ASAIO Journal最新文献

Heart transplantation is a well-established treatment for end-stage heart failure, but many patients present in poor physical condition, complicating outcomes. The Impella 5.5 device, used in cardiogenic shock, may support pretransplant rehabilitation by stabilizing organ function and promoting functional improvement. This retrospective cohort study assessed the relationship between functional status, measured by standardized Activity Measure for Post-Acute Care Basic Mobility (AM-PAC) scores, and days alive outside the hospital within 30 days post-transplant (DAOH-30). Patients who received Impella 5.5 support before transplantation between January 2019 and October 2023 were included, excluding those without AM-PAC scores within 24 hours pretransplant. Among 65 patients, the median DAOH-30 was 15 days (interquartile range [IQR], 8-19). Higher pretransplant standardized AM-PAC scores correlate with increased DAOH-30 (adjusted coefficient 0.3; 95% confidence interval [CI] = 0.01-0.6; p = 0.04), as did AM-PAC score improvement during rehabilitation (adjusted coefficient 0.35; 95% CI = 0.01-0.6; p = 0.04). Extended rehabilitation was associated with greater functional gains. These findings suggest that better pretransplant functional status and rehabilitation-related improvements were associated with increased DAOH-30. The Impella 5.5 device facilitates rehabilitation and may enhance post-transplant outcomes. Further research should refine strategies to optimize rehabilitation and recovery in this high-risk population.

The use of ventricular assist devices (VADs) in children with restrictive (RCM) and hypertrophic cardiomyopathy (HCM) remains rare. We describe the outcomes of patients with RCM and HCM supported by VAD in the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) registry from March 2012 to December 2024. Thirty-four patients were identified: 20 left-sided VAD (LVAD), 13 biventricular VAD (BiVAD), and 1 total artificial heart (TAH). Median age at implant was 2.5 years (0.3-17.5), weight was 11.8 kg (4.5-81.8), and body surface area (BSA) was 0.54 m 2 (0.26-2.01). Diagnoses included RCM in 25 (73.5%) patients and HCM in 9 (26.5%). Illness severity at implant was high with 38.2% Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile 1, 41.2% on extracorporeal membrane oxygenation (ECMO), 52.9% on ventilator support, 88.2% treated with greater than or equal to 1 inotrope, and 52.9% supported with TPN. Four patients (11.8%) died on device, 25 (73.5%) were transplanted, 4 (11.8%) were alive on device, and 1 (2.9%) was transferred to another center. Patients who died all had HCM diagnosis, required BiVAD support, and experienced adverse events. The cause of death was inadequate support (1), infection (2), and multi-organ failure (1). Ventricular assist device support is a reasonable strategy for select RCM and HCM patients, although outcomes in HCM are less favorable.

The absolute blood volume of dialysis patients at the start of treatment can be calculated using a method that combines continuous relative blood volume measurement and dialysate infusion. In this study, we applied this method to patients undergoing intermittent infusion hemodiafiltration. The initial absolute blood volume was measured based on the relative blood volume changes observed during each of the five intermittent dialysate infusions (dilutions). Initial absolute blood volumes, determined via the first to fifth dilutions, were 4,288 ± 900, 4,377 ± 1,476, 4,170 ± 1,037, 4,009 ± 951, and 3,871 ± 929 ml (specific volumes were 79.5 ± 12.5, 81.2 ± 20.9, 78.2 ± 15.8, 75.1 ± 13.4, and 72.7 ± 13.9 ml/kg). The final absolute blood volumes were 3,813 ± 857, 3,953 ± 1,430, 3,764 ± 1,034, 3,611 ± 919, and 3,488 ± 908 ml (specific volumes were 71.1 ± 11.5, 73.0 ± 20.4, 70.3 ± 15.5, 67.3 ± 12.7, and 65.2 ± 13.2 ml/kg). The initial absolute blood volume measured using the fifth dilution was significantly lower than that of the first dilution ( p < 0.05). The use of intermittent infusion hemodiafiltration, along with relative blood volume measurement, is an easy method for determining absolute blood volume.

Although the goal of extracorporeal cardiopulmonary resuscitation (ECPR) remains survival with meaningful neurologic recovery, secondary contribution to organ donation is increasingly recognized. We identified standardized outcome metrics for quality improvement and reporting and explored the feasibility of developing an ECPR Cumulative Impact Index. Fourteen international ECPR experts completed a modified Delphi process to achieve these aims. Qualitative analysis of free-text responses further informed framework development. Consensus was not reached on a unified scoring index. However, participants endorsed several reporting domains with greater than 75% agreement, including cerebral performance categorization and modified Rankin score with organ donation as outcomes, and specific metric tracking pertaining to organ donation. Similarly, there was greater than 75% agreement not to stratify organ donation into neurological versus circulatory determination of death. Qualitative analysis explored five themes: death without donation, non-neurologically intact survival, organ donation benefit, score implementation, and ethical principles. Particular emphasis was placed on avoiding incentivization of cannulation solely for organ donation and understanding that the lived patient and family experience cannot be so simply summarized through numeric quantification. Ultimately, the panel agreed that while a unified ECPR beneficence score remains elusive, consensus-based outcome metrics offer a practical and ethically grounded framework for program evaluation.

