Publications by authors named "Roberto Lorusso"

304 Publications

Sex differences in outcomes following less-invasive left ventricular assist device implantation.

Ann Cardiothorac Surg 2021 Mar;10(2):255-267

Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.

Background: Worse outcomes in women compared to men undergoing left ventricular assist device (LVAD) implantation remain an underestimated problem in heart failure (HF) patients. With device miniaturization, less-invasive LVAD implantation techniques have gained relevance, but their impact on outcomes in women is unknown. This study investigates sex-related differences in patients undergoing LVAD implantation through less-invasive procedures.

Methods: This retrospective single-center cohort study included patients who underwent isolated LVAD implantation between 2011 and 2018 through less-invasive techniques. Propensity score matching (PSM) was utilized to balance preoperative heterogeneity. Primary endpoint was two-year survival, and secondary endpoints included long-term survival, surgical outcomes and postoperative adverse events.

Results: Baseline analysis of 191 patients (females 18.3%) showed differences in terms of age [female (median, 52; IQR, 47-61); male (median, 58.5; IQR, 49-66); P=0.005], underlying diagnosis (P<0.001), INTERMACS profile (P=0.009), history of previous cardiac surgery (P=0.049) and preoperative creatinine values [female (median, 110; IQR, 71-146); male (median, 126; IQR, 9-168); P=0.049]. Over a follow-up of 460.68 patient-years, Kaplan-Meyer analysis showed better survival in females (P=0.027) and a similar probability of cardiac transplantation (P=0.288). After PSM, females showed higher needs for intraoperative fresh frozen plasma (P=0.044) and platelets (P=0.001) but comparable postoperative outcomes. No sex-related differences were noticed regarding two-year outcomes, long-term survival and adverse events. LVAD-related infections remained the most common complication with males experiencing more pump infections than women (P=0.050).

Conclusions: Patients receiving less-invasive LVAD implantation do not show significant sex-related differences in short and long-term outcomes and survival. Prospective studies are needed to evaluate the role of less-invasive techniques in reducing sex-based disparities after LVAD implantation.
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http://dx.doi.org/10.21037/acs-2020-cfmcs-21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8033266PMC
March 2021

Do Women Require Less Permanent Pacemaker After Transcatheter Aortic Valve Implantation? A Meta-Analysis and Meta-Regression.

J Am Heart Assoc 2021 Apr 27;10(7):e019429. Epub 2021 Mar 27.

Department of Cardio-Thoracic Surgery Heart and Vascular Centre Maastricht University Medical Centre (MUMC) Maastricht The Netherlands.

Background Limited clinical evidence and literature are available about the potential impact of sex on permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI). The aim of this work was to evaluate the relationship between sexes and atrioventricular conduction disturbances requiring PPI after TAVI. Methods and Results Data were obtained from 46 studies from PubMed reporting information about the impact of patient sex on PPI after TAVI. Total proportions with 95% Cls were reported. Funnel plot and Egger test were used for estimation of publication bias. The primary end point was 30-day or in-hospital PPI after TAVI, with odds ratios and 95% CIs extracted. A total of 70 313 patients were included, with a cumulative proportion of 51.5% of women (35 691 patients; 95% CI, 50.2-52.7). The proportion of women undergoing TAVI dropped significantly over time (<0.0001). The cumulative PPI rate was 15.6% (95% CI, 13.3-18.3). The cumulative rate of PPI in women was 14.9% (95% CI, 12.6-17.6), lower than in men (16.6%; 95% CI, 14.2-19.4). The risk for post-TAVI PPI was lower in women (odds ratio, 0.90; 95% CI, 0.84-0.96 [=0.0022]). By meta-regression analysis, age (=0.874) and ventricular function (=0.302) were not significantly associated with PPI among the sexes. Balloon-expandable TAVI significantly decrease the advantage of women for PPI, approaching the same rate as in men (=0.0061). Conclusions Female sex is associated with a reduced rate of PPI after TAVI, without influence of age or ventricular function. Balloon-expandable devices attenuate this advantage in favor of women. Additional investigations are warranted to elucidate sex-based differences in developing conduction disturbances after TAVI.
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http://dx.doi.org/10.1161/JAHA.120.019429DOI Listing
April 2021

Neurological complications during veno-venous extracorporeal membrane oxygenation: Does the configuration matter? A retrospective analysis of the ELSO database.

Crit Care 2021 03 17;25(1):107. Epub 2021 Mar 17.

Departments of Surgery, University of Maryland School of Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, USA.

Background: Single- (SL) and double-lumen (DL) catheters are used in clinical practice for veno-venous extracorporeal membrane oxygenation (V-V ECMO) therapy. However, information is lacking regarding the effects of the cannulation on neurological complications.

Methods: A retrospective observational study based on data from the Extracorporeal Life Support Organization (ELSO) registry. All adult patients included in the ELSO registry from 2011 to 2018 submitted to a single run of V-V ECMO were analyzed. Propensity score (PS) inverse probability of treatment weighting estimation for multiple treatments was used. The average treatment effect (ATE) was chosen as the causal effect estimate of outcome. The aim of the study was to evaluate differences in the occurrence and the type of neurological complications in adult patients undergoing V-V ECMO when treated with SL or DL cannulas.

Results: From a population of 6834 patients, the weighted propensity score matching included 6245 patients (i.e., 91% of the total cohort; 4175 with SL and 20,270 with DL cannulation). The proportion of patients with at least one neurological complication was similar in the SL (306, 7.2%) and DL (189, 7.7%; odds ratio 1.10 [95% confidence intervals 0.91-1.32]; p = 0.33). After weighted propensity score, the ATE for the occurrence of least one neurological complication was 0.005 (95% CI - 0.009 to 0.018; p = 0.50). Also, the occurrence of specific neurological complications, including intracerebral hemorrhage, acute ischemic stroke, seizures or brain death, was similar between groups. Overall mortality was similar between patients with neurological complications in the two groups.

Conclusions: In this large registry, the occurrence of neurological complications was not related to the type of cannulation in patients undergoing V-V ECMO.
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http://dx.doi.org/10.1186/s13054-021-03533-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968168PMC
March 2021

Venoarterial Extracorporeal Membrane Oxygenation for Postcardiotomy Shock-Analysis of the Extracorporeal Life Support Organization Registry.

Crit Care Med 2021 Feb 23. Epub 2021 Feb 23.

