Podcasts about va ecmo

In this webinar, the CardioNerds collaborated with the Cardiogenic Shock Working Group (CSWG) to discuss LV unloading and the updated AMI guidelines, which upgraded transvalvular flow pumps to a Class 2A recommendation in AMI shock. Dr. Rachel Goodman and Dr. Gurleen Kaur from CardioNerds were joined by Dr. Navin Kapur (Tufts Medical Center), Dr. Shashank Sinha (INOVA Fairfax Hospital), and Dr. Rachna Kataria (Brown University) from the CSWG. Together, they explore a case of an older woman who presented with inferior STEMI and was found to have complete occlusion of an anomalous single coronary artery originating from the right coronary cusp and supplying the entire left ventricle. She was treated with DES to the anomalous RCA. Her course was complicated by AMI shock with re-occlusion of the DES, which was treated with thrombectomy and balloon angioplasty. An IABP was placed. After transfer to a tertiary care center, a pulmonary artery catheter revealed a CI of 0.96. With worsening shock, rising lactate, and end organ dysfunction, the team proceeded with VA-ECMO and Impella CP for LV unloading. Her lactate subsequently normalized. Produced by CardioNerds in collaboration with the Cardiogenic Shock Working Group. CardioNerds Cardiac Critical Care PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!

In this month's episode of The Atrium, host Dr. Alice Copperwheat speaks with Dr. Jose Fernandes from the Department of Clinical Perfusion at Royal Papworth Hospital, Cambridge, UK, about extracorporeal membrane oxygenation (ECMO). Chapters 00:00 Introduction 01:47 History 04:46 Basics 09:58 Circuit 14:09 Cannulation 22:44 Indications for Use 28:14 VV ECMO 32:18 VA ECMO 36:44 Monitoring 42:31 Complications 47:03 ECMO CPR 49:17 Trainee Tips 50:57 Guest Advice They discuss cannulation, general indications and contraindications, venovenous (VV) ECMO, venoarterial (VA) ECMO, peripheral VA ECMO, and central VA ECMO. They also explore monitoring, cardiac function monitoring in VA ECMO, complications, ECMO cardiopulmonary resuscitation (CPR), and important tips for trainees.   The Atrium is a monthly podcast presenting clinical and career-focused topics for residents and early career professionals across all cardiothoracic surgery subspecialties. Watch for next month's one-year anniversary episode with a very special guest.   Disclaimer The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.

Thanks to Dr. Abhinav Totapally who is a pediatric intensivist at Nicklaus Children's Hospital in Miami and Dr. Brian Bridges, the Division Chief of Pediatric Critical Care Medicine at the Medical University of South Carolina in Charleston for joining us for this series. Check out their paper published in PCCM in January 2025Learning Objectives:By the end of this podcast, listeners should be able to discuss:The rationale supporting and the limitations of using VA ECMO for children with refractory septic shock.Patient selection in the use of VA ECMO for children with refractory septic shock.The benefits and risks of common cannulation strategies for VA ECMO in children with refractory septic shock.An expert approach to supporting children with refractory septic shock on VA ECMO.Reference:Totapally A, Stark R, Danko M, Chen H, Altheimer A, Hardison D, Malone MP, Zivick E, Bridges B. Central or Peripheral Venoarterial Extracorporeal Membrane Oxygenation for Pediatric Sepsis: Outcomes Comparison in the Extracorporeal Life Support Organization Dataset, 2000-2021. Pediatr Crit Care Med. 2025 Jan 23.Questions, comments or feedback? Please send us a message at this link (leave email address if you would like us to relpy) Thanks! -Alice & ZacSupport the showHow to support PedsCrit:Please complete our Listener Feedback SurveyPlease rate and review on Spotify and Apple Podcasts!Donations are appreciated @PedsCrit on Venmo , you can also support us by becoming a patron on Patreon. 100% of funds go to supporting the show. Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.com for detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updates.

Thanks to Dr. Abhinav Totapally who is a pediatric intensivist at Nicklaus Children's Hospital in Miami and Dr. Brian Bridges, the Division Chief of Pediatric Critical Care Medicine at the Medical University of South Carolina in Charleston for joining us for this series. Check out their paper published in PCCM in January 2025Learning Objectives:By the end of this podcast, listeners should be able to discuss:The rationale supporting and the limitations of using VA ECMO for children with refractory septic shock.Patient selection in the use of VA ECMO for children with refractory septic shock.The benefits and risks of common cannulation strategies for VA ECMO in children with refractory septic shock.An expert approach to supporting children with refractory septic shock on VA ECMO.Reference:Totapally A, Stark R, Danko M, Chen H, Altheimer A, Hardison D, Malone MP, Zivick E, Bridges B. Central or Peripheral Venoarterial Extracorporeal Membrane Oxygenation for Pediatric Sepsis: Outcomes Comparison in the Extracorporeal Life Support Organization Dataset, 2000-2021. Pediatr Crit Care Med. 2025 Jan 23.Questions, comments or feedback? Please send us a message at this link (leave email address if you would like us to relpy) Thanks! -Alice & ZacSupport the showHow to support PedsCrit:Please complete our Listener Feedback SurveyPlease rate and review on Spotify and Apple Podcasts!Donations are appreciated @PedsCrit on Venmo , you can also support us by becoming a patron on Patreon. 100% of funds go to supporting the show. Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.com for detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updates.

On this week's episode of Critical Care Time, we sit down with two brilliant early-career ECMOlogists for an “intro-plus” to VV and VA ECMO. Not only do we cover the basics, but we couldn't help ourselves and went on some deep dives along the way that you guys will hopefully find interesting! With the help of our good friends Nick Villalobos and Kha Dinh, we review indications for ECMO, approaches to configuration and management, touch on some of the complications and… even spend some time demystifying the European unit for girth! We hope you guys will have as much fun listening to this as we did producing it. If so, leave us a review and let us know what you think! Hosted on Acast. See acast.com/privacy for more information.

Holger Thiele and C. Michael Gibson discuss the impact of VA-ECMO on patients with acute MI and advanced cardiogenic shock.

Acil tıbbın geniş kapsamı, güncel literatürü takip etmeyi sağlık profesyonelleri için bir zorluk haline getirmektedir. Acil tıbbın karşılaştığı çok çeşitli hastalık ve durumlar, sürekli olarak değişen tedavi yaklaşımlarını takip etmeyi gerektirir. Bu gerekliliği göz önünde bulunduran Acil Tıp Farmakoterapi Araştırma Ağı (EMPHARM-NET), her yıl önemli farmakoterapi ile ilgili literatürü gözden geçirmekte ve derlemektedir. Bu yazıda, EMPHARM-NET'in 2023 yılı boyunca acil tıpta farmakoterapi alanında yayımlanan en dikkat çekici çalışmaları derledikleri yazısını özetlemekteyiz.1 İleri okuma için makalenin tam metnine buradan ulaşabilirsiniz. 2023 yılı, acil serviste farmakoterapinin önemli gelişmeler gösterdiği bir yıl olmuştur. Özellikle hızlı ardışık entübasyon, kardiyak arrest yönetimi ve travma sonrası majör kanamaların tedavisi gibi kritik konularda güncellemeler yapılmıştır. Ayrıca, iskemik inme tedavisinde kullanılan zaman ve tedavi modaliteleri, toplumsal kökenli pnömonide steroid kullanımı ve hedeflenen kan ürünlerinin uygulanması gibi çeşitli konularda da önemli gelişmeler kaydedilmiştir. Bu yazı, acil serviste farmakoterapi alanında 2023 yılında yayımlanan en önemli 13 makaleyi, 6 rehberi ve 5 meta-analizi kapsamaktadır. Makaleler, modifiye bir Delphi yöntemi kullanılarak seçilmiş ve ilgili dergilerde yayımlanan makaleler GRADE sistemi aracılığıyla bağımsız olarak değerlendirilmiştir. GRADE 1A ve 1B olarak kabul edilen yayınlar, incelemeye dahil edilmek üzere grup tarafından yeniden incelenmiştir. Yazımızı iki bölümde sunacağız; bu ilk bölümde, farmakoterapinin toksikoloji, resüsitasyon ve nöroloji alanlarındaki 2023 yılı gelişmelerine odaklanacağız. İkinci bölümde ise pulmoner, travma, enfeksiyon hastalıkları ve diğer çeşitli konular üzerine odaklanacağız. 1. Toksikoloji 1.1. 2023 Amerikan Kalp Derneği zehirlenmeye bağlı kardiyak arrest veya yaşamı tehdit eden toksisitesi olan hastaların yönetimine odaklanmış güncelleme: kardiyopulmoner resüsitasyon ve acil kardiyovasküler bakım için Amerikan Kalp Derneği kılavuzlarında güncelleme2 ABD'de zehirlenme, kazara ölümlerin başlıca nedenidir. Kardiyovasküler kollaps yaşayan kritik durumdaki zehirlenmiş hastaların resüsitasyonu, standart prosedürlerden farklı olarak daha fazla antidot kullanımı ve venoarteriyel ekstrakorporeal membran oksijenasyonuna (VA-ECMO) odaklanmaktadır. Amerikan Kalp Derneği (AHA), beta-blokerler, benzodiazepinler, kalsiyum kanal blokerleri, kokain, siyanür, digoksin, opioidler ve diğer zehirlenmelere bağlı yaşamı tehdit eden durumlar için güncel tedavi önerileri sunmuştur. Özellikle, opioid aşırı dozlarına bağlı kardiyak arrest vakalarında odak noktasının nalokson yerine kardiyopulmoner resüsitasyon (KPR) olması gerektiği vurgulanmıştır. Beta-bloker ve kalsiyum kanal blokeri toksisitelerinde hipotansiyon için vazopressörler ve yüksek doz insülin önerilmekte, ancak intralipid emülsiyonun kullanılması tavsiye edilmemektedir. Ayrıca, kılavuzlar VA-ECMO'nun, zehirlenmeye bağlı kardiyojenik şok veya ritim bozukluğu yaşayan hastalar için uygun bir tedavi seçeneği olduğunu ve bu tedavinin erken aşamada değerlendirilmesi gerektiğini belirtmektedir. Bu güncellemeyle ilgili detaylı bilgiye sitemizde yer alan yazı serisinden erişebilirsiniz. 1.2. ABD ve Kanada'da asetaminofen zehirlenmesinin yönetimi3 Asetaminofen aşırı dozu, Kuzey Amerika'da önemli bir morbidite ve mortalite kaynağıdır. Tedavi ile ilgili tartışmalar, Rumack-Matthew (RM) nomogramına uygunluk, kronik alımlarda risk değerlendirmesi ve uygun n-asetilsistein (NAC) dozu gibi konuları ele almak için dört klinik toksikoloji topluluğu bir fikir birliği bildirisi yayımlamıştır. Bildiri, 24 saat içinde potansiyel olarak toksik bir asetaminofen dozu alan herkesin RM nomogramı ile değerlendirilmesi gerektiğini ve ilk alımın başlangıç zamanını belirlediğini açıklığa kavuşturmaktadır. Ayrıca, asetaminofen seviyelerinin RM nomogramının tedavi eşiğinin iki katı olduğu durumlarda daha y...

Complete your knowledge around mechanical circulatory support (MCS) devices with this episode on Temporary MCS with Dr. Pankaj Jain from Sydney. This episode touches on cardiogenic shock before exploring the ins and outs of temporary MCS devices including the balloon pump, the impella devices and VA ECMO. DanGer Shock - a large RCT evaluating the Impella device - was released during the recording of this podcast so be sure to stick around for the discussion of DanGer Shock at the end of the podcast.As always, happy listening! If you have any suggestions or would like to join me on the show please reach out to me at rahul@mattersoftheheartcast.com

VA-ECMO outcome scores have been previously developed and used extensively for risk adjustment, patient prognostication, and quality control across time and centres. The limitation of such scores is the derivation by using traditional statistical methods which are not capable of covering the complexity of ECMO outcomes. The Extracorporeal Life Support Organization Member Centres have developed a study where they aimed to leverage a large international patient cohort to develop and validate an AI-driven tool for predicting in-hospital mortality of VA-ECMO. The tool was derived entirely from pre-ECMO variables, allowing for mortality prediction immediately after ECMO initiation.To learn more about this study listen to the podcast.

CardioNerds cofounder Dr. Dan Ambinder joins Dr. Angie Molina, Dr. Cullen Soares, and Dr. Andrew Lutz from the University of Maryland Medical Center for some beers and history by Fort McHenry. They discuss a case of disseminated haemophilus influenzapresumed fulminant bacterial myocarditis with mixed septic/cardiogenic shock. Expert commentary is provided by Dr. Stanley Liu (Assistant Professor, Division of Cardiovascular Medicine, University of Maryland School of Medicine). Episode audio was edited by Dr. Chelsea Amo-Tweneboah. A woman in her twenties with a history of intravenous drug use presented with acute onset fevers and sore throat, subsequently developed respiratory distress and cardiac arrest, and was noted to have epiglottic edema on intubation. She developed shock and multiorgan failure. ECG showed diffuse ST elevations, TTE revealed biventricular dysfunction, and pleural fluid culture grew Haemophilus influenza. Right heart catheterization showed evidence of cardiogenic shock. She improved with supportive care and antibiotics. US Cardiology Review is now the official journal of CardioNerds! Submit your manuscript here. CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls - Sore Throat, Fever, and Myocarditis - It's not always COVID-19 The post-cardiac arrest ECG provides helpful information for diagnosing the underlying etiology.​ Be aware of diagnostic biases - availability and anchoring biases are particularly common during respiratory viral (such as COVID-19, RSV) surges. Consider a broad differential diagnosis in evaluating myocarditis, including non-viral etiologies. Right heart catheterization provides crucial information for diagnosis and management of undifferentiated shock​. When assessing the need for mechanical circulatory support, consider the current hemodynamics, type of support needed, and risks associated with each type. Show Notes - Sore Throat, Fever, and Myocarditis - It's not always COVID-19 ECG findings consistent with pericarditis include diffuse concave-up ST elevations and downsloping T-P segment (Spodick's sign) as well as PR depression (lead II), and PR elevation (lead aVR). In contrast, regional ST elevations with “reciprocal” ST depressions and/or Q-waves should raise concern for myocardial ischemia as the etiology. Biventricular dysfunction and elevated troponin are commonly seen post-cardiac arrest and may be secondary findings. However, an elevation in troponin that is out of proportion to expected demand ischemia, ECG changes (pericarditis, ischemic ST elevations), and cardiogenic shock suggest a primary cardiac etiology for cardiac arrest. The differential diagnosis of infectious myopericarditis includes, most commonly, viral infection (respiratory viruses) and, more rarely, bacterial, fungal, or parasitic. Noninfectious myopericarditis may be autoimmune (such as lupus, sarcoidosis, checkpoint inhibitors), toxin-induced (alcohol, cocaine), and medication-induced (anthracyclines and others). Right heart catheterization can help diagnose the etiology of undifferentiated shock, including distinguishing between septic and cardiogenic shock, by providing right and left-sided filling pressures, pulmonary and systemic vascular resistance, and cardiac output. Mechanical circulatory support (MCS) is indicated for patients in cardiogenic shock with worsening end-organ perfusion despite inotropic and pressor support. MCS includes intra-aortic balloon pump, percutaneous VAD, TandemHeart, and VA-ECMO. The decision to use specific types of MCS should be individualized to each patient with their comorbidities and hemodynamic profile. Shock teams are vital to guide decision-making. References Witting MD, Hu KM, Westreich AA, Tewelde S, Farzad A,

In this episode of CTSNet's flagship podcast, editor in chief Joel Dunning runs through the latest, most popular content on ctsnet.org—the largest online community of CT surgeons and source of CT surgery information—and breaking cardiothoracic surgery news and research from around the world. Joel discusses a VA ECMO case study, a consensus statement from EACTS and EAPC on frailty assessment, and a study on diversity, equity, and inclusion for women in cardiothoracic surgery. He also talks about a new video from the team behind the Surgeon's Cookbook, the first two videos in the mastering redo surgery after TAVR series, and in interview with Hans-Joachim Schäfers. After discussing upcoming events in CT surgery, Joel closes with a shoutout to the organizers of The Heart Surgeon's Cookbook project.  JANS Items Mentioned Veno-Arterial Extracorporeal Membrane Oxygenation as a Perioperative Support to Redo Cardiac Surgery for Inoperable Adult Patients: A Case Series  Preinterventional Frailty Assessment in Patients Scheduled for Cardiac Surgery or Transcatheter Aortic Valve Implantation: A Consensus Statement of EACTS and EAPC  The Cost of Being a Woman in Academic Cardiothoracic Surgery: Joint Collaboration of The Society of Thoracic Surgeons Workforces on Diversity, Equity, and Inclusion and Cardiothoracic Surgery Practice Models  CTSNet Content Mentioned Introducing: The Heart Surgeon's Cookbook  Mastering Redo Surgery after TAVR: An Introduction and LVOT Enlargement  Learning from Aortic Valve Repair: An Interview with Hans-Joachim Schäfers  Other Items Mentioned CTSNet Events Calendar Disclaimer The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.

Merhabalar. Bu yazımızda Amerikan Kalp Cemiyeti'nin (AHA) zehirlenmiş hastalarda yaşamı tehdit eden toksisite ve kardiyak arrest yönetimi ile ilgili yayınladığı güncellenmenin​1​ son kısmını paylaşacağız. İlgili güncellemenin; Dr. Emre Kudu tarafından yazılan giriş kısmını içeren 1. Bölümüne buradan Dr. Emir ünal tarafından yazılan 2. Bölümüne buradan Dr. Betül İşcan Er tarafından yazılan 3. Bölümüne buradan ulaşabilirsiniz. Keyifli okumalar dilerim. Sodyum Kanal Blokörleri Giriş Birçok etken madde , sınıf Ia veya Ic antidisritmiklerine benzer özelliklerle kardiyak sodyum kanallarını bloke edebilir. Sodyum kanal blokerleri ile zehirlenme durumları EKG'de QRS uzaması, ventriküler aritmiler, hipotansiyon ve kardiyovasküler kollapsa neden olabilir. Trisiklik antidepresanlar (TCA) sodyum kanallarınıı bloke ettiği bilinen ve en yaygın olarak tanımlanan ajan olmasına rağmen, başka etken maddeler de aşırı doz kullanımlarında hayatı tehdit eden sodyum kanal blokajına neden olabilirler (Tablo 1). Tablo 1: Seçilmiş Sodyum Kanal Blokerleri DifenhidraminLakozamid  TCA'lar‡  KarbamazepinPropafenon  Venlafaksin  Klorokin*Kinin  ZonisamidKokain†Kinidin  Topiramat  FlekainidTiyoridazin  LamotrijinHidroksiklorokin*Taxus spp. (porsuk ağacı)   TCA, trisiklik ve tetrasiklik antidepresanı belirtir.*Klorokin ve hidroksiklorokin toksisitesinin tedavisi bu odaklı güncellemenin kapsamı dışındadır.†Hayatı tehdit eden kokain toksisitesinin yönetimi, bu odaklı güncellemenin 6. Bölümünde tartışılmaktadır.‡Yaygın TCA'lar arasında amitriptilin, amoksapin, klomipramin, desipramin, doksepin, imipramin, maprotilin, nortriptilin, protriptilin ve trimipramin bulunur. Sodyum kanal blokeri zehirlenmesi olan hastalarda karakteristik elektrokardiyogram (EKG) değişiklikleri görülebilmektedir. Bu değişiklikler içerisinde en iyi tanımlananları intraventriküler iletim gecikmesi (QRS aralığı uzaması) ve aVR'de görülen terminal sağ aks sapmasıdır (Şekil 1). Bu bulgular ventriküler aritmilerden önce gelmekte ve aritmi için risk teşkil ettiği düşünülmektedir. Şekil 1. Sodyum kanal blokeri zehirlenmesi olan bir hastada tipik elektrokardiyografik bulgular. Sodyum kanal bloker zehirlenmesine bağlı kardiyopulmoner arrest vakalarının yönetimi ile ilgili yapılmış çalışmalar kısıtlı olup bilgiler vaka raporları üzerinden sağlanmaktadır. En fazla kanıta sahip tedavi, tipik olarak hipertonik solüsyonlarla bolus intravenöz uygulama olarak verilen sodyum bikarbonattır (uygulama dozu yetişkinlerde 1000 mEq/L, çocuklarda 500 mEq/L). Nöbetler için sodyum bikarbonat ve benzodiazepinler, geniş kompleks taşikardi için magnezyum ve hipotansiyon için yüksek doz glukagon dahil olmak üzere diğer tedaviler bir öneride bulunmak için yeterli kanıtla desteklenmemektedir. Hayatı Tehdit Eden Sodyum Kanal Bloker Zehirlenmesi Olan Hastaların Tedavisine Yönelik ÖnerilerCORLOEÖneriler1B-NR1. Trisiklik ve/veya tetrasiklik antidepresan zehirlenmesinden kaynaklanan yaşamı tehdit eden kardiyotoksisiteyi tedavi etmek için sodyum bikarbonat kullanılmasını öneririz.2aC-LD2. Trisiklik veya tetrasiklik antidepresanlar dışındaki sodyum kanal blokerlerinden kaynaklanan zehirlenmenin neden olduğu hayatı tehdit eden kardiyotoksisiteyi tedavi etmek için sodyum bikarbonatın kullanılması mantıklıdır.2aC-LD3. Sodyum kanal bloker zehirlenmesinden kaynaklanan dirençli kardiyojenik şoku tedavi etmek için VA-ECMO gibi ekstrakorporeal yaşam desteğinin kullanılması mantıklıdır.2bC-LD4. Sınıf Ia veya Ic sodyum kanal blokerlerinden kaynaklanan hayatı tehdit eden kardiyotoksisiteyi tedavi etmek için Vaughan-Williams sınıf Ib antidisritmiklerinin (örn. lidokain) kullanılması mantıklı olabilir.2bC-LD5. Diğer tedavi yöntemlerine dirençli, yaşamı tehdit eden sodyum kanal blokeri zehirlenmesinin tedavisinde intravenöz lipid emülsiyonunun kullanılması mantıklı olabilir.COR: Class of recommendation (Tavsiye sınıfı)LOE: Level of evidence (Kanıt düzeyi) Öneriye Özgü Destekleyici Metin 1.

