Extracorporeal Life Support and Increased Risk of Stroke with Carotid Cannulation: Maybe, Maybe Not No abstract available

Pediatric Femoral Arterial Cannulations in Extracorporeal Membrane Oxygenation: A Review and Strategies for Optimization Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) is a treatment strategy for pediatric patients with cardiopulmonary failure. Femoral cannulation is a commonly used technique for obtaining central access in children and adolescents despite high rates of vascular complications. Ischemic limb complications remain one of the most common problems facing survivors of femoral VA ECMO. Our aim is to review the literature on femoral cannulation in children and to present a review of techniques for femoral cannula placement, decannulation, and arterial repair to help minimize and ameliorate complications related to cannulation. We performed a literature review for pediatric ECMO cannulation, complications, and femoral artery repair in pediatric patients. We focused on the management of arterial and ischemia-related complications during and after ECMO support via femoral cannulation. Vascular complications are not infrequent for patients requiring ECMO support via femoral cannulation. As such, judicious distal perfusion monitoring as well as augmentation of distal flow are important strategies during mechanical support. The use of distal perfusion catheters can be used to minimize the risk of limb ischemia. As femoral cannulation grows more popular in pediatric patients, strategies for arterial repair are essential to ensure extremity perfusion upon decannulation.

Clinical Outcomes of Impella Microaxial Devices Used to Salvage Cardiogenic Shock as a Bridge to Durable Circulatory Support or Cardiac Transplantation Temporary mechanical circulatory support (MCS) can be a bridge to decision for patients in severe cardiogenic shock who may be eligible for durable support or transplantation. Outcomes with Impella microaxial devices for salvage of severe shock in the end-stage heart failure population are not well described. Patients who underwent Impella placement as a bridge to decision, durable MCS, or transplantation were included. Eighty Impella devices (2.5 [1.3%], CP [53.8%], and 5.0 [45.0%]) were placed in 64 patients. Implant age was 56.2 ± 12.5 years. Mean duration of assisted support was 13.2 ± 15.1 days, and median duration per device was 7 days (interquartile range: 3–14). A total of 48.4% were in Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS 1) shock at implant, 51.6% in profile 2. Recent cardiopulmonary resuscitation (CPR) (26.7%), ventilator use (67.2%), and extracorporeal membrane oxygenation (ECMO) use (26.7%) were frequent. Forty four of sixty four (68.8%) survived to next therapy: durable MCS (40.9%), heart transplant (OHT) (36.4%), and recovery (22.7%). Overall 30 and 60 day survival were 67.2% and 65.6%, respectively. Thirty and 60 day survival conditional on having survived to next therapy were 94.1% and 91.2%, respectively. Survivors were less likely to be on ventilators (p = 0.049) or continuous renal replacement therapy (p < 0.001) but were otherwise not different from nonsurvivors by age, sex, INTERMACS profile, CPR, prevalence of ischemic cardiomyopathy, among other characteristics. Sixteen patients were directly bridged to heart transplantation, and all were alive at long-term follow-up. Impella devices can be used to salvage patients in severe heart failure as a bridge to decision, durable MCS, or transplantation. Baseline demographics are not predictive of survival. Their use for this indication is increasing and further investigations are warranted.

Meet the Authors No abstract available

Anticoagulation Reversal and Risk of Thromboembolic Events Among Heart Transplant Recipients Bridged with Durable Mechanical Circulatory Support Devices Anticoagulation reversal agents (ARAs) can minimize bleeding complications associated with mechanical circulatory support devices (MCSDs) explantation at the time of heart transplantation (HT); data on thromboembolic (TE) risk associated with ARAs are limited in this patient population. In this single-center study, we retrospectively analyzed 118 consecutive adults who were supported with durable MCSDs and underwent HT between May 2013 and October 2016. Patients were categorized based on intraoperative use of ARAs (recombinant factor VIIa [n=23], 4-factor prothrombin complex concentrate [n=48], or factor IX complex [n=2]) at the time of HT; these agents were used at discretion of implanting surgeons for bleeding control. The primary outcome of interest was presence of venous or systemic TE events within 3 months of HT. Multivariable logistic regression analyses were used to assess association between TE events and use of ARAs. A total of 71 (60%) patients received ARAs, and a total of 32 patients (27.1%) had TE events (25 venous [median time to diagnosis: 11.5 days; interquartile range {IQR}: 9–31 days], and 10 systemic [median time to diagnosis: 5.5 days; IQR: 4–8 days]); 26 (81.2%) of those with TE events had ARAs used at the time of HT. Multivariable analysis identified use of ARAs as an independent predictor of TE events (multivariable odds ratio: 3.06; 95% CI: 1.09–8.58; p = 0.034). Unplanned intraoperative use of ARAs to control bleeding was associated with a significantly higher risk of TE events among HT recipients bridged with durable MCSD. Future studies are required to further assess safety of these agents and their impact on patient outcomes.

