Left ventricular(LV) thrombus is a life-threatening complication of severe LV dysfunction. Ventriculotomy has been a commonly performed procedure for LV thrombus; however, it often further decrease LV function after s...Left ventricular(LV) thrombus is a life-threatening complication of severe LV dysfunction. Ventriculotomy has been a commonly performed procedure for LV thrombus; however, it often further decrease LV function after surgery. We present an alternative approach to thrombectomy in order to minimize the postoperative LV dysfunction. A 37-year-old female with a postpartum cardiomyopathy found to have poor LV function and a large left ventricular apical thrombus(3 cm × 3 cm) attached to the apex by a narrow stalk. Given her severe LV dysfunction, the LV thrombus was approached via left atriotomy under cardiopulmonary bypass. The LV thrombus was easily extracted with gentle traction via the mitral valve. Postoperatively, the patient was discharged home without any embolization event or inotropic support. LV thrombectomy via left atriotomy through the mitral valve could be an alternative option for the patients with poor LV function with a mobile LV thrombus.展开更多
Introduction: Lung protective ventilation therapy with low tidal volume-high PEEP is the standard treatment for the patients with acute respiratory distress syndrome (ARDS). Oscillators are occasionally used for salva...Introduction: Lung protective ventilation therapy with low tidal volume-high PEEP is the standard treatment for the patients with acute respiratory distress syndrome (ARDS). Oscillators are occasionally used for salvage ventilation in cases where poor compliance restricts the use of traditional ventilation with ARDS. In addition to ventilator therapy, prone positioning has been used to improve oxygenation. We presented a challenging case of ARDS, which failed medical management extracorporeal membrane oxygenation (ECMO) support and oscillatory ventilation. Prone positioning was initiated which improved oxygenation, respiratory compliance and posterior atelectasis. Case presentation: A 41-year-old morbid obese female developed ARDS due to influenza pneumonia. The patient remained hypoxic despite optimum medical and ventilator management and required veno-venous extracorporeal membrane oxygenation (VV ECMO). CT scan of the chest showed ARDS with posterior consolidation. Despite ARDSnet ventilation support, antiviral therapy and ECMO support, there was no clinical improvement. High frequency oscillatory ventilation was initiated on ECMO day #13, which resulted in no respiratory improvement over the next 5 days. On ECMO day #18, the patient was placed on a Rotaprone? bed Therapy, utilizing a proning strategy of 16 hours a day. The clinical improvements observed were resolving of the consolidation on CXR, improvements in ventilatory parameters and decreased oxygen requirements. The patient was successfully weaned off ECMO on POD#25 (8 days post prone bed). Conclusions: Prone position improved oxygen saturation and pulmonary compliance in severe ARDS requiring ECMO and it might facilitate early weaning.展开更多
Background: Even with the use of extracorporeal membrane oxygenation (ECMO) in acute respiratory distress syndrome (ARDS), mortality remains high. Also, prognostication of patients with ARDS and ECMO is difficult. Cyt...Background: Even with the use of extracorporeal membrane oxygenation (ECMO) in acute respiratory distress syndrome (ARDS), mortality remains high. Also, prognostication of patients with ARDS and ECMO is difficult. Cytokines are thought to be markers of inflammation in both ARDS and in ECMO, however, understanding is limited. We aimed to study the association of three serum cytokine levels with mortality in these patients with ARDS on ECMO. Methods: We performed a retrospective chart review of ARDS patients on ECMO between 2011 and 2017. Patients with serum TNF-α, IL-6 and IL-2 measured while on ECMO were included, with measurements recorded weekly up to a maximum of 4 measurements. A multivariable regression analysis was performed and generalizing estimating equations were used to analyze longitudinal trend of cytokines with mortality. Results: There were 47 patients with ARDS on ECMO, of which 31 (68.9%) survived at 30 days and 2 were lost to follow up. Initial IL-2 levels were found to be significantly higher among those who were alive compared