Herkese merhaba! Geçtiğimiz aylarda Amerikan Kalp Cemiyeti (AHA) tarafından zehirlenmiş hastalarda hayatı tehdit eden toksisite veya kardiyak arrest yönetimine yönelik odaklanmış güncellenme yayınlanmıştı.​1​ Acilci.net ailesi olarak bu yazı serimizde bu güncellemeyi sizlere sunacağız.    İlk yazımızda, güncellemenin Giriş bölümüne yer vereceğiz. Serinin devam eden yazıları ise spesifik olarak kritik zehirlenmelere yönelik konular ile devam edecek. Zehirlenmiş Hastalarda Hayatı Tehdit Eden Toksisite veya Kardiyak Arrest Yönetimine Dair Eve Götürülecek 10 Mesaj Zehirlenmeye bağlı kardiyak arrest ve yaşamı tehdit eden toksisitenin tedavisi, etkili temel ve ileri yaşam desteğinin yanı sıra çoğu zaman antidotlar ve venoarteriyel ekstrakorporeal membran oksijenasyonu (VA-ECMO) gibi çoğu klinisyenin sıklıkla kullanmadığı özel tedavileri gerektirir. Tıbbi toksikolog, klinik toksikolog veya bölgesel zehir merkezi ile zamanında konsültasyon, hızlı ve etkili tedaviyi kolaylaştırır. Opioid doz aşımı, Kuzey Amerika'da zehirlenmeye bağlı kardiyak arrestin önde gelen nedeni olmaya devam etmektedir. Nalokson uygulaması solunum durmasını tersine çevirerek kardiyak arreste ilerlemeyi önleyebilir. Hayatı tehdit eden β-bloker ve kalsiyum kanal bloker zehirlenmesi olan hastaların tedavisinde erken dönemde yüksek doz insülin tedavisi önerilmektedir. Sodyum bikarbonat uygulamasının eklendiği standart ileri yaşam desteği, kokain veya diğer sodyum kanal blokerlerinin neden olduğu hayatı tehdit eden disritmilerin tedavisi için uygundur. Siyanür zehirlenmesinden şüpheleniliyorsa doğrulama testini beklenmemelidir. Hemen hidroksokobalamin (tercih edilir) veya sodyum nitrit + sodyum tiyosülfat ile tedavisi uygulanmalıdır. Digoksin spesifik immün antikor fragmanlarının uygulanması, digoksin zehirlenmesinden kaynaklanan yaşamı tehdit eden aritmileri tersine çevirebilir. Özellikle bupivakainden kaynaklanan yaşamı tehdit eden lokal anestezik toksisitesinin resüsitasyonunda %20 intravenöz lipid emülsiyonunun kullanılması etkili olabilir. Sempatomimetik zehirlenmesinden dolayı şiddetli ajitasyonu olan hastalarda sedasyon uygulamasına ihtiyaç duyarlar. Böylece hipertermi ve asidozu yönetimine, rabdomiyoliz ve yaralanmayı önlenmesine ve yaşamı tehdit eden diğer durumların değerlendirilmesine olanak sağlanmış olur. Flumazenil, benzodiazepin zehirlenmesinden kaynaklanan merkezi sinir sistemini ve solunum depresyonunu tersine çevirir, ancak önemli riskler ve kontrendikasyonlar kullanımını sınırlar. VA ECMO, diğer tedavi önlemlerine dirençli kardiyojenik şok veya disritmileri olan hastalar için hayat kurtarıcı olabilir. Venoarteriyel ECMO uygulaması zaman aldığından diğer tedavilere iyi yanıt vermeyen hastalarda işleme erken başlanmalıdır. Önsöz Nisan 2021'de sona eren 12 aylık dönemde, Amerika Birleşik Devletleri'nde 100.000'den fazla kişi zehirlenme ve ilaç aşırı dozundan dolayı öldü ve bu sayı önceki yıla göre %28,5'lik bir artış gösterdi.​2​ Bu ölümlerin yüzde doksanı kasıtsızdı. Her ne kadar bu ölümlerin çoğunluğu (75.673) opioid doz aşımına atfedilmiş olsa da diğer toksinlerden kaynaklanan zehirlenmeler önemli sayıda can kaybına yol açmaya devam ediyor. Kardiyak arrest, dirençli şok veya kardiyak arrest tehdidi oluşturan diğer durumlar olarak tanımlanan kritik zehirlenmeli hastaların yönetimi, genellikle standart resüsitasyondan farklıdır. Örneğin hastalar, β-adrenerjik reseptör antagonisti (β-bloker) veya kalsiyum kanalı antagonisti (kalsiyum kanal blokeri [CCB]) zehirlenmesinden dolayı hipotansiyon geliştirebilirler. Bu durum sıklıkla atropine, standart vazopresörlere veya kalp pili uygulamasına yanıt vermez iken hedefe yönelik yüksek doz insülin gibi tedavilerden fayda görebilir. Siyanür zehirlenmesinin mitokondriyal inhibisyonu, kalp ve beyindeki hücresel adenozin trifosfat konsantrasyonlarını eski haline getirmek için hidroksokobalamin gibi spesifik antidotlar gerektirir. Zehirlenen hastalar,

Priya Bhaskar, M.D. is an Associate Professor of Pediatrics at UT Southwestern and an attending in the Cardiac ICU at Children's Medical Center Dallas. She completed her pediatric residency at Inova Children's Hospital in Virginia and critical care fellowship at UTSW prior to completing a 1 year CICU fellowship at Laurie Children's in Chicago. Prior to her current position here at UTSW she was a cardiac intensivist at Arkansas Children's Hospital. Her professional interests include extracorporeal support and education. She serves on the ECMO team as a core staff physician, and she has co-authored a review on this topic that we will use to guide our conversation. Learning Objectives:By the end of this podcast, listeners should be able to discuss:The general indications for VA-ECMO in pediatrics.The anatomic and physiologic rationale supporting various VA-ECMO cannulation strategies.Physiologic targets to ensure adequate oxygen delivery for patients on VA-ECMO.Hemodynamic complications of VA-ECMO such as left atrial hypertension and harlequin syndrome and general strategies in their management. Liberation strategies for VA-ECMO either to decannulation or conversion to ventricular assist device.How to support PedsCrit:Please rate and review on Spotify and Apple Podcasts!Donations are appreciated @PedsCrit on Venmo , you can also support us by becoming a patron on Patreon. 100% of funds go to supporting the show.Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.com for detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updates.References:Bhaskar, P., Davila, S., Hoskote, A., & Thiagarajan, R. (2021). Use of ECMO for Cardiogenic Shock in Pediatric Population. Journal of clinical medicine, 10(8), 1573. https://doi.org/10.3390/jcm10081573Brown G, Moynihan KM, Deatrick KB, Hoskote A, Sandhu HS, Aganga D, Deshpande SR, Menon AP, Rozen T, Raman L, Alexander PMA. Extracorporeal Life Support Organization (ELSO): Guidelines for Pediatric Cardiac Failure. ASAIO J. 2021 May 1;67(5):463-475. doi: 10.1097/MAT.0000000000001431. Erratum in: ASAIO J. 2022 Jul 1;68(7):e129. PMID: 33788796.Xie A, Forrest P, Loforte A. Left ventricular decompression in veno-arterial extracorporeal membrane oxygenation. Ann Cardiothorac Surg. 2019 Jan;8(1):9-18. doi: 10.21037/acs.2018.11.07. PMID: 30854308; PMCID: PMC6379183. https://www.elso.org/ecmo-resources/elso-ecmo-guidelines.aspx https://www.congenitalheartacademy.com/home Support the show

La American Heart Association publicó un documento con recomendaciones específicas para el manejo del paciente en paro cardiaco por intoxicación. Este artículo repasará las principales recomendaciones. Este es el segundo episodio de una serie de episodios relacionados al manejo del paro cardiaco por envenenamientos. A pesar del efecto de bloqueo de los receptores beta 1 y beta 2, el propranlol y el sotalol pueden causar inestabilidad cardiaca por bloqueo de canales de sodio y bloqueo de canales de potasio, respectivamente. Por lo tanto, el manejo de estos dos β-bloqueadores requiere una discusión adicional. Bloqueadores de canales beta La presentación del paciente con intoxicación con betabloqueadores incluye: Hipotensión Bradicardia Hipoglicemia Hiperkalemia Coma, convulsiones Manejo de sobredosis con betabloqueadores Atropina Glucagón Calcio (debido a hiperkalemia por intoxicación) Vasopresores Insulina en altas dosis Dextrosa (hipoglucemia debido a intoxicación, y debido a la insulina) ILE Therapy Resumen de las recomendaciones de la AHA para intoxicaciones con betabloqueadores Recomendamos la administración de insulina en altas dosis para la hipotensión debido a envenenamiento con betabloqueadores refractario a, o en conjunto con, terapia con vasopresores. Clase de recomendación: 1, Nivel de evidencia: B, NR Recomendamos que se administren vasopresores para la hipotensión debido a envenenamiento con betabloqueadores. Clase de recomendación: 1, Nivel de evidencia: C-LD) Es razonable usar un bolo de glucagón, seguido de una infusión continua, para la bradicardia o hipotensión debido a envenenamiento por betabloqueadores. Clase de recomendación: 2a, Nivel de evidencia: C-LD Es razonable utilizar técnicas de soporte vital extracorpóreo como VA-ECMO para amenaza a la vida por sobredosis de betabloqueadores con shock cardiogénico refractario a intervenciones farmacológicas. Clase de recomendación: 2a, Nivel de evidencia: C-LD Puede ser razonable administrar atropina para bradicardia inducida por betabloqueadores. Nivel de recomendación: 2b, Clase de evidencia: C-LD Puede ser razonable intentar el uso de marcapasos eléctrico para bradicardia inducida por betabloqueadores. Nivel de recomendación: 2b, Clase de evidencia: C-LD Puede ser razonable usar hemodiálisis para amenazas a la vida por sobredosis con atenolol o sotalol. Clase de recomendación: 2b, Nivel de evidencia: C-LD La terapia de emulsión de lípidos intravenosos no es de beneficio para envenenamientos que amenazan la vida con betabloqueadores. Clase de recomendación: 3 no hay beneficio. Nivel de evidencia: C-LD Notas adicionales sobre el propranolol La sobredosis con propranolol puede producir un bloqueo en los canales de sodio. Los bloqueos de canales de sodio se manifiestan prolongación del complejo QRS y un complejo QRS predominantemente positivo en aVR. El manejo de los pacientes con intoxicaciones con bloqueadores de canales de sodio requiere la administración de bicarbonato de sodio. La amiodarona y la procainamida están contraindicadas en el manejo de los pacientes con intoxicación con bloqueadores de canales de sodio. Esta Guía de la AHA discute el tema de las intoxicaciones con bloqueadores de canales de sodio en otra sección, por lo que este tema no se expandió en esta sección de intoxicaciones con betabloqueadores. Notas adicionales sobre sotalol La sobredosis con sotalol puede producir prolongación del completo QTc, y como resultado el paciente puede tener torsada de punto.  Bloqueadores de canales de calcio Dos tipos de bloqueadores de canales de calcio: Dihidropiridinos (frecuencia) Nifedipina Amlodipina No-dihidropiridinos (vasodilatación) Diltiazem Verapamil Resumen de recomendaciones de la AHA para intoxicaciones con bloqueadores de canales de calcio Recomendamos la administración de vasopresores para la hipotensión por envenenamiento con bloqueadores de canales de calcio. (Clase de recomendación: 1, Nivel de evidencia: B-NR) Recomendamos la administración de insulina en dosis alta para hipotenso debido a envenenamiento con bloqueadores de canales de calcio. (Clase de recomendación: 1, Nivel de evidencia: B-NR) Es razonable administrar calcio para envenenamiento por bloqueadores de canales de calcio. (Clase de recomendación: 2a, Nivel de evidencia: C-LD) Es razonable administrar atropina para bradicardias hemodinámicamente significativas debido a envenenamiento por bloqueadores de canales de calcio. (Clase de recomendación: 2a, Nivel de evidencia: C-LD) Es razonable utilizar técnicas de soporte vital extracorpóreo tales como VA-ECMO para shock cardiogénico debido a envenenamiento por bloqueadores de canales de calcio que sea refractario a intervenciones farmacológicas. (Clase de recomendación: 2a, Nivel de evidencia: C-LD) Puede ser razonable tratar con marcapasos eléctrico para envenenamientos con bloqueadores de canales de calcio con bradicardia refractaria. (Clase de recomendación: 2b, Nivel de evidencia: C-LD). La utilidad de los bolos e infusión de glucagón para envenenamientos por bloqueadores de canales de calcio es incierta. (Clase de recomendación: 2b, Nivel de evidencia: C-LD) La utilidad de administrar azul de metileno para shock vasodilatorio refractario debido a envenenamiento por bloqueadores de canales de calcio es incierta. (Clase de recomendación: 2b, Nivel de evidencia: C-LD) El uso rutinario de terapia con emulsión de lípidos intravenosos para envenenamiento por bloqueadores de canales de calcio no está recomendado. (Clase de recomendación: 3, no hay beneficio, Nivel de evidencia: C-LD) Referencias Lavonas EJ, Akpunonu PD, Arens AM, Babu KM, Cao D, Hoffman RS, Hoyte CO, Mazer-Amirshahi ME, Stolbach A, St-Onge M, Thompson TM, Wang GS, Hoover AV, Drennan IR; on behalf of the American Heart Association. 2023 American Heart Association focused update on the management of patients with cardiac arrest or life-threatening toxicity due to poisoning: an update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2023;148:e•••–e•••. doi: 10.1161/ CIR.0000000000001161 https://litfl.com/beta-blocker-toxicity/  https://litfl.com/glucagon-as-an-antidote/ https://litfl.com/high-dose-insulin-euglycaemic-therapy/

La American Heart Association publicó un documento con recomendaciones específicas para el manejo del paciente en paro cardiaco por intoxicación. Este artículo repasará las principales recomendaciones. Este es el segundo episodio de una serie de episodios relacionados al manejo del paro cardiaco por envenenamientos. A pesar del efecto de bloqueo de los receptores beta 1 y beta 2, el propranlol y el sotalol pueden causar inestabilidad cardiaca por bloqueo de canales de sodio y bloqueo de canales de potasio, respectivamente. Por lo tanto, el manejo de estos dos β-bloqueadores requiere una discusión adicional. Bloqueadores de canales beta La presentación del paciente con intoxicación con betabloqueadores incluye: Hipotensión Bradicardia Hipoglicemia Hiperkalemia Coma, convulsiones Manejo de sobredosis con betabloqueadores Atropina Glucagón Calcio (debido a hiperkalemia por intoxicación) Vasopresores Insulina en altas dosis Dextrosa (hipoglucemia debido a intoxicación, y debido a la insulina) ILE Therapy Resumen de las recomendaciones de la AHA para intoxicaciones con betabloqueadores Recomendamos la administración de insulina en altas dosis para la hipotensión debido a envenenamiento con betabloqueadores refractario a, o en conjunto con, terapia con vasopresores. Clase de recomendación: 1, Nivel de evidencia: B, NR Recomendamos que se administren vasopresores para la hipotensión debido a envenenamiento con betabloqueadores. Clase de recomendación: 1, Nivel de evidencia: C-LD) Es razonable usar un bolo de glucagón, seguido de una infusión continua, para la bradicardia o hipotensión debido a envenenamiento por betabloqueadores. Clase de recomendación: 2a, Nivel de evidencia: C-LD Es razonable utilizar técnicas de soporte vital extracorpóreo como VA-ECMO para amenaza a la vida por sobredosis de betabloqueadores con shock cardiogénico refractario a intervenciones farmacológicas. Clase de recomendación: 2a, Nivel de evidencia: C-LD Puede ser razonable administrar atropina para bradicardia inducida por betabloqueadores. Nivel de recomendación: 2b, Clase de evidencia: C-LD Puede ser razonable intentar el uso de marcapasos eléctrico para bradicardia inducida por betabloqueadores. Nivel de recomendación: 2b, Clase de evidencia: C-LD Puede ser razonable usar hemodiálisis para amenazas a la vida por sobredosis con atenolol o sotalol. Clase de recomendación: 2b, Nivel de evidencia: C-LD La terapia de emulsión de lípidos intravenosos no es de beneficio para envenenamientos que amenazan la vida con betabloqueadores. Clase de recomendación: 3 no hay beneficio. Nivel de evidencia: C-LD Notas adicionales sobre el propranolol La sobredosis con propranolol puede producir un bloqueo en los canales de sodio. Los bloqueos de canales de sodio se manifiestan prolongación del complejo QRS y un complejo QRS predominantemente positivo en aVR. El manejo de los pacientes con intoxicaciones con bloqueadores de canales de sodio requiere la administración de bicarbonato de sodio. La amiodarona y la procainamida están contraindicadas en el manejo de los pacientes con intoxicación con bloqueadores de canales de sodio. Esta Guía de la AHA discute el tema de las intoxicaciones con bloqueadores de canales de sodio en otra sección, por lo que este tema no se expandió en esta sección de intoxicaciones con betabloqueadores. Notas adicionales sobre sotalol La sobredosis con sotalol puede producir prolongación del completo QTc, y como resultado el paciente puede tener torsada de punto.  Bloqueadores de canales de calcio Dos tipos de bloqueadores de canales de calcio: Dihidropiridinos (frecuencia) Nifedipina Amlodipina No-dihidropiridinos (vasodilatación) Diltiazem Verapamil Resumen de recomendaciones de la AHA para intoxicaciones con bloqueadores de canales de calcio Recomendamos la administración de vasopresores para la hipotensión por envenenamiento con bloqueadores de canales de calcio. (Clase de recomendación: 1, Nivel de evidencia: B-NR) Recomendamos la administración de insulina en dosis alta para hipotenso debido a envenenamiento con bloqueadores de canales de calcio. (Clase de recomendación: 1, Nivel de evidencia: B-NR) Es razonable administrar calcio para envenenamiento por bloqueadores de canales de calcio. (Clase de recomendación: 2a, Nivel de evidencia: C-LD) Es razonable administrar atropina para bradicardias hemodinámicamente significativas debido a envenenamiento por bloqueadores de canales de calcio. (Clase de recomendación: 2a, Nivel de evidencia: C-LD) Es razonable utilizar técnicas de soporte vital extracorpóreo tales como VA-ECMO para shock cardiogénico debido a envenenamiento por bloqueadores de canales de calcio que sea refractario a intervenciones farmacológicas. (Clase de recomendación: 2a, Nivel de evidencia: C-LD) Puede ser razonable tratar con marcapasos eléctrico para envenenamientos con bloqueadores de canales de calcio con bradicardia refractaria. (Clase de recomendación: 2b, Nivel de evidencia: C-LD). La utilidad de los bolos e infusión de glucagón para envenenamientos por bloqueadores de canales de calcio es incierta. (Clase de recomendación: 2b, Nivel de evidencia: C-LD) La utilidad de administrar azul de metileno para shock vasodilatorio refractario debido a envenenamiento por bloqueadores de canales de calcio es incierta. (Clase de recomendación: 2b, Nivel de evidencia: C-LD) El uso rutinario de terapia con emulsión de lípidos intravenosos para envenenamiento por bloqueadores de canales de calcio no está recomendado. (Clase de recomendación: 3, no hay beneficio, Nivel de evidencia: C-LD) Referencias Lavonas EJ, Akpunonu PD, Arens AM, Babu KM, Cao D, Hoffman RS, Hoyte CO, Mazer-Amirshahi ME, Stolbach A, St-Onge M, Thompson TM, Wang GS, Hoover AV, Drennan IR; on behalf of the American Heart Association. 2023 American Heart Association focused update on the management of patients with cardiac arrest or life-threatening toxicity due to poisoning: an update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2023;148:e•••–e•••. doi: 10.1161/ CIR.0000000000001161 https://litfl.com/beta-blocker-toxicity/  https://litfl.com/glucagon-as-an-antidote/ https://litfl.com/high-dose-insulin-euglycaemic-therapy/

Extracorporeal Cardiopulmonary Resuscitation (ECPR)  Special Guests: Caitlin Brown, PharmD, BCCCP, FCCM Patrick Wieruszewski, PharmD, BCCCP 04:22 – Definition/History of use 06:48 – ECPR vs. ACLS 11:40 – ECPR research 22:00 –VA ECMO overview 24:02 – Ideal patients/Contraindications 30:52 – ECPR overview from presentation to cannulation 41:15 – Pharmacotherapy in longer ECPR cardiac arrests 49:00 – ECPR post-resuscitation care 50:42 – Guideline recommendations 52:50 – Post-cannulation acute complications 56:10 – ECMO-induced PK/PD changes 59:07 – Advice for new ECPR programs 62:20 – Pharmacist's role/Take-home points ECPR: A Primer for Pharmacists https://pubmed.ncbi.nlm.nih.gov/37070401/ Reference List: https://pharmacytodose.files.wordpress.com/2023/09/ecpr-references.pdf Curious Boxwood Etsy Shop: https://www.etsy.com/shop/curiousboxwood PharmacyToDose.Com  @PharmacyToDose  PharmacyToDose@Gmail.com Learn more about your ad choices. Visit megaphone.fm/adchoices

What are the pediatric #ECMO scenarios that even experts struggle with? "Challenging Pediatric ECMO Scenarios" Special Collaboration w @PCICS @ECMOPedi and @PedsIntensiva 3 cases covering what our expert hosts and panelists all decided were three of the HARDEST scenarios to deal with: 1. VA ECMO for respiratory support; 2. L heart decompression on VA ECMO &; 3. "Inadequate" VV ECMO support Feat. international experts @drpetaalexander @deanna_md @ETEmrath @DrGregKelly @JFurlongDillard @ozmen001 and Dr Ariane Willems As usual, the audio content will be released as a tweet thread that you can find and comment on - here is the link Pedsintensiva.com      

We chat with Scott Weingart of Emcrit about the use of crash VA ECMO for the cardiac arrest patient. Check out the REANIMATE course here! Listen to the ED ECMO podcast on ECPR here Find us on Patreon here! Buy your merch here! Takeaway lessons

Listener Feedback SurveyAbout our Guest:  Scott Weiss, MD is an Associate Professor of Pediatrics and Pathology at Thomas Jefferson University. He serves as the Chair of the Division of Pediatric Critical Care Medicine at Nemours Children's Hospital in Wilmington, Delaware.  Dr. Weiss' research focuses on epidemiology of pediatric sepsis and mitochondrial dysfunction in sepsis-associated organ injury. He recently served as the Co-Vice Chair for the international Pediatric Surviving Sepsis Campaign and was first author on the 2020 pediatric sepsis guidelines.Learning Objectives: By the end of this podcast series, listeners should be able to: Describe the high-quality literature of fluid boluses in the management of pediatric septic shock.Recognize how healthcare settings and resource availability may affect the utility of fluid boluses in select pediatric patients with suspected septic shock.Recall the limitation of the beside assessment to determine if a patient with sepsis is suffering from “cold” or “warm” shock.Describe the role of advanced hemodynamic monitoring in determining a patient's underlying physiology in septic shock.Describe an approach to choosing initial and second-line vasoactive medications in septic shock.Describe the physiologic rationale, evidence, and limitations of targeting a higher hemoglobin threshold for patients with ongoing septic shock. Describe the physiologic rationale, evidence, and limitations of using a combination of hydrocortisone, ascorbic acid, and thiamine (HAT) in the management of septic shock. Recognize when VA-ECMO might be indicated in pediatric septic shock.How to support PedsCrit:Please rate and review on Spotify and Apple Podcasts!Donations are appreciated @PedsCrit on Venmo , you can also support us by becoming a patron on Patreon. 100% of funds go to supporting the show.Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.com for detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updates.Reference:Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, Nadel S, Schlapbach LJ, Tasker RC, Argent AC, Brierley J, Carcillo J, Carrol ED, Carroll CL, Cheifetz IM, Choong K, Cies JJ, Cruz AT, De Luca D, Deep A, Faust SN, De Oliveira CF, Hall MW, Ishimine P, Javouhey E, Joosten KFM, Joshi P, Karam O, Kneyber MCJ, Lemson J, MacLaren G, Mehta NM, Møller MH, Newth CJL, Nguyen TC, Nishisaki A, Nunnally ME, Parker MM, Paul RM, Randolph AG, Ranjit S, Romer LH, Scott HF, Tume LN, Verger JT, Williams EA, Wolf J, Wong HR, Zimmerman JJ, Kissoon N, Tissieres P. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatr Crit Care Med. 2020 Feb;21(2):e52-e106. doi: 10.1097/PCC.0000000000002198. PMID: 32032273.Support the show

