ASAIO Journal最新文献

External outflow graft obstruction (eOGO) is an increasingly recognized long-term complication in patients with HeartMate 3 left ventricular assist devices. While percutaneous treatment provides a less invasive alternative to surgery, it introduces the challenge of stenosis migration-especially when graft twist is a contributing factor. This migration can extend to the edge or even beyond the Bend Relief toward the aortic or pump anastomosis, posing procedural risks in fragile anatomical zones. In this case series, we present three patients with eOGO who experienced migration of the stenotic lesion during percutaneous treatment. In the first case, the procedure was aborted due to lesion migration close to both anastomotic sites. In the second, full-graft stenting resolved the obstruction but required stenting close to the aortic anastomosis, raising concern for rupture. In the last, a preemptive "migration-aware" strategy-placing a protective stent near the anastomosis before treating the main lesion-safely contained the obstruction and prevented high-risk migration. We propose that in patients with obstruction migration or when the initial stenosis is already near an anastomotic site, clinicians should consider a migration-aware stenting strategy. This approach may help avoid uncontrolled stenosis shifts, reduce the need for high-risk anastomotic stenting, and improve procedural safety.

Venoarterial extracorporeal membrane oxygenation (VA ECMO) may provide temporary hemodynamic support for patients with severe vasodilatory shock due to toxicologic ingestion. In a series of 10 cases of children less than 18 years of age who received VA ECMO support for toxicologic-induced vasodilatory shock, there were eight survivors and two nonsurvivors who died of significant neurologic injury. Upon initiation of ECMO support, survivors had decline in Vasoactive-Inotrope Scores (VIS). With the exception of one survivor who had a VIS range of 5-10, the seven remaining survivors had reduction in VIS by half at a median of 5.3 (interquartile range [IQR]: 3.7-12) hours. Nonsurvivors demonstrated no VIS reduction on ECMO before death. Six of 10 patients received continuous renal replacement therapy (CRRT) while on ECMO and potentially had augmentation of toxin clearance or treatment of severe acidosis as a result. Of the eight survivors, four patients had ECMO-related bleeding or thrombotic complications (three patients with stroke and one patient with extremity compartment syndrome). Venoarterial extracorporeal membrane oxygenation, with and without CRRT, may have potential utility and benefit in supporting poisoned patients with vasodilatory shock.

Heart failure with preserved ejection fraction (HFpEF) often presents with elevated left atrial (LA) pressure. Interatrial shunt devices (IASD) were developed and rotary blood pumps implanted off-label to reduce LA pressure in HFpEF patients. This study modeled an HFpEF patient in a mock circulation loop, comparing pulmonary decompression using an IASD (2-12 mm diameter) and a continuous flow (CF) centrifugal rotary blood pump (HeartMate 3; Abbott Laboratories, Abbott Park, IL) in LA to aortic configuration (1-6 L/min support). Left atrial pressure, pulmonary artery pressure (PAP), and cardiac output (CO) at 12 mm shunt diameter and 6 L/min pump support were primarily used to quantify pulmonary decompression. The IASD reduced LA pressure by 28% and 45%, while the CF reduced LA pressure by 135% and 51% at rest and exercise, respectively. Both devices reduced mean PAP by 13% (IASD) and 57% (CF) at rest and by 21% (IASD) and 32% (HM3) at exercise. The IASD resulted in reduced CO (rest: 14%, exercise 8%), but the CF increased CO (rest: 63%, exercise: 28%) and ventricular loading due to the LA to aortic configuration. Automated changes to rotary blood pump speed or IASD diameter may assist with unloading as physiologic conditions change.