Patients with continuous-flow ventricular assist devices (CF-VADs) face an elevated risk of nonsurgical bleeding. One hypothetical cause is that the loss of pulsatility promotes unraveling and enzymatic degradation of von Willebrand factor (VWF), a key clotting protein. Artificial pulsatility has been proposed to counter this effect, but the role of pulse frequency in VWF unraveling remains unclear. This study investigates VWF conformational changes in response to varying pulse frequencies. Membrane-bound VWF on human aortic endothelial cells (HAECs) exposed to pulsatile in vitro conditions exhibited significantly less unraveling than under continuous flow (p < 0.005). To enable real-time observation of VWF conformation, VWF was immobilized in a microfluidic device and exposed to continuous or pulsatile flows (20, 40, or 60 pulses/min) to model HAEC-bound unraveling. Results showed that frequencies greater than or equal to 40 pulses/min significantly reduced maximum extension compared with continuous flow and low-frequency conditions (≤ 20 pulses/min), whereas minimum extension was greatest under continuous flow and declined as frequency increased. Step-change flow experiments revealed a time constant of 0.19 ± 0.04 seconds for extension and ~1 second for recoiling. These findings support optimizing pulsatile flow frequency as a strategy to minimize VWF unfolding and mitigate nonsurgical bleeding in CF-VAD patients.

Severe respiratory failure is frequently complicated by right ventricular dysfunction (RVD), which occurs in 20-50% of cases. In patients on venovenous extracorporeal membrane oxygenation (VV ECMO) with refractory RVD, conversion to venopulmonary (VP) ECMO can provide additional mechanical support. This study evaluates the impact of VV to VP ECMO conversion on mortality and end-organ dysfunction in severe respiratory failure. A retrospective cohort study of 19 adult patients on VV ECMO who were converted to VP ECMO was performed. Outcomes included in-hospital mortality, resolution of acute kidney injury (AKI), pressor requirements, ventilator and ECMO parameters, and ECMO support duration. Venopulmonary ECMO conversion facilitated AKI resolution in 62.5% of patients with pre-conversion AKI (5/8) and was associated with liberation from continuous renal replacement therapy in 40% of patients (2/5). Conversion resulted in reduced pressor requirements (7/9, 78%), ECMO flows (15/19, 79%), sweep gas flow (12/19, 63%), ECMO fraction of inspired oxygen (FiO2; 5/19, 26%), and ventilator FiO2 (3/19, 16%). Venopulmonary ECMO conversion facilitated sedation weaning in 10 patients (53%) which was previously not tolerated due to desaturation events on VV ECMO. Overall, VP ECMO conversion was associated with improved oxygenation, hemodynamic stability, and end-organ function in the majority of patients.

The University of Wisconsin (UW) solution is widely used for cardiac allograft preservation. In early 2021, our center transitioned to Del Nido (DN) cardioplegia for all donors. This study evaluated whether this shift affected post-transplant outcomes. Adult, single-organ, donation after brain death heart transplants from January 2020 to December 2023 were included; congenital cases and non-ice storage techniques were excluded. Recipients were grouped by preservation solution. Interrupted time series (ITS) regression accounted for temporal bias and baseline differences, while exponential decay analysis evaluated lactate clearance. Of 203 transplants, 71 used UW and 132 used DN. Baseline characteristics were similar aside from longer ischemic times in the DN group. Unadjusted outcomes showed no significant differences in severe primary graft dysfunction (PGD), early mortality, cardiac index, or 24 hour vasoactive inotrope score (VIS). Intensive care unit and hospital stays were longer in the DN group. Lactate clearance was faster with DN (half-life 11.3 vs. 18.6 hours; p = 0.07). Interrupted time series regression showed no significant impact of DN on PGD, mortality, or morbidity scores, though VIS modestly increased (p = 0.048), and peak lactate levels decreased (p = 0.004). Del Nido provides comparable preservation to UW, supporting its use based on logistics and availability.

Anticoagulation is mandatory during venoarterial extracorporeal membrane oxygenation (V-A ECMO) flow reduction trials with very low blood flow. Anticoagulation in the ECMO circuit might be intensified with less effect in the patient by temporarily increasing the heparin dose directly connected to the oxygenator. We performed a prospective observational study in 16 patients on V-A ECMO, measuring anticoagulation parameters before and at the end of flow reduction trials in both the patients' circulation and the ECMO circuit, while having increased the heparin infusion rate during the flow reduction trial. The heparin infusion rate was doubled in eight patients for 30 [25-30] minutes, which resulted in an increase in activated partial thromboplastin time (APTT) of 5 seconds [2-6] in the patient and 13 seconds [5-20] in the ECMO circuit (p = 0.03). Heparin was tripled in eight patients for 22 [18-27] minutes, which resulted in an increase in APTT with 5 seconds [3-9] in the patient and 10 seconds [5-22] in the ECMO circuit (p = 0.02). In conclusion, increased APTT levels in the ECMO circuit during flow reduction trials can be achieved by increasing heparin infusion rates via the ECMO circuit, with minor effects in the patient. This can be helpful in patients with high bleeding risk.