Listener Feedback SurveyAbout our Guest:  Scott Weiss, MD is an Associate Professor of Pediatrics and Pathology at Thomas Jefferson University. He serves as the Chair of the Division of Pediatric Critical Care Medicine at Nemours Children's Hospital in Wilmington, Delaware.  Dr. Weiss' research focuses on epidemiology of pediatric sepsis and mitochondrial dysfunction in sepsis-associated organ injury. He recently served as the Co-Vice Chair for the international Pediatric Surviving Sepsis Campaign and was first author on the 2020 pediatric sepsis guidelines.Learning Objectives: By the end of this podcast series, listeners should be able to: Describe the high-quality literature of fluid boluses in the management of pediatric septic shock.Recognize how healthcare settings and resource availability may affect the utility of fluid boluses in select pediatric patients with suspected septic shock.Recall the limitation of the beside assessment to determine if a patient with sepsis is suffering from “cold” or “warm” shock.Describe the role of advanced hemodynamic monitoring in determining a patient's underlying physiology in septic shock.Describe an approach to choosing initial and second-line vasoactive medications in septic shock.Describe the physiologic rationale, evidence, and limitations of targeting a higher hemoglobin threshold for patients with ongoing septic shock. Describe the physiologic rationale, evidence, and limitations of using a combination of hydrocortisone, ascorbic acid, and thiamine (HAT) in the management of septic shock. Recognize when VA-ECMO might be indicated in pediatric septic shock.How to support PedsCrit:Please rate and review on Spotify and Apple Podcasts!Donations are appreciated @PedsCrit on Venmo , you can also support us by becoming a patron on Patreon. 100% of funds go to supporting the show.Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.com for detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updates.Reference:Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, Nadel S, Schlapbach LJ, Tasker RC, Argent AC, Brierley J, Carcillo J, Carrol ED, Carroll CL, Cheifetz IM, Choong K, Cies JJ, Cruz AT, De Luca D, Deep A, Faust SN, De Oliveira CF, Hall MW, Ishimine P, Javouhey E, Joosten KFM, Joshi P, Karam O, Kneyber MCJ, Lemson J, MacLaren G, Mehta NM, Møller MH, Newth CJL, Nguyen TC, Nishisaki A, Nunnally ME, Parker MM, Paul RM, Randolph AG, Ranjit S, Romer LH, Scott HF, Tume LN, Verger JT, Williams EA, Wolf J, Wong HR, Zimmerman JJ, Kissoon N, Tissieres P. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatr Crit Care Med. 2020 Feb;21(2):e52-e106. doi: 10.1097/PCC.0000000000002198. PMID: 32032273.Support the show

It's another session of CardioNerds Rounds! In these rounds, Dr. Karan Desai (Formerly FIT at University of Maryland Medical Center and currently faculty at Johns Hopkins School of Medicine) joins Dr. Dan Burkhoff (Director of Heart Failure, Hemodynamics and MCS Research at the Cardiovascular Research Foundation) to discuss mechanical circulatory support options through the lens of pressure-volume loops! Dr. Burkhoff is the author of Harvi, an interactive simulation-based application for teaching and researching many aspects of ventricular hemodynamics. Don't miss this wonderfully nerdy episode with a world-renowned expert in hemodynamics and MCS! Audio editing by CardioNerds Academy Intern, student doctor Chelsea Amo Tweneboah. This episode is supported with unrestricted funding from Zoll LifeVest. A special thank you to Mitzy Applegate and Ivan Chevere for their production skills that help make CardioNerds Rounds such an amazing success. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds. Case details are altered to protect patient health information. CardioNerds Rounds is co-chaired by Dr. Karan Desai and Dr. Natalie Stokes.  Challenging Cases - Atrial Fibrillation with Dr. Hugh Calkins CardioNerds Rounds PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Show notes - Hemodynamics and Mechanical Circulatory Support Case Synopsis: Case SynopsisWe focused on one case during these rounds. A man in his mid-50s presented to his local community hospital with 3 days of chest pain, nausea, and vomiting. He appeared ill in the emergency room with HR in the 150s, BP 90/70s and ECG demonstrating inferior ST elevations. He was taken emergently to the catheterization lab and received overlapping stents to his right coronary artery. Over the next 24 hours, he developed a new harsh systolic murmur heard throughout his precordium and progressed to cardiogenic shock. Echocardiogram demonstrated a large basal inferoseptum ventricular septal rupture. From this point, we discussed the hemodynamics of VSR and MCS options. Case Takeaways Dr. Burkhoff took us through the hemodynamics of VSR with pressure-volume loops to better understand the pathology and impact of various MCS options. Of note, there are no MCS devices specifically approved to treat acute ventricular septal rupture. In regards to the acute hemodynamic effects of a VSR (an abrupt left to right shunt), there are several aspects to note. First, the effective LV afterload is reduced; however, there is less “forward flow” as well and as a consequence, decreased left-sided cardiac output (“Qs”) and blood pressure. At the same time, flow through the pulmonary artery increases (the “Qp”). Additionally, due to the abrupt shunt flow, there is increased RV “loading” with increasing central venous pressure and pulmonary artery pressure. The hemodynamic priorities in treating patients with cardiogenic shock and VSR are to normalize blood pressure, cardiac output, and oxygen delivery, while attempting to minimize shunt flow to allow healing. However, medications and MCS are unlikely to completely normalize hemodynamics. For instance, if the patient was placed on peripheral VA ECMO, while total CO and BP may increase, flow across the VSR could also increase at high ECMO flows (e.g., by introducing more LV afterload). In patients with persistent cardiogenic shock and VSR, short-term MCS to divert flow away from the shunt can be an effective strategy. LV-to-aorta or LA-to-arterial MCS may provide the best single-device hemodynamic profiles by decreasing shunt flow, reducing pulmonary capillary wedge pressure, and improving blood pressure. Surgical and percutaneous VSD repair are the definitive treatment options. If able to stabilize patients and pursue delayed repair,

Please join author Petr Ostadal and Associate Editor Dharam Kumbhani as they discuss the article "Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock: Results of the ECMO-CS Randomized Clinical Trial." Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. We're your co-hosts. I'm Dr. Carolyn Lam, associate editor from the National Heart Center and Duke National University of Singapore. Dr. Peder Myhre: And I'm Dr. Peder Myhre, social media editor from Akershus University Hospital and University of Oslo in Norway. And today Carolyn will have such an interesting feature discussion. We are going to look into the use of ECMO to treat patients with cardiogenic shock, the results of the ECMO-CS randomized clinical trial. Isn't that interesting? Dr. Carolyn Lam: Awesome. Can't wait. But I suppose you're going to tell us about some papers in the issue first. I'm getting my coffee. Dr. Peder Myhre: Yeah, go ahead. Because first we're going to talk about a very interesting paper that relates to diabetes and the progression of coronary artery disease. So as you know, Carolyn, diabetes remains associated with an increased risk of cardiovascular morbidity and mortality. And although the absolute risk difference between patients with and without diabetes have declined over the past 20 years, we still don't know what is the diabetes associated differences in coronary plaque morphology and lipid content. Dr. Carolyn Lam: It's true. That's a very interesting question. And will you tell us more? Dr. Peder Myhre: Yeah. So the investigators in the prospect two study who enrolled patients exclusively from Denmark, Norway in Sweden who presented with biomarker positive MI and assessed both culprit lesions and untreated non-culprit lesions in these patients. And then they stratified the patients by diabetes status and examined with three vessel quantitative coronary angiography and near infrared spectroscopy and intravascular ultrasound imaging after successful percutaneous coronary intervention. Dr. Carolyn Lam: Okay, that's deep investigation. And what did they find? Dr. Peder Myhre: So diabetes was present in about 12% of patients and during a median or 3.7 year follow up, MACE occurred almost twice as free frequently in patients with versus without diabetes. And that was primarily due to an increased risk of MI related to culprit lesion stenosis and non-culprit relation related spontaneous MI. However, baseline prevalence of high-risk plaque characteristics was similar for patients with versus without diabetes, concerning culprit and the non-culprit lesions and in multi-variable models, diabetes was associated with MACE in lesions but not with prevalence of high-risk plaque characteristics. So Carolyn, the authors conclude that diabetes related plaque characteristics that might underlie the increased risk were not identified by multimodal imaging. Dr. Carolyn Lam: Oh, I just love studies like that so elegant with just a really, really intriguing results that make us ask more important questions. Love it. Thank you. Well, the next paper is also about myocardial infarction, but this time looking at the fibrotic remodeling after myocardial infarction because we know that MI induces a repair response that ultimately generates a stable fibrotic scar. And although the scar is important to prevent cardiac rupture, excessive pro-fibrotic response impairs optimal recovery because it promotes a development of non-contractual fibrotic areas. So would it be possible to regulate the expansion of cardiac fibroblast after MI through a paracrine action on the cardiac stromal cells? So the authors led by corresponding author Dr. Hulot from University of Paris performed a bioinformatic secretome analysis of cardiac stromal PW1 positive cells isolated from normal and post MI mouse hearts to identify novel secreted proteins. And they found that first cardiac PW1 positive stromal cells responded to myocardial infarction by secreting factors that promoted the proliferation and activation of resident fibroblasts and one such factor growth differentiation factor three or GDF3 was highly upregulated in the ischemic hearts and promoted a high induction of fibroblast proliferation via interaction with TGF beta receptors and activation of SMAD1/5 and SMAD2/3 signaling cascades. The upregulation of GDF3 was detected in the plasma of mice and humans following MI and high levels of plasma GDF3 in the days following MI predicted adverse outcomes measured six months later including cardiac dilation and limited recovery of contractile function in humans. Dr. Peder Myhre: Oh, that's so interesting. We already know GDF15 were very well, but now we hear about GDF3 in predicting fibrotic remodeling post myocardial infarction. So Carolyn, what are the clinical implications of these findings? Dr. Carolyn Lam: Exactly, Peder, in fact you said it. So the detection of high circulating GDF3 in plasma may serve as a novel biomarker of adverse fibrotic remodeling in heart tissue. That's one. And next the measurement of GDF3 plasma levels in the early post MI phase may allow for the identification of patients within an increased risk of severe myocardial fibrosis and heart failure and therefore could guide specific disease management. Dr. Peder Myhre: Thank you. That was an excellent summary of the paper, Carolyn. And now I'm going to look into a paper that relates to the important issue of arteriosclerosis following heart transplantation because as you know, transplant arteriosclerosis characterized by concentric and diffuse narrowing of vastly lumen is a major complication in long-term survivors of heart transplant patients. And increased lymph flow from donor heart to host lymph nodes has been reported to play a role in transplant arteriosclerosis. But how lymphangiogenesis affects this process is unknown. The authors of this paper, which comes to us from corresponding author Sue from Sejong University, transplanted vascular allografts between various combinations of mice including mice with severe combined immune deficiency and studied the lymphatic vessels within the grafted arteries. Dr. Carolyn Lam: Wow, that is really cool. Studying lymphatics and lymphangiogenesis in atherosclerosis. Interesting. What did they find, and what are the clinical implications? Dr. Peder Myhre: So Carolyn, lymphangiogenesis within allograft vessels began at the anastomotic sites and extended from preexisting lymphatic vessels in the host. Tertiary lymphatic organs were identified in transplanted arteries at the anastomotic site and lymphatic vessels expressing CCL21 were associated with these immune structures. Fibroblasts in the vascular allografts released VEGFC, which stimulated lymphangiogenesis into the grafts and inhibition of VEGFC signaling inhibited lymphangiogenesis, neointima formation and adventitial fibrosis of vascular allografts. And these studies identified VEGFC released from fibroblasts as signal stimulating lymphangiogenesis extending from the host into the vascular allografts. So, Carolyn, the authors conclude that the formation of lymphatic vessels play a key role in the immune response to vascular transplantation and inhibition of lymphangiogenesis may be a novel approach to prevent transplant atherosclerosis. Dr. Carolyn Lam: Wow, that is super interesting. Thanks, Peder. While also in this issue, there's an exchange of letters between Drs. Tanaka and Schulze regarding SGLT2 inhibitor treatment in acute decompensated heart failure. Why do we initiate it early? There's also a really nice On My Mind paper by Dr. Schiattarella on Cardiometabolic HFpEF. Is it the NASH of the heart? Dr. Peder Myhre: Oh, that's interesting. We also have some cardiology news by our own ‪Bridget Kuehn entitled “No Benefit Seen for Nighttime Dosing Over Morning Dosing for Antihypertensive Medications.” And this is a summary of the time trial, which was presented at European Society of Cardiology Congress in 2022. And finally, Carolyn, we have a Research Letter entitled “Stepwise Generation of Human-Induced Pluripotent Stem Cell Derived Cardiac Parasites to Model Coronary Microvascular Dysfunction” by Dr. Joseph Wu from Stanford University School of Medicine. Dr. Carolyn Lam: While cool, Peder. But now I'm so excited to hear about the ECMO-CS randomized trial. Let's go. Dr. Greg Hundley: Welcome listeners to this February 7th feature discussion and we have with us today Dr. Petr Ostadal from Na Homolce Hospital in Prague in the Czech Republic and our own associate editor, Dr. Dharam Kumbhani from UT Southwestern in Dallas, Texas. Welcome, gentlemen. Well, Petr, we'll start with you. Can you describe for us some of the background information that really led you to perform this study, and what was the hypothesis that you wanted to address? Dr. Petr Ostadal: According to the current guidelines from the management for the management of cariogenic shock, it should be considered administration of inotropes and vasopressor for hemodynamic stabilization, or it may be considered administration of inotropes and vasopressors and it should be considered the use of short-term mechanical circulatory support. And the aim of the ECMO-CS trial was to compare early conservative therapy with inotropes and vasopressors and immediate implementation of ECMO in patients with the rapidly deteriorating or severe cardiogenic shock. The hypothesis of the ECMO-CS trial was that immediate implantation of ECMO in patients with cardiogenic shock and critical hemodynamic condition will be associated with improved outcomes. Dr. Greg Hundley: Very nice. Can you describe for us this study population and then also what study design did you use to address your hypothesis? Dr. Petr Ostadal: We try to select patients who can really profit from the early ECMO implantation, and we define two categories of patients. First category where the patients with rapidly deteriorating cardiogenic shock corresponding to current sky stage D or E. This patient should have evidence of left ventricle pump failure as left ventricle ejection fraction below 35% or ejection fraction 35 to 55 in case of severe mitral regurgitation or aortic stenosis. And this patient also should require a repeated both of vasopressors to maintain mean arterial pressure about 50 millimeters of mercury. The second category where the patients with severe cardiogenic shock corresponding to current sky stage D and this patient should have the criterion of a hemodynamic conditions which was cardiac index less than 2.2 or systemic blood pressure below 100 millimeters of mercury in both situation with higher doses of inotropes and vasopressors. And in case of a low systolic blood pressure, also the evidence of left ventricle pump failure based on ejection fractional below 35 or ejection fraction 35 to 55 in case of severe mitral regurgitation of aortic stenosis. The second criteria for the metabolic criteria, that was the evidence of tissue hypoperfusion and this was defined as a higher lactate above three millimeters per litter or low ScvO2 below 50%. And the third criterion was exclusion of hypovolemia, and this was based on central venous pressure or pulmonary artery wedge pressure. So this was the major inclusion criteria in the ECMO trial. The study population was not defined based on theology of cardiogenic shock, but just on severity of cardiogenic shock. Dr. Greg Hundley: Very nice. And so your design, did you have a one-to-one randomization, or how did that work? And then also how many subjects did you include in this important trial? Dr. Petr Ostadal: The patients were randomized in one-to-one ratio to immediate implementation of ECMO or to early conservative therapy. But it is important to point out that in the early conservative therapy downstream use of ECMO was allowed in case of further hemodynamic worsening defined as increase of what lactate by three millimeters per litter. We enrolled 122 patients, 61 were randomized to early ECMO and 61 to early conservative strategy. Five patients were excluded due to absence of informed consent and finally 58 patients were analyzed in the early ECMO or immediate ECMO arm and 59 patients were analyzed in the early conservative arm. Dr. Greg Hundley: Sounds great Petr. And then tell us and describe your study results. Dr. Petr Ostadal: The primary endpoint was composite of death from any cause, resuscitated circulatory RS and implementation of another mechanical circulatory support including ECMO in the early conservative arm at 30 days. And there was no difference in the primary endpoint with P 0.2221 and has a ratio of 0.72 with a 95% confidence in interval 0.46 to 1.12. There was also no difference in the incidence of death from any cause. 50% in the immediate ECMO arm and 28%, 47.5% in the early conservative arm. There was no difference in the incidence of resuscitated circulatory arrest, 10.3 in the immediate ECMO arm and 13.6 in the early conservative arm. Less patient required another mechanical circulatory support in the early ECMO arm through 17.2 in comparison with 42.4% in the early conservative arm and downstream ECMO was used in 39% of patients in the early conservative arm. Dr. Greg Hundley: Very nice. So similar results both immediately and then 30 days later for both arms. And I think that last point that you make is very interesting. 39% of the individuals randomized to the conservative arm went on to receive VA-ECMO. Well, listeners next, we're going to turn to one of our associate editors and Dharam, you have many papers that you see. How do we put the results that Petr has just described really in the context of management of shock and results that have been published previously? Dr. Dharam Kumbhani: Yeah, Greg, thank you. And Petr, thank you for this important paper and again, I'm really honored to be here on behalf of Circulation on the Run. So again, want to congratulate the authors for really an important study. I think in terms of context, what is really interesting is the use of ECMO, particularly VA-ECMO for patients with shock has really skyrocketed. And it is interesting that this expansion has occurred in the absence despite, I guess high quality clinical trials, this trial certainly fills an important void. Although it is a small patient population, it is randomized, it is a largest randomized trial to date on this important population. And so I think most of the studies that have been done so far have been done using observational data sets which have sort of inherent limitations. So I certainly want to congratulate you on trying to study this very challenging population because in sort of that acute setting, it's frequently very hard to get patients randomized. So just broadly in that context, I think at the same time this study does sort of pose some important questions and sort of perhaps leads, just given the limitations of the sample size does sort of leave a few unanswered questions. So one question I have is, Petr, in addition to the 40% crossover rate is obviously important as Greg pointed out. The other thing is it appears that the use of other mechanical support during the conduct of this trial was also close to 40%, about 42%. So pretty much everybody in the conservative arm ended up with some kind of mechanical support. Now, at least in the last few years, a concept that has gained a lot of traction is a concept of a shock team where a number of providers with particular expertise from different disciplines would get together and sort of decide next steps was a shock team sort of part of the decision-making, especially for the conservative arm. Dr. Petr Ostadal: Thank you for this question. The situation is maybe a little bit more simple in the Czech Republic here, the cardiologist are responsible for the acute cardiac care, usually competent and experience not only for the diagnosis and examinations and monitoring of patients in cardiogenic shock, but also experience in insertion and management of the mechanical circulatory support. So here this attending cardiologist competent to manage this patient from different sites from the manage not only the conservative therapy but also the mechanical circulatory support therapy in these patients. So in this respect, this is more simple situation in the Czech Republic. Dr. Dharam Kumbhani: I just had a very quick question about, and I don't know if you want to include this, but Petr, I was curious, were patients with cardiac arrest, I know you mentioned sky shocks in were patients with cardiac arrest on the field or in the hospital included? Dr. Petr Ostadal: Thank you for this excellent question. And in comparison, with other trials comparing the or focusing on patients with cardiogenic shock in the ECMO-CS trials, cardiac arrest survivors were excluded. And the reason was that the brain damage, which is the major cause of death in these patients cannot be influenced by ECMO insertion. And second, in majority of patients after cardiac arrest, if there is a presence of shock, there is frequently combined shock with important peripheral component. And again, it cannot be assumed that this peripheral component can be reversed by ECMO implantation. So in the ECMO-CS trial, the cardiac arrest survivors were excluded from that enrollment. Dr. Greg Hundley: Well, thank you so much Petr. Petr, what do you think is the next study to be performed really in this area of research? Dr. Petr Ostadal: I think that we are happy because several other clinical trials focusing on the mechanical circulatory support in patients with cardiogenic shock underway. And there are other trials focused on ECMO and trials a bit focused on combination of ECMO with balloon pump and trials focused on Impella. So I think in the very close time we will be able to see the results of these current running trials1. Dr. Greg Hundley: And Dharam, do you have anything to add? Dr. Dharam Kumbhani: No, I agree completely with Petr. I think this is a very exciting field. I know there's a lot of interest in doing well conducted clinical trials in this space. And so certainly, I think the future is bright for investigation in this field. Dr. Greg Hundley: Very nice. Well, listeners, we want to thank Dr. Petr Ostadal from Prague in the Czech Republic and our own associate editor, Dr. Dharam Kumbhani from Dallas, Texas for bringing us this study highlighting that immediate implementation of VA-ECMO in patients with rapidly deteriorating, or severe cardiogenic shock did not improve clinical outcomes compared to an early conservative strategy that permitted downstream use of VA-ECMO in the case when the patient's hemodynamic status worsened. Well, on behalf of Carolyn, and Peder, and myself, we want to wish you a great week and we will catch you next week on the run. This program is copyright of the American Heart Association 2023. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more, please visit ahajournals.org.

