Francesco Alessandri, Giovanni Giordano, Vlad Cristian Sanda, Gabriella D'Ettorre, Francesco Pugliese, Giancarlo Ceccarelli
Background: Invasive aspergillosis (IA) can lead to life-threatening respiratory failure necessitating extracorporeal membrane oxygenation (ECMO) support. However, data on ECMO experience in the management of IA patients are scarce.
Objectives: The purpose of this systematic review was to evaluate the potential benefits and risks of ECMO as a supportive intervention for critically ill patients with IA.
Methods: We conducted a systematic review of the literature using the search terms ECMO, extracorporeal membrane oxygenation, Aspergillus and Aspergillosis in two databases (Medline and Scopus). Clinical data were extracted by two independent investigators. Clinical parameters, such as mode of ECMO support, duration of treatment and clinical outcomes, were assessed.
Results: Overall, 32 patients were included in the analysis. The age ranged from 5 to 69 years, 59% were male, and 38% were female. The majority of patients suffered from ARDS (82%). 82% received VV-ECMO, and 18% received VA-ECMO. Aspergillus fumigatus was the most frequent cause of IA, coinfections were frequently observed (51%). The overall mortality was 78%. Complications during ECMO support were observed in 21 of the 39 cases (53.8%).
Conclusions: IA poses significant management challenges for critically ill ICU patients, even with ECMO support. Although ECMO appears to improve survival of patients at high risk of AI, potential risks such as bacterial superinfection and altered pharmacokinetics of antifungal drugs must be carefully considered.
{"title":"Outcomes of severe aspergillosis in patients undergoing extracorporeal membrane oxygenation: A systematic review.","authors":"Francesco Alessandri, Giovanni Giordano, Vlad Cristian Sanda, Gabriella D'Ettorre, Francesco Pugliese, Giancarlo Ceccarelli","doi":"10.1111/aor.14871","DOIUrl":"https://doi.org/10.1111/aor.14871","url":null,"abstract":"<p><strong>Background: </strong>Invasive aspergillosis (IA) can lead to life-threatening respiratory failure necessitating extracorporeal membrane oxygenation (ECMO) support. However, data on ECMO experience in the management of IA patients are scarce.</p><p><strong>Objectives: </strong>The purpose of this systematic review was to evaluate the potential benefits and risks of ECMO as a supportive intervention for critically ill patients with IA.</p><p><strong>Methods: </strong>We conducted a systematic review of the literature using the search terms ECMO, extracorporeal membrane oxygenation, Aspergillus and Aspergillosis in two databases (Medline and Scopus). Clinical data were extracted by two independent investigators. Clinical parameters, such as mode of ECMO support, duration of treatment and clinical outcomes, were assessed.</p><p><strong>Results: </strong>Overall, 32 patients were included in the analysis. The age ranged from 5 to 69 years, 59% were male, and 38% were female. The majority of patients suffered from ARDS (82%). 82% received VV-ECMO, and 18% received VA-ECMO. Aspergillus fumigatus was the most frequent cause of IA, coinfections were frequently observed (51%). The overall mortality was 78%. Complications during ECMO support were observed in 21 of the 39 cases (53.8%).</p><p><strong>Conclusions: </strong>IA poses significant management challenges for critically ill ICU patients, even with ECMO support. Although ECMO appears to improve survival of patients at high risk of AI, potential risks such as bacterial superinfection and altered pharmacokinetics of antifungal drugs must be carefully considered.</p>","PeriodicalId":8450,"journal":{"name":"Artificial organs","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-09-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142279821","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Phase I clinical trial of an artificial oxygen carrier (liposome-encapsulated hemoglobin vesicles [HbVs]) is safely completed, considering the other clinical application. Herein, we aimed to investigate the resuscitation effects of HbVs in cases of lethal hemorrhage, including the mechanisms involved.
Methods: Optical mapping analysis (OMP) and electrophysiological studies (EPS), immunostaining pathological examination for hypoxia-inducible factor-1α (HIF1-alpha) in the heart tissue, and blood troponin I (TnI) level measurements were performed in rats that underwent five rounds of spontaneous arterial bleeding with up to 65% hemorrhage.
