ASAIO Journal最新文献

First-month renal function trajectories after left ventricular assist device (LVAD) implantation vary widely. Lack of renal function improvement (RFI) and postoperative acute kidney injury (AKI) are associated with increased mortality. This study evaluates plasma levels of endostatin and cystatin C as predictors of RFI and AKI 1 month post-LVAD implantation. We prospectively enrolled 52 advanced heart failure patients undergoing LVAD implantation. Blood samples were collected pre-implant and at 1, 2, 3, and 4 weeks post-implant. Plasma levels of endostatin and cystatin C were measured. Among 52 patients, 24 (46.2%) achieved RFI, whereas 28 (53.8%) did not. Of the non-RFI group, 15 (53.6%) developed AKI within the first month. Baseline endostatin was highly significant in predicting RFI (p = 0.012), followed by cystatin C (p = 0.045). The patients without RFI were considered high-risk patients for postoperative AKI. We noticed distinct trajectories for postoperative 1 week cystatin C value, not endostatin, between AKI and no-AKI patients. Postoperative 1 week level of cystatin C is identified as a good biomarker for postoperative AKI prediction in these high-risk group patients. Baseline endostatin levels can help identify patients with reduced renal adaptive capacity. For patients with high pre-implant plasma endostatin values, monitoring circulating postoperative 1 week cystatin C allows physicians to detect AKI early.

Predictive scoring systems for adult patients receiving extracorporeal membrane oxygenation (ECMO) support for sepsis have not been yet reported. Based on the Chinese Society of ExtraCorporeal Life Support (CSECLS) Registry database, we conducted a retrospective observational study on adult patients supported with ECMO for sepsis (n = 465). On the basis of multivariable logistic regression analyses, four parameters at 24 h post-ECMO initiation (T24) were identified as prognostic factors associated with in-hospital mortality: age, vasoactive inotropic score (VIS), partial pressure of oxygen in arterial blood (PaO2), and lactate clearance. The sepsis-ECMO score was calculated based on these prognostic factors, which were converted into categorical variables. The area under the receiver operating characteristic curve for the sepsis-ECMO score was 0.704 (95% confidence interval [CI]: 0.658-0.751). Four risk classes, namely class Ⅰ (score 0), class Ⅱ (score 5), class Ⅲ (score 6-10), and class Ⅳ (score ≥ 11), were identified according to sepsis-ECMO score quartiles. Patients in the lower sepsis-ECMO score classes had significantly better survival than those in the higher classes (log-rank test, p < 0.001). The sepsis-ECMO score may help in the risk stratification of patients, facilitate the communication of objective prognostic information, and provide a clearer direction for shared decision-making.

Outflow graft obstruction (OGO) is an under-reported but severe complication after insertion of magnetically levitated centrifugal-flow left ventricular assist devices (LVADs). The optimal treatment and long-term outcomes have not been well-described. We report a retrospective single high-volume center's experience with surgical exploration for OGO from June 2019 to October 2023. Outflow graft obstruction was identified in 19 LVAD recipients from a total experience of 550 LVAD implants (3.3%). Median time of LVAD support to development of OGO was 32.5 months (interquartile range [IQR], 28-47.5). Low-flow alarms were the most common presentation, followed by dyspnea on exertion, and syncope. Computed tomography angiography (CTA) and echocardiography were the most common diagnostic modalities. Aortic valve opening with every beat and worsened mitral insufficiency were both more common at presentation compared to prior echocardiographic studies. Surgical excision of the bend relief (BR) and evacuation of proteinaceous material between the BR and the outflow graft immediately improved hemodynamics and LVAD function. There were no in-hospital mortalities, and all patients were discharged home after a median length of stay of 9 days (IQR, 10-21). All but four patients were alive at median follow-up 21 months. Thirteen of the 19 patients were readmitted a total of 50 times, none for recurrent OGO.

Early right heart failure (RHF) after left ventricular assist device (LVAD) implantation poses significant morbidity and mortality risks. Existing RHF prediction scores are complex, typically requiring multiple indicators and evaluation steps. This research aimed to explore a more feasible predictor for initial screening of early RHF. This multicenter, retrospective analysis included 83 consecutively enrolled patients undergoing continuous-flow LVAD implantation. Multivariable logistic regression identified independent predictors of early RHF, whereas receiver operating characteristic (ROC) curve analysis assessed predictive value. Among the 83 patients, 21 (25.3%) experienced early RHF. Logistic regression analyses revealed that the direct bilirubin to total bilirubin (DBIL/TBIL) ratio on admission was significantly correlated with early RHF (adjusted odds ratio [OR]: 2.41, 95% confidence interval [CI]: 1.35-4.31, p = 0.003). The DBIL/TBIL ratio on admission exhibited the highest area under the receiver operating characteristic curve (AUC) (0.767, 95% CI: 0.661-0.852). Internal validation using bootstrap techniques resulted in a mean AUC of 0.767 (95% CI: 0.640-0.879), whereas external validation in a cohort of 31 patients demonstrated an AUC of 0.682 (95% CI: 0.491-0.837). An optimal DBIL/TBIL ratio threshold of 0.52 yielded 76.19% sensitivity and 79.03% specificity for early RHF prediction. In subgroups with different TBIL levels, sensitivity and specificity were 70.0% and 86.67% for TBIL greater than or equal to 2 mg/dl, and 81.82% and 76.60% for TBIL less than 2 mg/dl, respectively. The DBIL/TBIL ratio upon admission is a viable predictor of early RHF following LVAD implantation, demonstrating acceptable predictive efficacy.