In this episode, we discuss the utility of veno-arterial extra-corporeal membrane oxygenation (VA-ECMO) for the temporary management of biventricular failure and cardiogenic shock requiring full cardiopulmonary support. Here, we define the types of ECMO and describe the unique physiology of this mechanical circulatory support platform, as well as review the potential complications and management strategies. Most notably, we highlight indications for and contraindications to the use of VA-ECMO and review the importance of patient selection.  Lastly, we discuss de-escalation and de-cannulation strategies for patients on VA-ECMO as a bridge to recovery. Join Dr. Amit Goyal (CardioNerds Cofounder and FIT at Cleveland Clinic), Dr. Yoav Karpenshif (Series Co-chair and FIT at University of Pennsylvania), and Dr. Megan Burke (Episode FIT Lead and FIT at University of Pennsylvania) as they learn about how to care for some of our sickest patients from Dr. Ann Gage, interventional and critical care cardiologist at Centennial Heart. At the beginning of the episode, enjoy a message from the very first CardioNerds Scholar, Dr. Katie Vaughan (Chief Resident and soon Cardiology Fellow at BIDMC). Episode notes were developed by Dr. Megan Burke. Audio editing by CardioNerds Academy Intern, Hirsh Elhence. The CardioNerds Cardiac Critical Care Series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Mark Belkin, Dr. Eunice Dugan, Dr. Karan Desai, and Dr. Yoav Karpenshif. Pearls • Notes • References • Production Team CardioNerds Cardiac Critical Care PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls and Quotes - Biventricular Failure and the Use of VA-ECMO Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a form of temporary mechanical circulatory support that can do the work of both the heart and lungs. The ECMO circuit is a narcissist, i.e. cannulas are named in reference to the circuit and not the patient (“inflow” vs “outflow”). The decision to utilize ECMO should be made by a multidisciplinary shock team and patient selection is KEY! ECMO physiology rule #1: VA-ECMO increases LV afterload Patients on VA-ECMO should be monitored with a PA catheter and an arterial line in the right arm Show notes - Biventricular Failure and the Use of VA-ECMO Notes drafted by Dr. Megan Burke. 1. What is ECMO and what are the different types? Extracorporeal membrane oxygenation (ECMO) is a temporary form of mechanical life support that comes in two flavors: veno-arterial, or “VA” and veno-venous, or “VV.”  VV-ECMO supports extracorporeal gas exchange in the setting of acute respiratory failure VA-ECMO provides full circulatory support in addition to gas exchange, doing the work of both the heart and lungs.  2. What are the components and “anatomy” of the VA-ECMO circuit? The circuit is made up of the following major components: Venous (inflow) cannula Centrifugal Pump Oxygenator (also responsible for CO2 removal) Arterial (outflow) cannula The cannulas are named in reference to the ECMO circuit, not the patient. Dr. Gage suggests that we think of the ECMO circuit (and mechanical circulatory support in general) as narcissistic, i.e. flow is always in reference to the device. Gas exchange happens in the oxygenator. In the oxygenator blood flows through thin filaments that allow for diffusion of oxygen and carbon dioxide. Gas flows in the opposite direction of blood flow to maximize diffusion through the countercurrent effect. Oxygenation is determined by rate of blood flow through the oxygenator and FiO2 delivered. Carbon dioxide removal is determined by rate of countercurrent gas flow,

In this episode, we explore the concept of pulsatile flow versus non-pulsatile flow and the benefits and consequences associated. We go into a case study of a pretend VA ECMO patient that goes into cardiac arrest and what that situation might look like. Link to IntensiveBlog article: https://intensiveblog.com/cardiac-arrest-on-ecmo-does-it-still-count/ Link to Etsy Store: https://www.etsy.com/shop/NurseDose --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app

Early experience of pump-controlled retrograde trial off for weaning from veno-arterial extracorporeal membrane oxygenation (VA ECMO) in adult patients with cardiogenic shock. Pump-controlled retrograde trial off has recently been introduced as an effective method for weaning from veno-arterial extracorporeal membrane oxygenation in pediatric patients. However, studies on pump-controlled retrograde trial off in adults are still lacking. Thus, this study aimed to examine the outcomes of pump-controlled retrograde trial off for weaning from veno-arterial extracorporeal membrane oxygenation in adult patients. Tammy Sparacino, CCP is your host.

This week, join authors Maryjane Farr and Josef Stehlik as they discuss their Perspective article "Heart Xenotransplant: A Door That Is Finally Opening." Dr. Carolyn Lam: Welcome to Circulation On the Run, your weekly podcast summary and backstage pass to the Journal and its editors. We're your co-hosts. I'm Dr. Carolyn Lam, Associate Editor from the National Heart Center in Duke National University of Singapore. Dr. Greg Hundley: And I'm, Dr. Greg Hundley, Associate Editor, Director of the Pauley Heart Center, at VCU Health in Richmond, Virginia. Dr. Greg Hundley: Well, Carolyn, this week's feature, very interesting, xenotransplantation, where organs from other species are transplanted into humans. And it's a perspective piece. And so, we're going to get a weighted conversation from two different individuals that have a different perspective on the topic. Dr. Greg Hundley: But, before we get to that, how about we grab a cup of coffee, and start with some of the other articles in the issue? Would you like to go first? Dr. Carolyn Lam: Absolutely, Greg. Although man, that is a big hook you just gave us. Xenotransplantation is seriously, seriously, a hot topic. Can't wait to learn more. Dr. Carolyn Lam: But, for this first paper I want to talk about, well, we know that sequencing Mendelian arrhythmia genes in individuals without an indication for arrhythmia genetic testing, can identify carriers of pathogenic, or lightly pathogenic, variants. However, to what extent do these variants associate with clinically meaningful phenotypes, and what do we know about variants of uncertain significance? Dr. Carolyn Lam: So to answer this question, Dr. Dan Roden, from Vanderbilt University, and his colleagues, looked at 10 arrhythmia susceptibility genes, that were sequenced in more are than 20,000 participants without an indication for arrhythmia genetic testing in the eMERGE III study, which is a multi-center prospective cohort. Variants, previously designated pathogenic, or likely pathogenic, were identified in 120 individuals, or 0.6% population. And electronic health records revealed an over-representation of arrhythmia phenotypes. Some variants of uncertain significance were also found in individuals with arrhythmias and patch clamping, confirmed reclassification, to likely pathogenic. Dr. Greg Hundley: Really interesting results from this eMERGE III study, Carolyn. So what's the take home message? Dr. Carolyn Lam: As genetic testing becomes more common, the combination of electronic health records and in vitro testing, will help classify variant pathogenicity. Population screening has the potential to identify patients with undiagnosed Mendelian rhythm disorders. However, we need to consider the pros and cons of such an approach. And this is discussed in an accompanying editorial by doctors, Walsh, and Bezzina, and Wilde, from Amsterdam University Medical Center. Dr. Greg Hundley: Very nice, Carolyn. Well, my first paper comes to us from Professor Karl Heusler from the University of Wurzburg. Carolyn, this study was a pre-specified analysis of the anticoagulation using the direct factor Xa inhibitor, apixaban, during atrial fibrillation catheter ablation comparison to vitamin K antagonist therapy, or the AXAFA–AFNET 5 trial. And it randomized 674 patients with atrial fibrillation, in a one-to-one fashion, to uninterrupted apixaban, or vitamin K antagonist therapy, prior to first time ablation, with a goal to assess the prevalence of magnetic resonance imaging detected ischemic brain lesions, and their association with cognitive function, three months after first time ablation, using the continuous oral anticoagulation in patients with paroxysmal atrial fibrillation. Dr. Carolyn Lam: Huh. Nice. So what did they find, Greg? Dr. Greg Hundley: Right, Carolyn. They found that brain MRI detected chronic white matter damage, as well as, acute ischemic lesions, were frequently found after first time ablation for paroxysmal atrial fibrillation, using uninterrupted oral anticoagulation. Including, 27.2% of those receiving apixaban, and 24.8% of those receiving the vitamin K antagonists. So Carolyn, no difference there. MRI detected acute ischemic brain lesions were not associated with cognitive function at three months after ablation. And then, Carolyn, the lower Montreal Cognitive Assessment scores, both before and after ablation, were associated with older age only, highlighting the safety of atrial fibrillation ablation on uninterrupted oral anticoagulation. Dr. Carolyn Lam: Oh, thank you, Greg. Well, my next paper talks about basilar artery occlusion, which we know is a devastating condition without definitive evidence to guide treatment. Now, while we do know that faster treatment times with endovascular therapy is associated with better outcomes in the anterior circulation of the brain. What about this relationship for basilar artery occlusion? See? So that's the question that this paper sought to answer, and it's led by Dr. Smith from University of Calgary in Alberta, Canada, and colleagues. They used individual level patient data from the Get With The Guidelines-Stroke nationwide US registry, prospectively collected from January 2015 to December 2019, and identified 3015 patients with basilar artery occlusion treated with endovascular therapy. Dr. Greg Hundley: Ah, Carolyn. And so what did they find here? Dr. Carolyn Lam: So, here are the results. Treatment of basilar artery occlusion with endovascular therapy, within six hours of last known well, is associated with better outcomes, compared to treatment after six hours. Including, lower odds of mortality and higher odds of reperfusion, independence, and discharge home.   Dr. Carolyn Lam: There was a non-linear association between, faster treatment with endovascular therapy for basilar artery occlusion, and better outcomes, with the greatest per hour improvement in outcomes seen within six hours of the last known well. In summary, results indicate that, faster treatment with endovascular therapy may improve outcomes in basilar artery occlusion. Efforts should therefore be made, to optimize workflow, including pre-hospital, inner-hospital, intra-hospital processes, to achieve rapid treatment with endovascular therapy in acute stroke with basilar artery occlusion. Dr. Greg Hundley: Very nice, Carolyn. Well, my next paper comes to us from the world of pre-clinical science. And Carolyn, as we know, pulmonary hypertension can be caused by chronic hypoxia, leading to hyperproliferation of pulmonary arterial smooth muscle cells, and apoptosis-resistant pulmonary microvascular endothelial cells. And then, upon re-exposure to normoxia chronic hypoxia induced pulmonary hypertension in mice, is reversible. So in this study, the authors led by Dr. Christine Veith, from Justus Liebig University in Giessen, aimed to identify novel candidate genes involved in pulmonary vascular remodeling, specifically, in the pulmonary vasculature. Dr. Carolyn Lam: Ah, a very interesting and important topic. So what, or how, did they do this, Greg? Dr. Greg Hundley: Right, Carolyn. So following a microarray analysis, the investigative team assessed the role of secreted protein, acidic, and rich in cysteine, or SPARC, using lung tissue from idiopathic pulmonary arterial hypertension patients, as well as from chronic hypoxic mice. In this experiment, the mice were exposed to normoxia, chronic hypoxia, or chronic hypoxia with subsequent re-exposure to normoxia, at different time points Dr. Carolyn Lam: Okay, so what were the results? Dr. Greg Hundley: Okay, Carolyn, the big drum roll. So the microarray analysis of the pulmonary vascular compartment, after laser micro dissection, identified SPARC as one of the genes down-regulated at all reoxygenation time points that were investigated. Intriguingly, SPARC was vice versa, up-regulated in lungs, during development of hypoxia induced pulmonary hypertension in mice, as well as in idiopathic pulmonary hypertension. Although, SPARC plasma levels were not elevated in pulmonary hypertension. Dr. Greg Hundley: Transforming growth factor, or TGF-beta 1, or hypoxia induced factor to a signaling pathways, induced SPARC expression in human pulmonary arterial smooth muscle cells. In loss of function studies, SPARC silencing enhanced apoptosis, and reduced proliferation. And so Carolyn, in conclusion, these authors provide evidence for the involvement of SPARC in the pathogenesis of human pulmonary hypertension, and chronic hypoxia induced pulmonary hypertension in mice, most probably, by affecting vascular cell function. Dr. Carolyn Lam: Wow. Thanks for that, Greg. Well, let me give a tour of what else there is in today's issue. There's a letter from Dr. Ng on could cardiologists support, improve, the cardiovascular risk of GnRH agonists. There's a Case Series, by Dr. Blumer, on [entitled] Hemophagocytic Lymphohistiocytosis Associated with Endocarditis: A Case Years in the Making.” There's a Perspective piece by Dr. Hillis on [entitled], Is Asymptomatic Severe Aortic Stenosis Still a Waiting Game?” Dr. Greg Hundley: And Carolyn, from the mailbag, we have a Research Letter, from Professor McFadyen entitled, Inherited Thrombophilias are Associated with a Higher Risk of COVID-19 Associated Venous Thromboembolism, a Prospective Population Based Cohort Study. Dr. Greg Hundley: Well, now onto that perspective and discussion from two viewpoints on xenotransplantation. Dr. Carolyn Lam: Xenotransplantation. Cool. Let's go. Dr. Greg Hundley: Well welcome everyone, to this feature discussion. And today, we're taking a little bit of a, different tact, and we are going to discuss a perspective piece. As you know, usually we will discuss an original article, but we have a perspective. And we have with us, the two authors that created this perspective. Dr. Jane Farr from UT Southwestern, in Dallas, Texas, and Dr. Josef Stehlik, from University of Utah. Welcome to you both. Dr. Greg Hundley: And listeners, our discussion today is on cardiac xenotransplantation, taking a heart from another species and implanting it in a human subject. So Josef, we'll start with you. Could you tell us a little bit about the history of cardiac xenotransplantation, and what are some of the obstacles that have to be overcome, if we're considering performing this procedure in a patient? Dr. Josef Stehlik: Greg, thank you for that question. The concept of xenotransplantation has been around for a long time, with the biggest attraction being, a large and ideally safe source of organs for our patients. As far as cardiac xenotransplantation, the first human art xenotransplant was done in 1964, in a man with terminal heart failure, who received a chimpanzee heart at the University of Mississippi. Dr. Josef Stehlik: The patient didn't survive the surgery, and the way it was done back then, brought up a number of ethical issues, and other issues as well. And so, the next xenotransplant was not done until 1984, in a neonate with hypoplastic left heart syndrome, at Loma Linda University. You might have heard the term, Baby Fae, before. And this infant survived about 20 days, and so we couldn't consider it, long term success. However, these two first xenotransplant brought up some important issues that would be studied for years to come. And I think, that the biggest lesson was that, the intra-species immune barriers were a formidable obstacle, and that really, new technologies, and then new medications, would probably have to come into the clinical arena, before we could do it again. Dr. Greg Hundley: Very nice. Well listeners, now we're going to turn to our second author on this particular paper. And Jane, can you describe some of the circumstances pertaining to this most recent cardiac xenotransplantation? What transpired, and what's been the outcome with that individual? Dr. Maryjane Farr: Thanks, Greg. And thanks for having us here on this program today. So the circumstance around this particular groundbreaking transplant was such that, there was a critically ill patient. This man who was in cardiogenic shock. Both sides of his heart were not working. He was on life saving temporary mechanical support with VA ECMO. And he unfortunately, despite his cardiogenic shock, he was not eligible for standard allotransplantation. Dr. Maryjane Farr: Part of that story was really about, not meeting standard criteria for organ transplantation, probably just about anywhere, in terms of a long history of, maybe not taking his meds, or taking care of himself. And there's, certain criteria that he didn't fit into. And he actually had been assessed, as I understand it, by a number of programs, before the University of Maryland approached him with this possibility. Dr. Maryjane Farr: One other option that could have been taken, was a mechanical circulatory assist device. But as I say, both sides of his heart were not working, and so really, total cardiac replacement was really his only option. Dr. Greg Hundley: And so Jane, do we know anything about what happened? How did the surgical procedure go? Do we know anything about the outcomes? Dr. Maryjane Farr: This is of course, patient privacy. So what we know is really, what's in the public arena. And it's actually, there's been a lot of transparency, which has been terrific, by the patient, and the family, and the doctors, because this is such groundbreaking information. But this patient was truly critically ill. There was some paperwork done to try to get FDA approval for emergency experimental surgery, with xenotransplantation. And of course, all the research at University of Maryland, and in many other centers, nationally, and internationally, have been done over the years. And so finally, there was an approval to do this, and it was basically a scheduled surgery. Dr. Maryjane Farr: And as I understand it, it went just like any other transplant surgery. There was obviously, a procurement team for the genetically modified pig. There was cold storage of the device. Transport, at least as far as to the next operating room, or however it went. And then, standard implantation, and release of cross clamp, and perfusion. And at least by what you can read about, the heart started to work almost immediately. And then of course, I think that's the easy part. It was really all the intense and multi blockade immunosuppressive therapy, which is really, the challenge of this type of therapy. Dr. Greg Hundley: Very nice. Well, Josef, Jane's alluded to this a little bit, but who would be a candidate for this therapeutic, this form of therapy? Dr. Josef Stehlik: Greg, so that's an excellent question. And I would like to address it. Before I do that, maybe we should also mention, very briefly, a little bit of the science behind the genetically engineered pig, that Jane mentioned. Dr. Josef Stehlik: There were three main things that have been done, and what enabled that is gene editing. And here, I would like to actually mention Dr. Mario Capecchi, who received a Nobel Prize in 2007, for his groundbreaking work at the University of Utah, by describing mouse gene knockout. That has been part of what has been used for engineering, of course, in newer approaches, like CRISPR. Dr. Josef Stehlik: Some of the things that have been done is that, the highly antigenic carbohydrates that pigs have on their cell surface, have been edited out. There have been genes that have been edited out and in, connected to coagulation and compliment, to prevent clotting and bleeding in the organ and the recipient after transplant. Dr. Josef Stehlik: And of course, one thing that it's very relevant also to our COVID pandemic, there has always, with xenotransplantation, been a question. Could there be trans-species infection? And pigs do have endogenous retroviruses that are parts of their genome, and those have been edited out as well. And so in this way, some of the previous obstacles have been removed. Dr. Josef Stehlik: So to your question, who might be a candidate? And I absolutely agree with Jane, that in the first step, it should really be patients who are not candidates for other clinically approved approaches, like allotransplantation from human donors, or mechanical assist, that can be durable, and those are the characteristics that the patient met. And I think, the next patients that will come now, hopefully, will probably be in the same category. Dr. Josef Stehlik: Now, I believe, and again, this is a little bit of a speculation, that the next step will be patients who are not eligible for transplant, but who may be eligible for durable ventricular assist devices. And our goal will be to show, that survival and quality of life after xenotransplantation can approach survival and quality of life, on LVADs. And of course, LVADs are evolving, as well. Dr. Josef Stehlik: And then, to some degree, it might be the choice of the recommendation of the team, of the multidisciplinary team. What is the best match for the patient? And to some degree, I think patient preference, to really share decision making in patient preference. Dr. Josef Stehlik: And in the next step, I believe, that's what we are hoping for, that at some point, we will achieve is that, xenotransplant will rival the outcomes of human allotransplantation. And so, that will be probably, the next group of patients. How long this will take is to be seen. But I think, that it addresses your question, who could be the candidates for xenotransplant in the future? Dr. Greg Hundley: Very good. And Jane, Josef was touching on a topic here. How do the anti-rejection treatments differ in xenotransplantation, as compared to allograft transplantation? Dr. Maryjane Farr: And so, that's been the thing for all these decades. And so, the first thing is, genetically engineered xenotransplant organs, that can mitigate some of the anticipated xenoantigenic responses. Dr. Maryjane Farr: So first, these carbohydrates that we do not see, so they are foreign to us, so there can be acute fulminant rejection. So that's, one step, and the gene knockout can take care of that mostly, but not completely. And then there's humeral rejection, and then, cellular rejection. Dr. Maryjane Farr: The cocktail that gets put together for a xenotransplant includes, some of the things that we standardly use, like steroids, ATGAM, or antithymocyte globulin, which is a generalized T and B-cell depleting therapy. What's nuanced, and there's also some role for anti-CD20 B-cell therapy, but what it is nuanced in xenotransplant is anti-CD40 monoclonal antibody therapy. And that was specifically developed, and then studied in heterotopics, or non-human primate pig transplant. Because what turns out is that, the robust T-cell responses, by what's called the indirect pathway, really requires significant costimulatory blockade, where anti-CD40 therapy has been critically important, and well studied by these scientists and others at the University of Maryland, and elsewhere. Dr. Maryjane Farr: And as I understand it, anti-CD40 was really, is the basis, the backbone, of this therapy. And then there's one last thing. And that is, temsirolimus, which is a pro drug of proliferation signal inhibitor therapy, that we standardly use in transplant. That's utilized to arrest the further growth of the xenotransplant. So that sounds like it's the cocktail, and there's some published reports, on these scientists using just such cocktail in their non-human primate transplant models. Dr. Greg Hundley: Well, listeners, we've heard a really interesting story here. But now, let's ask these experts, first, Josef, and then, Jane. Josef, moving forward, what are the concerns that you really see in this aspect of research? Dr. Josef Stehlik: Greg, I think, one of the issues that will have to be addressed, are ethical considerations. And we've seen, that after the news of xenotransplant was made public, there has been a lot of discussion among public about ethics of xenotransplant. I think it will be important to really proactively address that. Dr. Josef Stehlik: One aspect from the past is, we knew that primate xenotransplant have not been embraced by the public, just because of the closeness of primates to humans. I think, some of that will be mitigated, now that we are using pigs. But of course, there are many who feel strongly about humane treatment of animals. And so I think, regulation will need to be established that will address that, and that will make both the professionals and the wary public, comfortable with this approach. Dr. Josef Stehlik: And another thing that will need to be addressed, and Jane talked about it a little bit is, what parts of care for xenotransplant will be different from human allotransplant. Right? So how do the assessment of the biopsies differ? Right? We'll probably have a new grading scheme looking at xenotransplant. Should the antimicrobial prophylaxis be different? So we do prevent the possibility of trans-species infections we haven't seen before, et cetera. So there would be a lot of work for the transplant teams to do, as well. Dr. Greg Hundley: And, Jane. Dr. Maryjane Farr: Yes. One thing that's hard, this is amazing science, and this is a huge opportunity to transplant more patients, many of whom die on the wait list every year. But what really needs to be understood also, as we move into this area, and this is where us, as clinicians, get involved in some of these conversations in particular, is that this patient actually wasn't eligible for transplant. And these are very, very difficult decisions that centers are tasked to make. Dr. Maryjane Farr: It can get really tricky, and there's lots of patients who say, "Okay, I'm not a transplant candidate.", because of this or that, or the other reason. And there's, some reasons that are more important than others. They'll say, "Transplant me anyway. Give me a heart that you might turn down. Just give me a chance." And we don't do that. And insurance companies don't pay for that. And we have to actually find a way to be rational in our approach. Dr. Maryjane Farr: But truly, acknowledging that, if we had more resources, we could probably expand transplant even with the organs that we do have, because we turn down about, probably about 40% of organs, and maybe even more, every year, because we want to match the best organs. So it's really important that xenotransplant, in centers that can do this, demonstrate that this therapy works, and it provides a good quality and quantity of life, for at least, to be reasonable. And once you get there, then you can start to talk about, whether you need to think about allocation, and all that. So you can see how the conversation's going to go on for the next 10 years, about how this fits in. Dr. Greg Hundley: You both alluded to the fact, we need more research. And so, incrementally, for maybe each of you in 30 seconds. What do you see as the next research study that needs to be performed in this space? First, Josef, and then again, Jane. Dr. Josef Stehlik: That's a tough question, but I'll try to address it. I think, it will be a little bit in parallel to the first human allotransplant. Now that we've figured out the procedure and the organ that we can use, I think, it will be research focused on the care of the transplant recipient. And the task, number one, will be to identify immunosuppression that will be safe and effective, to protect this heart from dysfunction for many years after transplant. Dr. Greg Hundley: And Jane? Dr. Maryjane Farr: Yeah. You need to do a case series. The handful of centers in this country, and maybe the world, but I only know about this country, that have been studying and working towards this day, should take the lead. University of Maryland has taken the lead, and there are other centers who have been thinking hard about this, and preparing for this time for a long time, and they should lead the way, and try to do this with all the expertise that they've already built. And then as time passes, we can see what their outcomes are, and then we can start to think about, should there be a randomized controlled clinical trial? What should we compare it against? Who should be offered the opportunity? But at first, we need to find that there's safety and efficacy in the patients that are selected, and also, they themselves select, to go through this operation and therapy. Dr. Greg Hundley: Well listeners, we want to thank Dr. Jane Farr and Dr. Josef Stehlik, for providing their perspective on a recent procedure, involving the xenotransplantation of a genetically engineered porcine heart, into a human subject with advanced biventricular heart failure, that was not well suited for human heart allograft transplantation. Dr. Greg Hundley: Well, on behalf of Carolyn and myself, we want to wish you a great week, and we will catch you next week On the Run. Dr. Greg Hundley: This program is copyright of the American Heart Association, 2022. The opinions expressed by speakers in this podcast are their own, and not necessarily, those of the editors, or of the American Heart Association. For more, please visit ahajournals.org.