Results: Ten rats in each group were resuscitated by a transvenous infusion of 5% albumin (ALB), washed erythrocytes (wRBC), HbVs (HbV), 50% HbV diluted by 5% albumin (50% HbV), and 66% HbV diluted by 5% albumin (66% HbV). The rats in the ALB and 50% HbV groups died, whereas those in the other groups survived. OMP showed impaired action potential duration dispersion (APDd) in the left ventricle in the ALB and 50% HbV groups, which was attenuated in the other groups. Lethal arrhythmias were provoked by EPS in the ALB and 50% HbV groups but not in the other groups. HIF1-alpha was positively stained only in the ALB and 50% HbV groups. TnI levels were elevated in the ALB and 50% HbV groups.
Conclusions: Acute lethal hemorrhage causes myocardial ischemia with hypoxia and arrhythmias, which may be induced by impaired APDd and myocardial damage, reflected in the increased levels of HIF1-alpha and TnI. HbVs could be useful for resuscitation and may help save patients with injuries such as gunshot wounds.
{"title":"Liposome-encapsulated hemoglobin rescues hemorrhagic shock heart through anti-ischemic and anti-arrhythmogenic effects on myocardium in repetitive 65% bleeding rat model.","authors":"Bonpei Takase, Yuko Higashimura, Nobuyuki Masaki, Manabu Kinoshita, Takeshi Adachi, Hiromi Sakai","doi":"10.1111/aor.14858","DOIUrl":"https://doi.org/10.1111/aor.14858","url":null,"abstract":"<p><strong>Background: </strong>Phase I clinical trial of an artificial oxygen carrier (liposome-encapsulated hemoglobin vesicles [HbVs]) is safely completed, considering the other clinical application. Herein, we aimed to investigate the resuscitation effects of HbVs in cases of lethal hemorrhage, including the mechanisms involved.</p><p><strong>Methods: </strong>Optical mapping analysis (OMP) and electrophysiological studies (EPS), immunostaining pathological examination for hypoxia-inducible factor-1α (HIF1-alpha) in the heart tissue, and blood troponin I (TnI) level measurements were performed in rats that underwent five rounds of spontaneous arterial bleeding with up to 65% hemorrhage.</p><p><strong>Results: </strong>Ten rats in each group were resuscitated by a transvenous infusion of 5% albumin (ALB), washed erythrocytes (wRBC), HbVs (HbV), 50% HbV diluted by 5% albumin (50% HbV), and 66% HbV diluted by 5% albumin (66% HbV). The rats in the ALB and 50% HbV groups died, whereas those in the other groups survived. OMP showed impaired action potential duration dispersion (APDd) in the left ventricle in the ALB and 50% HbV groups, which was attenuated in the other groups. Lethal arrhythmias were provoked by EPS in the ALB and 50% HbV groups but not in the other groups. HIF1-alpha was positively stained only in the ALB and 50% HbV groups. TnI levels were elevated in the ALB and 50% HbV groups.</p><p><strong>Conclusions: </strong>Acute lethal hemorrhage causes myocardial ischemia with hypoxia and arrhythmias, which may be induced by impaired APDd and myocardial damage, reflected in the increased levels of HIF1-alpha and TnI. HbVs could be useful for resuscitation and may help save patients with injuries such as gunshot wounds.</p>","PeriodicalId":8450,"journal":{"name":"Artificial organs","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-09-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142279820","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Alessandro Belletti, Jacopo D'Andria Ursoleo, Enrica Piazza, Edoardo Mongardini, Gianluca Paternoster, Fabio Guarracino, Diego Palumbo, Giacomo Monti, Marilena Marmiere, Maria Grazia Calabrò, Giovanni Landoni, Alberto Zangrillo
Background: Barotrauma is a frequent complication in patients with severe respiratory failure and is associated with poor outcomes. Extracorporeal membrane oxygenation (ECMO) implantation allows to introduce lung-protective ventilation strategies that limit barotrauma development or progression, but available data are scarce. We performed a scoping review to summarize current knowledge on this therapeutic approach.
Methods: We systematically searched PubMed/MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials for studies investigating ECMO as a strategy to prevent/limit barotrauma progression in patients with respiratory failure. Pediatric studies, studies on perioperative implantation of ECMO, and studies not reporting original data were excluded. The primary outcome was the rate of barotrauma development/progression.