to those who died at 30 days (2720 ± 2432 pg/ml vs. 1293 ± 693 pg/ml);p = 0.0460. At any given time, an increase in IL-2 was associated with a decrease in odds of death at 30 days (adjusted odds ratio 0.98, 95% confidence interval 0.97 - 0.99, p = 0.08). There was no significant difference in average or initial levels of TNF-α and IL-6 among those who were alive vs. those who died at 30 days. There was no association between either of these cytokine levels with death while on ECMO. Conclusions: Higher levels of cytokine IL-2 were associated with lower 30-day mortality. Further studies are needed to elucidate the pathobiology of cytokines while on ECMO and their use in predicting outcomes.展开更多
A 50-year-old male who underwent a Heart Mate Ⅱ left ventricular assist device placement for ischemic cardiomyopathy presented with discolored urine and hemolysis 3 mo after the operation. His hemolysis was thought t...A 50-year-old male who underwent a Heart Mate Ⅱ left ventricular assist device placement for ischemic cardiomyopathy presented with discolored urine and hemolysis 3 mo after the operation. His hemolysis was thought to be due to thrombosis within the pump. Imaging studies were not able to visualize a left ventricular thrombus. Medical management with anticoagulation failed and he underwent surgery for a pump exchange. Intraoperatively, a firm thrombus was found within the pump of the Heart Mate Ⅱ, and the color of the urine changed dramatically from cola-colored to yellow which enabled us to confirm the diagnosis.展开更多
Introduction: Extracorporeal Membrane Oxygenation (ECMO) is used in selected patient with cardiogenic and/or re- spiratory shock. We report our experience with standardized management protocols and the application of ...Introduction: Extracorporeal Membrane Oxygenation (ECMO) is used in selected patient with cardiogenic and/or re- spiratory shock. We report our experience with standardized management protocols and the application of the Qua- droxD oxygenator with a centrifugal pump to maximize end-organ recovery and improve survival. Methods: This is an Internal Review Board (IRB) approved, single institution retrospective study of end-organ recovery and survival in pa- tients who required ECMO for cardiogenic and/or respiratory shock between July 2010 and June 2011. Results: Sixteen patients (median age: 46 years) were initiated on either Veno-Arterial (VA) or Veno-Venous (VV) ECMO. Cardiogenic shock, acute respiratory distress syndrome (ARDS) and a combined respiratory and cardiogenic compromise were the primary indications for ECMO in 8 (50%), 5 (31%) and 3 (19%) patients respectively. The median time on ECMO was 8 days (range: 4 - 26 days). Twelve patients (75%) were successfully weaned off ECMO, of which four (25%) were bridged to a ventricular assist device (VAD) and eight (50%) were weaned to recovery. All eight patients (100%) that were weaned to recovery and two patients (50%) that were bridged to a VAD were successfully discharged from the hospital, resulting in a discharge rate of 63%. There was an improvement in pre- vs. post-ECMO AST (449 IU/L vs. 63 IU/L, p Conclusion: ECMO using the QuadroxD oxygenator and a centrifugal pump, coupled with standardized management protocols is beneficial in carefully selected patients. Improvement or main- tenance of end-organ function is associated with successful bridge to device therapy and/or increased survival.展开更多
Introduction: Inadequate nutritional support after LVAD placement is known to increase postoperative infections and to decrease survival. LVAD patients with prolonged mechanical ventilation and complicated postoperati...Introduction: Inadequate nutritional support after LVAD placement is known to increase postoperative infections and to decrease survival. LVAD patients with prolonged mechanical ventilation and complicated postoperative recovery requiring prolonged mechanical ventilation may require long-term tube feedings. Placement of a PEG requires knowledge of the location of the LVAD pocket and driveline to avoid device infection and injury. Methods: Between August 2008 and December 2011, 39 patients underwent HeartMate II LVAD placement in our institution. Among them, 5 patients underwent PEG tube placement for long-term nutritional support. Procedure management consisted of cessation of anticoagulation and correction of abnormal coagulation;a cardiothoracic