In this episode, hosts Jayneel Limbachia, Dakoda Herman, and Jake Domm discuss ECMO and mature ECMO programs, appraise the ARREST trial and consider the future of cardiac arrest care with expert guest Dr. James Gould.  References: Yannopoulos D, Bartos J, Raveendran G, Walser E, Connett J, Murray TA, Collins G, Zhang L, Kalra R, Kosmopoulos M, John R, Shaffer A, Frascone RJ, Wesley K, Conterato M, Biros M, Tolar J, Aufderheide TP. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial. Lancet. 2020 Dec 5;396(10265):1807-1816. doi: 10.1016/S0140-6736(20)32338-2. Epub 2020 Nov 13. PMID: 33197396; PMCID: PMC7856571. Lamhaut L, Hutin A, Puymirat E, Jouan J, Raphalen JH, Jouffroy R, Jaffry M, Dagron C, An K, Dumas F, Marijon E, Bougouin W, Tourtier JP, Baud F, Jouven X, Danchin N, Spaulding C, Carli P. A Pre-Hospital Extracorporeal Cardio Pulmonary Resuscitation (ECPR) strategy for treatment of refractory out hospital cardiac arrest: An observational study and propensity analysis. Resuscitation. 2017 Aug;117:109-117. doi: 10.1016/j.resuscitation.2017.04.014. Epub 2017 Apr 14. PMID: 28414164. Matsuoka Y, Goto R, Atsumi T, Morimura N, Nagao K, Tahara Y, Asai Y, Yokota H, Ariyoshi K, Yamamoto Y, Sakamoto T; SAVE-J Study Group. Cost-effectiveness of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A multi-centre prospective cohort study. Resuscitation. 2020 Dec;157:32-38. doi: 10.1016/j.resuscitation.2020.10.009. Epub 2020 Oct 17. PMID: 33080369. Grunau B, Shemie SD, Wilson LC, Dainty KN, Nagpal D, Hornby L, Lamarche Y, van Diepen S, Kanji HD, Gould J, Saczkowski R, Brooks SC. Current Use, Capacity, and Perceived Barriers to the Use of Extracorporeal Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest in Canada. CJC Open. 2020 Nov 13;3(3):327-336. doi: 10.1016/j.cjco.2020.11.005. PMID: 33778449; PMCID: PMC7985000. Sun T, Guy A, Sidhu A, Finlayson G, Grunau B, Ding L, Harle S, Dewar L, Cook R, Kanji HD. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for emergency cardiac support. J Crit Care. 2018 Apr;44:31-38. doi: 10.1016/j.jcrc.2017.10.011. Epub 2017 Oct 12. PMID: 29040883. Hsu CH, Meurer WJ, Domeier R, Fowler J, Whitmore SP, Bassin BS, Gunnerson KJ, Haft JW, Lynch WR, Nallamothu BK, Havey RA, Kidwell KM, Stacey WC, Silbergleit R, Bartlett RH, Neumar RW. Extracorporeal Cardiopulmonary Resuscitation for Refractory Out-of-Hospital Cardiac Arrest (EROCA): Results of a Randomized Feasibility Trial of Expedited Out-of-Hospital Transport. Ann Emerg Med. 2021 Jul;78(1):92-101. doi: 10.1016/j.annemergmed.2020.11.011. Epub 2021 Feb 1. PMID: 33541748; PMCID: PMC8238799.

In this episode,  Dr. Gillian Beauchamp sits down with Dr. Susanna Byram to discuss the use of VV and VA ECMO and other Mechanical Circulatory Support Devices in poisoned patients. 

CardioNerds (Amit Goyal and Daniel Ambinder) join Dr. Loie Farina (Northwestern University CardioNerds Ambassador), Dr. Josh Cheema, and Dr. Graham Peigh from Northwestern University for drinks along the shores of Lake Michigan at North Avenue Beach. They discuss a case of a 52-year-old woman with limited cutaneous systemic sclerosis who presents with progressive symptoms of heart failure and is found to have a severe, non-ischemic cardiomyopathy. The etiology of her cardiomyopathy is not clear until her untimely death. She is ultimately diagnosed with cardiac AL amyloidosis with isolated vascular involvement a real occam's razor or hickam's dictum conundrum. We discuss the work-up and management of her condition including a detailed discussion of the differential diagnosis, the underlying features of systemic sclerosis with cardiac involvement as well as cardiac amyloidosis, the role of a shock team in managing cardiogenic shock, and how to identify those with advanced or stage D heart failure. Advanced heart failure expert Dr. Yasmin Raza (Northwestern University) provides the ECPR segment.  Episode introduction by CardioNerds Clinical Trialist Dr. Liane Arcinas. Claim free CME just for enjoying this episode!  Disclosures: NoneJump to: Pearls - Notes - References CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Case Summary - Occam's Razor or Hickam's Dictum? This is a case of a 52-year-old woman with limited cutaneous systemic sclerosis who presented with progressive dyspnea on exertion and weight loss over the course of 1 year. Her initial work-up was notable for abnormal PFTs and finding of interstitial pneumonia on high-resolution CT, an ECG with frequent PVCs and normal voltage, a transthoracic echocardiogram with a mildly reduced ejection fraction of 40%, and a right/left heart catheterization with normal coronary arteries, filling pressures, and cardiac output. Scleroderma-related cardiac involvement is suspected. She is placed on GDMT, but her condition worsens over the next several months, and repeat echocardiogram shows severely reduced biventricular function, reduced LV global longitudinal strain (GLS) with apical preservation of strain, severely reduced mitral annular tissue Doppler velocities, and a normal left ventricular wall thickness. Scleroderma-related cardiac involvement remains highest on the differential, but because of some findings on the echo that are concerning for cardiac amyloidosis, an endomyocardial biopsy was obtained. It showed vascular amyloid deposition without interstitial involvement. The diagnosis of cardiac amyloid was discussed but deemed unlikely due to lack of interstitial involvement. However, a serologic work-up soon revealed a monoclonal serum lambda light chain and a follow-up bone marrow biopsy showed 20% plasma cells. She was discharged with very near-term follow-up in oncology clinic with a presumptive diagnosis of AL amyloidosis, but she unfortunately returned in shock and suffered a cardiac arrest. She initially survived and underwent emergent veno-arterial extracorporeal membrane oxygenation (VA ECMO) cannulation with subsequent left ventricular assist device placement (LVAD). However, she passed away due to post-operative hemorrhage. Autopsy was consistent with a final diagnosis of cardiac AL amyloidosis with isolated vascular involvement.  Case Media - Occam's Razor or Hickam's Dictum? EKG CXR TTE Pathology CMR Episode Teaching -Occam's Razor or Hickam's Dictum? Pearls Scleroderma causes repeated focal ischemia-reperfusion injuries which result in patchy myocardial fibrosis. Cardiac involvement in scleroderma is frequent but often not clinically evident; when symptomatic, it is associated with a poor prognosis.

Approximately 350,000 adults per year in the US experienced out-of-hospital cardiac arrest (OHCA). Only about 10% of such patients survive their initial hospitalization. The key drivers of successful resuscitation from OHCA are bystander cardiopulmonary resuscitation (CPR) and public use of an automated external defibrillator (AED). Survival rates from OHCA vary dramatically between US regions. For instance, the extracorporeal CPR (eCPR) program at the University of Minnesota has over a 40% survival rate in patients with OHCA and refractory ventricular fibrillation (VF) based on data published in the ARREST trial. In this episode, we are joined by experts from the University of Minnesota, including Dr. Jason Bartos (Interventional and Critical Care Faculty) and Dr. Julie Power (Chief Fellow at University of Minnesota and CardioNerds Academy Fellow), along with Dr. Yoav Karpenshif (Co-Chair Critical Care Series, University of Pennsylvania) and CardioNerds Co-Founders (Amit Goyal and Dan Ambinder) to discuss cardiac arrest, E-CPR, & post-arrest care. This includes targeted temperature management, coronary angiography and revascularization, as well as the growing field of eCPR and VA ECMO.  Episode introduction by CardioNerds Clinical Trialist Dr. Jason Feinman. Audio editing by CardioNerds Academy Intern, Shivani Reddy. The CardioNerds Cardiac Critical Care Series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Mark Belkin, Dr. Eunice Dugan, Dr. Karan Desai, and Dr. Yoav Karpenshif. Claim free CME for enjoying this episode! Disclosures: None Pearls • Notes • References • Guest Profiles • Production Team CardioNerds Cardiac Critical Care PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Abbreviations - Cardiac Arrest, E-CPR, & Post-Arrest Care eCPR- extracorporeal cardiopulmonary resuscitation VA ECMO- veno-arterial extracorporeal membrane oxygenation VT/VF- ventricular tachycardia/ventricular fibrillation ACLS- advanced cardiovascular life support ROSC- return of spontaneous circulation- OHCA- out-of-hospital cardiac arrest IHCA- in-hospital cardiac arrest TTM- targeted temperature management Pearls and Quotes - Cardiac Arrest, E-CPR, & Post-Arrest Care The ARREST trial showed early VA ECMO-facilitated resuscitation for patients with OHCA and refractory VF significantly improved survival to hospital discharge when compared to standard ACLS treatment.Coronary artery disease is common in the setting of cardiac arrest, with up to 96% of patients with STEMI on post resuscitation EKG and up to 85% of refractory out-of-hospital VT/VF arrests.Guidelines recommend emergent coronary angiography for patients with ST-segment elevation on the post-ROSC ECG.The role of timing of revascularization after ROSC in patients without STEMI or shock is unknown.The role of coronary angiography in cardiac arrest with nonshockable rhythms is also unclear.The current AHA guidelines recommend initiation of targeted temperature management between 32°C and 36°C for at least 24 hours for all patients who do not follow commands after ROSC in both OHCA and IHCA. Show notes - Cardiac Arrest, E-CPR, & Post-Arrest Care 1. What are early post arrest management considerations? The key drivers of successful resuscitations from OHCA: CPR and public use of AEDs in the field. After initial stabilization, care of the critically ill post-arrest patient hinges on hemodynamic support, mechanical ventilation, temperature management, attending to adverse sequelae of arrest, and diagnosis and treatment of underlying causes of arrest. Coronary artery disease is common in the setting of VT/VF cardiac arrest,

CardioNerds (Amit Goyal and Daniel Ambinder) join Dr. Jaya Kanduri, Dr. Dan Lu, and Dr. Joe Wang from Weill Cornell Cardiology for Levain cookies in Central Park. The ECPR is provided by Dr. Harsimran Singh (Cardiology Program Director and Interventional Cardiologist with expertise in ACHD). We discuss a case of a 24-year-old female with a history of unicuspid aortic valve with associated aortopathy status post mechanical aortic valve replacement and Bentall procedure at age 16 presents with acute onset substernal chest pain and shortness of breath. She was found to have mechanical aortic valve obstruction and severe aortic regurgitation resulting in cardiogenic shock. Unfortunately, the shock quickly progressed to refractory cardiac arrest requiring mechanical support with VA-ECMO before valve debridement was performed in the operating room. The differential for mechanical prosthetic valve stenosis includes pannus, thrombus, or vegetation. She was eventually found to have thrombus obstructing the outflow tract and holding the mechanical leaflets open leading to torrential regurgitation. She underwent successful surgical debridement. We discuss unicuspid aortic valve and associated aortopathy, surgical considerations regarding AVR, diagnosis and management of prosthetic valve dysfunction, approach to cardiogenic shock and considerations around activating and managing VA-ECMO. With this episode, the CardioNerds family warmly welcomes Weill Cornell Cardiology to the CardioNerds Healy Honor Roll. The CardioNerds Healy Honor Roll programs support and foster the the CardioNerds spirit and mission of democratizing cardiovascular education. Healy Honor Roll programs nominate fellows from their program who are highly motivated and are passionate about medical education. The Weill Cornell fellowship program director, Dr. Harsimran Singh has nominated Dr. Jaya Kanduri for this position. Claim free CME just for enjoying this episode!  Disclosures: NoneJump to: Pearls - Notes - References CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Case Media ECGCXREchoRHC PSL AP3 Color LHC - LCA LHC - LCA RCA Aortogram TEE TEE 2 Episode Teaching Pearls - Mechanical Valve Thrombosis (1) Unicuspid aortic valves present with aortic stenosis earlier in life. There can be concurrent aortic regurgitation and, like bicuspid aortic valves, unicuspids can be associated with aortopathy as well as other congenital anomalies. (2) Prosthetic valve stenosis is assessed with different echocardiographic parameters than what we use for native valves. The differential for mechanical valve stenosis includes pannus, thrombus, or vegetation. Patient prosthesis mismatch may also lead to elevated gradients. (3) VA-ECMO provides robust flow in the setting of cardiogenic shock as well as gas exchange. While this flow may improve end-organ perfusion, it also increases left ventricular afterload, thereby potentially worsening LV ischemia and impeding LV recovery. Elevated afterload may also decrease innate contractility and prevent aortic valve leaflets from opening. Therefore, if a patient with a mechanical valve is on VA-ECMO, ensuring valve opening to prevent valve (or ventricular) thrombosis is paramount. (4) Venting is sometimes necessary to decrease the left ventricular end diastolic pressure from the high afterload imposed by VA-ECMO. A microaxial temporary LVAD (example – Impella device) directly unloads the left ventricle, but cannot be used in the setting of a mechanical aortic valve. TandemHeart is also a consideration (inflow cannula placed across the interatrial septum in the left atrium) to unload the LV, but does not improve flow across the aortic valve so can lead to thrombus if a...

Theme: Pulmonary Embolism.Participants: Dr Jimmy Chien (senior respiratory physician), Dr Kevin Lai (senior emergency physician), Dr Arwen Morath (emergency physician), Dr Pramod Chandru, Harry Hong, Kit Rowe, and Caroline Tyers.   Discussion:The Use of PE Response Teams (PERT) in the Care of High-Risk Pulmonary Embolism   This is a discussion with senior respiratory physician Dr Jimmy Chien who helped to develop the PERT system at Westmead Hospital.  Within this segment, “Venoarterial Extracorporeal Membrane Oxygenation in Massive Pulmonary Embolism-Related Cardiac Arrest: A Systematic Review” by Scott et al, is also discussed.  The graphs included in this study are examined closely, so we would recommend reviewing this article while listening to this segment.   Summary: The first place to establish a PE response team was in Massachusetts.   It took 2 years to form the PE response team at Westmead Hospital (involving a respiratory physician, an ED physician, an intensivist, an interventional radiologist, a vascular surgeon, and a haematologist).  We call a PERT call for patients who have high or intermediate-risk PE.   High-risk PE entails a patient with haemodynamic instability (in whom mortality lies between 25-50%).  Within the intermediate group, there are two subdivisions: intermediate high-risk (with radiological signs of RV strain with an increase in troponin or pro-BNP) and intermediate low-risk (with either evidence of RV strain OR a troponin rise, or a PE-severity index score class III-IV).   When looking within the high-risk PE group, the age group with the worst outcomes (both in PE and with thrombolysis) was those aged > 65 years.   The study exploring VA-ECMO in patients with high-risk PE and cardiac arrest (detailed above) also demonstrated that survival rates below the age of 65 years were relatively high, while those over the age of 65 years had a significantly higher mortality rate.  The Westmead PERT team has data on 52 patients thus far; of whom 21% were high-risk, 58% were intermediate high-risk and 21% were intermediate low-risk.  The most recent analysis of mortality for the Westmead PERT team high-risk PE patients demonstrated a mortality rate of only 10% (compared with the previously stated 25-50%).   Take-Home Points: In addition, the length of stay for these patients managed by the PERT team has been reduced from 13 days pre-PERT to around 8.5 days.   The PERT team facilitates high-level nuanced conversations dependent on the clinical judgment, experience, and knowledge of the specialists involved.  The development of this PERT team has resulted in improved outcomes for PE patients, and more streamlined care for these patients while in the emergency department and on the ward.   References:  Scott, J., Gordon, M., Vender, R., Pettigrew, S., Desai, P., Marchetti, N., Mamary, A., Panaro, J., Cohen, G., Bashir, R., Lakhter, V., Roth, S., Zhao, H., Toyoda, Y., Criner, G., Moores, L. and Rali, P., 2021. Venoarterial Extracorporeal Membrane Oxygenation in Massive Pulmonary Embolism-Related Cardiac Arrest: A Systematic Review*. Critical Care Medicine, 49(5), pp.760-769.  Piazza, G., Hohlfelder, B., Jaff, M., Ouriel, K., Engelhardt, T., Sterling, K., Jones, N., Gurley, J., Bhatheja, R., Kennedy, R., Goswami, N., Natarajan, K., Rundback, J., Sadiq, I., Liu, S., Bhalla, N., Raja, M., Weinstock, B., Cynamon, J., Elmasri, F., Garcia, M., Kumar, M., Ayerdi, J., Soukas, P., Kuo, W., Liu, P. and Goldhaber, S., 2015. A Prospective, Single-Arm, Multicenter Trial of Ultrasound-Facilitated, Catheter-Directed, Low-Dose Fibrinolysis for Acute Massive and Submassive Pulmonary Embolism. JACC: Cardiovascular Interventions, 8(10), pp.1382-1392.  Herzallah, K., Saleh, Y., Elkinany, S., Abdelkarim, O., Abdelnabi, M. and Almaghraby, A., 2020. Saddle pulmonary embolism successfully managed by thrombus aspiration followed by ultrasound-enhanced catheter-directed thrombolysis. Journal of the American College of Cardiology, 75(11), p.2445.  Credits:This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney and, Deepa Dasgupta. Music/Sound Effects Be Myself by Nettson | https://soundcloud.com/nettson, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US. Chile by ASHUTOSH | https://soundcloud.com/grandakt, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US. Happier by LiQWYD | https://www.liqwydmusic.com, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US. Memories by Roa Music | https://soundcloud.com/roa_music1031, Music promoted by https://www.free-stock-music.comCreative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US. Sound effects from https://www.free-stock-music.com. Thank you for listening!Please send us an email to let us know what you thought.You can contact us at westmeadedjournalclub@gmail.com.You can also follow us on Facebook, Instagram, and Twitter!See you next time,Caroline, Kit, Pramod, Samoda, and Shreyas.~

It’s the JournalFeed Podcast for the week of Mar 15-19, 2021. We cover COVID-19 myocarditis among college athletes, VA ECMO for massive PE, risk of EMS transport refusal after naloxone, a meta-analysis of TXA for trauma, and the downside of resident self-assignment of patients - a.k.a. cherry picking.

By the end of this lecture, the attendee will be able to: Differentiate between VV and VA ECMO support Describe the impact of the COVID19 virus and the increased need for higher level support for patients Discuss recently published literature regarding outcomes with the use of ECMO therapy for COVID19 patients

Episode 02:Ambulation on VA ECMO Host: David Werho, MD; Guests: Emily Weissler, MD and Vamsi Yarlagadda, MD (Lucile Packard Children's Hospital); Producer: David Werho, MD. We discuss the strategies used to ambulate a pediatric patient with heart failure while on venoarterial extracorporeal membrane oxygenation support (VA ECMO) while waiting for heart transplant.