Passive Leg Raising After Left Ventricular Assist Device Implantation Left ventricular assist device (LVAD) implantation is a common procedure in patients with end-stage heart failure. Although optimal fluid management is essential for acceptable postoperative treatment, it is critical to identify which patients will benefit from fluid administration. Passive leg raising (PLR) is a validated dynamic method that predicts fluid responsiveness in patients with heart failure by inducing a transient increase in cardiac preload. We performed a prospective study on 20 consecutive patients who underwent PLR maneuvers after LVAD implantation. Left ventricular assist device flow, end-tidal carbon dioxide, central venous pressure (CVP), and mean arterial pressure (MAP) were measured before and after PLR. Passive leg raising responsiveness was defined as at least a 15% increase in LVAD flow: (11 were responders and 9 nonresponders). Of the responders, 7 had right ventricular dysfunction (≥3). Passive leg raising responsiveness was associated with an increase of 19% in the LVAD flow, the mean CVP was raised from 11.3 to 14.4 mm Hg and the MAP from 82.6 to 86.7 mm Hg. After PLR, end-tidal carbon dioxide was increased by 4.6 mm Hg in the responders and 1.1 mm Hg in the nonresponders. The PLR maneuver is a noninvasive and easy to perform method that uses LVAD flow to assess fluid responsiveness in patients with heart failure after LVAD implantation.

Survival and Functional Status After Bridge-to-Transplant with a Left Ventricular Assist Device The use left ventricular assist devices (LVAD) as a bridge-to-transplant (BTT) has become a common modality to treat end-stage heart failure. We sought to examine the impact of BTT on long-term survival and quality of life after heart transplant. The population was all adult patients undergoing isolated heart transplantation in the United States between 2007 and 2017. Inclusion criteria covered BTT patients with a LVAD (only Heartmate II [HMII] or HeartWare Ventricular Assist System [HVAD]) and compared these with patients undergoing de novo heart transplantation. Our primary end-point was survival at 1, 2, and 5 years. Secondary end-points were functional status, return to work, and rates of hospital readmission and graft rejection. Unconditional and conditional survival was estimated with the Kaplan-Meier method. The independent influence of BTT on risk-adjusted mortality was determined using Cox proportional hazards models. In this period, 5,584 patients were bridged with an LVAD and 12,295 underwent de novo transplantation. Unconditional survival was 2% higher in de novo patients at 1, 2, and 5 years. After risk adjustment, BTT was associated with increased mortality at each time point. Unadjusted 5 year survival, conditional on 90 day survival, was similar between groups (82.6% vs. 83.4%; p = 0.15). Functional status, return to work, and unadjusted rates of hospital readmission and graft rejection were similar at 1, 2, 5 years. Bridge-to-transplant with LVADs provides excellent survival and similar quality of life to that of patients undergoing de novo heart transplantation. Bridge-to-transplant patients experience a slightly higher mortality rate within 90 days of transplantation.