surgeon or intensivist in the operating room to communicate with the surgeon who performed the PEG procedure;and VAD coordinator or perfusionist in the operating room to assist in monitoring the VAD. Data were retrospectively analyzed to investigate complications related to the PEG placement. Results: The studied patients consisted of 3 males and 2 females with mean age of 58 +/﹣5.0. The interval of LVAD to PEG placement was a mean 21 +/﹣8.8 days. PEG was successfully performed in the operating room in all patients. There were no LVAD device or driveline injuries related to the PEG procedure. There were no postoperative short-term or long-term PEG related complications such as acute gastric bleeding or dislodgement of the PEG tube. Conclusions: PEG placement for HeartMate II LVAD patients can be done without increasing the risk of device or intraabdominal organ injury with carefully coordinated efforts from both the mechanical support team and surgical services.展开更多
<b><span style="font-family:Verdana;">INTRODUCTION</span></b><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="...<b><span style="font-family:Verdana;">INTRODUCTION</span></b><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">: Extracorporeal membrane oxygenation (ECMO) is commonly used for refractory cardiac or respiratory failure. There are reported cases of successful use of ECMO in patients with septic shock;however, there is a lack of evidence to prove its overall efficacy. Thus, we conducted this study to analyze the relationship between sepsis and ECMO in our own patients.</span></span></span><span><span><span style="font-family:;" "=""> </span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><b><span style="font-family:Verdana;">METHODS</span></b></span></span><span><span><span style="font-family:;" "=""><span style="font-family:Verdana;">: 305 patients who were placed on ECMO between 2010 and 2020 were identified within an IRB-approved database. Their clinical outcomes were an</span><span><span style="font-family:Verdana;">alyzed with a specific focus on patients who were septic before or during ECMO, defined as a positive blood culture. Group S was composed of patients with a positive blood culture before or during ECMO, while Group N was composed of all patients without a positive blood culture before or during ECMO. The primary outcome compared between groups was </span><span style="font-family:Verdana;">ECMO</span><span style="font-family:Verdana;"> survival rate. </span><b><span style="font-family:Verdana;">RESULTS</span></b><span style="font-family:Verdana;">: Among the 305 patients on ECMO, 58 (19%) were in Group S and 247 (81%) were in Group N. ECMO survival rates were 45% in Group S and 62% in Group N (p = 0.017).</span></span></span></span></span><span><span><span style="font-family:;" "=""> </span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><b><span style="font-family:Verdana;">CONCLUSION</span></b></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">: Of our 305 patients, patients who were septic upon ECMO </span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">placement or those who developed sepsis during ECMO had worse ECMO survival rates than non-septic patients. Ultimately, patients who are septic or have a high probability of becoming septic may not be indicated for ECMO placement, and cautious administration of ECMO to these patients may be necessary.</span></span></span>展开更多
文摘Left ventricular(LV) thrombus is a life-threatening complication of severe LV dysfunction. Ventriculotomy has been a commonly performed procedure for LV thrombus; however, it often further decrease LV function after surgery. We present an alternative approach to thrombectomy in order to minimize the postoperative LV dysfunction. A 37-year-old female with a postpartum cardiomyopathy found to have poor LV function and a large left ventricular apical thrombus(3 cm × 3 cm) attached to the apex by a narrow stalk. Given her severe LV dysfunction, the LV thrombus was approached via left atriotomy under cardiopulmonary bypass. The LV thrombus was easily extracted with gentle traction via the mitral valve. Postoperatively, the patient was discharged home without any embolization event or inotropic support. LV thrombectomy via left atriotomy through the mitral valve could be an alternative option for the patients with poor LV function with a mobile LV thrombus.