1 Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands. 2 Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland. 3 Thoracic Research Centre, Collegium Medicum, Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland. 4 Warsaw Medical University, Warsaw, Poland. 5 Center for Acute Respiratory Failure and Department of Medicine, Columbia University College of Physicians & Surgeons/New York-Presbyterian Hospital, New York, NY. 6 Cardiothoracic Intensive Care Unit, National University Hospital, Singapore;. 7 Cardiovascular Surgery Intensive Care Unit, Johns Hopkins Hospital, Baltimore, MD. 8 Cardiac Surgery Unit, ISMETT, Palermo, Italy. 9 Department of Cardiac Surgery, University of Dusseldorf, Dusseldorf, Germany. 10 Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, VIC, Australia. 11 Cardiovascular Surgery and Pediatric Cardiovascular Surgery, National Taiwan University Hospital, Taipei, Taiwan. 12 Department of Cardiothoracic Surgery, Jefferson University, Philadelphia, PA. 13 Department of Cardio-Thoracic Surgery, Massachusetts Medical Centre, Boston, MA. 14 Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, P.R. of China. 15 Section of Cardiac Surgery, University of Michigan, Ann Arbor, MI. 16 2nd Department of Medicine-Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University, Prague, and General University Hospital, Prague, Czech Republic. 17 Department of Pathophysiology, Faculty of Pharmacy, Collegium Medicum, Nicolaus Copernicus University, Toruń, Poland. 18 Department of Cardiology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA. 19 Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan Ann Arbor, MI. 20 Department of Cardio-Thoracic Surgery, Well Cornell Medicine, New York, NY. 21 Cardiac Surgery Unit, University Hospital, University of Chieti, Chieti, Italy. 22 Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands.

Objectives: Refractory postcardiotomy cardiogenic shock complicating cardiac surgery yields nearly 100% mortality when untreated. Use of venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock has increased worldwide recently. The aim of the current analysis was to outline the trends in use, changing patient profiles, and in-hospital outcomes including complications in patients undergoing venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock.

Design: Analysis of extracorporeal life support organization registry from January 2010 to December 2018.

Setting: Multicenter worldwide registry.

Patients: Seven-thousand one-hundred eighty-five patients supported with venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock.

Interventions: Venoarterial extracorporeal membrane oxygenation.

Measurements And Main Results: Hospital death, weaning from extracorporeal membrane oxygenation, hospital complications. Mortality predictors were assessed by multivariable logistic regression. Propensity score matching was performed for comparison of peripheral and central cannulation for extracorporeal membrane oxygenation. A significant trend toward more extracorporeal membrane oxygenation use in recent years (coefficient, 0.009; p < 0.001) was found. Mean age was 56.3 ± 14.9 years and significantly increased over time (coefficient, 0.513; p < 0.001). Most commonly, venoarterial extracorporeal membrane oxygenation was instituted after coronary artery bypass surgery (26.8%) and valvular surgery (25.6%), followed by heart transplantation (20.7%). Overall, successful extracorporeal membrane oxygenation weaning was possible in 4,520 cases (56.4%), and survival to hospital discharge was achieved in 41.7% of cases. In-hospital mortality rates remained constant over time (coefficient, -8.775; p = 0.682), whereas complication rates were significantly reduced (coefficient, -0.009; p = 0.003). Higher mortality was observed after coronary artery bypass surgery (65.4%), combined coronary artery bypass surgery with valve (68.4%), and aortic (69.6%) procedures than other indications. Lower mortality rates were observed in heart transplantation recipients (46.0%). Age (p < 0.001), central cannulation (p < 0.001), and occurrence of complications while on extracorporeal membrane oxygenation were independently associated with poorer prognosis.

Conclusions: The analysis confirmed increased use of venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock. Mortality rates remained relatively constant over time despite a decrease in complications, in the setting of supporting older patients.
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http://dx.doi.org/10.1097/CCM.0000000000004922DOI Listing
February 2021

Right ventricular failure after left ventricular assist device implantation: a review of the literature.

J Thorac Dis 2021 Feb;13(2):1256-1269

Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands.

Right ventricular failure (RVF) following left ventricular assist device (LVAD) implantation remains a major complication which may significantly impair patient outcome. The genesis of RVF is, however, multifactorial, and the mechanisms underlying such a condition have not been fully elucidated, making its prevention challenging and the course not always predictable. Although preoperative risks factors can be associated with RV impairment, the physiologic changes after the LV support, can still hamper the function of the RV. Current medical treatment options are limited and sometimes, patients with a severe post-LVAD RVF may be unresponsive to pharmacological therapy and require more aggressive treatment, such as temporary RV support. We retrieved 11 publications which we assessed and divided in groups based on the RV support [extracorporeal membrane oxygenation (ECMO), right ventricular assist device (RVAD), TandemHeart with ProtekDuo cannula]. The current review comprehensively summarizes the main studies of the literature with particular attention to the RV physiology and its changes after the LVAD implantation, the predictors and prognostic score as well as the different modalities of temporary mechanical cardio-circulatory support, and its effects on patient prognosis for RVF in such a setting. In addition, it provides a decision making of the pre-, intra and post-operative management in high- and moderate- risk patients.
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http://dx.doi.org/10.21037/jtd-20-2228DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7947472PMC
February 2021

Infective endocarditis and neurologic events: indications and timing for surgical interventions.

Eur Heart J Suppl 2020 Nov 6;22(Suppl M):M19-M25. Epub 2020 Dec 6.

Department of Cardiac Surgery, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria.

A therapeutic dilemma arises when infective endocarditis (IE) is complicated by a neurologic event. Postponement of surgery up to 4 weeks is recommended by the guidelines, however, this negatively impacts outcomes in many patients with an urgent indication for surgery due to uncontrolled infection, disease progression, or haemodynamic deterioration. The current literature is ambiguous regarding the safety of cardiopulmonary bypass in patients with recent neurologic injury. Nevertheless, most publications demonstrate a lower risk for secondary haemorrhagic conversion of uncomplicated ischaemic lesions than the risk for recurrent embolism under antibiotic treatment. Here, we discuss the current literature regarding neurologic stroke complicating IE with an indication for surgery.
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http://dx.doi.org/10.1093/eurheartj/suaa167DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7916418PMC
November 2020

ECMO for COVID-19: Updated 2021 Guidelines from the Extracorporeal Life Support Organization (ELSO).