Results: We identified 21 manuscripts presenting data on a total of 45 ECMO patients. All patients underwent veno-venous ECMO. Of these, 21 (46.7%) received ECMO before invasive mechanical ventilation. In most cases, ECMO implantation allowed to modify the respiratory support strategy (e.g., introduction of ultraprotective/low pressure ventilation in 12 patients, extubation while on ECMO in one case, and avoidance of invasive ventilation in 15 cases). Barotrauma development/progression occurred in <10% of patients. Overall mortality was 8/45 (17.8%).
Conclusion: ECMO implantation to prevent barotrauma development/progression is a feasible strategy and may be a promising support option.
{"title":"Extracorporeal membrane oxygenation for prevention of barotrauma in patients with respiratory failure: A scoping review.","authors":"Alessandro Belletti, Jacopo D'Andria Ursoleo, Enrica Piazza, Edoardo Mongardini, Gianluca Paternoster, Fabio Guarracino, Diego Palumbo, Giacomo Monti, Marilena Marmiere, Maria Grazia Calabrò, Giovanni Landoni, Alberto Zangrillo","doi":"10.1111/aor.14864","DOIUrl":"https://doi.org/10.1111/aor.14864","url":null,"abstract":"<p><strong>Background: </strong>Barotrauma is a frequent complication in patients with severe respiratory failure and is associated with poor outcomes. Extracorporeal membrane oxygenation (ECMO) implantation allows to introduce lung-protective ventilation strategies that limit barotrauma development or progression, but available data are scarce. We performed a scoping review to summarize current knowledge on this therapeutic approach.</p><p><strong>Methods: </strong>We systematically searched PubMed/MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials for studies investigating ECMO as a strategy to prevent/limit barotrauma progression in patients with respiratory failure. Pediatric studies, studies on perioperative implantation of ECMO, and studies not reporting original data were excluded. The primary outcome was the rate of barotrauma development/progression.</p><p><strong>Results: </strong>We identified 21 manuscripts presenting data on a total of 45 ECMO patients. All patients underwent veno-venous ECMO. Of these, 21 (46.7%) received ECMO before invasive mechanical ventilation. In most cases, ECMO implantation allowed to modify the respiratory support strategy (e.g., introduction of ultraprotective/low pressure ventilation in 12 patients, extubation while on ECMO in one case, and avoidance of invasive ventilation in 15 cases). Barotrauma development/progression occurred in <10% of patients. Overall mortality was 8/45 (17.8%).</p><p><strong>Conclusion: </strong>ECMO implantation to prevent barotrauma development/progression is a feasible strategy and may be a promising support option.</p>","PeriodicalId":8450,"journal":{"name":"Artificial organs","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-09-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142279819","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Renal replacement therapy (RRT) may affect coagulation and platelet function in critically ill patients. However, the mechanism and the difference in the impact on coagulation between intermittent hemodialysis (iHD) and continuous renal replacement therapy (CRRT) remains unclear. This study aimed to investigate and compare the impact of iHD and CRRT on coagulation and platelet function.
{"title":"Impact of renal replacement therapy modality on coagulation and platelet function in critically ill patients: A prospective observational study","authors":"Hyunjae Im, Jaehoon Jeong, Seung-Young Oh, Leerang Lim, Hannah Lee, Ho Geol Ryu","doi":"10.1111/aor.14872","DOIUrl":"https://doi.org/10.1111/aor.14872","url":null,"abstract":"Renal replacement therapy (RRT) may affect coagulation and platelet function in critically ill patients. However, the mechanism and the difference in the impact on coagulation between intermittent hemodialysis (iHD) and continuous renal replacement therapy (CRRT) remains unclear. This study aimed to investigate and compare the impact of iHD and CRRT on coagulation and platelet function.","PeriodicalId":8450,"journal":{"name":"Artificial organs","volume":null,"pages":null},"PeriodicalIF":2.4,"publicationDate":"2024-09-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248637","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Johanna Schachl, Markus Königshofer, Martin Stoiber, Martina Socha, Christian Grasl, Theodor Abart, Ina Michel-Behnke, Dominik Wiedemann, Julia Riebandt, Daniel Zimpfer, Thomas Schlöglhofer
Cold atmospheric plasma (CAP) therapy has been recognized as effective treatment option for reducing bacterial load in chronic wounds, such as adult ventricular assist device (VAD) driveline exit-site infections. Currently, there have been no reports on the safety and efficacy of CAP therapy for pediatric cannula infections and inflammations in paracorporeal pulsatile VADs.
