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- Biancari, Fausto, et al.
(author)
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Gender and the Outcome of Postcardiotomy Veno-arterial Extracorporeal Membrane Oxygenation
- 2022
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In: Journal of Cardiothoracic and Vascular Anesthesia. - : Elsevier BV. - 1053-0770 .- 1532-8422. ; 36:6, s. 1678-1685
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Journal article (peer-reviewed)abstract
- Objective: There is a paucity of sex-specific data on patients’ postcardiotomy venoarterial extracorporeal membrane oxygenation (VA-ECMO). The present study sought to assess this issue in a multicenter study. Design: Retrospective, propensity score–matched analysis of an international registry. Setting: Multicenter study, tertiary university hospitals. Participants: Data on adult patients undergoing postcardiotomy VA-ECMO. Measurements and Main Results: Between January 2010 and March 2018, patients treated with postcardiotomy VA-ECMO at 17 cardiac surgery centers were analyzed. Index procedures considered were coronary artery bypass graft surgery, isolated valve surgery, their combination, and proximal aortic root surgery. Hospital and five-year mortality constituted the endpoints of interest. Propensity score matching was adopted with logistic regression. A total of 358 patients (mean age: 63.3 ± 12.3 years; 29.6% female) were identified. Among 94 propensity score–matched pairs, women had a higher hospital mortality (70.5% v 56.4%, p = 0.049) compared with men. Logistic regression analysis showed that women (odds ratio [OR], 1.87; 95% confidence interval [CI] 1.10-3.16), age (OR, 1.06; 95%CI 1.04-1.08) and pre-ECMO arterial lactate (OR, 1.09; 95%CI 1.04-1.16) were independent predictors of hospital mortality. No differences between female and male patients were observed for other outcomes. Among propensity score–matched pairs, one-, three-, and five-year mortality were 60.6%, 65.0%, and 65.0% among men, and 71.3%, 71.3%, and 74.0% among women, respectively (p = 0.110, adjusted hazard ratio, 1.27; 95%CI 0.96-1.66). Conclusions: In postcardiotomy VA-ECMO, female patients demonstrated higher hospital mortality than men. Morbidity and late mortality were similar between the two groups.
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- Biancari, Fausto, et al.
(author)
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Multicenter study on postcardiotomy venoarterial extracorporeal membrane oxygenation
- 2020
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In: Journal of Thoracic and Cardiovascular Surgery. - : Elsevier BV. - 0022-5223 .- 1097-685X. ; 159:5, s. 1844-1854
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Journal article (peer-reviewed)abstract
- Objectives: The aim of this study was to identify the risk factors associated with early mortality after postcardiotomy venoarterial extracorporeal membrane oxygenation. Methods: This is an analysis of the postcardiotomy extracorporeal membrane oxygenation registry, a retrospective multicenter cohort study including 781 patients aged more than 18 years who required venoarterial extracorporeal membrane oxygenation for cardiopulmonary failure after cardiac surgery from 2010 to 2018 at 19 cardiac surgery centers. Results: After a mean venoarterial extracorporeal membrane oxygenation therapy of 6.9 ± 6.2 days, hospital and 1-year mortality were 64.4% and 67.2%, respectively. Hospital mortality after venoarterial extracorporeal membrane oxygenation therapy for more than 7 days was 60.5% (P = .105). Centers that had treated more than 50 patients with postcardiotomy venoarterial extracorporeal membrane oxygenation had a significantly lower hospital mortality than lower-volume centers (60.7% vs 70.7%, adjusted odds ratio, 0.58; 95% confidence interval, 0.41-0.82). The postcardiotomy extracorporeal membrane oxygenation score was derived by assigning a weighted integer to each independent pre–venoarterial extracorporeal membrane oxygenation predictors of hospital mortality as follows: female gender (1 point), advanced age (60-69 years, 2 points; ≥70 years, 4 points), prior cardiac surgery (1 point), arterial lactate 6.0 mmol/L or greater before venoarterial extracorporeal membrane oxygenation (2 points), aortic arch surgery (4 points), and preoperative stroke/unconsciousness (5 points). The hospital mortality rates according to the postcardiotomy extracorporeal membrane oxygenation score was 0 point, 45.6%; 1 point, 40.5%; 2 points, 51.1%; 3 points, 57.8%; 4 points, 70.7%; 5 points, 68.3%; 6 points, 77.5%; and 7 points or more, 89.7% (P < .0001). Conclusions: Age, female gender, prior cardiac surgery, preoperative acute neurologic events, aortic arch surgery, and increased arterial lactate were associated with increased risk of early mortality after postcardiotomy venoarterial extracorporeal membrane oxygenation. Center experience with postcardiotomy venoarterial extracorporeal membrane oxygenation may contribute to improved results.