ASAIO J 2021 Feb 26. Epub 2021 Feb 26.

Department of Emergency Medicine, University of Washington, USA Division of Pulmonary Critical Care and Sleep Medicine, University of Washington, USA General ICU, University Hospital of Parma, Italy Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Italy Extracorporeal Life Support Organization Texas Children's Hospital, Baylor College of Medicine Children's Medical Center of Dallas, University of Texas Southwestern Medical Center Extracorporeal Life Support Organization, President; Children's Healthcare of Atlanta, Emory University Department of Medicine, Columbia University College of Physicians and Surgeons, New York, USA Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, USA University of Michigan Department of Critical Care, Guy's and St. Thomas' NHS Foundation Trust Centre for Human & Applied Physiological Sciences, Faculty of Life Sciences & Medicine, King's College London Sorbonne Université, INSERM, Institute of Cardiometabolism and Nutrition Service de médecine intensive-réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, F-75013 PARIS, France Department of Cardio-Thoracic Surgery - Maastricht University Medical Centre - Cardiovascular Research Institute Maastricht Maastricht, The Netherlands Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany Nemours Children's Health System Congenital Heart Center, Departments of Surgery and Pediatrics, University of Florida, Gainesville, USA Intensive Care Unit, Alfred Health Melbourne, Victoria, Australia Critical Care ECMO service, King Saud Medical City - Ministry Of Health (MOH), Riyadh - Saudi Arabia. Fundación Cardiovascular de Colombia Service de Médecine Intensive-Réanimation, Institut de Cardiologie, AP-HP, Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France. Sorbonne Université, GRC n°30, GRC RESPIRE, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France. Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia National University Hospital, Singapore Department of Medicine, Columbia University College of Physicians and Surgeons, New York, USA Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, USA.

This is an updated guideline from the Extracorporeal Life Support Organization (ELSO) for the role of extracorporeal membrane oxygenation (ECMO) for patients with severe cardiopulmonary failure due to coronavirus disease 2019 (COVID-19). The great majority of COVID-19 patients (>90%) requiring ECMO have been supported using venovenous (V-V) ECMO for acute respiratory distress syndrome (ARDS). While COVID-19 ECMO run duration may be longer than in non-COVID-19 ECMO patients, published mortality appears to be similar between the two groups. However, data collection is ongoing, and there is a signal that overall mortality may be increasing. Conventional selection criteria for COVID-19-related ECMO should be used; however, when resources become more constrained during a pandemic, more stringent contraindications should be implemented. Formation of regional ECMO referral networks may facilitate communication, resource sharing, expedited patient referral, and mobile ECMO retrieval. There are no data to suggest deviation from conventional ECMO device or patient management when applying ECMO for COVID-19 patients. Rarely, children may require ECMO support for COVID-19-related ARDS, myocarditis or multisystem inflammatory syndrome in children (MIS-C); conventional selection criteria and management practices should be the standard. We strongly encourage participation in data submission to investigate the optimal use of ECMO for COVID-19.
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http://dx.doi.org/10.1097/MAT.0000000000001422DOI Listing
February 2021

The best approach for functional tricuspid regurgitation: A network meta-analysis.

J Card Surg 2021 Mar 2. Epub 2021 Mar 2.

Department of Cardiac Surgery, Gemelli Molise, Campobasso, Italy.

Objective: For many years, functional tricuspid regurgitation (FTR) was considered negligible after treatment of left-sided heart valve surgery. The aim of the present network meta-analysis is to summarize the results of four approaches to establish the possible gold standard.

Methods: A systematic search was performed to identify all publications reporting the outcomes of four approaches for FTR, not tricuspid annuloplasty (no TA), suture annuloplasty (SA), flexible (FRA), rigid rings (RRA). All studies reporting at least one the four endpoints (early and late mortality, early and late moderate or more TFR) were included in a Bayesian network meta-analysis.

Results: There were 31 included studies with 9663 patients. Aggregate early mortality was 5.3% no TA, 7.2% SA, 6.6% FRA, and 6.4% RRA; early TR moderate-or-more was 9.6%, 4.8%, 4.6%, and 3.8%; late mortality was 22.5%, 18.2%, 11.9%, and 11.9%; late TR moderate-or-more was 27.9%, 18.3%, 14.3%, and 6.4%. Rigid or semirigid ring annuloplasty was the most effective approach for decreasing the risk of late moderate or more FTR (-85% vs. no TA; -64% vs. SA; -32% vs. FRA). Concerning late mortality, no significant differences were found among different surgical approaches; however, flexible or rigid rings reduced significantly the risk of late mortality (78% and 47%, respectively) compared with not performing TA mortality. No differences were found for early outcomes.

Conclusions: Ring annuloplasty seems to offer better late outcomes compare to either suture annuloplasty or not performing TA. In particular rigid or semirigid rings provide more stable FTR across time.
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http://dx.doi.org/10.1111/jocs.15378DOI Listing
March 2021

Lateral Thoracotomy for Ventricular Assist Device Implantation: A Meta-Analysis of Literature.

ASAIO J 2021 Feb 4. Epub 2021 Feb 4.

From the *Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany †Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany ‡Cardio-Thoracic Surgery Department, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands.

The use of lateral thoracotomy (LT) for implanting left ventricular assist devices (LVADs) is worldwide increasing, although the available evidence for its positive effects compared with conventional sternotomy (CS) is limited. This systematic review and meta-analysis analyzes the outcomes of LT compared with CS in patients undergoing implantation of a centrifugal continuous-flow LVAD. Four databases and 1,053 publications were screened until December 2019. Articles including patients undergoing implantation of a centrifugal continuous-flow LVAD through LT were included. A meta-analysis to compare LT and CS was performed to summarize evidences from studies including both LT and CS patients extracted from the same population. Primary outcome measure was in-hospital or 30-day mortality. Eight studies reporting on 730 patients undergoing LVAD implantation through LT (n = 242) or CS (n = 488) were included in the meta-analysis. Left thoracotomy showed lower in-hospital/30-day mortality (odds ratio [OR]: 0.520, 95% confidence interval [CI]: 0.27-0.99, p = 0.050), shorter intensive care unit (ICU) stay (mean difference [MD]: 3.29, CI: 1.76-4.82, p < 0.001), lower incidence of severe right heart failure (OR: 0.41; CI: 0.19-0.87, p = 0.020) and postoperative right ventricular assist device (RVAD) implantation (OR: 0.27, CI: 0.10-0.76, p = 0.010), fewer perioperative transfusions (MD: 0.75, CI: 0.36-1.14, p < 0.001), and lower incidence of renal failure (OR: 0.45, CI: 0.20-1.01, p = 0.050) and device-related infections (OR: 0.45, CI: 0.20-1.01, p = 0.050), respectively. This meta-analysis demonstrates that implantation of a centrifugal continuous-flow LVAD system via LT benefits from higher short-term survival, less right heart failure, lower postoperative RVAD need, shorter ICU stay, less transfusions, lower risk of device-related infections and kidney failure. Prospective studies are needed for further proof.
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http://dx.doi.org/10.1097/MAT.0000000000001359DOI Listing
February 2021

