ASAIO Journal最新文献

Cell-free hemoglobin (CFH) is used to detect hemolysis and was recently suggested to trigger acute lung injury. However, its role has not been elucidated in severe acute respiratory distress syndrome (ARDS) patients undergoing extracorporeal membrane oxygenation (ECMO). We investigated the association of carboxyhemoglobin (COHb) and haptoglobin-two indirect markers of hemolysis-with mortality in critically ill patients undergoing veno-venous ECMO (VV-ECMO) with adjusted and longitudinal models (primary aim). Secondary aims included assessment of association between COHb and haptoglobin with the development of ventilator-associated pneumonia (VAP) and with hemodynamics. We retrospectively collected physiological, laboratory biomarkers, and outcome data in 147 patients undergoing VV-ECMO for severe ARDS. Forty-seven patients (32%) died in the intensive care unit (ICU). Average levels of COHb and haptoglobin were higher and lower, respectively, in patients who died. Higher haptoglobin was associated with lower pulmonary (PVR) and systemic vascular resistance, whereas higher COHb was associated with higher PVR. Carboxyhemoglobin was an independent predictor of VAP. Both haptoglobin and COHb independently predicted ICU mortality. In summary, indirect signs of hemolysis including COHb and haptoglobin are associated with modulation of vascular tone, VAP, and ICU mortality in respiratory ECMO. These findings suggest that CFH may be a mechanism of injury in this patient population.

We investigated the association of preimplant left ventricular end-diastolic diameter (LVEDD) with outcomes after HeartMate 3 (HM3) left ventricular assist device (LVAD) implantation. Patients from the European Registry for Patients with Mechanical Circulatory Support (EUROMACS) registry who underwent HM3 implantation from August 2014 to February 2023 (n = 834) were analyzed according to preoperative LVEDD: less than or equal to 65 (n = 251), 65-80 (n = 441), and greater than or equal to 80 mm (n = 142). The mean age was 54.4 ± 12.4 years, body surface area (BSA) 2.0 ± 0.23 m2, body mass index (BMI) 27.3 ± 5.0 kg/m2; 87.9% were male and 40% had ischemic cardiomyopathy. Patients with LVEDD less than or equal to 65 mm were older (56.1 ± 11.0 vs. 53.8 ± 13.0 vs. 53.0 ± 12.3 years; p = 0.015), more female (17.9% vs. 11.6% vs. 4.9%; p < 0.001), smaller BSA (1.95 ± 2.03 vs. 2.01 ± 0.22 vs. 2.08 ± 0.22 m2; p < 0.01) and lower BMI (26.6 ± 4.8 vs. 27.4 ± 5.1 vs. 28.2 ± 5.0; p = 0.01) compared to LVEDD 65-80 and greater than or equal to 80 mm, respectively. One year survival was associated with increasing LVEDD (75.7% vs. 84.6% vs. 89.5%; p = 0.003). Patients with LVEDD less than or equal to 65 mm had a higher risk of postoperative right heart failure (14.7% vs.10.4% vs. 6.8%; p = 0.03), the risk for postoperative stroke was similar (10% vs. 12.8% vs. 9.5%; p = 0.4). A small left ventricular (LV) size (LVEDD ≤ 65 mm) was associated with an increase in postoperative right heart failure and unadjusted 1 year mortality in adults who underwent HM3 LVAD implantation.

As the Fontan population grows, understanding successful strategies for ventricular assist device (VAD) support of the failing Fontan circulation is needed. We performed a retrospective analysis of patients with Fontan circulation and systemic VAD support in the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) registry. Competing outcomes and Kaplan-Meier estimated survival methods were used. Between January 2012 and December 2022, 106 Fontan patients underwent VAD implant (median age 10 years, 20% age ≥18 years). At time of implant, 58% were on greater than or equal to 2 inotropes, 26% on extracorporeal membrane oxygenation (ECMO), and 41% intubated. Since 2018, there have been more patients implanted at INTERMACS profile 1 or 2 (88% vs. 71%, p = 0.02) and on inotropic support (95% vs. 76%, p = 0.01). Median duration of VAD support was 113 (interquartile range (IQR): 43-266) days. At 12 months post-VAD implant, 53% were transplanted, 27% were alive on device, 2% had successful recovery, and 18% had died. Overall, 75% experienced greater than or equal to 1 adverse event, with bleeding, infection, and neurologic dysfunction most common. Despite high acuity at the time of VAD implant and high rate of adverse events, the majority of Fontan patients were transplanted or still alive on device at 12 months post-VAD implant.