冷大气等离子（CAP）疗法已被公认为是减少慢性伤口（如成人心室辅助装置（VAD）干线出口部位感染）细菌负荷的有效治疗方法。目前，还没有关于 CAP 疗法对小儿插管感染和体外脉冲式 VAD 炎症的安全性和有效性的报道。
{"title":"Cold atmospheric plasma therapy as a novel treatment for Berlin Heart EXCOR pediatric cannula infections","authors":"Johanna Schachl, Markus Königshofer, Martin Stoiber, Martina Socha, Christian Grasl, Theodor Abart, Ina Michel-Behnke, Dominik Wiedemann, Julia Riebandt, Daniel Zimpfer, Thomas Schlöglhofer","doi":"10.1111/aor.14869","DOIUrl":"https://doi.org/10.1111/aor.14869","url":null,"abstract":"Cold atmospheric plasma (CAP) therapy has been recognized as effective treatment option for reducing bacterial load in chronic wounds, such as adult ventricular assist device (VAD) driveline exit-site infections. Currently, there have been no reports on the safety and efficacy of CAP therapy for pediatric cannula infections and inflammations in paracorporeal pulsatile VADs.","PeriodicalId":8450,"journal":{"name":"Artificial organs","volume":null,"pages":null},"PeriodicalIF":2.4,"publicationDate":"2024-09-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248638","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Akinori Maeda, Graham Starkey, Sofia Spano, Anis Chaba, Glenn Eastwood, Osamu Yoshino, Marcos Vinicius Perini, Michael Fink, Rinaldo Bellomo, Robert Jones
BackgroundNormothermic machine perfusion (NMP) aims to reduce ischemia–reperfusion injury in donor livers and its clinical manifestation, early allograft dysfunction (EAD) by maintaining perfusion and oxygenation. However, there is limited data on which NMP perfusate biomarkers might be associated with such EAD and the role of perfusate hemoglobin has not been assessed.MethodsWe performed a pilot retrospective analysis of adult donor livers undergoing NMP between 2020 and 2022 at our center. NMP was commenced at the recipient hospital after initial static cold storage. All NMP circuits were primed in the same manner according to the manufacturer's instructions. Livers were stratified by initial perfusate hemoglobin below (≤5.2 mmol/L) or above (>5.2 mmol/L) the median. The association between hemoglobin levels and EAD or recipient peak transaminase levels was assessed.ResultsAmong 23 livers, eight were considered unsuitable for transplantation, leaving 15 livers for assessment. Higher initial hemoglobin was associated with a lower risk of EAD (0% vs. 55.6%, p = 0.04). Perfusate hemoglobin decreased after NMP initiation (p = 0.003) and negatively correlated with recipient peak transaminase levels (ALT: ρ = −0.72, p = 0.002; AST: ρ = −0.79, p < 0.001). Consistently, higher hemoglobin livers also demonstrated lower perfusate liver enzymes.ConclusionsPerfusate hemoglobin levels decreased during NMP, and lower perfusate hemoglobin levels were associated with a higher incidence of EAD and higher levels of liver injury markers. Maintaining higher hemoglobin levels during NMP may help reduce ischemia–reperfusion injury and prevent or attenuate EAD. Larger prospective studies are needed to validate the findings of this pilot study.