Prophylactic mechanical circulatory support for protected ventricular tachycardia ablation: A meta-analysis of the literature.

Artif Organs 2021 Feb 22. Epub 2021 Feb 22.

Cardio-Thoracic Surgery Department, Heart and Vascular Center, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.

Acute hemodynamic decompensation (AHD) during ventricular tachycardia (VT) ablation occurs in about 11% of cases. Prophylactic use of temporary mechanical circulatory support (pro-tMCS) has been applied to prevent AHD during VT ablation, but evidence supporting this practice is still lacking. This systematic review and meta-analysis assessed the procedural characteristics and outcomes of pro-tMCS for VT ablation. PubMed/Medline was screened until February 2020. Articles including adults receiving pro-tMCS for VT ablation were included, and a meta-analysis to compare proMCS and no-tMCS was performed. Primary outcome was in-hospital/30-day mortality. Five observational studies presenting 400 procedures (pro-tMCS: n = 187; no-tMCS: n = 213) were included. Baseline characteristics were comparable between groups. Impella and TandemHeart were used in 86.6% and 13.4% of cases, respectively. In the pro-tMCS group, more VTs were induced (mean difference: 0.52, confidence interval [CI]: 0.26-0.77, P < .0001), and patients remained in VT on average for 24.04 minutes longer (CI: 18.28-29.80, P < .00001). Procedural success was comparable between groups, as was VT recurrence. Pro-tMCS patients had an odds ratio of 0.55 (CI: 0.28-1.05, P = .07) for in-hospital/30-day mortality and 0.55 (CI: 0.32-0.94, P = .03) for mortality at follow-up. Sixty-four percent of no-tMCS patients received rescue tMCS. The most common tMCS-related complications were bleeding events. Pro-tMCS allowed for a prolonged time on VTs and the induction of more VTs. Although these advantages were not associated with differences in procedural success, VT recurrence, or in-hospital/30-day mortality in the overall population, pro-tMCS might improve long-term survival. Further prospective studies are urgently needed to confirm these results.
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http://dx.doi.org/10.1111/aor.13945DOI Listing
February 2021

Extracorporeal life support in COVID-19-related acute respiratory distress syndrome: A EuroELSO international survey.

Artif Organs 2021 Feb 16. Epub 2021 Feb 16.

Interdisciplinary COVID-19-Center, University Medical Centre, Saarland University, Homburg, Germany.

Extracorporeal life support (ECLS) is a means to support patients with acute respiratory failure. Initially, recommendations to treat severe cases of pandemic coronavirus disease 2019 (COVID-19) with ECLS have been restrained. In the meantime, ECLS has been shown to produce similar outcomes in patients with severe COVID-19 compared to existing data on ARDS mortality. We performed an international email survey to assess how ECLS providers worldwide have previously used ECLS during the treatment of critically ill patients with COVID-19. A questionnaire with 45 questions (covering, e.g., indication, technical aspects, benefit, and reasons for treatment discontinuation), mostly multiple choice, was distributed by email to ECLS centers. The survey was approved by the European branch of the Extracorporeal Life Support Organization (ELSO); 276 ECMO professionals from 98 centers in 30 different countries on four continents reported that they employed ECMO for very severe COVID-19 cases, mostly in veno-venous configuration (87%). The most common reason to establish ECLS was isolated hypoxemic respiratory failure (50%), followed by a combination of hypoxemia and hypercapnia (39%). Only a small fraction of patients required veno-arterial cannulation due to heart failure (3%). Time on ECLS varied between less than 2 and more than 4 weeks. The main reason to discontinue ECLS treatment prior to patient's recovery was lack of clinical improvement (53%), followed by major bleeding, mostly intracranially (13%). Only 4% of respondents reported that triage situations, lack of staff or lack of oxygenators, were responsible for discontinuation of ECLS support. Most ECLS physicians (51%, IQR 30%) agreed that patients with COVID-19-induced ARDS (CARDS) benefitted from ECLS. Overall mortality of COVID-19 patients on ECLS was estimated to be about 55%. ECLS has been utilized successfully during the COVID-19 pandemic to stabilize CARDS patients in hypoxemic or hypercapnic lung failure. Age and multimorbidity limited the use of ECLS. Triage situations were rarely a concern. ECLS providers stated that patients with severe COVID-19 benefitted from ECLS.
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http://dx.doi.org/10.1111/aor.13940DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8014805PMC
February 2021

The Effectiveness of Levosimendan on Veno-Arterial Extracorporeal Membrane Oxygenation Management and Outcome: A Systematic Review and Meta-Analysis.

J Cardiothorac Vasc Anesth 2021 Jan 16. Epub 2021 Jan 16.

Cardiology, Erasmus University Medical Center, Roterdam, Netherlands.

Objectives: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides a temporary support system for patients with cardiogenic shock refractory to conventional medical therapies. It has been reported that levosimendan may facilitate VA-ECMO weaning and improve survival. The primary objective of this review was to examine the effect of levosimendan use on VA-ECMO weaning and mortality in critically ill patients on VA-ECMO.

Design: MEDLINE, EMBASE, and CENTRAL were searched. A pair of reviewers identified eligible clinical trials. Two reviewers extracted data and independently assessed the risk of bias. A random-effect model was used to combine data. The primary outcome was the success of weaning from VA-ECMO.

