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Provisional Circulatory Support with Extracorporeal Membrane Oxygenation during Ventricular Tachycardia Ablation in Intermediate Risk Patients: A Case Series.

ABSTRACT: Background: Cardiogenic shock with acute hemodynamic decompensation may be one of the most serious risks in patients affected by ventricular tachycardia (VT). Its proper identification may have important implications in terms of pharmacological management, as might procedural planning in case of patients undergoing catheter ablation. Methods: We describe a case series of patients with provisional strategies for circulatory support in VT ablation, including the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) and vascular accesses in the electrophysiology lab but no initial ECMO activation due to an estimated intermediate pre-procedural risk from the case-series population. Results: In total, 10 patients (mean age 70 ± 11 years old, 9 males) with severe cardiomyopathy were admitted for incessant ventricular arrhythmia episodes, further diagnosis, and therapy planning; 1/10 patients (10%), documenting a PAINESD score of 14, underwent VA-ECMO cannulation due to electromechanical dissociation. All 10 patients were discharged alive. Conclusions: A pre-defined strategy before VT ablation is crucial. In our case series, the use of provisional circulatory support with VA-ECMO during incessant ablation of ventricular arrhythmia was a safe and winning alternative to upfront strategies.

SUBMITTER: Mascia G

PROVIDER: S-EPMC11312705 | biostudies-literature | 2024 Jul

REPOSITORIES: biostudies-literature

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Provisional Circulatory Support with Extracorporeal Membrane Oxygenation during Ventricular Tachycardia Ablation in Intermediate Risk Patients: A Case Series.

Mascia Giuseppe G Barca Luca L Sartori Paolo P Bianco Daniele D Della Bona Roberta R Di Donna Paolo P Porto Italo I

Journal of clinical medicine 20240731 15

<b>Background:</b> Cardiogenic shock with acute hemodynamic decompensation may be one of the most serious risks in patients affected by ventricular tachycardia (VT). Its proper identification may have important implications in terms of pharmacological management, as might procedural planning in case of patients undergoing catheter ablation. <b>Methods:</b> We describe a case series of patients with provisional strategies for circulatory support in VT ablation, including the use of venoarterial e ...[more]

PMID: 39124744

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Project description:Despite progress with adult ventricular assist devices, limited options exist to support pediatric patients with life-threatening heart disease. Extracorporeal membrane oxygenation remains the clinical standard. To characterize (patho)physiologic responses to different modes of mechanical unloading of the failing pediatric heart, extracorporeal membrane oxygenation was compared to intra-aortic balloon pump, pulsatile-flow ventricular assist device, or continuous-flow ventricular assist device support in a pediatric heart failure model.Experimental.Large animal laboratory operating room.Yorkshire piglets (n = 47; 11.7 ± 2.6 kg).In piglets with coronary ligation-induced cardiac dysfunction, mechanical circulatory support devices were implanted and studied during maximum support.Left ventricular, right ventricular, coronary, carotid, systemic arterial, and pulmonary arterial hemodynamics were measured with pressure and flow transducers. Myocardial oxygen consumption and total-body oxygen consumption were calculated from arterial, venous, and coronary sinus blood sampling. Blood flow was measured in 17 organs with microspheres. Paired Student t tests compared baseline and heart failure conditions. One-way repeated-measures analysis of variance compared heart failure, device support mode(s), and extracorporeal membrane oxygenation. Statistically significant (p < 0.05) findings included 1) an improved left ventricular blood supply/demand ratio during pulsatile-flow ventricular assist device, continuous-flow ventricular assist device, and extracorporeal membrane oxygenation but not intra-aortic balloon pump support, 2) an improved global myocardial blood supply/demand ratio during pulsatile-flow ventricular assist device and continuous-flow ventricular assist device but not intra-aortic balloon pump or extracorporeal membrane oxygenation support, and 3) diminished pulsatility during extracorporeal membrane oxygenation and continuous-flow ventricular assist device but not intra-aortic balloon pump and pulsatile-flow ventricular assist device support. A profile of systems-based responses was established for each type of support.Each type of pediatric ventricular assist device provided hemodynamic support by unloading the heart with a different mechanism that created a unique profile of physiological changes. These data contribute novel, clinically relevant insight into pediatric mechanical circulatory support and establish an important resource for pediatric device development and patient selection.

Project description:ObjectiveVeno-venous (V-V) extracorporeal membrane oxygenation (ECMO) is increasingly used to support patients with severe acute respiratory distress syndrome (ARDS). In case of additional cardio-circulatory failure, some experienced centers upgrade the V-V ECMO with an additional arterial return cannula (termed V-VA ECMO). Here we analyzed short- and long-term outcome together with potential predictors of mortality.DesignMulticenter, retrospective analysis between January 2008 and September 2021.SettingThree tertiary care ECMO centers in Germany (Hannover, Bonn) and Switzerland (Zurich).PatientsSeventy-three V-V ECMO patients with ARDS and additional acute cardio-circulatory deterioration required an upgrade to V-VA ECMO were included in this study.Measurements and main resultsFifty-three patients required an upgrade from V-V to V-VA and 20 patients were directly triple cannulated. Median (Interquartile Range) age was 49 (28-57) years and SOFA score was 14 (12-17) at V-VA ECMO upgrade. Vasoactive-inotropic score decreased from 53 (12-123) at V-VA ECMO upgrade to 9 (3-37) after 24 h of V-VA ECMO support. Weaning from V-VA and V-V ECMO was successful in 47 (64%) and 40 (55%) patients, respectively. Duration of ECMO support was 12 (6-22) days and ICU length of stay was 32 (16-46) days. Overall ICU mortality was 48% and hospital mortality 51%. Two additional patients died after hospital discharge while the remaining patients survived up to two years (with six patients being lost to follow-up). The vast majority of patients was free from higher degree persistent organ dysfunction at follow-up. A SOFA score > 14 and higher lactate concentrations at the day of V-VA upgrade were independent predictors of mortality in the multivariate regression analysis.ConclusionIn this analysis, the use of V-VA ECMO in patients with ARDS and concomitant cardiocirculatory failure was associated with a hospital survival of about 50%, and most of these patients survived up to 2 years. A SOFA score > 14 and elevated lactate levels at the day of V-VA upgrade predict unfavorable outcome.

Dataset Information

Provisional Circulatory Support with Extracorporeal Membrane Oxygenation during Ventricular Tachycardia Ablation in Intermediate Risk Patients: A Case Series.

Publications

Provisional Circulatory Support with Extracorporeal Membrane Oxygenation during Ventricular Tachycardia Ablation in Intermediate Risk Patients: A Case Series.

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