External outflow graft obstruction (EOGO) is a known complication in left ventricular assist devices (LVADs), particularly around limited spaces such as the bend relief in HeartMate pumps. While EOGO in HeartMate 3 commonly occurs due to accumulation of biodebris between the bend relief and outflow graft, the incidence of EOGO in the HeartWare Ventricular Assist Device (HVAD) is much lower (0.006 events per patient-year) than that in HeartMate 3 because of the unique grid-like strain relief structure. We report an atypical case of EOGO in a 59 year old man with previous coronary artery bypass grafting who developed progressive dyspnea and decreased pump flow 4 years after HVAD implantation. Surgical exploration revealed aggressive ingrowth of dense fibrinous tissue into the strain relief, causing outflow graft compression. Pump flow improved dramatically after debridement. This case demonstrates that EOGO can occur in any LVAD when the outflow graft passes through a confined space, such as with dense adhesions due to prior surgery. This case report implies that strategies to prevent EOGO in LVADs may require not only bend relief fenestration to avoid biodebris accumulation but also improvement of confined spaces around the outflow graft such as adhesions after surgery.

In patients with a mechanical aortic valve in need of left ventricular assist device (LVAD) support, replacement with a biological valve should be considered. We present a case of partial mechanical valve explantation followed by direct transcatheter valve replacement during LVAD implantation. This approach offers a simpler and faster alternative to conventional valve replacement, with reduced cross-clamp time.

To explore whether reducing airflow and maintaining blood flow can improve the success rate of the apnea test (AT) and whether two auxiliary test strategies can improve the completion rate of brain death determination (BDD). To perform a multicenter retrospective analysis of the effect of reducing air flow and maintaining constant blood flow during extracorporeal membrane oxygenation (ECMO) on AT parameters and the role of auxiliary detection in the absence of an AT. Among the 31 BDD patients, 18, 10, and 3 had hypoxic-ischemic encephalopathy, stroke, and traumatic brain injury, respectively. All patients received V-V ECMO (3 patients) or V-A ECMO support (28 patients). The median gas flow before and after the AT was 3.5 (3.0-4.0) vs . 0.5 (0.5-1) L/min ( p < 0.01); PaCO 2 and pH in the right radial artery and the postoxygenator circuit met the AT-positive criteria after AT. All patients had at least two auxiliary tests that met the positive criteria for BDD. Twenty-five patients (81%) donated organs. Precise regulation of ECMO gas flow and blood flow can improve the completion rate of the AT. Performing at least two positive auxiliary tests increases BDD completion rates and the likelihood of organ donation.

Acute decompensated heart failure is a common problem and is frequently associated with diuretic resistance from cardiorenal syndrome. We present the first in human use of the JuxtaFlow Renal Assist Device (RAD) to treat congestion in patients admitted to the hospital with acute decompensated heart failure. In an open-label single-arm trial, patients admitted with acute decompensated heart failure who were diuretic resistant underwent placement of the RAD catheter system and received treatment for 24 hours with RAD. The primary endpoints were safety metrics (safe use of the device) and markers of hematuria. Secondary endpoints included markers of efficacy, including 24 hour urine output and biomarkers of renal function. Seven patients underwent an implant of the RAD catheter system, with six patients successfully completing the protocol. Among patients who completed the protocol, no structural abnormalities were identified on renal ultrasound. Significant improvements in 24 hour urine output and sodium excretion were noted despite a small sample size. The volume optimization incorporating negative pressure diuresis in heart failure (VOID-HF) trial demonstrated the early feasibility of the RAD catheter system, with six of seven patients completing the protocol. Further studies are indicated to determine if this novel therapy is a safe and effective addition to current standards of care.

Venovenous (VV) extracorporeal membrane oxygenation (ECMO) supports end-organ oxygen delivery in patients with refractory respiratory failure. Physical therapy (PT) while on ECMO provides conceptual benefits of strength and conditioning. Physical therapy can additionally be used to facilitate improvements in functional status of pulmonary reserve while VV ECMO is used to bridge to lung transplant or recovery. We report the case of a patient initially supported with VV ECMO that due to a course complicated by refractory hypoxia, cardiac arrest, and cardiogenic shock, was successfully supported with parallel, independent VV ECMO circuits, allowing for ongoing PT, to bridge to lung transplant, decannulation, and hospital discharge.