Measurements And Main Results: Seven studies of observational design, including a total of 630 patients, were selected in the final analysis. The sample size ranged from ten-to-240 patients, with a mean age between 53 and 65 years, and more than half of them underwent cardiac surgeries. The VA-ECMO durations varied between four and 11.6 days. Overall, levosimendan use was significantly associated with successful weaning compared with control (odds ratio [OR] 2.89, 95% CI, 1.53-5.46; p = 0.001); I = 49%). For survival, six studies (n = 617) were included in the meta-analysis involving 326 patients in the levosimendan group and 291 in the comparator group. Pooled results showed a significantly higher survival rate in the levosimendan group (OR 0.46, 95% CI, 0.30-0.71; p = 0.0004; I = 20%).

Conclusions: Levosimendan therapy was significantly associated with successful weaning and survival benefit in patients with cardiogenic or postcardiotomy shock needing VA-ECMO support for severe cardiocirculatory compromise. To date, there is limited literature and absence of evidence from randomized trials addressing the use of levosimendan in VA-ECMO weaning. This study may be considered a hypothesis-generating research for randomized controlled trials to confirm its findings.
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http://dx.doi.org/10.1053/j.jvca.2021.01.019DOI Listing
January 2021

Quantitative and Qualitative Platelet Derangements in Cardiac Surgery and Extracorporeal Life Support.

J Clin Med 2021 Feb 6;10(4). Epub 2021 Feb 6.

Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), 6229HX Maastricht, The Netherlands.

Thrombocytopenia and impaired platelet function are known as intrinsic drawbacks of cardiac surgery and extracorporeal life supports (ECLS). A number of different factors influence platelet count and function including the inflammatory response to a cardiopulmonary bypass (CPB) or to ECLS, hemodilution, hypothermia, mechanical damage and preoperative treatment with platelet-inhibiting agents. Moreover, although underestimated, heparin-induced thrombocytopenia is still a hiccup in the perioperative management of cardiac surgical and, above all, ECLS patients. Moreover, recent investigations have highlighted how platelet disorders also affect patients undergoing biological prosthesis implantation. Though many hypotheses have been suggested, the mechanism underlying thrombocytopenia and platelet disorders is still to be cleared. This narrative review aims to offer clinicians a summary of their major causes in the cardiac surgery setting.
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http://dx.doi.org/10.3390/jcm10040615DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7914426PMC
February 2021

Active cancer and cardiac surgery: Possible scenarios in patient decision-making.

Monaldi Arch Chest Dis 2021 Feb 5;91(1). Epub 2021 Feb 5.

Cardiology Unit, Spedali Civili and University of Brescia; Fondazione Poliambulanza, Brescia.

Heart disease and cancer are often found simultaneously in the same patient, and may require cardiac and non-cardiac surgery. Cancer may be part of the past medical history; in other cases the presence of an active malignancy makes the clinical management more complex. No general evidence-based recommendations are available to help in the decision-making process. Because of the lack of specific guidelines we provided a series of possible scenarios describing not unusual cases. We focused on cases where the concomitant presence of heart disease and active malignancies involved a multidisciplinary team. Four real patients with active cancer referred to our Center were assessed. Three of them had valve disease requiring cardiac surgery. Defining the timing of surgery and choosing the surgical approach required a careful and comprehensive evaluation. In the last case, the complicated balance between the thrombotic and the hemorrhagic risk involved difficult decision. Several critical points, which characterized the management of this kind of patients, were identified. In particular, the hemodynamic status, the type and stage of the tumor, the need for cancer therapy, as well as the comorbidities of the patient, had to be taken into account. This narrative review shows the importance of submitting every challenging case to the assessment of a multidisciplinary team, which involves different clinical figures, in order to guarantee the most comprehensive evaluation. When clinical management deviates from the general recommendations, an individualized approach should be used.
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http://dx.doi.org/10.4081/monaldi.2021.1655DOI Listing
February 2021

Do-(Not-)Mechanical-Circulatory-Support Orders: Should We Ask All Cardiac Surgery Patients for Informed Consent for Post-Cardiotomy Extracorporeal Life Circulatory Support?

J Clin Med 2021 Jan 20;10(3). Epub 2021 Jan 20.

Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands.

Post-cardiotomy extracorporeal life support (PC-ECLS) has seen a substantial increase in use over the past 10 years. PC-ECLS can be a life-saving procedure and is mostly applied in the presence of unexpected, severe cardio-respiratory complication. Despite PC-ECLS being critical in allowing for organ recovery, it is unfortunately closely connected with an unpredictable outcomes, high morbidity, and, even in the case of cardiac function improvement, potential sustained disabilities that have a life-changing impact for the patient and his or her family. Since the decision to start PC-ECLS is made in an acute setting, there is often only limited or no time for self-determined choices. Due to the major impact of the intervention, it would be highly desirable to obtain informed consent before starting PC-ECLS, since the autonomy of the patient and shared-decision making are two of the most important ethical values in modern medicine. Recent developments regarding awareness of the impacts of a prolonged intensive care stay make this a particularly relevant topic. Therefore, it would be desirable to develop a structural strategy that takes into account the likelihood of such an intervention and the wishes and preferences of the patient, and thus the related autonomy of the patient. This article proposes key points for such a strategy in the form of a PC-ECLS informed consent, a do-(not-)mechanical-circulatory-support order (D(N)MCS), and specific guidelines to determine the extent of the shared decision making. The concept presented in this article could be a starting point for improved and ethical PC-ECLS treatment and application.
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http://dx.doi.org/10.3390/jcm10030383DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7864157PMC
January 2021

Sutureless versus conventional bioprostheses for aortic valve replacement in severe symptomatic aortic valve stenosis.

J Thorac Cardiovasc Surg 2021 03 14;161(3):920-932. Epub 2020 Dec 14.

Cardio-Thoracic Surgery Department, Heart and Vascular Center, Maastricht University Medical Center (MUMC+), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands.

Objective: Sutureless aortic valves are a novel option for aortic valve replacement. We sought to demonstrate noninferiority of sutureless versus standard bioprostheses in severe symptomatic aortic stenosis.

Methods: The Perceval Sutureless Implant Versus Standard-Aortic Valve Replacement is a prospective, randomized, adaptive, open-label trial. Patients were randomized (March 2016 to September 2018) to aortic valve replacement with a sutureless or stented valve using conventional or minimally invasive approach. Primary outcome was freedom from major adverse cerebral and cardiovascular events (composite of all-cause death, myocardial infarction, stroke, or valve reintervention) at 1 year.