文摘Introduction: Lung protective ventilation therapy with low tidal volume-high PEEP is the standard treatment for the patients with acute respiratory distress syndrome (ARDS). Oscillators are occasionally used for salvage ventilation in cases where poor compliance restricts the use of traditional ventilation with ARDS. In addition to ventilator therapy, prone positioning has been used to improve oxygenation. We presented a challenging case of ARDS, which failed medical management extracorporeal membrane oxygenation (ECMO) support and oscillatory ventilation. Prone positioning was initiated which improved oxygenation, respiratory compliance and posterior atelectasis. Case presentation: A 41-year-old morbid obese female developed ARDS due to influenza pneumonia. The patient remained hypoxic despite optimum medical and ventilator management and required veno-venous extracorporeal membrane oxygenation (VV ECMO). CT scan of the chest showed ARDS with posterior consolidation. Despite ARDSnet ventilation support, antiviral therapy and ECMO support, there was no clinical improvement. High frequency oscillatory ventilation was initiated on ECMO day #13, which resulted in no respiratory improvement over the next 5 days. On ECMO day #18, the patient was placed on a Rotaprone? bed Therapy, utilizing a proning strategy of 16 hours a day. The clinical improvements observed were resolving of the consolidation on CXR, improvements in ventilatory parameters and decreased oxygen requirements. The patient was successfully weaned off ECMO on POD#25 (8 days post prone bed). Conclusions: Prone position improved oxygen saturation and pulmonary compliance in severe ARDS requiring ECMO and it might facilitate early weaning.
文摘Background: Even with the use of extracorporeal membrane oxygenation (ECMO) in acute respiratory distress syndrome (ARDS), mortality remains high. Also, prognostication of patients with ARDS and ECMO is difficult. Cytokines are thought to be markers of inflammation in both ARDS and in ECMO, however, understanding is limited. We aimed to study the association of three serum cytokine levels with mortality in these patients with ARDS on ECMO. Methods: We performed a retrospective chart review of ARDS patients on ECMO between 2011 and 2017. Patients with serum TNF-α, IL-6 and IL-2 measured while on ECMO were included, with measurements recorded weekly up to a maximum of 4 measurements. A multivariable regression analysis was performed and generalizing estimating equations were used to analyze longitudinal trend of cytokines with mortality. Results: There were 47 patients with ARDS on ECMO, of which 31 (68.9%) survived at 30 days and 2 were lost to follow up. Initial IL-2 levels were found to be significantly higher among those who were alive compared to those who died at 30 days (2720 ± 2432 pg/ml vs. 1293 ± 693 pg/ml);p = 0.0460. At any given time, an increase in IL-2 was associated with a decrease in odds of death at 30 days (adjusted odds ratio 0.98, 95% confidence interval 0.97 - 0.99, p = 0.08). There was no significant difference in average or initial levels of TNF-α and IL-6 among those who were alive vs. those who died at 30 days. There was no association between either of these cytokine levels with death while on ECMO. Conclusions: Higher levels of cytokine IL-2 were associated with lower 30-day mortality. Further studies are needed to elucidate the pathobiology of cytokines while on ECMO and their use in predicting outcomes.
文摘A 50-year-old male who underwent a Heart Mate Ⅱ left ventricular assist device placement for ischemic cardiomyopathy presented with discolored urine and hemolysis 3 mo after the operation. His hemolysis was thought to be due to thrombosis within the pump. Imaging studies were not able to visualize a left ventricular thrombus. Medical management with anticoagulation failed and he underwent surgery for a pump exchange. Intraoperatively, a firm thrombus was found within the pump of the Heart Mate Ⅱ, and the color of the urine changed dramatically from cola-colored to yellow which enabled us to confirm the diagnosis.
文摘Introduction: Extracorporeal Membrane Oxygenation (ECMO) is used in selected patient with cardiogenic and/or re- spiratory shock. We report our experience with standardized management protocols and the application of the Qua- droxD oxygenator with a centrifugal pump to maximize end-organ recovery and improve survival. Methods: This is an Internal Review Board (IRB) approved, single institution retrospective study of end-organ recovery and survival in pa- tients who required ECMO for cardiogenic and/or respiratory shock between July 2010 and June 2011. Results: Sixteen patients (median age: 46 years) were initiated on either Veno-Arterial (VA) or Veno-Venous (VV) ECMO. Cardiogenic shock, acute respiratory distress syndrome (ARDS) and a combined respiratory and cardiogenic compromise were the primary indications for ECMO in 8 (50%), 5 (31%) and 3 (19%) patients respectively. The median time on ECMO was 8 days (range: 4 - 26 days). Twelve patients (75%) were successfully weaned off ECMO, of which four (25%) were bridged to a ventricular assist device (VAD) and eight (50%) were weaned to recovery. All eight patients (100%) that were weaned to recovery and two patients (50%) that were bridged to a VAD were successfully discharged from the hospital, resulting in a discharge rate of 63%. There was an improvement in pre- vs. post-ECMO AST (449 IU/L vs. 63 IU/L, p Conclusion: ECMO using the QuadroxD oxygenator and a centrifugal pump, coupled with standardized management protocols is beneficial in carefully selected patients. Improvement or main- tenance of end-organ function is associated with successful bridge to device therapy and/or increased survival.