This week's episode features author Torbjørn Omland and Senior Guest Editor Vera Bittner as they discuss the artile "Growth Differentiation Factor-15 Provides Prognostic Information Superior to Established Cardiovascular and Inflammatory Biomarkers in Unselected Patients Hospitalized with COVID-19." TRANSCRIPT BELOW: Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary, and backstage pass to the journal and its editors. We are your co-hosts, I'm Dr. Carolyn Lam, associate editor from the National Heart Center and Duke National University of Singapore. Dr. Greg Hundley: I'm Dr. Greg Hundley, Director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Well, Carolyn our feature this week gets into inflammatory biomarkers in patients that have been hospitalized with COVID-19, but before we get to that, how about we grab a cup of coffee and work through some of the papers in the issue. Would you like to go first? Dr. Carolyn Lam: Absolutely. With both the coffee and the papers. So great, for this first paper, have you thought about concentric versus eccentric cardiac hypertrophy? We traditionally associate them with pressure versus volume overload respectively in cardiovascular disease, both though conferring an increased risk of heart failure. These contrasting forms of hypertrophy are characterized by asymmetric growth of the cardiac myocytes in mainly width or length respectively. However, the molecular mechanisms determining myocyte preferential growth in width versus length remain poorly understood. Dr. Carolyn Lam: That is until today's paper, and it is from Dr. Kapiloff from Stanford University, and Dr. Rosenfeld from UCSD, School of Medicine and their colleagues, and what they did was used primary adult rat ventricular myocytes, as well as Adeno associated virus mediated gene delivery in mice, to define a regulatory pathway controlling pathological myocyte hypertrophy, and they found that asymmetric cardiac myocyte hypertrophy is modulated by serum response factor phosphorylation, constituting an epigenomic switch balancing the growth in width versus length of adult ventricular myocytes In vitro, and In vivo. Dr. Carolyn Lam: Serum response factor phosphorylation was bi-directionally regulated at signalosomes organized by the scaffold protein muscle, A kinase anchoring protein beta. This newly identified molecular switch controlled a transcriptional program responsible for modulating changes in cardiomyocyte morphology that occurs secondary to pathological stressors. Dr. Greg Hundley: Very nice, Carolyn. So switches controlling this transcriptional program. Tell us a little bit, and bring us back to the clinical relevance of this and starting with that concentric versus eccentric hypertrophy? Dr. Carolyn Lam: I thought you may ask. The identification of a molecular mechanism regulating that asymmetric cardiomyocyte growth, really provides a new target for the inhibition of pathological cardiac hypertrophy. Studies in mice using these Adeno associated virus based gene therapies to modulate that signalosome, really provided proof of concept for translational potential in the treatment of pathological cardiac remodeling and prevention of heart failure. Dr. Greg Hundley: Oh, wow. Very nice, Carolyn. Well, my first paper comes to us from Professor Dirk Westermann from Hamburg, and focuses on cardiogenic shock patients, and veno-arterial ECMO, the results from the international multicenter cohort study. So Carolyn this study evaluated data from 686 consecutive patients with cardiogenic shock treated with VA ECMO with or without left ventricular unloading using an Impella, and they conducted this at 16 tertiary care centers across four countries. They examined the association between left ventricular unloading and 30 day mortality. Dr. Carolyn Lam: Huh, so what did they find? Dr. Greg Hundley: Okay. Carolyn. Well, left ventricular unloading was used in 337 of the 686 patients enrolled, and after propensity matching 255 patients with left ventricular unloading were compared with the 255 patients without left ventricular unloading. In the match cohort, left ventricular unloading was associated with lower 30 day mortality without differences in the various subgroups. However, complications occurred more frequently in patients with left ventricular unloading, like severe bleeding, which happened in 38.4% versus only 17.9% in those without unloading. There was also access-related ischemia and renal replacement therapy. Dr. Greg Hundley: So Carolyn, the take-home message from this International multi-center cohort study, is that left ventricular unloading is associated with lower mortality, and cardiogenic shock patients treated with VA ECMO, despite higher complication rates. In the absence of randomized trial data these findings support the use of left ventricular unloading and cardiogenic shock patients treated with VA ECMO, and call for further validation, ideally in a randomized controlled trial. Dr. Carolyn Lam: Very nice. Well for my next paper, Greg, it's all about desmin. Now we know that mutations in the human desmin gene caused myopathies and cardiomyopathies. Well, today's authors, Dr. Hermann and Schroeder from University Hospital Erlangen in Germany and Dr. Lilienbaum from University of Paris and France and their colleagues, report an adolescent patient who underwent cardiac transplantation, due to restrictive cardiomyopathy caused by a heterozygous R406W desmin mutation. Sections of the explanted heart were analyzed with antibodies specific to 406W-desmin, and to intercalated disc proteins. Effects of this mutation on the molecular properties of desmin were then addressed by cell transfection and In vitro assembly experiments. They further generated these desmin mutation knock-in mice haboring the orthologous form of the human, R406W-desmin. Dr. Greg Hundley: So Carolyn, what did they find? Dr. Carolyn Lam: Well, they demonstrated a novel pathomechanism in which cardiotoxic R406W-desmin, could adapt dual functional status with the abilities to integrate into the indogenous intermediate filament network, and to cause formation a protein aggregates. This R406W-desmin modified the extra sarcomeric cytoskeleton, such that desmin filaments were not anchored to desmosomes anymore. Thereby destroying the structural, and functional integrity of intercalated discs. Dr. Greg Hundley: What are the clinical implications? Dr. Carolyn Lam: Well, since these cardiotoxic desmin mutations could affect the integrity of intercalated discs, thereby inducing conduction defects and malignant arrhythmias, they suggest early implantation of pacemaker, or cardioverter defibrillator devices, may be considered to prevent certain cardiac death in patients with these mutations. Furthermore, state-of-the-art basic molecular risk stratification of desmin mutations may encompass a multidisciplinary experimental approach as exemplified by the approach taken here, which comprises assessment of the tissue pathology in conjunction with genome analysis and desmin assembly studies as well as patient mimicking cell and animal models for the In vivo validation of these mutations. Dr. Greg Hundley: Well, fantastic, Carolyn. Well, my next paper comes to us from Dr. Ravi Shah from the Massachusetts General Hospital. This study evaluated 2,330 white and black young adults, average age of 32 years, in the Coronary Artery Risk Development in Young Adults, or the cardiac study, to identify metabolite profiles associated with an adverse cardiovascular disease phenom that included, myocardial structure and function, fitness, vascular calcification, and then also mechanisms, and other cardiovascular outcomes that would occur over the next two decades. Statistical learning methods, including elastic nets and principal component analysis, and Cox regression generated parsimonious metabolite based risk scores, validated in over 1800 individuals in the Framingham Heart Study. Dr. Carolyn Lam: Wow. What did they show, Greg? Wow, that's a lot of work. Dr. Greg Hundley: Yeah. So Carolyn, the authors found two multiparametric metabolite-based scores linked independently to vascular, and myocardial health. With metabolites included in each score specifying microbial metabolism, hepatic steatosis, oxidative stress, nitric oxide modulation, and finally collagen metabolism. Over nearly 25 year median follow-up, and cardia, this metabolite based vascular score, and the myocardial score, and the third and fourth decade of life were associated with clinical cardiovascular disease. Importantly, the authors replicated these findings in 1,898 individuals in the Framingham Heart Study followed over two decades, such that young adults with poor metabolite based health scores had higher hazard ratios of future cardiovascular disease related events. Dr. Carolyn Lam: Oh wow. Greg, what an elegant study with both development and validation cohort evaluating the metabolome. Dr. Greg Hundley: Yes. Carolyn. So metabolic signatures of myocardial, and vascular health in young adulthood specify known novel pathways of metabolic dysfunction, relevant to cardiovascular disease associated with outcomes in two independent cohorts. So these data suggests that efforts to include precision measures of metabolic health in risk stratification to interrupt cardiovascular disease at an early at stage, are warranted. Dr. Carolyn Lam: Wow. So interesting. Other very interesting articles in today's issue, there's an In Depth article by Dr. Angiolillo entitled, “The Antithrombotic Therapy for Atherosclerotic Cardiovascular Disease Risk Mitigation in Patients with Coronary Artery Disease and Diabetes.” There's also Research Letters, one by Dr. Sultan on, “The Longterm Outcomes of Primary Cardiac Lymphoma” and one by Dr. Wang on, “Loss of Phosphatase and Tensin Homolog Promotes Cardiomyocyte Proliferation and Cardiac Repair Following Myocardial Infarction.” Dr. Greg Hundley: Great, Carolyn. Well, I've got a couple other articles in this issue as well. One is by Professor Ganesan Karthikeyan who has an On My Mind piece entitled an “Alternative Hypothesis to explain Disease Progression in Rheumatic Heart Disease.” Dr. Stuart Chen has an ECG challenge entitled, “Alternating QRS Duration and a Normal T-waves. What is the mechanism?” Then finally, Carolyn, a series of Letters to the Editor, one by Dr. Peterzan and the other by Dr. Mehmood regarding the prior published article, entitled “Cardiac Energetics in Patients with Aortic Stenosis and Preserved Ejection Fraction.” Well, Carolyn, how about we get onto that feature article and learn more about inflammatory biomarkers in hospitalized patients with COVID-19? Dr. Carolyn Lam: Yes. Let's go. Greg. Biomarkers are really playing an increasingly important role in cardiovascular disease, and even in the current COVID 19 pandemic, there's been a lot of news about how biomarkers such as traponin may be prognostic, and in fact, we're all wondering about maybe even newer biomarkers. In fact, today's feature discussion does bring to light one of the newest, and in fact, this is the first publication on the role of Growth Differentiation Factor 15 or GDF-15 in COVID-19. We're so pleased to be discussing this with the corresponding author, Dr. Torbjørn Omland from University of Oslo, in Norway, as well as our senior guest editor, Dr. Vera Bittner from University of Alabama at Birmingham. So welcome both. Tobjorn, could you tell us a little bit about GDF-15 and what made you look at it, and what did you find? Dr. Torbjørn Omland: Yeah, so GDF-15, that's a very interesting biomarker. It's considered a biomarker of biological aging cellular stress, and perhaps also the inflammation, and tests being studied within the cardiovascular field for some years now, and it has been shown to be a strong prognostic indicator across the cardiovascular spectrum, actually. So it is a new biomarker in one sense, but there are some data already in the cardiovascular field. Dr. Carolyn Lam: Not in COVID. So this is the first study to really look at its prognostic value in COVID 19. So congratulations Torbjorn, and if I may also to the first author, Dr. Peter Meer, a good friend as well, but please, could you tell us about your study and what you found? Dr. Torbjørn Omland: Yes. So when the COVID pandemic hit Norway in the spring, we thought that we should plan a prospective biomarker study. So we had to really fast track approval by the IRB and so forth, and we're able to actually cover most of the patients that were hospitalized in our hospital, Akershus University hospital, which is right outside of Oslo, and it's a pretty large hospital by Norwegian standards. It covers about 11% of the Norwegian population. Dr. Torbjørn Omland: So in that period, when we were including, we had 136 patients hospitalized with confirmed COVID 19, and we have biobank bank samples from 123 of these, and then there have been reports from retrospective studies, first from China, that seemed to suggest that markers like cardiac troponin, Anti-Troponin T, and Ferritin were associated with outcome, but those studies were prone to selection bias in that the measurements were performed in the most sick patients. So in this study we included all patients and then we thought we should examine a broad panel of biomarkers, and that included Interleukin 6, CRP, Procalcitonin, Ferritin, and the D-dimer Cardiac troponin, and N-terminal pro B, and GDF-15. Dr. Carolyn Lam: Wow. Thank you, Torbjorn. Even before you carry on with the results, can I just say having visited your hospital in pre-COVID days, I can only imagine what a work of love this was to do it prospectively. Any particular experiences to talk about, to get a fast-track even in the midst of to perform a well done prospective study, that must have taken a lot. Dr. Torbjørn Omland: Yes. But it's also interesting in that the whole sort of ablation on Norway was very much into this from the highest political level. Also, the decision that the older research on COVID should be prepared to retire, then the IRB had an eight hour and deadline for them to approve or not approve the study. So that's went surprisingly smoothly, I must say. Dr. Carolyn Lam: Wow, that's great. So what did you find? Dr. Torbjørn Omland: Yeah, so we found that among these biomarkers, several seem to predict outcome, and the primary end point of this study was to combined end-point of the hospitalization in the ICU, or death. We found that also markers like cardio traponin, BNP, ferritin, and the D-dimer and so forth, in univariable analysis, were very associated with outcome, but when we perform a more comprehensive, mostly variable modeling, then the prognostic value of some of these markers disappeared. In contrast, for GDF-15, it seemed to perform very strongly, both on the baseline sample, and interestingly also it increased in those reaching the primary end-point during the hospitalization. So it provided a very strong and independent information also when we adjusted for clinical risk scores, like the NEWS score. So that was a very pleasant surprise to see that there was one marker that's actually performed so well. The other marker that's also performed well was Ferritin. Dr. Carolyn Lam: Very interesting, and so the new score being the National Early Warning Score. Thank you. Verra, I really love to bring in your thoughts. I mean, could you take us behind the scenes with the editors? What did you think when you saw this paper? Dr. Vera Bittner: As you know, I mean, a lot of journals have been inundated by COVID papers, and so this one stuck out to us, because it's the first time that we had seen that anybody linked GDF-15 to a COVID population, even though it has been out in the literature for ACS, and in my prognostication, and in a healthy populations, and in chronic coronary disease populations, heart failure, and so on. So this is the first time that we've seen it applied there. Dr. Vera Bittner: Then I would echo some of the things that Torbjorn said, that we were also impressed, that it was prospective, because when you look at some of the other biomarker studies, what was prognostic in one with then not shake out the other one, because either different variables were included in the models, because the population's differed. So to have something that was representative of the population that was actually admitted to this, Norwegian Academic Hospital, stood out to us. So we're excited to get this paper basically for circulation, and hope that it also will be impetus for future research. Dr. Carolyn Lam: Thank you so much for sharing that end for helping us publish such a beautiful paper. Did you have some questions for two of your own? Dr. Vera Bittner: Yeah. So what stuck out to me is that you had this a whole crew of biomarkers, and then when you looked ultimately at the final model, there were two that were standing out, that was ferritin, and it was the GDF-15, and then when I looked at your graph, it looks like not only did these biomarkers measure different contrasts, but their time-course also seemed to be different, and so I was just wondering whether you had thought about, maybe using these to joint the model outcome, and whether we might even be able to get more information that way. Dr. Torbjørn Omland: I think that's an excellent suggestion, and as you correctly pointed out, they do have different sort of profiles and ferritin being an acute phase reactant, having various sort of dramatic early rise whereas we see that GDF-15 increased progressively during the course of hospitalization in the most severe patients. I think when combining them, is actually a great IMT that we should look further into. Dr. Carolyn Lam: Very nice. Torbjorn, if I could, I've got a couple of questions too. So 123 patients, 35 of whom had the primary outcome, right? So that may be sort of seen as, is this too small? and they're all hospitalized patients. So could I ask, what do you predict maybe seen in a larger population or outside of Norway or in a non-hospitalized population? Dr. Torbjørn Omland: So as you say, we were early with this report, but since it was submitted, there has been a couple of smaller studies that seemed to confirm our results. So that is reassuring, but of course we would like to have studied this in logical patients. We are in touch with the other biobank samples that could possibly confirm the data. So that's one obvious step. Then it's very interesting, as you say, could we sort of expand this to also apply to non-hospitalized patients? I think that it would be a very interesting hypothesis to test, and I think there's still a pretty good rationale for this. Dr. Torbjørn Omland: It's interesting that the insoluble group actually showed a correlation that when the soluble ST2 concentrations and GDF-15. So there might be that those with more susceptibility to COVID infections, actually, I thought that, that is actually reflected by GDF-15 concentrations, but the challenge is how to sort of get a representative non-hospitalized population, but interestingly, I was approached by some of the hospital staff that actually are in contact with general practitioners, and wanted sort of implement this test also for this group. Dr. Carolyn Lam: So Verra, we're really grateful that Allan Jaffe was working with you in managing this beautiful paper, and if you don't mind me cheekily paraphrasing that you said you might channel him, if you could, what would the channeled Allan Jaffe perhaps say about what's needed in this whole biomarkers fear in COVID-19? Dr. Vera Bittner: Hopefully, many. A channeling element is obviously difficult, because he is such an incredible expert on biomarkers that I can't even pretend to be able to see, that you might be thinking, but it seems to me that one thing that we could all agree on is that it would be really exciting if something like the: get with the guidelines COVID registry, could decide to measure this marker perspectively in the participating hospitals, for example. Dr. Vera Bittner: Then be able to look at this in a much, much larger population. I mean, especially with different ethnic backgrounds as well. I mean, I noticed actually to my surprise that, this Norwegian study how to fairly high proportion of Asians in the sample, but that may not be the ethnic distribution that we might see in different regions of the US, or different regions of the world. So it would be really nice to incorporate the measurement of this biomarker in much larger datasets. So things can be explored a bit further. Dr. Carolyn Lam: That's excellent, and Torbjorn, if you could channel Allan. What would you say? Dr. Torbjørn Omland: That's a difficult path, but absolutely just to me what Verra said. Then I think the importance of prospective studies in the COVID biomarker field, I think is our at most importance. Dr. Carolyn Lam: I think on behalf of both Torbjorn and I, and in fact everyone in circulation. Thank you, Verra for the amazing work that you and your team do for circulation as well. Thank you so much for making the time to share your thoughts today and thank you for that beautiful, beautiful paper both of you. Thank you. (singing). Listeners you've been listening to Circulation on the Run. Thank you for joining us from Greg and I. Don't forget to tune in again next week. Dr. Greg Hundley: This program is copyright, the American Heart Association 2020.  

CardioNerds (Amit Goyal & Daniel Ambinder) join University of Michigan cardiology fellows (Apu Chakrabarti, Jessica Guidi, and Amrish Deshmukh) for some craft brews in Ann Arbor! They discuss a challenging case of Ventricular Septal Rupture after acute MI. Dr. Kim Eagle, editor of ACC.org & host of Eagle's Eye View Podcast, and Dr. Devraj Sukul provide the E-CPR and message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident, Eunice Dugan, with mentorship from University of Maryland cardiology fellow Karan Desai.   Jump to: Patient summary - Case media - Case teaching - References D The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus. We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director. CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza Patient Summary A male in his 60s with medical history of obesity and GERD presents with five days of progressive chest pressure radiating to bilateral arms and associated with dyspnea on exertion. Due to worsening chest pain with new lightheadedness, he decided to come to the ED. His presentation to the hospital was delayed due to fear of contracting COVID-19. In the ED, patient was afebrile, blood pressure 96/56, HR 137, RR 22, and oxygen saturation 94% on room air. On exam, he was ill appearing, acutely distressed, and altered. He had a 3/6 mid systolic murmur loudest at L sternal border, JVP to 10 cm H2O and had crackles up to mid-lung fields. His extremities were cool to touch. Labs notable for Cr 1.5, High-Sensitivity Troponin-T up to 5756, and lactate 3.9. EKG showed incomplete RBBB, PVCs, and ST elevations in the inferior leads with depressions in lateral and precordial leads. Coronary Angiography showed mid-RCA occlusion with faint L to right collaterals. He underwent PCI with restoration of TIMI 3 flow. After PCI, he continued to be hypotensive requiring IABP and norepinephrine. PA catheter demonstrated (in mmHg): RA 26, RV 63/29 (31), 55/36 (44), PCWP 29, and CO 5 L/min, CI 2.2, and SVR 467. Shunt run of mixed venous O2 saturation showed: SVC 71%, RA 72%, RV 62%, PA 85% with oxygen step up in the R-sided circuit. Left ventriculogram then confirmed septal rupture with contrast extravasation from LV into RV. Due to worsening shock, he was stabilized on VA ECMO which was complicated by hemolysis and acute renal failure requiring CVVHD. On day 7 after presentation, he underwent surgery which revealed a large 6x6 cm ventricular septal defect on the posterior aspect of the septum and repaired with a large bovine pericardial path. He was eventually discharged after a prolonged stay and repeat TTE on follow up showed biventricular dysfunction and residual 1cm VSD.   Case Media ABCDClick to Enlarge A. ECG: Incomplete RBBB, PVCs, and ST elevations in the inferior leads with depressions in lateral and precordial leads. B. Coronary angiography: mid-RCA occlusion with faint L to right collaterals.C-D.

CardioNerds (Amit Goyal & Daniel Ambinder) join University of California San Diego (UCSD) cardiology fellows (Harpreet Bhatia, Dan Mangels, and Quan Bui) for a relaxing beach bonfire in the beautiful city of San Diego! They discuss a challenging case of post-transplant cardiac allograft vasculopathy. Dr. Hao (Howie) Tran provides the E-CPR and program director Dr. Daniel Blanchard provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Richard Ferraro with mentorship from University of Maryland cardiology fellow Karan Desai.   Jump to: Patient summary - Case media - Case teaching - References The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus. We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director. CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza Patient Summary A man in his late 20s with a past medical history of orthotopic heart transplant, presents with one-week of progressive lower extremity edema and dyspnea with NYHA class IV symptoms. 5 years prior, he underwent orthotopic heart transplant for arrhythmogenic right ventricular cardiomyopathy. Subsequently, he has had multiple episodes of rejection or recurrent graft dysfunction. On presentation, he was normotensive and borderline tachycardic. Exam revealed elevated JVP, decreased breath sounds, and pitting edema.  Labs demonstrated leukocytosis, acute kidney injury, and elevated pro-BNP. TTE demonstrated LVEF 35%, apical akinesis, and grade III diastolic dysfunction (all similar to prior). He was initially diuresed and RHC/EMB was performed to evaluate for rejection. Early in his course, the patient unfortunately suffered a PEA arrest with ROSC was quickly achieved after 1 minute of CPR. He was intubated and cannulated for VA ECMO. EMB demonstrated ISHLT Grade 1R cellular rejection and he was ultimately listed for re-transplant. Shortly thereafter, the patient received an OHT. His pathology demonstrated intimal thickening of all his coronaries, consistent with coronary artery vasculopathy, felt to be the major contributor to his presentation.   Case Media ECG Episode Schematics & Teaching Click to enlarge! The CardioNerds 5! – 5 major takeaways from the #CNCR case 1. What is CAV?   CAV stands for cardiac allograft vasculopathy. Within the transplanted heart, CAV is the proliferation of vascular smooth muscle and intimal thickening in the epicardial coronary arteries and microvasculature leading to diffuse narrowing. CAV is common, present in greater than 30% of patients at 5 years post-transplant. It is a significant contributor to post-transplant mortality after the first year.  CAV, in contrast to typical atherosclerotic lesions, is diffuse and concentric while atherosclerosis tends to be focal with eccentric luminal narrowing and heterogenous plaque composition. Patients s/p OHT can still develop typical coronary artery disease,

CardioNerds (Amit Goyal & Daniel Ambinder) join  join UCLA cardiology fellows (Jay Patel, Hillary Shapiro, and Ruth Hsiao) for some beach bonfire in Santa Monica! They discuss a challenging case of Spontaneous Coronary Artery Dissection (SCAD) requiring heart transplantation. Dr. Jonathan Tobis provides the E-CPR and program director Dr. Karol Watson provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Evelyn Song with mentorship from University of Maryland cardiology fellow Karan Desai.   Jump to: Patient summary - Case media - Case teaching - References Episode graphic by Dr. Carine Hamo The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus. We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director. CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza Patient Summary A woman in her late 40s presented with a one day history of intermittent chest pain. EKG showed anteroseptal and lateral STE with reciprocal ST depressions in the inferior leads. High-sensitivity troponin was elevated at 333 ng/mL. Emergent LHC showed a long and narrow left main with areas of additional contrast filling into a false lumen with no flow in the LAD. RCA and LCx were normal appearing (make sure you check out the angiogram videos below!). IVUS showed dissection and heavy thrombus burden in the left main artery. Shortly after the diagnostic angiogram, the patient went into V-fib arrest and received one shock with ROSC. Amiodarone was started and an Impella CP was placed for additional left ventricular support. ECMO and emergent CABG were not readily available at this time so the interventional team attempted revascularization with PCI to the left main given patient's hemodynamic instability from ongoing ischemia. However, even after PCI to left main, flow to LAD remained poor and the LCx now also appeared occluded. The decision was made to cease further attempts at revascularization. Unfortunately, post-procedure TTE showed a reduced EF of 22% with anterior and anterolateral hypokinesis. She was transferred to CCU on maximal Impella support. Patient eventually developed acute renal and liver failure secondary to cardiogenic shock and suffered an additional V-fib arrest with ROSC. Eventually, Ronald Reagan UCLA was contacted for transfer and the mobile ECMO team was dispatched. They placed the patient on VA-ECMO in the outside facility and transferred her to Ronald Reagan UCLA. At Ronald Reagan, revascularization was attempted given persistent cardiogenic shock and 3 stents were successfully deployed in the LAD. She was eventually weaned off of both Impella and ECMO after successful PCIs to LAD. However, TTE showed persistently low EF and patient eventually underwent successful heart-kidney transplantation.  Case Media ABCDClick to Enlarge A. ECG: Anterior STE, STE in I/aVL but depressedions in V4-V6, inferior reciprocal ST depressionB.