Results: At 47 centers (12 countries), 910 patients were randomized to sutureless (n = 453) or conventional stented (n = 457) valves; mean ages were 75.4 ± 5.6 and 75.0 ± 6.1 years, and 50.1% and 44.9% were female, respectively. Mean ± standard deviation Society of Thoracic Surgeons scores were 2.4 ± 1.7 and 2.1 ± 1.3, and a ministernotomy approach was used in 50.4% and 47.3%, respectively. Concomitant procedures were performed with similar rates in both groups. Noninferiority was demonstrated for major adverse cerebral and cardiovascular events at 1 year, whereas aortic valve hemodynamics improved equally in both groups. Use of sutureless valves significantly reduced surgical times (mean extracorporeal circulation times: 71.0 ± 34.1 minutes vs 87.8 ± 33.9 minutes; mean crossclamp times: 48.5 ± 24.7 vs 65.2 ± 23.6; both P < .0001), but resulted in a higher rate of pacemaker implantation (11.1% vs 3.6% at 1 year). Incidences of perivalvular and central leak were similar.

Conclusions: Sutureless valves were noninferior to stented valves with respect to major adverse cerebral and cardiovascular events at 1 year in patients undergoing aortic valve replacement (alone or with coronary artery bypass grafting). This suggests that sutureless valves should be considered as part of a comprehensive valve program.
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http://dx.doi.org/10.1016/j.jtcvs.2020.11.162DOI Listing
March 2021

Allocating scarce intensive care resources during the COVID-19 pandemic: practical challenges to theoretical frameworks.

Lancet Respir Med 2021 04 12;9(4):430-434. Epub 2021 Jan 12.

Columbia University College of Physicians & Surgeons, New York-Presbyterian Hospital, New York, NY, USA; Center for Acute Respiratory Failure, Columbia University Medical Center, New York, NY, USA.

The COVID-19 pandemic strained health-care systems throughout the world. For some, available medical resources could not meet the increased demand and rationing was ultimately required. Hospitals and governments often sought to establish triage committees to assist with allocation decisions. However, for institutions operating under crisis standards of care (during times when standards of care must be substantially lowered in the setting of crisis), relying on these committees for rationing decisions was impractical-circumstances were changing too rapidly, occurring in too many diverse locations within hospitals, and the available information for decision making was notably scarce. Furthermore, a utilitarian approach to decision making based on an analysis of outcomes is problematic due to uncertainty regarding outcomes of different therapeutic options. We propose that triage committees could be involved in providing policies and guidance for clinicians to help ensure equity in the application of rationing under crisis standards of care. An approach guided by egalitarian principles, integrated with utilitarian principles, can support physicians at the bedside when they must ration scarce resources.
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http://dx.doi.org/10.1016/S2213-2600(20)30580-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7837018PMC
April 2021

Is surgery the fair competitor for MitraClip?

J Card Surg 2021 Mar 11;36(3):1120-1122. Epub 2021 Jan 11.

Department of Cardiac Surgery, Gemelli Molise, Campobasso, Italy.

In the last decades, the overlapping areas of intervention between cardiac surgeons and interventional cardiologists are rocketing, especially in the field of treatment of heart valve disease. But, while for the aortic valve the competition, even for nonhigh risk patients, has become tightened, in the context of mitral regurgitation, the surgery seems to not have competitors. In fact looking the results of studies published so far, a question arises: Is surgery the fair competitor for the Mitraclip? The meta-analysis by Abdul Khader et al. summarized few evidences present in this field, only 11 observational studies and 1 randomized trial, providing an awesome response: "NO." Is therefore not a case if recently two trials, MITRA-FR and COAPT, chose to use as competitor for MitraClip, more rightly, medical therapy instead of surgery. In conclusions, in case of mitral regurgitation (MR), surgery is still largely the gold standard treatment and so MitraClip cannot be mention at all as competitor of surgery. It can be the right choice of case of primary MR where patients showed high risk for surgery. In case of secondary MR, especially with large and poor left ventricle we should wait for a clear answer on its role, yet.
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http://dx.doi.org/10.1111/jocs.15295DOI Listing
March 2021

Patient-prosthesis mismatch is a preventable disease but how to prevent it is a story not yet written.

J Card Surg 2021 Mar 11;36(3):978-980. Epub 2021 Jan 11.

Cardio-Thoracic Surgery Unit, Heart and Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands.

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http://dx.doi.org/10.1111/jocs.15317DOI Listing
March 2021

ECMO for COVID-19 patients in Europe and Israel.

Intensive Care Med 2021 Mar 9;47(3):344-348. Epub 2021 Jan 9.

2nd Department of Internal Medicine, Cardiovascular Medicine General Teaching Hospital and 1st Faculty of Medicine, Charles University in Prague, U Nemocnice 2, Praha 2, Prague, 128 00, Czech Republic.

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http://dx.doi.org/10.1007/s00134-020-06272-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7796689PMC
March 2021

Mechanical Power during Veno-Venous Extracorporeal Membrane Oxygenation Initiation: A Pilot-Study.

Membranes (Basel) 2021 Jan 2;11(1). Epub 2021 Jan 2.

Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), 6229 HX Maastricht, The Netherlands.

Mechanical power (MP) represents a useful parameter to describe and quantify the forces applied to the lungs during mechanical ventilation (MV). In this multi-center, prospective, observational study, we analyzed MP variations following MV adjustments after veno-venous extra-corporeal membrane oxygenation (VV ECMO) initiation. We also investigated whether the MV parameters (including MP) in the early phases of VV ECMO run may be related to the intensive care unit (ICU) mortality. Thirty-five patients with severe acute respiratory distress syndrome were prospectively enrolled and analyzed. After VV ECMO initiation, we observed a significant decrease in median MP (32.4 vs. 8.2 J/min, < 0.001), plateau pressure (27 vs. 21 cmHO, = 0.012), driving pressure (11 vs. 8 cmHO, = 0.014), respiratory rate (RR, 22 vs. 14 breaths/min, < 0.001), and tidal volume adjusted to patient ideal body weight (V/IBW, 5.5 vs. 4.0 mL/kg, = 0.001) values. During the early phase of ECMO run, RR (17 vs. 13 breaths/min, = 0.003) was significantly higher, while positive end-expiratory pressure (10 vs. 14 cmHO, = 0.048) and V/IBW (3.0 vs. 4.0 mL/kg, = 0.028) were lower in ICU non-survivors, when compared to the survivors. The observed decrease in MP after ECMO initiation did not influence ICU outcome. Waiting for large studies assessing the role of these parameters in VV ECMO patients, RR and MP monitoring should not be underrated during ECMO.
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http://dx.doi.org/10.3390/membranes11010030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7824596PMC
January 2021

Identification of a Circulating miRNA Signature to Stratify Acute Respiratory Distress Syndrome Patients.