Cannula-associated deep vein thrombosis (CaDVT) following decannulation from extracorporeal life support (ECLS) is a commonly reported complication with several associated risk factors. This study investigated the incidence and risk factors of CaDVT after ECLS decannulation from a nationwide registry. We analyzed consecutive patients who were successfully decannulated from ECLS and screened for CaDVT from two medical-surgical intensive care units (ICU) in Kuwait between 2016 and 2023. The incidence of CaDVT was assessed and correlated with risk factors such as baseline characteristics, ECLS mode and duration, and cannula sizes. Length of stay (LOS) in the ICU, along with ICU and in-hospital mortality were reported. Of 403 patients supported with ECLS, 144 underwent postdecannulation ultrasound. Cannula-associated deep vein thrombosis occurred in 94 (65%) patients. Venovenous ECLS (V-V ECLS) was the only independent risk factor associated with post-ECLS CaDVT (odds ratio [OR]: 4.78; 95% confidence interval [CI]: 1.18-19.4). Length of stay in the ICU and mortality were similar between patients with and without CaDVT. Cannula-associated deep vein thrombosis is a frequent complication of ECLS, occurring in more than half of patients. The use of V-V ECLS appears to be an independent risk factor for the development of post-ECLS CaDVT. Further efforts are needed to develop formal recommendations for screening and managing CaDVT post-ECLS.

External outflow graft obstruction (OGO) in durable left ventricular assist devices (LVADs) is a rare but critical complication. Detecting external OGO can be challenging because of its nonspecific symptoms and a wide variety of differential diagnoses. We report the case of a 45 year old man with LVAD admitted with complaints of recurrent syncope and frequent low-flow alarms. Laboratory tests and chest radiography revealed no specific findings. Transthoracic echocardiography via the left subcostal approach revealed an outflow graft compressed by a low-echo area within a bend relief. This finding led to a diagnosis of external OGO, which was consistent with what was observed on contrast-enhanced computed tomography. The patient underwent surgery and the gelatinous substance compressing the outflow graft was successfully removed. This case highlights the utility of transthoracic echocardiography as a noninvasive and effective method for detecting external OGOs, emphasizing its role as a valuable tool for the initial screening of patients with suspected OGO.

As questions remain about the risk-benefit of left ventricular assist device (LVAD) therapy, we evaluated the association between LVAD versus medical therapy for the competing risk of all-cause mortality and all-cause readmission. Among consecutive patients evaluated for advanced heart failure (HF) therapy, 260 were referred for LVAD implantation and 292 continued medical therapy in this retrospective, observational database study. At 2 years, all-cause mortality was significantly higher among medically managed patients versus LVAD recipients (37% vs. 25%, p = 0.014). Separation in event rates appeared within 3 months and was sustained throughout follow-up. The cumulative incidence rate of all-cause readmissions at 2 years was higher among LVAD recipients (78% vs. 40%, p < 0.001). In multivariate analysis, compared with medical therapy, LVAD therapy was associated with a significant 35% lower risk of death (p = 0.005), driven by a 57% reduction in the risk of death within the first 3 months (p < 0.001), and a 2.8-fold increased risk of readmission. Among medically managed patients, lower baseline hemoglobin and blood pressure, older age, and increased creatinine were predictors of death. In conclusion, among patients with advanced HF, LVAD therapy was associated with pronounced survival benefit, but a higher 2-year readmission rate compared with medical management.

Disclaimer: This Extracorporeal Life Support Organization guideline describes early rehabilitation or mobilization of patients on extracorporeal membrane oxygenation (ECMO). The guideline describes useful and safe practices put together by an international interprofessional team with extensive experience in the field of ECMO and ECMO rehabilitation or mobilization. The guideline is not intended to define the delivery of care or substitute sound clinical judgment. The guideline is subject to regular revision as new scientific evidence becomes available.

This case report explores the successful use of the Impella 5.5 (Abiomed Inc., Danvers, MA) device in a 22 kg, 0.89 body surface area (BSA) pediatric patient with longstanding dilated cardiomyopathy and elevated pulmonary vascular resistance. The article details the device selection, management, and outcome demonstrating the feasibility and potential benefits of the Impella 5.5 as a device within the pediatric population.

Calcium channel blocker (CCB) toxicity presents a significant mortality risk, highlighting the need for effective treatment strategies such as extracorporeal membrane oxygenation (ECMO). This study analyzes Extracorporeal Life Support Organization (ELSO) registry data to determine the mortality rate in adults treated with ECMO for CCB toxicity and identifies clinical predictors of mortality. A retrospective analysis of the ELSO registry from January 2016 to April 2023 was conducted, focusing on adults diagnosed with CCB toxicity (ICD-10 T46.1) who received ECMO. Data collected included patient demographics, ECMO details (mode, duration, type), pre-ECMO clinical indicators (pH, lactate levels, cardiac arrest incidence), and in-hospital mortality. The analysis employed descriptive statistics to profile the patient population, with independent t-tests and chi-square tests comparing survivors to nonsurvivors. Logistic regression identified mortality predictors, integrating multiple imputations to remedy missing data, thus ensuring the analysis's integrity. The mortality rate for ECMO-treated CCB toxicity was 40.6%. Severe acidosis and the need for pre-ECMO renal replacement therapy were identified as key predictors of mortality. Further research is needed to determine if early ECMO initiation before a significant pH drop improves outcomes.