{"title":"Perfusate hemoglobin during normothermic liver machine perfusion as biomarker of early allograft dysfunction: A pilot study","authors":"Akinori Maeda, Graham Starkey, Sofia Spano, Anis Chaba, Glenn Eastwood, Osamu Yoshino, Marcos Vinicius Perini, Michael Fink, Rinaldo Bellomo, Robert Jones","doi":"10.1111/aor.14862","DOIUrl":"https://doi.org/10.1111/aor.14862","url":null,"abstract":"BackgroundNormothermic machine perfusion (NMP) aims to reduce ischemia–reperfusion injury in donor livers and its clinical manifestation, early allograft dysfunction (EAD) by maintaining perfusion and oxygenation. However, there is limited data on which NMP perfusate biomarkers might be associated with such EAD and the role of perfusate hemoglobin has not been assessed.MethodsWe performed a pilot retrospective analysis of adult donor livers undergoing NMP between 2020 and 2022 at our center. NMP was commenced at the recipient hospital after initial static cold storage. All NMP circuits were primed in the same manner according to the manufacturer's instructions. Livers were stratified by initial perfusate hemoglobin below (≤5.2 mmol/L) or above (>5.2 mmol/L) the median. The association between hemoglobin levels and EAD or recipient peak transaminase levels was assessed.ResultsAmong 23 livers, eight were considered unsuitable for transplantation, leaving 15 livers for assessment. Higher initial hemoglobin was associated with a lower risk of EAD (0% vs. 55.6%, <jats:italic>p</jats:italic> = 0.04). Perfusate hemoglobin decreased after NMP initiation (<jats:italic>p</jats:italic> = 0.003) and negatively correlated with recipient peak transaminase levels (ALT: <jats:italic>ρ</jats:italic> = −0.72, <jats:italic>p</jats:italic> = 0.002; AST: <jats:italic>ρ</jats:italic> = −0.79, <jats:italic>p</jats:italic> < 0.001). Consistently, higher hemoglobin livers also demonstrated lower perfusate liver enzymes.ConclusionsPerfusate hemoglobin levels decreased during NMP, and lower perfusate hemoglobin levels were associated with a higher incidence of EAD and higher levels of liver injury markers. Maintaining higher hemoglobin levels during NMP may help reduce ischemia–reperfusion injury and prevent or attenuate EAD. Larger prospective studies are needed to validate the findings of this pilot study.","PeriodicalId":8450,"journal":{"name":"Artificial organs","volume":null,"pages":null},"PeriodicalIF":2.4,"publicationDate":"2024-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248640","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Recent progress in the field of Artificial Organs","authors":"","doi":"10.1111/aor.14866","DOIUrl":"10.1111/aor.14866","url":null,"abstract":"","PeriodicalId":8450,"journal":{"name":"Artificial organs","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248639","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
BackgroundPolymyxin‐B direct hemoperfusion (PMX‐DHP) is an endotoxin adsorption column‐based blood purification therapy. Since one of the most potent effects of PMX‐DHP is blood pressure elevations, it may be the most effective when it is introduced at the time when the need for vasopressors is the greatest, which, in turn, may reduce mortality.MethodsA multicenter retrospective study was conducted at 24 ICUs in Japan. In each ICU, the 20 most recent consecutive cases of septic shock treated with PMX‐DHP were analyzed. The duration between the time of the peak vasopressive agent dose, expressed as the noradrenaline equivalent dose (NEq), and the time of PMX initiation was evaluated. The primary outcome was 28‐day mortality, and a multivariable analysis was performed to investigate factors associated with mortality.ResultsA total of 480 septic shock patients were included in the analysis. Among all patients, the 28‐day mortality group was older, more severely ill, and had a higher body mass index. The NEq peak and NEq on PMX‐DHP initiation were both higher in deceased patients. Regarding the timing of PMX‐DHP initiation from the NEq peak, −4 << 4 h had more survivors (229/304, 75.3%) than ≤−4 h (50/75, 66.7%) and ≥4 h (66/101, 65.4%) (p = 0.085). When −4 << 4 h was assigned as a reference, the timing of PMX‐DHP initiation from the NEq peak of ≤−4 h had an odds ratio of 1.96 (1.07–3.58), p = 0.029, while ≥4 h had an odds ratio of 1.64 (0.94–2.87), p = 0.082 for 28‐day mortality, in the multivariable regression analysis. A spline curve of the relationship between the probability of death and the timing of PMX‐DHP initiation from the NEq peak showed a downward convex curve with a nadir at timing = 0. The odds ratios of the timing of PMX‐DHP initiation other than −4 << 4 h were significantly higher in an older age, male sex, lower BMI, more severe illness, and higher oxygenation.ConclusionsThe induction of PMX‐DHP at the time of the peak vasopressor dose correlated with lower mortality. PMX‐DHP is one of the options available for elevating blood pressure in septic shock, and its initiation either too early or late for shock peak may not improve the outcome.