J Pers Med 2020 Dec 27;11(1). Epub 2020 Dec 27.

Research Department, IRCCS-ISMETT, 90133 Palermo, Italy.

There is a need to improve acute respiratory distress syndrome (ARDS) diagnosis and management, particularly with extracorporeal membrane oxygenation (ECMO), and different biomarkers have been tested to implement a precision-focused approach. We included ARDS patients on veno-venous (V-V) ECMO in a prospective observational pilot study. Blood samples were obtained before cannulation, and screened for the expression of 754 circulating microRNA (miRNAs) using high-throughput qPCR and hierarchical cluster analysis. The miRNet database was used to predict target genes of deregulated miRNAs, and the DIANA tool was used to identify significant enrichment pathways. A hierarchical cluster of 229 miRNAs (identified after quality control screening) produced a clear separation of 11 patients into two groups: considering the baseline SAPS II, SOFA, and RESP score cluster A ( = 6) showed higher severity compared to cluster B ( = 5); values < 0.05. After analysis of differentially expressed miRNAs between the two clusters, 95 deregulated miRNAs were identified, and reduced to 13 by in silico analysis. These miRNAs target genes implicated in tissue remodeling, immune system, and blood coagulation pathways. The blood levels of 13 miRNAs are altered in severe ARDS. Further investigations will have to match miRNA results with inflammatory biomarkers and clinical data.
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http://dx.doi.org/10.3390/jpm11010015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7824233PMC
December 2020

Evaluation of a New Extracorporeal CO Removal Device in an Experimental Setting.

Membranes (Basel) 2020 Dec 23;11(1). Epub 2020 Dec 23.

Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium.

Background: Ultra-protective lung ventilation in acute respiratory distress syndrome or early weaning and/or avoidance of mechanical ventilation in decompensated chronic obstructive pulmonary disease may be facilitated by the use of extracorporeal CO removal (ECCOR). We tested the CO removal performance of a new ECCOR (CORESET) device in an experimental animal model.

Methods: Three healthy pigs were mechanically ventilated and connected to the CORESET device (surface area = 1.8 m, EUROSETS S.r.l., Medolla, Italy). Respiratory settings were adjusted to induce respiratory acidosis with the adjunct of an external source of pure CO (target pre membrane lung venous PCO (PCO): 80-120 mmHg). The amount of CO removed (VCO, mL/min) by the membrane lung was assessed directly by the ECCOR device.

Results: Before the initiation of ECCOR, the median PCO was 102.50 (95.30-118.20) mmHg. Using fixed incremental steps of the sweep gas flow and maintaining a fixed blood flow of 600 mL/min, VCO progressively increased from 0 mL/min (gas flow of 0 mL/min) to 170.00 (160.00-200.00) mL/min at a gas flow of 10 L/min. In particular, a high increase of VCO was observed increasing the gas flow from 0 to 2 L/min, then, VCO tended to progressively achieve a steady-state for higher gas flows. No animal or pump complications were observed.

Conclusions: Medium-flow ECCOR devices with a blood flow of 600 mL/min and a high surface membrane lung (1.8 m) provided a high VCO using moderate sweep gas flows (i.e., >2 L/min) in an experimental swine models with healthy lungs.
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http://dx.doi.org/10.3390/membranes11010008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7823796PMC
December 2020

Veno-Arterial Extracorporeal Life Support in Heart Transplant and Ventricle Assist Device Centres. Meta-analysis.

ESC Heart Fail 2021 Apr 18;8(2):1064-1075. Epub 2020 Dec 18.

Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Maastricht, The Netherlands.

Aims: Because reported mortality on veno-arterial (V-A) extracorporeal life support (ECLS) substantially varies between centres, the aim of the current analysis was to assess the outcomes between units performing heart transplantation and/or implanting ventricular assist device (HTx/VAD) vs. non-HTx/VAD units in patients undergoing V-A ECLS for cardiogenic shock.

Methods And Results: Systematic search according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses was performed using PubMed/MEDLINE databases until 30 November 2019. Articles reporting in-hospital/30-day mortality and centre's HTx/VAD status were included. In-hospital outcomes and long-term survival were analysed in subgroup meta-analysis. A total of 174 studies enrolling n = 13 308 patients were included with 20 series performed in non-HTx/VAD centres (1016 patients, 7.8%). Majority of patients underwent V-A ECLS for post-cardiotomy shock (44.2%) and acute myocardial infarction (20.7%). Estimated overall in-hospital mortality was 57.2% (54.9-59.4%). Mortality rates were higher in non-HTx/VAD [65.5% (59.8-70.8%)] as compared with HTx/VAD centres [55.8% (53.3-58.2%)], P < 0.001. Estimated late survival was 61.8% (55.7-67.9%) without differences between non-HTx/VAD and HTx/VAD centres: 66.5% (30.3-1.02%) vs. 61.7% (55.5-67.8%), respectively (P = 0.797). No differences were seen with respect to ECLS duration, limb complications, and reoperations for bleeding, kidney injury, and sepsis. Yet, weaning rates were higher in HTx/VAD vs. non-HTx/VAD centres: 58.7% (56.2-61.1%) vs. 48.9% (42.0-55.9%), P = 0.010. Estimated rate of bridge to heart transplant was 6.6% (5.2-8.3%) with numerical, yet not statistically significant, difference between non-HTx/VAD [2.7% (0.8-8.3%)] as compared with HTx/VAD [6.7% (5.3-8.6%)] (P = 0.131).

Conclusions: Survival after V-A ECLS differed according to centre's HTx/VAD status. Potentially different risk profiles of patients must be taken account for before definite conclusions are drawn.
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http://dx.doi.org/10.1002/ehf2.13080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8006654PMC
April 2021

Bail-out extracorporeal membrane oxygenation for hydroxychloroquine intoxication: a warning for COVID-19 health-care givers.