CardioNerds (Amit Goyal & Daniel Ambinder) join Medical College of Wisconsin cardiology fellows (Katie Cohen, Div Mohananey, and Dave Lewandowski) for some cold brews by Lake Michigan in Cream City aka Milwaukee, WI! They discuss a case of a pregnant woman presenting cardiac arrest due to peripartum cardiomyopathy. Dr. Sarah Thordsen provides the E-CPR and program director, Dr. Gaglianello Nunzio, provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident, Eunice Dugan, with mentorship from University of Maryland cardiology fellow Karan Desai.   Jump to: Patient summary - Case media - Case teaching - References Episode graphic by Dr. Carine Hamo The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus. We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director. CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza Patient Summary A G2P1 woman in her early 30s with a history palpitations presented after a witnessed out-of-hospital cardiac arrest while at work. She received 6 rounds of CPR and 2 shocks before ROSC was achieved. She was intubated and given fluids but continued to remain hypoxic and hypotensive. Exam demonstrated sinus tachycardia, no murmurs, gravid abdomen and cool extremities. Initial labs demonstrated leukocytosis to 14k, lactic acid at 4.3 mmol/L, troponin-I peak at 0.07 ng/dL and elevated NT-proBNP. CXR demonstrated bilateral effusions and pulmonary congestion, and post-arrest EKG showed a wide complex tachycardia, leading to suspicion of VT arrest. In sinus, there  were no ST segment elevations and TTE showed LVEF 10-20%, global hypokinesis and no valvular disease. Given the severity of her shock, she was placed on central VA-ECMO with Impella support as an LV vent. During ECMO cannulation, she underwent emergent cesarean section due to fetal distress. Coronary angiography showed non-obstructive coronaries, but with sluggish flow in the setting of her cardiogenic shock and possible coronary spasm in setting of multiple vasoactive medications. Endomyocardial biopsy was negative for giant cell myocarditis. Within 4-5 days, she was weaned off all vasoactive agents and ECMO was decannulated; repeat echocardiogram showed LV functional recovery. GDMT was slowly titrated and a subcutaneous ICD was eventually placed before discharge. She and her child have done well over the course of a year!  Case Media ABClick to Enlarge A: ECG: Initially in sustained wide complex irregular tachycardiaB: CXR: Extensive consolidative changes throughout the lungs TTE: Parasternal Long Axis TTE: Apical 4 Chamber Episode Schematics & Teaching Click to enlarge! The CardioNerds 5! – 5 major takeaways from the #CNCR case 1. What is the differential for cardiac arrest in pregnant patients?  When thinking about a cardiac etiology of arrest, the differential should include pregnancy-induced hypertension,

Have you ever wondered how you would crash someone onto VV ECMO?  Have you ever wondered where is the best place to put the cannulas?  Have stayed up late at night wondering which patients in your department could benefit from VV rather than VA ECMO?  Then this is the episode for you!!  After a few recent cases of crash VV ECMO in our hospital, we have decided to focus on the subject.  Zack gets critical care physician David Willms to answer from a very practical standpoint the who, what, where of crash VVECMO. The post 66: Crash VV ECMO appeared first on ED ECMO.

In the swan song of ERcast Lite, we speak with Scott Weingart about the truths, misunderstandings, and physiology of ECMO. To subscribe to ERcast and get 2.5 hours of high yield monthly content, CME, and all sorts of goodies, use the code 'bacon' for a 3 month free trial. https://www.hippoed.com/em/ercast/   Pearls: VV ECMO takes over lung function and is used for those with severe lung disease (ie. ARDS, pneumonia, severe asthma). VA ECMO takes over the heart and lung. Ideal candidates are patients with massive PE or cardiogenic shock. Intubated patients who you can’t oxygenate despite rapidly escalating PEEP and a high FiO2 should be considered for VV ECMO.     There are 2 primary types of extracorporeal membrane oxygenation (ECMO):  veno-venous (VV) and veno-arterial (VA). VV ECMO takes over lung function. It drains blood from the IVC or SVC, sends it through a pump which delivers it to an oxygenator (a membrane which allows the influx of oxygen and removes CO2), and then pumps the oxygenated blood back into the right heart system (returning it to the IVC or SVC).   Useful for those with severe lung disease but decent heart function. Examples:  pneumonia, ARDS, severe asthma with CO2 retention, immunologic lung diseases, cystic fibrosis awaiting lung transplant Limited by its complications, cost, and logistical catastrophes. VA ECMO takes over lung AND heart function. It drains blood from the IVC/SVC, pumps it out and sends it to an oxygenator, and then returns the blood retrograde up the aorta so it can perfuse the abdominal viscera, brain, and possibly even the heart.   For patients with cardiogenic shock or massive PE. Does not yield as much benefit for patients with septic shock or other vasodilatory states (unless they had a sepsis-induced cardiomyopathy). Shares the same limitations as VV ECMO, with the addition that the physiology induced by the VA ECMO itself can be deleterious.   Which patients might benefit from transfer to an ECMO center? The threshold for transfer depends in part on the capabilities at your institution for advanced ventilatory modalities (ie. airway pressure release ventilation, proning patients, nitric oxide).  A large percentage of patients transferred for ECMO never end up receiving or needing it. However, they still greatly benefit from moving to a facility that has the ability to provide other nuanced critical care options. In general, transfer young patients who are on very high vent settings and not getting better.  At a community hospital with few vent resources, these patients should be transferred within hours.  At bigger institutions, transfer within 48 hours. Often people wait too long (5-7 days) to initiate the transfer.     Use the ARDSnet Mechanical Ventilation Protocol and Murray Score to help decide if a patient would be a good VV ECMO candidate.  The ARDSnet protocol is evidence-based and communicates where the patient is on their vent settings. It gives receiving centers a clean way to evaluate patients for potential transfer. Patients should be

What are the indications for ECMO beyond ARDS and refractory cardiogenic shock? In which patients should we consider eCPR and is this the new standard of care for patients sustaining out-of-hospital cardiac arrest? Finally, how do I work towards safely and efficiently weaning my patient from VV or VA ECMO? These are just a few of the questions that we address on Rounds with our guest faculty member and Director of the UCLA Adult ECMO Program, Dr. Peyman Benharash. In this comprehensive review of ECMO we also explore the regionalization of ECMO care here in Los Angeles County, as well as the day-to-day considerations that you want to bear in mind when assessing and caring for your patients requiring extracorporeal life support.Learning ObjectivesBy the end of rounds you should be able to:1. Understand the indications & contraindications to VV and VA ECMO support2. Describe the basic components of an ECMO circuit3. Describe the role of eCPR in the management of adult patients with out-of-hospital cardiac arrest4. Discuss key management strategies to safely wean patients from ECMO5. Describe common complications of ECMO and strategies to mitigate themTake Home PointsECMO is time-sensitive, therefore, early and safe cannulation is an important determinant of outcomeECMO is a bridge to therapyUse of scoring systems like the Murray Score may be useful to stratify the severity of ARDS among patients being considered for VV ECMO supportThe indications for ECMO are expanding to include technically challenging operative caseseCPR is a promising therapy for patients presenting to an ECMO center of excellence with refractory VF/VT cardiac arrest ECMO therapy, particularly VA ECMO, may affect virtually organ systemThe potential role of ECMO therapy during the current COVID-19 pandemic remains to be definedTime Stamps00:12 Introduction01:16 Overview of Rounds 02:13 The rise of ECMO 02:46 CESAR & EOLIA trials summarized 05:40 Venovenous (VV) vs. Venoarterial (VA) ECMO08:24 How to decide whether or not to place a patient on VA ECMO? 10:33 Timing & indications for ECMO support11:38 Murray Score explained12:24 Contraindications & patient selection for VV & VA ECMO13:56 Expanding indications for ECMO15:23 ECMO in the Setting of Trauma: Pneumonectomy & Retrohepatic IVC injuries17:45 Regionalization of ECMO in Los Angeles County21:52 Who should be cannulating?23:22 Approach to cannulation24:50 Distal perfusion catheters for VA ECMO26:10 Differences between VV & VA ECMO28:24 The W5H of eCPR34:26 Considerations for access for VV ECMO35:53 Avalon catheter 37:51 VV versus VA ECMO circuits/set-up explained43:30 Getting your patient off of ECMO & other key considerations48:56 Vasopressor & inotropic therapy during VA ECMO50:31 Virchow’s triad, antithrombotic therapy & bleeding on ECMO54:30 AKI, end-organ dysfunction & the daily assessment of patients on ECMO57:22 ECMO 2.0 & the role of evolving technologies61:20 Role of ECMO during the COVID-19 pandemic 66:45 Take-home points68:38 Outro

In this episode, Zack Shinar introduces a new physician to the podcast - Garrett Sterling.  Garrett and Zack discuss the sticky topic of ECMO for aortic dissection.  This traverses everything from VA ECMO in ECPR to VVECMO for pulmonary edema.  They go through the literature on the subject and make some conclusions based on this data. The ultimate question - "Is Aortic Dissection a Contraindication for ECMO?" The post 64: Contraindicated??? – Long Live the Aortic Dissection with Garrett Sterling appeared first on ED ECMO.

ED-intensivist Scott Weingart has developed several protocols for airway management in COVID-19 patients, but each of those answers brings up more questions. In this episode: ‘happy hypoxemia’, the 4 types of COVID patients, Covid L vs H, is there a role for ECMO in severe disease, why intubation should be a last resort, the importance of patient positioning, and much more.    One of the most astounding things about treating COVID-19 patients is how well they can look with extreme hypoxia. Patients with saturations of 50% (and consistent ABGs) can be talking, mentating normally, and have otherwise normal vital signs. Thus, this term:  “the happy hypoxemic”.  It is not well understood why these patients are able to tolerate such low sats without having compensatory measures, such as tachycardia. This led to a paradigm shift in the approach to managing hypoxemia. There are 4 types of COVID-19 patients: Those with mild disease -- may never enter the medical system. The “happy hypoxemics” -- many of these, if managed well, will be discharged without experiencing cytokine storm or needing intubation. The hyperacute progression patients -- these patients decompensate rapidly. Many go into cardiac arrest hours after ED arrival. Weingart believes these patients likely have the highest viral load and are the most dangerous to the healthcare workers. The indolent patients -- may look like the “happy hypoxemics” initially, but within 4-5 days develop cytokine storm and require intubation. When ventilated, there are 2 phenotypes: COVID L (low elastance/not stiff/normal compliance) This is the “happy hypoxemic” phase on the vent. The amount of gas in the lungs is nearly normal and there is low lung recruitability. Easy to ventilate. These patients can be damaged iatrogenically if you respond to their pulse ox with standard vent modes. Best managed with high FiO2 which allows you to limit the PEEP to just what you need. Recommended initial vent settings:   8 ml/kg TV, 100% FiO2 Increase the PEEP only if the patient is desaturating on a high FiO2. Can turn into COVID H patients on the vent. COVID H (high elastance/stiff/low compliance) Increased permeability of the lung leads to edema, atelectasis, decreased gas volume, and decreased TV for a given inspiratory pressure. High degree of lung recruitability. Manifests similar to ARDS patients and responds nicely to typical ARDS settings.  The ARDSNet ladder applies only to this subset of COVID patients. Link to ARDSNet protocol. How can you tell if a patient is COVID L or COVID H? Observe their plateau and driving pressures when on 8 ml/kg TV. COVID L patients will respond like normal lungs. COVID H patients will respond with high plateau and driving pressures, indicating terrible compliance and classic acute lung injury. What is the current treatment algorithm for the query COVID patient who presents with a severe asthma exacerbation? Use MDIs rather than nebulization to deliver bronchodilators. Consider terbutaline or epinephrine (0.3-0.5 mg IM). Many hospitals are not allowing CPAP, so more of these patients may need to be intubated if they deteriorate. Vent management:   Start with 8 ml/kg TV and high FiO2.  Follow the expired flow graph to make sure the respiratory rate is low enough to allow the patient to fully expire between breaths. Link to EMCrit Dominating the Ventilator Part 2 on Asthmatic Ventilation.  Which techniques can be used to minimize the aerosolization risk of intubation? Weingart argues that if you follow this procedure for intubation, the risk is very low.  Important measures include:   wearing full PPE, using a negative pressure room if you can, NOT intubating while the patient is getting chest compressions, attaching viral filters to occlusive face masks,  avoiding bag-valve-mask ventilation,  keeping the face mask on the patient until complete paralysis, releasing any pressure from the face mask before removal,  using video laryngoscopy rather than DL,  avoiding suctioning when you can, and consider single operator bougie intubation technique Link to video demonstration of Dr. Chris Holmes’ Intubation Shield which seems ergonomically superior to other aerosol containment boxes in use. Does ECMO have a role for these patients? Most centers are reserving ECMO for patients who only have single organ failure.  For patients with only pulmonary failure, this would be veno-venous (VV) ECMO. For those who have recovered from their lung issues but who have COVID myocarditis, they might get veno-arterial (VA) ECMO. Many COVID patients have multi-system organ failure and are being excluded from ECMO. Old age has been another common COVID ECMO exclusion.   COVID fluid management:  keep them dry, but not too dry. Replace insensible and external losses (ie. due to vomiting or diarrhea). Patients who you suspect are dehydrated based on history or a flat IVC on ultrasound may benefit from 500-1000 ml of fluids. ED patients who you have no reason to believe are dehydrated likely need no additional fluid replacement. In general, it is better to run these patients dry, but monitor urine output and your ultrasound findings to make sure the patient doesn’t develop renal failure due to dehydration. Consider early pressors if COVID patients are hypotensive. Non-invasive ventilation, done right, should be safe. Initially, people were worried about aerosolization and cautioned against it. This is because standard noninvasive used masks which vent to the environment. Weingart argues that the Italian helmets and his closed circuit CPAP masks have minimal dispersal and are much safer.  How is Weingart awake repositioning patients in the ED? He’s repositioning everyone every 60 minutes by asking them to rotate from lying on their left side, to their right side, and then sitting upright. Prone positioning is an option, but you need to verify it makes the patient feel better, not worse.  Complex if a patient is on CPAP (even more so if a patient is intubated). Does not appear to benefit COVID H patients.   What is being done during the apneic period, prior to intubation? Weingart uses the CPAP set-up which allows for apneic CPAP. Keeps the lungs inflated with a continuous source of oxygen, providing a high FiO2 and maintains recruitment. Link to EMCrit’s COVID CPAP Pre-oxygenation Set-up without nasal cannula Link to EMCrit’s COVID-19 Intubation Pack and Preox for Intubation Video  demonstrating that apneic CPAP inflates the lungs.   When COVID patients need supplemental oxygen, Weingart uses a stepwise progression. 1st tier -- normal nasal cannula @ 6 liter/minute 2nd tier -- Venturi mask up to 50% 3rd tier -- nasal cannula plus non-rebreather mask covered with a surgical mask 4th tier -- high flow nasal cannula 5th tier -- CPAP (using a machine that’s been altered to allow filtering)   Post-intubation sedation Weingart likes to keep his COVID L patients lightly sedated, arguing that spontaneous breathing is good for their lungs. Deep sedation is preferred by some to prevent self-extubations when patient monitoring is difficult.      Vent splitting Weingart is concerned about the deep sedation/paralysis required when intubated patients share vents. What he finds more attractive is splitting the vents between 2-4 patients to deliver CPAP, allowing the patients to spontaneously breathe. This saves the single ICU vents for patients who need individualized settings.     References: Gattinoni L. et al. COVID-19 pneumonia: different respiratory treatment for different phenotypes? (2020) Intensive Care Medicine; DOI: 10.1007/s00134-020-06033-2. Link to EMCrit’s COVID Airway Management Thoughts Link to EMCrit’s COVID CPAP Pre-oxygenation Set-up without nasal cannula Link to EMCrit’s COVID-19 Intubation Pack and Preox for Intubation Link to EMCrit Dominating the Ventilator Part 2 on Asthmatic Ventilation. Link to EMCrit Wee Alternatives to Vent Splitting

Cardiothoracic critical care PA Brendan Riordan (@concernecus) shows us his initial approach to the patient in cardiogenic shock, including initiating mechanical support, managing ECMO (plus Impella), and eventual weaning and discontinuation of support. Some pearls Anticoagulation on VA ECMO can be titrated to bleeding risk, with a balance between bleeding and circuit longevity—the latter being … Continue reading "Episode 5: Cardiogenic shock and ECMO with Brendan Riordan"

COVID-19 in the ICU: The CardioNerds follow the case of Sara S Covids through her journey with COVID-19 complicated by progressive respiratory failure. Learn how critical care physicians, Drs. David Furfaro and Sam Brusca approach cardiopulmonary mechanics, general ventilator settings, ventilation in patients with cardiac disease, ARDS diagnosis and management algorithms, including VV and VA ECMO support considerations. Importantly, we discuss these issues in the context of the COVID-19 era and how applies to the safety of the healthcare worker and appropriate use of personal protective equipment with a particular emphasis on COVID-19 in the ICU. Both physicians share tips and tricks on coping and staying motivated as they face this crisis. This episode is broadly applicable for anyone taking care of patients with cardiopulmonary disease. In the COVID era, this is every provider. Flutter Moment by Emily (Pediatric RN) Check out the COVID-19 series page! Take me to episode topics page Ventilation primer for the cardiologist (Youtube) Dr. Samuel Brusca received his medical degree from New York University School of Medicine. He went on to complete his internal medicine training in the Osler Residency Program at Johns Hopkins Hospital and is currently a research fellow in the Critical Care Medicine Fellowship at the National Institutes of Health. His current interests include critical care cardiology, pulmonary arterial hypertension, and right ventricular failure. He is thrilled to be joining the Cardiovascular Disease Fellowship at UCSF this coming July. Outside the hospital, Sam and his amazing wife, Becky, were recently joined by their first daughter, the adorable Madeleine. Dr. David Furfaro received a degree in chemistry with a minor in pharmacology from Duke University. After college, he volunteered with Americorps for a year working with patients with HIV. He received his MD from Harvard Medical School. From there he completed his internal medicine training in the Osler Residency at Johns Hopkins. He returned to Johns Hopkins as an Assistant Chief of Service. He is currently a Pulmonary and Critical Care Medicine Fellow at Columbia University Medical Center. He is interested in critical care, pulmonary hypertension, and lung transplantation. He is also a dedicated medical educator  and a huge Cardio Nerds fan!

As a cardiothoracic anesthesiologist, I have been trained extensively in cases which require cardiopulmonary bypass (“the heart-lung machine”). CPB is similar to VA-ECMO in many ways, but for the purposes of surgery, it allows the surgeons to have a motionless and bloodless field when combined with cardioplegic arrest. […]

As a cardiothoracic anesthesiologist, I have been trained extensively in cases which require cardiopulmonary bypass (“the heart-lung machine”). CPB is similar to VA-ECMO in many ways, but for the purposes of surgery, it allows the surgeons to have a motionless and bloodless field when combined with cardioplegic arrest. Listen to this week’s episode to learn …

As a cardiothoracic anesthesiologist, I have been trained extensively in cases which require cardiopulmonary bypass (“the heart-lung machine”). CPB is similar to VA-ECMO in many ways, but for the purposes of surgery, it allows the surgeons to have a motionless and bloodless field when combined with cardioplegic arrest. Listen to this week’s episode to learn …

As a cardiothoracic anesthesiologist, I have been trained extensively in cases which require cardiopulmonary bypass (“the heart-lung machine”). CPB is similar to VA-ECMO in many ways, but for the purposes of surgery, it allows the surgeons to have a motionless and bloodless field when combined with cardioplegic arrest. […]