{"title":"The polymyxin‐B direct hemoperfusion OPTimal Initiation timing with Catecholamine PMX‐OPTIC study: A multicenter retrospective observational study","authors":"Kensuke Nakamura, Tetsuya Okazaki, Akihito Tampo, Katsunori Mochizuki, Naoki Kanda, Takahiro Ono, Kunio Yanagita, Taro Shimomura, Taichi Murase, Ken Saito, Takahiro Hirayama, Tomoaki Ito, Koji Ogawa, Mizuki Nakamura, Tomohiro Oda, Takeshi Morishima, Takuma Fukushima, Hiroharu Yasui, Naoki Akashi, Kojiro Oshima, Hiroo Kawarazaki, Tsukasa Akiba, Susumu Uemura, Yuhei Honma, Kenichi Nitta, Koji Okamoto, Shunsuke Takaki, Hirotaka Takeda, Chizuru Yamashita","doi":"10.1111/aor.14865","DOIUrl":"https://doi.org/10.1111/aor.14865","url":null,"abstract":"BackgroundPolymyxin‐B direct hemoperfusion (PMX‐DHP) is an endotoxin adsorption column‐based blood purification therapy. Since one of the most potent effects of PMX‐DHP is blood pressure elevations, it may be the most effective when it is introduced at the time when the need for vasopressors is the greatest, which, in turn, may reduce mortality.MethodsA multicenter retrospective study was conducted at 24 ICUs in Japan. In each ICU, the 20 most recent consecutive cases of septic shock treated with PMX‐DHP were analyzed. The duration between the time of the peak vasopressive agent dose, expressed as the noradrenaline equivalent dose (NEq), and the time of PMX initiation was evaluated. The primary outcome was 28‐day mortality, and a multivariable analysis was performed to investigate factors associated with mortality.ResultsA total of 480 septic shock patients were included in the analysis. Among all patients, the 28‐day mortality group was older, more severely ill, and had a higher body mass index. The NEq peak and NEq on PMX‐DHP initiation were both higher in deceased patients. Regarding the timing of PMX‐DHP initiation from the NEq peak, −4 << 4 h had more survivors (229/304, 75.3%) than ≤−4 h (50/75, 66.7%) and ≥4 h (66/101, 65.4%) (<jats:italic>p</jats:italic> = 0.085). When −4 << 4 h was assigned as a reference, the timing of PMX‐DHP initiation from the NEq peak of ≤−4 h had an odds ratio of 1.96 (1.07–3.58), <jats:italic>p</jats:italic> = 0.029, while ≥4 h had an odds ratio of 1.64 (0.94–2.87), <jats:italic>p</jats:italic> = 0.082 for 28‐day mortality, in the multivariable regression analysis. A spline curve of the relationship between the probability of death and the timing of PMX‐DHP initiation from the NEq peak showed a downward convex curve with a nadir at timing = 0. The odds ratios of the timing of PMX‐DHP initiation other than −4 << 4 h were significantly higher in an older age, male sex, lower BMI, more severe illness, and higher oxygenation.ConclusionsThe induction of PMX‐DHP at the time of the peak vasopressor dose correlated with lower mortality. PMX‐DHP is one of the options available for elevating blood pressure in septic shock, and its initiation either too early or late for shock peak may not improve the outcome.","PeriodicalId":8450,"journal":{"name":"Artificial organs","volume":null,"pages":null},"PeriodicalIF":2.4,"publicationDate":"2024-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248642","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Diego Fernández‐Zapico, Thijs Peirelinck, Geert Deconinck, Dirk W. Donker, Libera Fresiello
BackgroundThe improvement of controllers of left ventricular assist device (LVAD) technology supporting heart failure (HF) patients has enormous impact, given the high prevalence and mortality of HF in the population. The use of reinforcement learning for control applications in LVAD remains minimally explored. This work introduces a preload‐based deep reinforcement learning control for LVAD based on the proximal policy optimization algorithm.MethodsThe deep reinforcement learning control is built upon data derived from a deterministic high‐fidelity cardiorespiratory simulator exposed to variations of total blood volume, heart rate, systemic vascular resistance, pulmonary vascular resistance, right ventricular end‐systolic elastance, and left ventricular end‐systolic elastance, to replicate realistic inter‐ and intra‐patient variability of patients with a severe HF supported by LVAD. The deep reinforcement learning control obtained in this work is trained to avoid ventricular suction and allow aortic valve opening by using left ventricular pressure signals: end‐diastolic pressure, maximum pressure in the left ventricle (LV), and maximum pressure in the aorta.ResultsThe results show controller obtained in this work, compared to the constant speed LVAD alternative, assures a more stable end‐diastolic volume (EDV), with a standard deviation of 5 mL and 9 mL, respectively, and a higher degree of aortic flow, with an average flow of 1.1 L/min and 0.9 L/min, respectively.ConclusionThis work implements a deep reinforcement learning controller in a high‐fidelity cardiorespiratory simulator, resulting in increases of flow through the aortic valve and increases of EDV stability, when compared to a constant speed LVAD strategy.