Impact of Change in Body Mass Index on Outcomes After Left Ventricular Assist Device Implantation in Obese Patients Obesity could be a risk factor portending a poor prognosis after left ventricular assist device (LVAD) implantation. We sought to determine the impact of change in body mass index (BMI) on outcomes in obese patients supported by LVAD. Fifty-nine patients, who received LVAD between January 2010 and June 2015, with BMI ≥30 kg/m2 at the time of LVAD implantation, were retrospectively analyzed. Patients were divided into two groups based upon whether BMI after 6 months of device support decreased when compared with before. Thirty-eight patients who experienced decrease in BMI (group D) were compared with 21 patients whose BMI increased (group I). Baseline characteristics were similar between the groups except for body weight and BMI, which were significantly higher in group D (BMI: 35.9 ± 4.0 kg/m2vs. 33.4 ± 3.5 kg/m2; p = 0.018). During mean follow-up of 560 ± 178 days, group I had significantly higher incidence of infection [events per patient-years (eppy): nondevice related: 0.18 vs. 0.35, p = 0.01; device related: 0.1 vs. 0.32, p < 0.01; sepsis: 0.1 vs. 0.32, p < 0.01], heart failure (eppy: 0.1 vs. 0.25, p < 0.01), and renal failure (eppy: 0.03 vs. 0.14, p < 0.01). Survival at 2 years was significantly lower in group I (84.8% vs. 57.1%, p = 0.025). Increase in BMI in obese patients on LVAD is associated with worse survival with a higher incidence of infection, heart failure, and renal failure. Weight control may be a modifiable factor to improve prognosis.

Large Dual-Lumen Extracorporeal Membrane Oxygenation Cannulas Are Associated with More Intracranial Hemorrhage Large dual-lumen veno-venous (VV) extracorporeal membrane oxygenation (ECMO) cannulas may increase venous pressure in the brain, contributing to intracranial hemorrhage (ICH). A retrospective cohort study was performed using the extracorporeal life support organization (ELSO) registry. Propensity score matching was used to control for confounding. The rate of ICH and rates of hemolysis, cannula complications, and mortality were compared between patients with a 27 French dual-lumen cannula and patients with a 31 French dual-lumen cannula. Seven hundred forty-four patients were included in the propensity score-matched cohort. Patients were well matched except there was some residual imbalance in body weight and sex. Patients with a 31 French cannula had an ICH rate of 4.3% compared with 1.6% in patients with a 27 French cannula (p = 0.03). There were no differences in hemolysis, cannula complications, or mortality between groups. After controlling for body weight and sex in the matched cohort, ICH odds remained higher in patients with a 31 French cannula; odds ratio = 2.74, (95% CI = 1.06–7.09, p = 0.03). Our study data suggest that large dual-lumen VV ECMO cannulas are associated with more ICH, and thus, smaller cannulas may be preferable when feasible.

Obesity Is Associated with Driveline Infection of Left Ventricular Assist Devices In patients with left ventricular assist devices (LVADs), the association of driveline infection (DLI) and body mass index (BMI) remains controversial. The aim of this study was to explore a potential correlation between BMI and DLI in the LVAD patient population. A retrospective, single-center study evaluated patients who underwent LVAD implantation between May 2012 and July 2016. Driveline infection was evaluated per Interagency Registry for Mechanically Assisted Circulatory Support established criteria. Of 222 included patients, 80% were male, the average age was 55 years, and the main underlying heart failure diagnosis was nonischemic cardiomyopathy (56%). The majority of patients (65%) received LVAD as destination therapy and 35% as a bridge to transplantation. Average time-to-first DLI was 296 days after LVAD implantation. In comparison to non-DLI group (80%, N = 177), patients in DLI group (20%, N = 45) had a higher BMI (33.5 ± 8.3 kg/m2 in DLI group vs. 28.8 ± 7.5 kg/m2 in non-DLI group, p = 0.0003) and were younger (51 ± 12 years in DLI group vs. 56 ± 12 years in non-DLI group, p = 0.013). There was a significant correlation between BMI and DLI (p < 0.0001), and age was negatively correlated with DLI (p = 0.01). Analysis revealed no correlation between time-to-first DLI and BMI. Our data confirm that higher BMI is associated with increased prevalence of DLI in LVAD population, particularly in younger patients. Addressing excessive body weight in this patient cohort may significantly reduce DLI and thereby improve long-term outcomes.