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- Biancari, Fausto, et al.
(author)
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Postcardiotomy Venoarterial Extracorporeal Membrane Oxygenation in Patients Aged 70 Years or Older
- 2019
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In: Annals of Thoracic Surgery. - : Elsevier BV. - 0003-4975 .- 1552-6259. ; 108:4, s. 1257-1264
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Research review (peer-reviewed)abstract
- Background: There is uncertainty whether venoarterial extracorporeal membrane oxygenation (VA-ECMO) should be used in older patients with cardiopulmonary failure after cardiac surgery. Methods: This was a retrospective multicenter study of 781 patients who required postcardiotomy VA-ECMO for cardiopulmonary failure after adult cardiac surgery from 2010 to 2018 at 19 cardiac surgery centers. A parallel systematic review with meta-analysis of the literature was performed. Results: The hospital mortality in the overall Postcardiotomy Venoarterial Extracorporeal Membrane Oxygenation (PC-ECMO) series was 64.4%. A total of 255 patients were 70 years old or older (32.7%), and their hospital mortality was significantly higher than in younger patients (76.1% vs 58.7%; adjusted odds ratio, 2.199; 95% confidence interval [CI], 1.536 to 3.149). Arterial lactate level greater than 6 mmol/L before starting VA-ECMO was the only predictor of hospital mortality among patients 70 years old or older in univariate analysis (82.6% vs 70.4%; P =.029). Meta-analysis of current and previous studies showed that early mortality after postcardiotomy VA-ECMO was significantly higher in patients aged 70 years or older compared with younger patients (odds ratio, 2.09; 95% CI, 1.59 to 2.75; 5 studies including 1547 patients; I2, 5.9%). The pooled early mortality rate among patients aged 70 years or older was 78.8% (95% CI, 74.1 to 83.5; 6 studies including 617 patients; I2, 41.8%). Two studies reported 1-year mortality (including hospital mortality) of 79.9% and 75.6%, respectively, in patients 70 years old or older. Conclusions: Advanced age should not be considered a contraindication for postcardiotomy VA-ECMO. However, in view of the high risk of early mortality, meaningful scrutiny is needed before using VA-ECMO after cardiac surgery in older patients.
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- Biancari, Fausto, et al.
(author)
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Prognostic Significance of Arterial Lactate Levels at Weaning from Postcardiotomy Venoarterial Extracorporeal Membrane Oxygenation
- 2019
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In: Journal of Clinical Medicine. - : MDPI AG. - 2077-0383. ; 8:12
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Journal article (peer-reviewed)abstract
- BACKGROUND: The outcome after weaning from postcardiotomy venoarterial extracorporeal membrane oxygenation (VA-ECMO) is poor. In this study, we investigated the prognostic impact of arterial lactate levels at the time of weaning from postcardiotomy VA.METHODS: This analysis included 338 patients from the multicenter PC-ECMO registry with available data on arterial lactate levels at weaning from VA-ECMO.RESULTS: Arterial lactate levels at weaning from VA-ECMO (adjusted OR 1.426, 95%CI 1.157-1.758) was an independent predictor of hospital mortality, and its best cutoff values was 1.6 mmol/L (<1.6 mmol/L, 26.2% vs. ≥ 1.6 mmol/L, 45.0%; adjusted OR 2.489, 95%CI 1.374-4.505). When 261 patients with arterial lactate at VA-ECMO weaning ≤2.0 mmol/L were analyzed, a cutoff of arterial lactate of 1.4 mmol/L for prediction of hospital mortality was identified (<1.4 mmol/L, 24.2% vs. ≥1.4 mmol/L, 38.5%, p = 0.014). Among 87 propensity score-matched pairs, hospital mortality was significantly higher in patients with arterial lactate ≥1.4 mmol/L (39.1% vs. 23.0%, p = 0.029) compared to those with lower arterial lactate.CONCLUSIONS: Increased arterial lactate levels at the time of weaning from postcardiotomy VA-ECMO increases significantly the risk of hospital mortality. Arterial lactate may be useful in guiding optimal timing of VA-ECMO weaning.
