centers for children with CHD in China. Methods: A total of 26,856 children undergoing cardiac surgery from January 1, 2012 to December 31, 2019 were included. Based on the clinical data, the causes of death were divided into ten categories and further compared among different periods, types of CHD and surgical procedures. Results: Of all patients, 513 (1.9%) died (median age 162 d, median weight 5.6 kg). The mortality in 2016–2019 was lower than that in 2012–2015 (1.4 ± 0.3% vs. 2.5 ± 0.3%, p = 0.005). A total of 42.5% of children died of heart failure, and 32.9% died of residual anatomic defects. Patients with transposition of the great arteries tended to die from residual anatomic defects (21.9%), while those with double-outlet right ventricle (20%) and single ventricle (20%) tended to die from pulmonary hypertension (PH) (p = 0.006). After biventricular repair, children tended to die from heart failure (90.4%), while after single-ventricle repair, children tended to die from PH (50%) (p < 0.0001). There is a negative correlation between mortality and the ECMO implantation rate (r = −0.898, p = 0.002). Conclusions: Heart failure and residual anatomic defects were the main causes of death after cardiac surgery. The cause of death patterns differed among CHD types and surgical strategies. ECMO may be a life-saving tool when other conventional therapies do not work.     

体外膜肺氧合在心脏危重症患者救治中的应用

目的:总结体外膜肺氧合(ECMO)辅助在心脏危重症患者中的临床救治经验与体会。方法:回顾性分析7例因药物治疗和/或主动脉内球囊反搏(IABP)无效而行ECMO辅助的心源性休克或血流动力学障碍患者的临床资料。ECMO辅助的主要原因:急性心肌梗死后心源性休克4例(57.1%),暴发性心肌炎1例(14.3%),心脏骤停2例(28.6%)。结果:7例患者ECMO平均辅助时间(4.7±3.2)d(范围:1~9 d),6例(85.7%)顺利撤除ECMO,3例行经皮冠状动脉介入治疗。主要并发症包括:出血2例(28.6%),肢体缺血1例(14.3%),急性肾衰竭1例(14.3%),多器官功能衰竭2例(28.6%)。1例在ECMO辅助情况下放弃治疗死亡,2例在成功撤除ECMO后死亡。其中,1例死于严重出血,2例死于多器官功能衰竭。其余4例(57.1%)好转存活出院。结论:ECMO能暂时性为心肺功能提供有效的支持,有利于稳定心脏危重患者的血流动力学,为心功能的恢复创造机会,减少ECMO相关并发症的发生可能会改善心脏危重患者预后。     

The benign course of liver disease in adults with cystic fibrosis and the effect of ursodeoxycholic acid

Background and Aims: The life expectancy of patients with cystic fibrosis (CF) has been increasing and the associated liver disease has emerged as a significant medical issue. Our aim was to describe the clinical features, course and effect of ursodeoxycholic acid (UDCA) on liver disease in an adult CF population. Study: From 1983 to 2005, 278 patients with CF were followed up at the Alfred Hospital, an adult tertiary referral centre. Twenty‐seven patients (9.7%) satisfied the criteria for liver disease and their clinico‐pathological features were assessed. The effect of UDCA on hepatobiliary symptoms and biochemical parameters was determined. Results: The mean age at liver disease diagnosis was 23 years (range 8–47 years). Portal hypertension was present in 18 (67%) patients. During a median follow‐up of 7 years (range 1.5–15), variceal haemorrhage occurred in two patients and ascites in three (one spontaneously). Nine (33%) patients died and five (19%) underwent lung transplantation. There was no encephalopathy, liver transplantation or liver‐related deaths. UDCA was taken by 22 patients and was associated with a significant improvement in hepatobiliary symptoms [11/22 (50%) in the pre‐UDCA period vs 1/22 (4%) in the post‐UDCA period; P=0.0003] and a significant reduction in aspartate aminotransferase (P=0.005); alanine aminotransferase (P<0.001); γ‐glutamyltranspeptidase (P=0.021); and alkaline phosphatase (P<0.001). Conclusions: Liver disease in adults with CF is commonly complicated by portal hypertension, but morbidity and mortality associated with this in our small patient population were low. UDCA is associated with improvement in hepatobiliary symptoms and liver function tests.     

Treating cardiogenic shock and cardiac arrest: The right place,the right time,the right equipment

• The use of VA‐ECMO for patients with cardiac arrest or cardiogenic shock in the cardiac catheterization laboratory may be associated with improved survival.
• Clinicians should be aware of a high complication rate of this therapy.
• Further data is needed to best select the appropriate form of mechanical circulatory support in this clinical context.

     

Atrial Septostomy for Left Ventricular Unloading During Extracorporeal Membrane Oxygenation for Cardiogenic Shock: Animal Model

ObjectivesThe aim of this study was to quantify and understand the unloading effect of percutaneous balloon atrial septostomy (BAS) in acute cardiogenic shock (CS) treated with venoarterial (VA) extracorporeal membranous oxygenation (ECMO).BackgroundIn CS treated with VA ECMO, increased left ventricular (LV) afterload is observed that commonly interferes with myocardial recovery or even promotes further LV deterioration. Several techniques for LV unloading exist, but the optimal strategy and the actual extent of such procedures have not been fully disclosed.MethodsIn a porcine model (n = 11; weight 56 kg [53-58 kg]), CS was induced by coronary artery balloon occlusion (57 minutes [53-64 minutes]). Then, a step-up VA ECMO protocol (40-80 mL/kg/min) was run before and after percutaneous BAS was performed. LV pressure-volume loops and multiple hemoglobin saturation data were evaluated. The Wilcoxon rank sum test was used to assess individual variable differences.ResultsImmediately after BAS while on VA ECMO support, LV work decreased significantly: pressure-volume area, end-diastolic pressure, and stroke volume to ∼78% and end-systolic pressure to ∼86%, while superior vena cava and tissue oximetry did not change. During elevating VA ECMO support (40-80 mL/kg/min) with BAS vs without BAS, we observed 1) significantly less mechanical work increase (122% vs 172%); 2) no end-diastolic volume increase (100% vs 111%); and 3) a considerable increase in end-systolic pressure (134% vs 144%).ConclusionsIn acute CS supported by VA ECMO, atrial septostomy is an effective LV unloading tool. LV pressure is a key component of LV work load, so whenever LV work reduction is a priority, arterial pressure should carefully be titrated low while maintaining organ perfusion.