ASAIO journal : a peer-reviewed journal of the American Society for Artificial Internal Organs
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Peripheral venoarterial extracorporeal membrane oxygenation (VA ECMO) for acute cardiac failure reestablishes normal oxygen delivery and perfusion. However, VA ECMO can be limited by insufficient ventricular unloading, resulting in thrombus formation and pulmonary edema. Impella 2.5 has been used to unload the left ventricle and provide hemodynamic support during acute heart failure. ⋯ Five patients on VA ECMO with ventricular distension underwent Impella 2.5 implantation, resulting in a decreased left ventricular end-diastolic diameter as measured by echocardiography (7.8 ± 1.4 vs. 6.2 ± 0.8 cm, p = 0.001). Four patients were subsequently transitioned to the HeartMate II LVAD after restoration of end-organ function. Impella 2.5 is a safe means to unload the left ventricle while on peripheral VA ECMO to prevent left ventricle thrombus formation and worsening pulmonary edema in patients transitioning to a HeartMate II LVAD.
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Case Reports
Octreotide for left ventricular assist device-related gastrointestinal hemorrhage: can we stop the bleeding?
Left ventricular support devices (LVADs) are associated with a propensity toward gastrointestinal bleeding. A postulated mechanism is related to gastrointestinal arteriovenous malformations secondary to nonpulsatile flow. We describe a case of LVAD-related, gastrointestinal bleeding successfully treated with a combination of subcutaneous and intramuscular depot formulations of octreotide.
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Early mobility is associated with improved outcomes in critically ill patients with acute respiratory failure. The Avalon Elite Bicaval Dual-Lumen cannula provides support for extracorporeal membrane oxygenation through a single cannula in the internal jugular position in the neck, avoiding femoral cannulation. ⋯ Placement of the Avalon bicaval cannula poses a potential risk of intracardiac placement and right ventricular rupture as a result of the flexibility of the guidewire. We present our endovascular technique for Avalon bicaval cannula placement with fluoroscopic guidance to prevent inadvertent intracardiac placement.
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Despite heparin coating and systemic anticoagulation, thrombotic clot formation is a serious complication in extracorporeal membrane oxygenation (ECMO). We describe our first results of visualization of thrombotic deposits in ECMO devices using advanced multidetector computed tomography (MDCT). A bioline-coated polymethylpentene membrane oxygenator (MO) after 8 days of ECMO treatment (device 1) and a factory-sealed MO serving as an internal quality control (device 2) were analyzed with three-dimensional (3D) visualization volume rendering technique (VRT) using a 0.6 mm3 voxel isotropic MDCT dataset. ⋯ Device 2 showed no signs of clot formation in MDCT using the same VRT settings. It was demonstrated that MDCT with VRT is able to detect thrombotic deposits in ECMO devices under ex vivo conditions. MDCT allows direct visualization of the actual thrombus load of a used ECMO device as well as the quantification of the thrombus volume and could, therefore, play a significant role in better understanding the oxygenator thrombosis in modern ECMO treatment.
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Left ventricular assist devices (LVADs) are an effective therapy for patients with advanced heart failure, increasing patient survival and quality of life. Left ventricular assist devices are associated with the risks of bleeding and thrombosis. We used lactate dehydrogenase (LDH) and brain natriuretic peptide (BNP) as biomarkers for developing a thrombosis risk index. ⋯ The TRI retrospectively was able to accurately predict patients with impending device thrombosis. Indexed rise in BNP and LDH in LVAD patients may be useful to identify early device dysfunction and possible future thrombosis. Fibrinogen and D-dimer assays are currently being evaluated in these patients for their possible inclusion and added value to the TRI.