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- Fux, Thomas
(author)
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Extracorporeal membrane oxygenation (ECMO) for the treatment of cardiogenic shock : identification of pre-implant outcome predictors
- 2018
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Doctoral thesis (other academic/artistic)abstract
- Background: Refractory cardiogenic shock (RCS), cardiac arrest (CA) and postarrest cardiogenic shock (CS) are associated with high mortality. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used and can offer acute cardiopulmonary life support in this critically ill population but selection of VA-ECMO candidates remains challenging. There are limited data on which pre-VA-ECMO variables that predict outcome. Aims: To identify pre-VA-ECMO predictors for 90-day mortality in Study I unselected, Study II postcardiotomy and Study III non-surgical patients with RCS, and Study IV in patients with CA or postarrest cardiogenic shock prior to VA-ECMO were studied. Methods: Study I-IV were observational and retrospective. Study I included 181 mixed patients with RCS, Study II 105 patients with refractory postcardiotomy CS, Study III 76 non-surgical patients with RCS and Study IV 72 patients with CA or postarrest CS prior to VA-ECMO cannulation. The association between pre-implant variables and all-cause mortality at 90 days was analyzed with uni- and multivariable logistic regression. Results: Study I. Main etiologies of RCS were post-cardiotomy failure 58%, acute myocardial infarction 22% and other medical etiologies 20%. Median duration of VA-ECMO support was 7 days (interquartile range [IQR]: 3-13). The 90-day overall mortality was 54%. Arterial lactate (odds ratio [OR] per unit: 1.14; 95% confidence interval [CI]: 1.06-1.23; p <0.001), number of inotropes and vasopressors (OR per agent: 1.58; 95% CI: 1.13-2.21; p = 0.008), and ischemic heart disease (IHD), (OR: 2.90; 95% CI: 1.31-6.39; p = 0.008) were independent predictors of 90-day mortality. Study II. Main surgical subgroups were single non-CABG 29%, isolated CABG 20%, 2 and 3 concomitant surgical procedures, 31% and 20%, respectively. Median duration of VA-ECMO was 7 days (IQR: 3-14). The 90-day overall mortality and in-hospital mortality was 57% and 56%, respectively. Arterial lactate (OR per unit: 1.22; 95% CI:1.07-1.40; p = 0.004), and IHD (OR: 7.87; 95% CI: 2.55-24.3; p <0.001) were independent predictors of 90-day mortality. Study III. Main etiologies of RCS were acute myocardial infarction 51% and acute heart failure of other etiologies 49%. Median duration of VA-ECMO was 5 days (IQR: 2-11). The 90-day overall mortality was 49% and in-hospital mortality was 50%. Arterial lactate (OR per mmol/L: 1.15; 95% CI: 1.06-1.24; p = 0.001) and number of inotropes and vasopressors (OR per agent: 2.14; 95% CI: 1.26-3.63; p = 0.005) were independent predictors of 90-day mortality. Study IV. Out-of-hospital CA occurred in 12% of the patients. Initial cardiac rhythm was non-shockable in 57%, and shockable in 43% of the patients. Median cardiopulmonary resuscitation duration was 21 minutes (IQR: 10-73, range:1-197). No return of spontaneous circulation (ROSC) was present in 64% and postarrest CS in 36% of the patients at VA-ECMO cannulation. Median duration of VA-ECMO was 5 days (IQR: 2-12). The 90-day overall mortality and in-hospital mortality were 57%, respectively, and 53% died during VA-ECMO. All survivors (43%) had cerebral performance category score 1-2 at discharge to home. Initial non-shockable CA rhythm (OR: 12.2; 95% CI 2.83-52.7; p = 0.001), arterial lactate (OR per unit: 1.15; 95% CI: 1.01-1.31; p = 0.041), and IHD (OR: 7.39; 95% CI: 1.57-34.7; p = 0.011) as independent predictors of 90-day mortality. Conclusions: Identified independent pre-implant predictors for 90-day mortality after VA-ECMO initiation were in Study I arterial lactate, number of inotropes and vasopressors, and IHD, Study II arterial lactate and IHD, Study III arterial lactate, number of inotropes and vasopressors, Study IV initial non-shockable CA rhythm, arterial lactate and IHD. These predictors are easily available for pre-VA-ECMO risk prediction.