文摘Introduction: Inadequate nutritional support after LVAD placement is known to increase postoperative infections and to decrease survival. LVAD patients with prolonged mechanical ventilation and complicated postoperative recovery requiring prolonged mechanical ventilation may require long-term tube feedings. Placement of a PEG requires knowledge of the location of the LVAD pocket and driveline to avoid device infection and injury. Methods: Between August 2008 and December 2011, 39 patients underwent HeartMate II LVAD placement in our institution. Among them, 5 patients underwent PEG tube placement for long-term nutritional support. Procedure management consisted of cessation of anticoagulation and correction of abnormal coagulation;a cardiothoracic surgeon or intensivist in the operating room to communicate with the surgeon who performed the PEG procedure;and VAD coordinator or perfusionist in the operating room to assist in monitoring the VAD. Data were retrospectively analyzed to investigate complications related to the PEG placement. Results: The studied patients consisted of 3 males and 2 females with mean age of 58 +/﹣5.0. The interval of LVAD to PEG placement was a mean 21 +/﹣8.8 days. PEG was successfully performed in the operating room in all patients. There were no LVAD device or driveline injuries related to the PEG procedure. There were no postoperative short-term or long-term PEG related complications such as acute gastric bleeding or dislodgement of the PEG tube. Conclusions: PEG placement for HeartMate II LVAD patients can be done without increasing the risk of device or intraabdominal organ injury with carefully coordinated efforts from both the mechanical support team and surgical services.
文摘<b><span style="font-family:Verdana;">INTRODUCTION</span></b><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">: Extracorporeal membrane oxygenation (ECMO) is commonly used for refractory cardiac or respiratory failure. There are reported cases of successful use of ECMO in patients with septic shock;however, there is a lack of evidence to prove its overall efficacy. Thus, we conducted this study to analyze the relationship between sepsis and ECMO in our own patients.</span></span></span><span><span><span style="font-family:;" "=""> </span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><b><span style="font-family:Verdana;">METHODS</span></b></span></span><span><span><span style="font-family:;" "=""><span style="font-family:Verdana;">: 305 patients who were placed on ECMO between 2010 and 2020 were identified within an IRB-approved database. Their clinical outcomes were an</span><span><span style="font-family:Verdana;">alyzed with a specific focus on patients who were septic before or during ECMO, defined as a positive blood culture. Group S was composed of patients with a positive blood culture before or during ECMO, while Group N was composed of all patients without a positive blood culture before or during ECMO. The primary outcome compared between groups was </span><span style="font-family:Verdana;">ECMO</span><span style="font-family:Verdana;"> survival rate. </span><b><span style="font-family:Verdana;">RESULTS</span></b><span style="font-family:Verdana;">: Among the 305 patients on ECMO, 58 (19%) were in Group S and 247 (81%) were in Group N. ECMO survival rates were 45% in Group S and 62% in Group N (p = 0.017).</span></span></span></span></span><span><span><span style="font-family:;" "=""> </span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><b><span style="font-family:Verdana;">CONCLUSION</span></b></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">: Of our 305 patients, patients who were septic upon ECMO </span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">placement or those who developed sepsis during ECMO had worse ECMO survival rates than non-septic patients. Ultimately, patients who are septic or have a high probability of becoming septic may not be indicated for ECMO placement, and cautious administration of ECMO to these patients may be necessary.</span></span></span>