{"title":"Physiological control for left ventricular assist devices based on deep reinforcement learning","authors":"Diego Fernández‐Zapico, Thijs Peirelinck, Geert Deconinck, Dirk W. Donker, Libera Fresiello","doi":"10.1111/aor.14845","DOIUrl":"https://doi.org/10.1111/aor.14845","url":null,"abstract":"BackgroundThe improvement of controllers of left ventricular assist device (LVAD) technology supporting heart failure (HF) patients has enormous impact, given the high prevalence and mortality of HF in the population. The use of reinforcement learning for control applications in LVAD remains minimally explored. This work introduces a preload‐based deep reinforcement learning control for LVAD based on the proximal policy optimization algorithm.MethodsThe deep reinforcement learning control is built upon data derived from a deterministic high‐fidelity cardiorespiratory simulator exposed to variations of total blood volume, heart rate, systemic vascular resistance, pulmonary vascular resistance, right ventricular end‐systolic elastance, and left ventricular end‐systolic elastance, to replicate realistic inter‐ and intra‐patient variability of patients with a severe HF supported by LVAD. The deep reinforcement learning control obtained in this work is trained to avoid ventricular suction and allow aortic valve opening by using left ventricular pressure signals: end‐diastolic pressure, maximum pressure in the left ventricle (LV), and maximum pressure in the aorta.ResultsThe results show controller obtained in this work, compared to the constant speed LVAD alternative, assures a more stable end‐diastolic volume (<jats:italic>EDV</jats:italic>), with a standard deviation of 5 mL and 9 mL, respectively, and a higher degree of aortic flow, with an average flow of 1.1 L/min and 0.9 L/min, respectively.ConclusionThis work implements a deep reinforcement learning controller in a high‐fidelity cardiorespiratory simulator, resulting in increases of flow through the aortic valve and increases of <jats:italic>EDV</jats:italic> stability, when compared to a constant speed LVAD strategy.","PeriodicalId":8450,"journal":{"name":"Artificial organs","volume":null,"pages":null},"PeriodicalIF":2.4,"publicationDate":"2024-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248641","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Shazli Khan, Ameesh Isath, Vasiliki Gregory, Guy Elgar, Avi Levine, Syed A. Haidry, Hasan Ahmad, Sooyun Caroline Tavolacci, Junichi Shimamura, Suguru Ohira
BackgroundThe Impella 5.5® is commonly inserted via the axillary artery (AX) in patients with cardiogenic shock. The right AX has traditionally been preferred to avoid crossing the aortic arch, and a minimum diameter of 7 mm has been recommended to accommodate the device (21 Fr). There is limited data on choice of laterality of access and AX size required, both in terms of technicality of the procedure as well as outcomes.MethodsWe performed a single‐center retrospective cohort analysis of patients who underwent Impella 5.5® implantation between December 2020 and February 2024 (N = 75). Data including demographics and outcomes were stratified both by diameter (small, <7 mm vs. normal, ≥7 mm) and laterality of access (right vs. left). Adverse events included stroke, limb ischemia, procedural bleeding or infection, and unplanned explant due to complications. Delivery time was defined as time from advancing the first wire to activation of the device.ResultsAX approach was attempted in all (N = 74) but one requiring innominate access, with a technical success rate of 95.9% (N = 71/74). The mean age was 58.8 ± 13.3 years, with 81.1% males. The median delivery time was 7.0 (25th, 75th percentiles: 4.0, 11.5) min with a median support duration