Dr Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. I'm Dr Carolyn Lam, associate editor from the National Heart Center and Duke National University of Singapore. Dr Greg Hundley: And this is Dr Greg Hundley from VCU health, the Poly Heart Center in Richmond, Virginia. Well, Carolyn, this week's feature analyzed a pool cohort of all patients in partner one and partner two, both the trials and registries. Patients had severe aortic stenosis and were treated with TAVR or SAVR and then were analyzed with respect to the development of prosthetic valve endocarditis. But more to come on that later. Dr Carolyn Lam: Let me start by telling you about my picks from this week's journal. So the first one is a really interesting natural experiment. First, do you think that a short term visit to a location with severe air pollution increases the risk of cardiovascular disease? Dr Greg Hundley: Well, Carolyn, I would say yes. Dr Carolyn Lam: Greg, you're too smart. But let me tell you what these investigators did. So their co-corresponding authors, Dr Araujo from David Geffen School of Medicine and UCLA, Dr Zhu from UCLA Fielding School of Public Health, and Dr Qiu from College of Environmental Sciences and Engineering in Peking University. These co-corresponding authors and their colleagues did a natural experiment by collecting urine and blood samples from 26 healthy adult residents of Los Angeles before, during, and after they spent 10 weeks in Beijing during the summer of 2014 and 2015. Dr Greg Hundley: I am really excited to hear this. Carolyn, what did they find? Dr Carolyn Lam: So traveling from less polluted Los Angeles to more polluted Beijing induced pro oxidative and pro inflammatory effects, which reversed after returning to Los Angeles. This is also the first human study associating exposures to polycyclic aromatic hydrocarbons with changes in paraoxonase 1, enzymatic activity, and circulating levels of hydroxyeicosatetraenoic and hydroxyoctadecadienoic acids. Cool, huh? Dr Greg Hundley: Absolutely. Carolyn, you did an awesome job. Very nice. Well, my article comes from the world of basic science and it's from Dr Philip Shaul at the University of Texas Southwestern medical Center. So Carolyn, in recent studies of obesity induced insulin resistance in mice with corroborating findings in human type 2 diabetics, this group, Shaul’s group, previously made the surprising discovery that the insulin resistance is driven by an altered post-translational modification in IgG that leads to enhanced activation of FCYR2B in endothelial cells. And as a result, there is an attenuation of insulin transcytosis across endothelial cells and delivery to skeletal muscle myocytes where up to 80% of glucose disposal usually occurs. Dr Carolyn Lam: Oh. Interesting, Greg. So what did the authors find in the study and how did these findings equate with obesity and hypertension? Dr Greg Hundley: Well, they found that hyposialyation of the Fc glycan on IgG is identified as a key contributing factor in obesity induced hypertension. And therefore low levels of IgG Fc glycan sialylation may identify individuals at greater risk of developing hypertension. In addition, the degree of sialylation of IgG may predict the relative response of an individual to any hypertensive therapy. Dr Carolyn Lam: Nice. So my next paper is from Dr Al-Lamee from Imperial College, London, and colleagues who studied the ability of a pre-randomization stress echocardiographic score to predict the placebo-controlled efficacy of PCI within the ORBITA trial. Now as a reminder, the primary results of the ORBITA trial showed us smaller than expected effect size of PCI in comparison with placebo in single vessel stable coronary artery disease on the primary end point of change in treadmill exercise time. Now in the current study, 183 patients underwent dobutamine stress echo cardiography before randomization, and they found that the degree of ischemia assessed by dobutamine stress echo cardiography predicted the placebo-controlled efficacy of PCI on patient reported angina frequency. Dr Greg Hundley: Hmm. Very interesting. So help me out again, Carolyn. What's the clinical importance of this? Dr Carolyn Lam: Ah, so this study really provides the first placebo-controlled evidence of an association between stress echo cardiography, ischemia, and the magnitude of placebo-controlled benefit attributable to PCI. And the greater the downstream stress echo cardiography abnormality caused by the stenosis, the greater the reduction in symptoms from PCI. That's the take home. Dr Greg Hundley: Oh wow. Very interesting. You know, especially we perform so many stress echo cardiograms. What a great relationship to unfold and present. Well, Carolyn, I'm going to walk through several other important publications in this issue of the journal. The first is from Dr Peter Eckman from the Minneapolis Heart Institute, and he provides an In-Depth review of veno-arterial extra corporal membrane oxygenation, or VA-ECMO, for cardiogenic shock and it's beautifully written for the busy clinician. Robert Platt, PhD, and colleagues discuss in an On My Mind piece the fact that those with adverse cardiovascular sequelae during pregnancy may require development of new cardiovascular risk prediction models. The hypertension or the diabetes that occurs during pregnancy, perhaps we need to incorporate that into our prediction models. Next. Our own associate editor Torbjørn Omland provides results in a research letter from the peace trial relating the relationship between smoking and high sensitivity troponin T levels. Dr Allen Sniderman from McGill University Health Center writes a letter to Welsh and Associates regarding their study of the UK bio bank database and measures of HDLC. A paper we discussed just a few weeks ago. Dr Derek Chew from the DCRI and Durham North Carolina has another EKG challenge for us. And Dr Tracy Hampton provides an updated news report regarding cardiovascular disease from several recently published articles in the world of basic science. And then finally Dr Thomas Krieg from the University of Cambridge has a nice piece regarding clinical implications of targeting succinate metabolism in ischemia reperfusion injury. Well, Carolyn, what a great slate, but I can't wait to get to that feature discussion related to prosthetic valve endocarditis. Dr Carolyn Lam: Me too. Let's go. Our feature discussion today is really the first paper that describes adjudicated evaluation of prosthetic valve endocarditis in patients with transcatheter and surgical aortic valve replacement. Very unique and valuable data from the partner's trial. I'm so pleased to have with us the corresponding author, Dr Wael Jaber from Cleveland Clinic as well as our associate editor, Dr Manos Brilakis from UT Southwestern. So Wael, very unique question. Could you please tell us how you went about doing this? And I suppose in this setting, the first question on everyone's mind is how did you make this diagnosis of prosthetic valve endocarditis? Dr Wael Jaber: Actually we saw this as an opportunity that probably we should never miss. I think this is one of the rarer instances where we can objectively not only look at SAVR data but also TAVR data. And over the past maybe seven years, eight years, we started getting here as a referral center patients with TAVR endocarditis for surgery. And we never thought we'd start seeing these weird organisms, different bugs. Of course this is a population that's frail or elderly, but we never had any idea if they behave similarly to SAVR or differently than SAVR in our previous experience with SAVR endocarditis. So we planned this actually about maybe five years ago, but we didn't have the data because you know the partner trials were undergoing another evolution by going to lower and lower risk population. So we pose this question about a year and a half ago to CRS by asking them, can you provide us with the data on all the endocarditis in partner. The idea was not only to answer one question but to answer multiple questions. So the first question was in the modern era, what happens in SAVR? All the SAVR endocarditis information we have so far as you will know has been from mainly single center studies or even when we learn about it from multiple centers sites, usually IN European studies, the Swedish registry, the Danish registry, and these are usually limited by the fact that there are a multicenter. The adjudication is at the site what endocarditis happened. So that was the first question. Then the second issue for us was, does TAVR, because of the unusual access to the heart and the fact that we dilate the valve, post dilate the valve, their paravalvular AI, they could be micro-fractures of the refis. This is provide a different opportunity for these bugs to form on the valve, and do they behave differently? And the third question was, is there any difference between SAVR and TAVR incidence of endocarditis? And bugs. And the final question was what happens to patients when they develop endocarditis in the current decade. Do they do well? Especially for septic endocarditis or do they succumb to their illness? And also this is how we came up with a strategy to answer all these questions. Dr Carolyn Lam: Very nice. So Wael, could you just expand a little bit more about how the diagnosis or adjudication of prosthetic valve endocarditis was done? And then tell us please, what did you find? Dr Wael Jaber: All the partner patients, the records were sent to a central place. So the ECHOS first were educated at central places. We were one of those centers. Other places were Columbia University, MedStar and Quebec, the group in Quebec. So all the ECHOS were adjudicated centrally. So that's first, as far as from the echo side of calling it endocarditis or not. On the clinical side, again, all the records and the forms were sent to a central adjudication committee, CDC group. We served at the Cleveland Clinic as the CDC for most of these trials and actually even for the current trials. So they were sent and they were adjudicated according to the Duke criteria. Which is, you know, the most, probably, reliable way still today to adjudicate these. And then there was the CDC and the echo core labs were separate. So the people who have information from the CDC did not have access to what's going on in the core lab and vice versa. So these were independently adjudicated as far as echocardiographic evidence and clinical evidence. And then they were fed into it. So by the end, when you hold it on a Duke criteria endocarditis, the echo was fed after the fact, not before. So this is in general how it happened. So all the events were educated centrally, not at the site. And the ECHOS, the same thing, were adjudicated centrally. Dr Carolyn Lam: Fantastic. And I would love to hear the results. Dr Wael Jaber: The first question was, what's the incidence of endocarditis? And we decided because of the way these trials were done, to report the incidents as you would see in the results section, to report the incidents of endocarditis per 1000 person year because of the imbalances in follow up and the competing risk for death from other reasons. So we found in general that the incidents of endocarditis was 5.2 endocarditis events per 1000 patients per year in the TAVR side and 4.1 in the SAVR side with a non statistically significant difference. More importantly, we found out that once you develop endocarditis, unfortunately most of these patients succumb to the illness and are dead after the diagnosis. So the risk of dying after developing endocarditis is 4.4 times higher than patients who did not have endocarditis in the trials. In all the trials. Now there's some caveats here. First, these are trials with different patient populations, as you well know. Starting with partner with the inoperable patients moving on to the most modern S3 trial, which was on the lowest kind of side of population. So we have totally different population groups. Some of them had prolonged hospitalizations before and after, so this should be taken with a little bit of caution. However, if you look at some of the individual trial data, we found that incidents of endocarditis at least have a trend towards a reduction of incidence of endocarditis over time going from partner, the initial experience with partner, all the way to the modern era. Dr Carolyn Lam: That is so great. Manos, you know, as an interventional cardiologist yourself, could you tell us how important these results are? Does it affect your practice? Dr Emmanouil Brilakis: Thanks again, Carolyn. I would like to congratulate Wael for a phenomenal paper. I think it's a very timely study and addresses one of the common concerns there is about whether TAVR does predispose people to more risk for endocarditis. Although again, the opposite grade was kind of low at 0.5% a year. I think this may be a little more than people are commonly seeing in the setting of TAVR, and I think the paper is a good reminder that this is something we should always be mindful and watching. Although typically we'll discuss with the patient about the risk of stroke or access complications, but the risk of infection may not be as well emphasized. And based on this one question I would have is about what can we do if there is something that could potentially lower that risk? I understand the limitations of retrospective study, but are there any recommendations that you have based on the study? Should give more aggressive antimicrobial therapy? Any other biotic prophylaxis or anything else that can be done to reduce the risk of endocarditis in those patients? Dr Wael Jaber: Actually this is the question we raised. Unfortunately we did not. So the guidelines did not catch up with what we know. So if you look right now, like I was reviewing this paper that came up last month from the Swedish Registry for Endocarditis, it came out in Europe in the European Heart Journal, and one of the questions they raised is how to address, in the editorial, how to address the risk of endocarditis and prophylaxis in this population. There are no standards for that. This is one aspect of it. We need first an update of the guidelines of how to address this issue. The second question is we do not have any idea, unfortunately, about duration of antibiotics. How the antibiotics prophylaxis were given before the procedure, like as we do right now commonly in surgery, and after the procedure in these patients. We do not know that. Like right now, at least at our center, if you go in for aortic or mitral valve surgery or any valve surgery, you have to have a dental clearance before you start, before you go to surgery. I don't know if this was rigorously applied in the setting of TAVR, and I think it would be a good idea to apply it to make sure that there are no dental, phosphide or potential infections and things like that. So I think it's a multi-front battle to get these patients to the lowest risk possible. I don't think there's one single silver bullet here. Dr Emmanouil Brilakis: So thanks again, Wael for addressing this. I agree that there's a lot of information to be gained understanding the intricacies of endocarditis prophylaxis. And building on this, let's say another patient develops endocarditis as you've shown in your 170 patients in the study. It was fascinating that staph aureus was actually less common than it was for surgical valves, which has been shown in other studies as well. So you think this affects the choice of the biotic prophylaxis? And then also if the patient develops endocarditis, I understand many people who are not candidates for surgery, but from the ones who did actually undergo surgery, what are the outcomes encouraging? Dr Wael Jaber: This is a fascinating question actually. This is one of the reasons we had... There was a delay for us in getting the paper out from when we presented it as an abstract at TCT a year and a half ago, is we didn't know. We wanted to answer that question. The second part of the question is how many patients went to surgery? And unfortunately, very few patients. So less than a handful of patients end up going to surgery. And we do not know why. So this is the dilemma here. Is why the rate of referral to surgery for redo surgery was very low. Was it because these patients were the sickest of the sick? Maybe it is because we waited too long and we did not treat them the same way. We should have treated prosthetic valve endocarditis, which is surgery to be offered as soon as possible because there's no really antibiotic cure for that. So we do not have the answer for that because these very few patients went to surgery and actually I think of those who went to surgery, even the mortality there even was similar to people who did not go to surgery. But we cannot speculate on that because the very few patients. As far as the bug involved, I think this could be a reflection of the antibiotics given at the time of the procedure, so probably we're covering that very well. But if you notice from the paper, most of the infections happen more than 30 days after the procedure. Whether this is something that was acquired because these patients are more likely to end up in the hospital again for other reasons, whether these patients had endocarditis because they have more instrumentation down the road... Remember this is a population in general above the age of 65 which would require colonoscopies, frequent urinary tract issues, and other procedures. So we know that we're covering very well, at least I can speculate, we're covering very well for the first 30 days because very few patients had endocarditis right after the procedure, but we're not covering probably after the 30 days. And that remains to be studied. And the worrisome thing is to try to treat these patients with prophylactic antibiotics for a long time and then end up with bug resistance and things like that. Now the CDC issued a big warning about this yesterday. I am not comfortable to speculate from this small number of patients on how to treat for prophylaxis, but I'm comfortable to say probably patients should be sent to surgery as soon as possible after developing endocarditis, especially prosthetic valve endocarditis because the outcomes are dismal. Dr Emmanouil Brilakis: And do you think... Let's say patient is not a candidate for surgery and gets endocarditis, and I presume they get into prolonged therapy. There were some patients like this that did okay, right? So there is some hope even for those patients. Dr Wael Jaber: I feel like I'm the cup half full here because if you look at the mortality curves here, we're talking about north of 95% death in this population. So the people who survive this must be very few people survive. So probably about seven patients who survive. So the mortality was 96% at six months versus 46%. So there are very few people who survived that event. Maybe I should go back now and figure out what was the quality of life after survival. So I don't think the picture we have right now is very rosy as far as the way we're managing endocarditis. Dr Carolyn Lam: Manos, I'm going to give you the final parting words from this very interesting discussion. I mean what do you think are the take home messages and future directions from here? Dr Emmanouil Brilakis: I agree that this is a phenomenal landmark study and my key takeaways are the same ones that Dr Jaber presented before. But the main thing is, on the consent process, who can tell the patients there is about 0.5% per year. So it's not zero, but it's very high either. The second thing is that this choice between TAVR versus SAVR, that should not have to do with the risk of infection because as it was shown very convincingly, it was very similar to the two groups. And number three that everything possible should be done to prevent this because if you do get infection, the outcomes are not very good. Dr Carolyn Lam: Thank you so much Manos, Wael. Thank you so much audience for joining us today. You've been listening to Circulation on the Run. Tune in again next week. This program is copyright American Heart Association 2019.  

Podcast 126 är en inspelning av Martin Slettengren, thoraxanestesiolog på Karolinska i Solna, som talar om VA-ECMO, VV-ECMO, indikationer för E-CPR, anestesi vid hjärtkirurgi såsom aortastenos, aortainsufficiens, mitralistenos, mitralisinsufficiens.

In this episode, we cover the 2019 version of a TCA overdose: Bupropion. AKA: Wellbutrin / Illbutrin (Shoutout to Tox & The Hound). Read the post then get an audio summary of the clinical diagnosis, risk stratification, Activated charcoal, whole-bowel irrigation and finally all things VA-ECMO for the extreme toxicities.

Commentary by Dr. Valentin Fuster

Dr Susanna Price trained in both cardiology and intensive care medicine in the UK, and completed a fellowship at the Thorax center with Jos Roelandt. She was awarded a PhD from Imperial College London, and following completion of her training was awarded the two-year BHF Jill Dando GUCH Fellowship in order to train further in critical care and imaging in congenital heart disease. She is a consultant at the Royal Brompton Hospital where she is Clinical Lead for Critical Care, Honorary Senior Lecturer at National Heart & Lung Institute, Imperial College London. Dr Price is President-elect of the European Society of Cardiology (ESC) Acute Cardiovascular Care Association, and sits on numerous committees including the ESC Education Committee, ESC Press & Media Committee, ALS subcommittee of the RCUK and SCCM US guideline committee. She is an Associate Editor of the European Heart Journal of Acute Cardiovascular Care, and an invited reviewer for a number of other journals. She has been a member of a number of Task Forces relating to international guidelines including VA-ECMO, acute cardiovascular care, the management of cardiovascular diseases including valvular disease, endocarditis, non-cardiac surgery, pulmonary hypertension, pericardial disease, cardiovascular disease in pregnancy and grown-up congenital heart disease. Dr Price has authored numerous papers and book chapters on cardiology, echocardiography and intensive care, and lectures regularly globally

I will consider this question in two parts;   Should ECMO be considered for all patients?  Should ECMO services be provided in all ICUs?    From a patient perspective, ECMO is a highly invasive intervention and like every other intervention that we consider, the benefits it provides must outweigh its risks for it to be worthwhile.   Clearly, veno-venous and veno-arterial ECMO supports are very different beasts – the patient profile, physiology, complications and outcomes differ considerably. At the extreme of the VA-ECMO spectrum is ECMO-CPR (e-CPR).  Whilst ECMO centres nationally and internationally have published indications and contraindications (which will be discussed), to make decisions around an individual case it is helpful to understand the burden that ECMO support imposes.   For patients this is the physiological burden of being placed on ECMO. This includes frequently the need for ongoing sedation and lack of mobility, the non-physiological cardiorespiratory effects conferred by ECMO, the complications at insertion and during support that patients are exposed to and the uncertain long-term outcomes. These will be discussed further.  The next question is whether all ICUs should be providing this service. The demand for this technology appears to be growing steadily, as is the expectation by other specialties within the hospital for an in-house ECMO service.   Again considering burdens imposed, housing an ECMO programme impacts workload and flow by utilising significant bed-days at the expense of other services that need to be provided, education and credentialing requirements for staff and a financial cost for these resource-intensive patients. These will be discussed individually.  Lastly, the patient outcome implications of centre volume for this highly specialised service will be debated. 

International outcomes of centres performing ECLS (extracorporeal life support) are highly variable due to differences in patient selection, cannulation technique, practitioner experience and hospital volume. We describe the experience of one of the first regional intensive care units in Australia to provide both VV (veno-venous) and rescue VA ECMO (veno-arterial extra-corporeal membrane oxygenation).   Methods  Review of internal registry and description of processes and procedures in an 11 bed regional general ICU without on-site cardiothoracic surgery.  Results  Over a 3.5 year period 21 patients received ECLS (90 ECMO days) with an overall 55% survival. All cannulations were peripheral. 4 patients were retrieved from peripheral site. 8 patients subsequently transferred to quaternary centre. Overall survival for VV ECMO was 64% (n=11), rescue VA ECMO (n=12, 8 from E-CPR) 33% survival.   Conclusion  Provision of ECLS (extracorporeal life support) in large regional centres is possible with outcomes similar to high volume centres if established with realistic goals, limitations, and referral pathways to a supportive high volume referral centre. Advantages include timely establishment of life support without the inherent delays of long distance weather dependent aero-medical retrieval and ability to stabilise and prognosticate at the local site. Straight-forward VV-ECMO can be entirely provided at a regional site whilst highly complex patients can safely await further transfer. Regional ECLS provision facilitates appropriate patients receiving ECLS at an optimal time that minimises excessive morbidity.    

Survival in patients with advanced heart failure (AHF) has improved over the last 2 decades. An increasing number of patients however, are dying with progressive heart failure over the same duration. Optimal utilization of medical therapies and devices like implantable defibrillators and biventricular pacemakers are the likely reasons patients are surviving longer albeit with progressive HF.   Evolution in mechanical circulatory support (MCS) devices has occurred over the same period, such that they can now be rapidly instituted providing support for pump failure, often percutaneously, with timely restitution of physiologic and metabolic derangements with fewer complications.    MCS devices can be classified as Short term and Long term. Short term devices such as Intraaortic balloon pumps (IABP), Impella ®, TandemHeart® or Venoarterial extracorporeal membrane oxygenation (VA – ECMO) using a Cardiohelp® device, are usually employed as ‘Bridge to Recovery’(BTR) or Bridge to Decision’(BTD), usually in acute settings. Long term devices such as implantable left ventricular assist devices (LVADs) e.g. Heartmate II® & 3®, Heart ware HVAD® are implanted as ‘Bridge to transplant’ (BTT) or ‘Destination therapy’ (DT) usually in patients ‘sliding’ on inotropes when they are transplant eligible (BTT) or ineligible (DT) respectively.     Ventricular assist devices have traditionally been developed for left ventricular support in case of severe left heart or biventricular dysfunction. Historically, right ventricular (RV) dysfunction following LVAD implantation or as a component of biventricular dysfunction was managed with either medical therapy, temporary VADs (i.e. ECMO configuration with continuous flow centrifugal pumps like CentriMag®, Rotaflow ®) or occasionally with LVADs placed on the right side. Recently the Impella RP® and ProtekDuo®, percutaneously placed pumps with inflow in the inferior vena cava & right atrium respectively and outflow in pulmonary artery, have become available as less invasive options, for short term RV support.    The Syncardia® is the only approved total artificial heart system currently in use; however various biventricular, total heart systems (e.g. BiVACOR®) in development show promise.     Mechanical circulatory devices provide attractive, viable, physiologically plausible ventricular support options that can be used effectively in carefully selected patients. 

Today we welcome Zachary Kon, M.D., Assistant Professor in the Department of Cardiothoracic Surgery at NYU. In addition to acting as the Surgical Director of Pulmonary Hypertension/Pulmonary Thromboendarterectomy Program, Dr. Kon also acts as the Surgical Director of the NYU Lung Transplantation Program. In addition to > 70 peer-reviewed publications, he has been invited all over the world as an expert speaker in the field pulmonary embolism therapy. We are fortunate to have him in-house to share his knowledge of what to do when the PE is starting to become overwhelming!

We discuss the strategies used to ambulate a pediatric patient with heart failure while on venoarterial extracorporeal membrane oxygenation support (VA ECMO) while waiting for heart transplant. Host: David Werho, MD; Guests: Emily Weissler, MD and Vamsi Yarlagadda, MD (Lucile Packard Children's Hospital); Producer: David Werho, MD.

We discuss the strategies used to ambulate a pediatric patient with heart failure while on venoarterial extracorporeal membrane oxygenation support (VA ECMO) while waiting for heart transplant. Host: David Werho, MD; Guests: Emily Weissler, MD and Vamsi Yarlagadda, MD (Lucile Packard Children's Hospital); Producer: David Werho, MD.

This episode is all about ECMO in trauma - not the usual ARDS, TRALI VV-ECMO - we’re talking about VA ECMO for the acutely dying trauma patient. Zack interviews Pål Ager-Wick from Tromso Norway, and Magnus Larsson from the Karolinska Institute in Stockholm. We talk about everything from how ECMO helps the hemorrhaging trauma patient to the futuristic “Emergency Preservation and Resuscitation” concept being done in Baltimore now. The post EDECMO 38 – ECMO and Trauma – with Pal Ager-Wick and Magnus Larsson appeared first on ED ECMO.

by Steve Morgan & Sophie Connolly Today we are going to cover the essentials of ECMO haemodynamics. Haemodynamics literally means blood movement and thus is the physical study of flowing blood and the structures through which it flows. In bedside vernacular we tend to use haemodynamics to refer to accessible surrogate measurements of cardiovascular performance, such as vascular and chamber pressures or quantifications of macrocirculatory blood flow. To understand the haemodynamic effects of ECMO we will consider the effects of the in-parallel VA circuit and the in-series VV circuit separately. The effect on cardiac performance can be best approached and compartmentalised by examining the impact of ECMO on each of the determinants of stroke volume: preload, afterload and contractility. This podcast covers: How can we best describe ventricular function and the effect of ECMO? What factors influence the net effect of VA ECMO on patient haemodynamics? What are the general primary haemodynamic effects of VA ECMO? How does cannulation site influence the haemodynamics of VA ECMO? What do you do about a non-ejecting heart on VA ECMO? What about the RV? How does the unique functional anatomy and physiology contribute to RV failure? What are the haemodynamic effects of VA ECMO on the RV? What are the haemodynamic effects of VV ECMO?

learnECMO Roger Pye on cannulation, part 1. This podcast is the first of 2 parts of the Cannulation 101 session from the recent ECMOcannulate course. It is delivered by a true expert in the form of Roger Pye, erstwhile renal physician, intensivist and cardiac anaesthetist with 10 years of ECMO retrieval experience. In part 1 Roger gets right down to the grain on VV cannulation and just how vital cannula configuration is to optimising systemic oxygenation, an essential consideration when bundling ECMO patients up for a 4000km aeromedical retrieval. Look out for part 2 which will cover the Avalon cannula and cannulation for VA ECMO. Thanks for listening. If you're interested in honing your cannulation skills go to learnECMO.com to register your interest for ECMOcannulate in 2017. We will also be in Berlin at the blue riband crit care conference, das SMACC, where we will invite all comers to set the ECMO cannulation world record.

In this episode, Zack and Joe talk with Deirdre Murphy, the Deputy Director of the ICU, director of the cardiothoracic ICU at the Alfred Hospital in Melbourne, Australia. The Alfred has put itself on the map in so many ways over the past decade. Home to Stephen Bernard (of the original Hypothermia after ROSC without RONF fame), Chris Nickson (@precordialthump, @I_C_N, @intensiveblog, #SMACC, lifeinthefastlane.com), and good friends Jason McClue, Steve McGloughlin, Josh Ihle, Paul Nixon, and Deirdre Murphy, The Alfred is becoming a mecca for advanced resuscitation and ECMO/ECPR. In this episode we sat down with Dr. Murphy to discuss the nuances of weaning a patient from ECMO. As ED Docs, Zack and I find ourselves at the heroic end of the resuscitation spectrum when the dying patient goes on pump...but what happens at the other end? What happens in the hours, days, and weeks that follow? Listen to this episode to find out... The post EDECMO 24 – Weaning VA-ECMO, with Deirdre Murphy appeared first on ED ECMO.