A critical factor in thrombus formation during venoarterial extracorporeal membrane oxygenation (VA ECMO) is prothrombotic flow dynamics generated by the drainage cannula's design. This study aimed to create and evaluate a novel drainage cannula design which optimized blood flow dynamics to reduce thrombus formation. Computational fluid dynamics (CFD) was used to iteratively vary drainage cannula design parameters such as inner wall shape and side hole shape. The final novel design was then placed in an ex vivo blood circulation loop, and compared against a Bio-Medicus cannula (n = 6, each). Clot volume, hemolysis, and other parameters were measured to assess thrombus formation markers. The novel design consisted of a parabolic inner wall profile with closely spaced side holes angled at 30º to align with flow. When tested in the ex vivo loop, the novel design resulted in lower instances (two vs . four) and volumes of clot in the cannula (360.5 ± 254.8 vs . 1258.0 ± 651.7 µl) when compared to the Bio-Medicus cannula. Results from tests assessing hemolysis, platelet activation, and other thrombotic markers revealed a noninferior relationship between the novel and Bio-Medicus designs. Future work will explore the clinical applicability of these findings.

Donor heart machine perfusion enables avoidance of prolonged cold ischemia, however the optimal temperature is yet to be elucidated. Given that maintenance of temperature beyond ambient levels demands significant energy, we sought to determine the suitability of room-temperature perfusion preservation of neonatal/pediatric-sized (5-20 kg) piglet donor hearts. A custom device was fabricated suitable for this purpose, with continuous readout of perfusion pressure, flow rate, temperature, and oxygen saturation. Oxygen delivery was automated to keep saturation above 90%. The perfusate consisted of a 1:1 mix of donor whole blood and modified Krebs-Henseleit solution with albumin. Donor hearts were procured from 5 kg (n = 5), 10 kg (n = 3), and 20 kg (n = 5) piglets, and perfused for 10 hours. Subsequently, 20 kg piglet hearts were transplanted. Hemodynamic stability and echocardiographic measurement of donor heart function were evaluated posttransplant. Perfusate parameters were stable through the perfusion interval. Temperature was consistently 23.8 ± 1.6°C. pH (7.35 ± 0.09) and pO2 (102 ± 29 mm Hg) were steady throughout. Glucose (5.9 ± 1.8 mmol/L) and lactate (2.4 ± 1.5 mmol/L) were metabolized by the heart over the course of perfusion. Transplanted hearts displayed durable hemodynamics and good biventricular function. We conclude that neonatal and pediatric hearts can be safely perfused for extended periods at subnormothermic conditions using blood-based perfusate.

The emerging ex vivo machine perfusion (MP) enables the extension of ex situ intervals, potentially expanding the heart transplant (OHT) donor pool. From October 18, 2018, to June 30, 2023, isolated OHT using donation after brain death (DBD) from extended distances (>500 miles) were identified in the United Network for Organ Sharing database, and categorized into cold storage (non-MP, N = 1,212) and MP group (N = 152). The MP utilization rate for DBD hearts from extended distances surged from 0% in 2018 to 27.7% in 2023. Recipient characteristics including listing status were similar except for history of cardiac surgery (non-MP, 32% vs. MP, 41%, p = 0.019). The travel distance was longer in MP group (696 vs. 894 miles, p < 0.001), as was donor organ preservation time (4.42 vs. 6.27 hours, p < 0.001). One-year survival was similar between groups (non-MP, 93.0 ± 0.8% vs. MP, 90.5 ± 2.9%, p = 0.23). In multivariable Cox hazards models, MP was not associated with mortality (hazard ratio, 1.19; p = 0.60). Among MP cohort, survival was comparable between hearts transported between 500-999 miles (N = 112) and those over 1,000 miles (N = 40). The utilization of MP for DBD heart recovery allows for safe DBD recovery from extended distance with comparable survival to cold storage.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is applied for the treatment of cardiogenic shock. Concomitant left ventricular unloading (LVU) with a microaxial flow pump (mAFP) enables myocardial and pulmonary recovery and may overcome some of the limitations of VA-ECMO. The study included 145 cardiogenic shock patients, 89 (61.4%) of whom were treated with VA-ECMO alone (ECMO group), whereas 56 (38.6%) received LVU with a surgically implanted mAFP on top of VA-ECMO (ECMELLA group). After 2:1 propensity score matching, 30 day and 1 year survival was similar between the groups ( p = 0.62 and 0.68, respectively). In the subgroup analysis, patients who received mAFP in the first 2 hours after VA-ECMO implantation had an improved 30 day (hazard ratio [HR]: 0.45 [95% confidence interval {CI}: 0.23-0.88], p = 0.02) and 1 year survival (HR: 0.52 [95% CI: 0.28-0.97], p = 0.04). The rate of limb ischemia, hemorrhage, and renal replacement therapy were comparable between the propensity score-matched cohorts. Early LVU with a surgically implanted mAFP in patients on VA-ECMO improved short-and long-term survival.