of 13 (7.7, 24) days. Ten patients (13.5%) had a small AX, with a mean diameter of 6.3 ± 0.5 mm and were more likely to be younger compared to the normal AX group. Fifty‐nine patients (79.7%) had insertion via the right AX. Median delivery time was comparable across all groups (small, 5.4 [3.5, 10.9] vs. normal, 7 [4.0, 12.1] min, p = 0.59) and (right, 10.4 [5.3, 15.2] vs. left, 6 [3.7, 10.4] min, p = 0.35). There was no difference between the rates of stroke, ischemia, bleeding, or infection when comparing by size or laterality. Survival to discharge was 59.5%, with 21.1% mortality on support, all in patients with a normal AX diameter, but with no difference between right versus left.ConclusionIn our study, laterality and a small diameter of AX access did not affect outcomes of Impella 5.5®, with a similar safety profile.
{"title":"Axillary artery access considerations in Impella 5.5 insertion: Insights from exclusive axillary approach for successful support","authors":"Shazli Khan, Ameesh Isath, Vasiliki Gregory, Guy Elgar, Avi Levine, Syed A. Haidry, Hasan Ahmad, Sooyun Caroline Tavolacci, Junichi Shimamura, Suguru Ohira","doi":"10.1111/aor.14861","DOIUrl":"https://doi.org/10.1111/aor.14861","url":null,"abstract":"BackgroundThe Impella 5.5® is commonly inserted via the axillary artery (AX) in patients with cardiogenic shock. The right AX has traditionally been preferred to avoid crossing the aortic arch, and a minimum diameter of 7 mm has been recommended to accommodate the device (21 Fr). There is limited data on choice of laterality of access and AX size required, both in terms of technicality of the procedure as well as outcomes.MethodsWe performed a single‐center retrospective cohort analysis of patients who underwent Impella 5.5® implantation between December 2020 and February 2024 (<jats:italic>N</jats:italic> = 75). Data including demographics and outcomes were stratified both by diameter (small, <7 mm vs. normal, ≥7 mm) and laterality of access (right vs. left). Adverse events included stroke, limb ischemia, procedural bleeding or infection, and unplanned explant due to complications. Delivery time was defined as time from advancing the first wire to activation of the device.ResultsAX approach was attempted in all (<jats:italic>N</jats:italic> = 74) but one requiring innominate access, with a technical success rate of 95.9% (<jats:italic>N</jats:italic> = 71/74). The mean age was 58.8 ± 13.3 years, with 81.1% males. The median delivery time was 7.0 (25th, 75th percentiles: 4.0, 11.5) min with a median support duration of 13 (7.7, 24) days. Ten patients (13.5%) had a small AX, with a mean diameter of 6.3 ± 0.5 mm and were more likely to be younger compared to the normal AX group. Fifty‐nine patients (79.7%) had insertion via the right AX. Median delivery time was comparable across all groups (small, 5.4 [3.5, 10.9] vs. normal, 7 [4.0, 12.1] min, <jats:italic>p</jats:italic> = 0.59) and (right, 10.4 [5.3, 15.2] vs. left, 6 [3.7, 10.4] min, <jats:italic>p</jats:italic> = 0.35). There was no difference between the rates of stroke, ischemia, bleeding, or infection when comparing by size or laterality. Survival to discharge was 59.5%, with 21.1% mortality on support, all in patients with a normal AX diameter, but with no difference between right versus left.ConclusionIn our study, laterality and a small diameter of AX access did not affect outcomes of Impella 5.5®, with a similar safety profile.","PeriodicalId":8450,"journal":{"name":"Artificial organs","volume":null,"pages":null},"PeriodicalIF":2.4,"publicationDate":"2024-09-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248643","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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