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| 9. |
- Fux, Thomas, et al.
(author)
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Synthetic tracheal grafts seeded with bone marrow cells fail to generate functional tracheae : First long-term follow-up study
- 2020
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In: Journal of Thoracic and Cardiovascular Surgery. - : MOSBY-ELSEVIER. - 0022-5223 .- 1097-685X. ; 159:6, s. 2525-2537.e23
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Journal article (peer-reviewed)abstract
- Objective: Synthetic tracheal grafts seeded with autologous bone marrow-mononuclear cells (BM-MNCs) have been described as becoming living and functional grafts representing a promising option for tracheal replacement for pathologies unamenable by segmental resection or autologous repair. This study aimed to present the first long-term follow-up of these procedures in humans.Methods: We retrospectively analyzed 3 patients who received synthetic tracheal grafts seeded with BM-MNCs implanted.Results: Patient 1 was a 37-year-old man with mucoepidermoid carcinoma, the first-ever human to receive a synthetic tracheal graft seeded with BM-MNCs. Patient 2 was a 30-year-old man with adenoid cystic carcinoma, and patient 3 was a 22-year-old woman with an iatrogenic tracheal injury. All patients developed graft-related complications necessitating multiple surgical reinterventions. Patient 1 was hospitalized for 8 months before dying from respiratory failure secondary to graft dehiscence 32 months after implantation. Patient 2 died 3.5 months after implantation from undisclosed causes. Patient 3 received a second synthetic tracheal graft after 11 months and an allogeneic trachea and lung transplantation 45 months after the primary implantation. Patient 3 underwent 191 surgical interventions after the primary implantation and spent 55 months in the intensive care unit before dying from airway bleeding. All patients' bronchoscopic, histologic, and radiologic investigations demonstrated graft-associated complications, including anastomotic fistulae and obstructive granulation tissue, without graft vascularization, mucosal lining, or integration into adjacent tissues.Conclusions: Synthetic tracheal grafts seeded with BM-MNCs do not become living functional tracheal grafts and lead to debilitating complications and death.
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- Kjellberg, Gunilla, et al.
(author)
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Calculation Algorithm Reduces Protamine Doses Without Increasing Blood Loss or the Transfusion Rate in Cardiac Surgery : Results of a Randomized Controlled Trial
- 2019
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In: Journal of Cardiothoracic and Vascular Anesthesia. - : W B SAUNDERS CO-ELSEVIER INC. - 1053-0770 .- 1532-8422. ; 33:4, s. 985-992
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Journal article (peer-reviewed)abstract
- Objectives: The aim of the study was to investigate whether the HeProCalc algorithm affects heparin and protamine dosage, postoperative blood loss, and transfusion rate.Design: Randomized controlled trial.Setting: University hospital.Participants: The study comprised 210 cardiac surgery patients undergoing cardiac surgery with cardiopulmonary bypass. Twenty patients were excluded because of re-exploration for localized surgical bleeding (n = 9), violation of protocol (n = 2), aprotinin use (n = 3 and nadir body temperature <32 degrees C (n = 6).Interventions: Study participants were randomly assigned to either traditional heparin and protamine dosage based on body weight only (control group) or dosage based on the HeProCalc algorithm (intervention group).Measurements and Main Results: The initial median heparin dose was 32,500 IU (interquartile range [IQR] 30,000-35,000) in the intervention group compared with 35,000 IU (IQR 30,000-37,500) (p = 0.025) in the control group. The total heparin dose in the intervention group was 40,000 IU (1QR 32,500-47,500) compared with 42,500 IU (IQR 35,000-50,000) in the control group (p = 0.685). The total protamine dose was 210 mg (IQR 190-240) in the intervention group compared with 350 mg (IQR 300-380) (p < 0.001) in the control group. The ratio of total protamine to initial dose of heparin in the intervention group was 0.62 compared with 1.0 (p < 0.001). The amount of chest tube bleeding after 12 postoperative hours was 320 mL (IQR 250-460) in the intervention group compared with 350 mL (IQR 250-450) (p = 0.754) in the control group. Neither the transfusion rate nor postoperative blood loss differed significantly between the 2 groups.Conclusion: Use of the HeProCalc algorithm reduced protamine dosage and the protamine/heparin ratio after cardiopulmonary bypass compared with conventional dosage based on weight without significant effect on postoperative blood loss or the transfusion rate.
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