Acta Cardiol 2020 Dec 14:1-4. Epub 2020 Dec 14.

Department of Intensive Care and Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.

This case report describes an intentional intoxication with 18 g of hydroxychloroquine (HCQ) presenting with unconsciousness, ventricular dysrhythmias, cardiogenic shock and pulmonary oedema. Initial treatment consisted of sodium bicarbonate, lipid emulsion, diazepam and norepinephrine. Because of persistent cardiogenic shock veno-arterial extracorporeal membrane oxygenation (V-A ECMO) was successfully used as a bridge to recovery. This case underscores the possible side effects of HCQ and the importance of considering ECMO in cardiogenic shock caused by HCQ intoxication which may occur also in patients with coronavirus disease 2019 (COVID-19) based on the currently frequent use of such a compound.
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http://dx.doi.org/10.1080/00015385.2020.1802903DOI Listing
December 2020

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

Ann Thorac Surg 2020 Dec 8. Epub 2020 Dec 8.

Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.

Background: Left ventricular free-wall rupture (LVFWR) is an uncommon but serious mechanical complication of acute myocardial infarction (AMI). Surgical repair, though challenging, is the only definitive treatment. However, given the rarity of this condition, results following 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.

Methods: Using the CAUTION study database, we identified 140 patients who were surgically treated for post-AMI 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.

Results: 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 subjects (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 re-rupture after surgery occurred in 10 patients (7.1%). Multivariable analysis revealed that preoperative left ventricular ejection fraction (p < 0.001), cardiac arrest at presentation (p = 0.011), female gender (p = 0.044), and the need for preoperative extracorporeal life support (p = 0.003) were independent predictors for operative mortality.

Conclusions: Surgical repair of post-infarction LVFWR carries a high operative mortality. Female gender, preoperative left ventricular ejection fraction, cardiac arrest, and extracorporeal life support, are predictors of early mortality.
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http://dx.doi.org/10.1016/j.athoracsur.2020.11.019DOI Listing
December 2020

How I approach membrane lung dysfunction in patients receiving ECMO.

Crit Care 2020 11 30;24(1):671. Epub 2020 Nov 30.

Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, USA.

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http://dx.doi.org/10.1186/s13054-020-03388-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7704102PMC
November 2020

Monitoring of Unfractionated Heparin in Severe COVID-19: An Observational Study of Patients on CRRT and ECMO.

TH Open 2020 Oct 19;4(4):e365-e375. Epub 2020 Nov 19.

Central Diagnostic Laboratory, Maastricht University Medical Centre, Maastricht, the Netherlands.

 Severe cases of coronavirus disease 2019 (COVID-19) can require continuous renal replacement therapy (CRRT) and/or extracorporeal membrane oxygenation (ECMO). Unfractionated heparin (UFH) to prevent circuit clotting is mandatory but monitoring is complicated by (pseudo)-heparin resistance. In this observational study, we compared two different activated partial thromboplastin time (aPTT) assays and a chromogenic anti-Xa assay in COVID-19 patients on CRRT or ECMO in relation to their UFH dosages and acute phase reactants.  The aPTT (optical [aPTT-CS] and/or mechanical [aPTT-STA] clot detection methods were used), anti-Xa, factor VIII (FVIII), antithrombin III (ATIII), and fibrinogen were measured in 342 samples from 7 COVID-19 patients on CRRT or ECMO during their UFH treatment. Dosage of UFH was primarily based on the aPTT-CS with a heparin therapeutic range (HTR) of 50-80s. Associations between different variables were made using linear regression and Bland-Altman analysis.  Dosage of UFH was above 35,000IU/24 hours in all patients. aPTT-CS and aPTT-STA were predominantly within the HTR. Anti-Xa was predominantly above the HTR (0.3-0.7 IU/mL) and ATIII concentration was >70% for all patients; mean FVIII and fibrinogen were 606% and 7.5 g/L, respectively. aPTT-CS correlated with aPTT-STA (  = 0.68) with a bias of 39.3%. Correlation between aPTT and anti-Xa was better for aPTT-CS (0.78 ≤   ≤ 0.94) than for aPTT-STA (0.34 ≤   ≤ 0.81). There was no general correlation between the aPTT-CS and ATIII, FVIII, fibrinogen, thrombocytes, C-reactive protein, or ferritin.  All included COVID-19 patients on CRRT or ECMO conformed to the definition of heparin resistance. A patient-specific association was found between aPTT and anti-Xa. This association could not be explained by FVIII or fibrinogen.
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http://dx.doi.org/10.1055/s-0040-1719083DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7676995PMC
October 2020

The Effect of Minimally Invasive Surgery and Sternotomy on Physical Activity and Quality of Life.

Heart Lung Circ 2020 Nov 12. Epub 2020 Nov 12.

Imperial College, National Heart and Lung Institute, London, UK.

Aim: The aim of this study was to compare minimally invasive surgery (MI) and median sternotomy (MS) in terms of post-procedure health-related quality of life (HRQoL) and functional outcome.

Method: We conducted a multicentre prospective cohort study that enrolled patients from January 2015 until February 2017. Combined cardiac procedures were performed with MS and isolated valve procedures with either MS or MI, depending on patient preference and surgeon experience. HRQoL was measured using the five-level version of the EQ-5D (EQ-5D-5L) and physical activity before and after surgery was evaluated using a wearable accelerometer. Activity patterns and intensity recorded by the accelerometer in each period were classified as "sedentary", "light physical activity", "moderate physical activity", and "vigorous physical activity" for each patient. We also conducted a sub-analysis of frail patients in each group, as identified by the Reported Edmonton Frail Scale (>10 points). Patients were followed for 1 year.

Results: The study included 100 consecutive patients who underwent MI (n=50) or MS (n=50) during the study period. Patients in the MI group showed a faster recovery of physical activity in the immediate postoperative period and superior HRQoL in the first 3 months (both p<0.001) versus the MS group. Differences between the MI and MS group were indistinguishable over a longer follow-up. A similar correlation was observed in the frailty subanalysis. Overall, the MS group had a higher cumulative incidence of events than the MI group (p<0.001).

Conclusions: Compared to conventional MS, MI was associated with better HRQoL and early functional outcome, even in frail patients.
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http://dx.doi.org/10.1016/j.hlc.2020.09.936DOI Listing
November 2020