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Mechanical Circulatory Support in Left Ventricular Heart Failure
Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kirurgiska vetenskaper, Thoraxkirurgi.
2018 (engelsk)Doktoravhandling, med artikler (Annet vitenskapelig)
Fritextbeskrivning
Abstract [en]

Short-term mechanical circulatory support (MCS) with ventricular assist devices or veno-arterial extracorporeal membrane oxygenation (VA ECMO) has become the standard treatment in patients with cardiogenic shock unresponsive to pharmacological treatment. However, the haemodynamic effects of these devices are not yet fully described, nor are their effects on ventricular function and myocardial recovery.

The aims of this thesis are to increase knowledge of the haemodynamic changes during MCS in different settings and to provide new insights into how MCS therapy should be guided in the specific patient.

In Studies I and II, we developed experimental animal models to investigate the effect of VA ECMO on left ventricular (LV) performance and size of myocardial infarction in different cannulation strategies. In Study I, we found that the LV performance was negatively affected by VA ECMO in both centrally and peripherally cannulated animals. In Study II, we specifically studied the effect of VA ECMO with and without the addition of LV drainage on the size of experimentally induced myocardial infarction. The results showed that active LV decompression had no effect on infarct size in the acute setting.

Studies III and IV are retrospective studies on patients in cardiogenic shock treated with short-term mechanical support with either Impella® (Studies III and IV) or VA ECMO (Study IV). In Study IV, we concluded that treatment with Impella® has excellent effects on haemodynamic parameters and an acceptable mortality and complication rate. The studied pre-implantation patient parameters did not significantly affect outcome. In Study IV, we compared the outcome of patients treated with Impella® with those treated with VA ECMO. After adjustment for pre-implantation patient status, as defined by SAVE score, no difference in short- or long-term mortality was seen between the two groups.

In conclusion, VA ECMO, whether central or peripheral, negatively affects the LV, and the addition of a LV drain has no effect on infarct size in these experimental models. Both Impella® and VA ECMO offer good haemodynamic results with acceptable mortality and complication rates in patients with refractory cardiogenic shock. When adjusted for the SAVE score, the outcomes of both treatment modalities are comparable.

sted, utgiver, år, opplag, sider
Uppsala: Acta Universitatis Upsaliensis, 2018. , s. 68
Serie
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1464
Emneord [en]
Mechanical Circulatory Support, Left Ventricular Heart Failure, Left Ventricular Assist Device, Extracorporeal Membrane Oxygenation, ECMO
HSV kategori
Forskningsprogram
Thoraxkirurgi
Identifikatorer
URN: urn:nbn:se:uu:diva-347427ISBN: 978-91-513-0330-7 (tryckt)OAI: oai:DiVA.org:uu-347427DiVA, id: diva2:1197412
Disputas
2018-06-06, Enghoffsalen, Ingång 50 bv, Akademiska sjukhuset, Uppsala, 09:15 (svensk)
Opponent
Veileder
Tilgjengelig fra: 2018-05-14 Laget: 2018-04-12 Sist oppdatert: 2018-05-14
Delarbeid
1. Experimental Venoarterial Extracorporeal Membrane Oxygenation Induces Left Ventricular Dysfunction
Åpne denne publikasjonen i ny fane eller vindu >>Experimental Venoarterial Extracorporeal Membrane Oxygenation Induces Left Ventricular Dysfunction
2016 (engelsk)Inngår i: ASAIO journal (1992), ISSN 1058-2916, E-ISSN 1538-943X, Vol. 62, nr 5, s. 518-524Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has experienced an increased use in acute cardiac failure. There are some reports on negative effects of VA-ECMO on cardiac function, such as left ventricular (LV) dilatation and cardiac stun, but the support in the literature is scarce. This study investigates the effects of experimental VA-ECMO on LV function in both peripheral and central cannulation. Ten pigs were randomized to VA-ECMO by either peripheral cannulation through the femoral vessels or central cannulation in the right atrium and ascending aorta. Left ventricular performance was measured with pressure-volume catheters during 5 hours of VA-ECMO. The LV enddiastolic and end-systolic volumes increased comparably in both groups during ECMO. Left ventricular ejection fraction, stroke work, and maximum rate of pressure change decreased comparably in both groups as a function of time on ECMO. The site of cannulation had no impact on the LV response to ECMO. In conclusion, VA-ECMO increased LV volumes and reduced LV function, irrespective of cannulation site in this experimental model. Reduced LV ejection fraction and stroke work indicated LV dysfunction during ECMO.

Emneord
extracorporeal membrane oxygenation, cannulation, left ventricle, left ventricular assist device
HSV kategori
Identifikatorer
urn:nbn:se:uu:diva-310680 (URN)10.1097/MAT.0000000000000392 (DOI)000387874900006 ()27195745 (PubMedID)
Tilgjengelig fra: 2017-01-09 Laget: 2016-12-19 Sist oppdatert: 2018-04-12bibliografisk kontrollert
2. Left Ventricular Decompression during Extracorporeal Membrane Oxygenation (ECMO) Treatment does not Reduce Size of Myocardial Infarction in an Experimental Model
Åpne denne publikasjonen i ny fane eller vindu >>Left Ventricular Decompression during Extracorporeal Membrane Oxygenation (ECMO) Treatment does not Reduce Size of Myocardial Infarction in an Experimental Model
(engelsk)Manuskript (preprint) (Annet vitenskapelig)
HSV kategori
Identifikatorer
urn:nbn:se:uu:diva-347425 (URN)
Tilgjengelig fra: 2018-04-02 Laget: 2018-04-02 Sist oppdatert: 2018-04-12
3. The Impella® Recover mechanical assist device in acute cardiogenic shock: a single-centre experience of 66 patients
Åpne denne publikasjonen i ny fane eller vindu >>The Impella® Recover mechanical assist device in acute cardiogenic shock: a single-centre experience of 66 patients
2016 (engelsk)Inngår i: Interactive Cardiovascular and Thoracic Surgery, ISSN 1569-9293, E-ISSN 1569-9285, Vol. 22, nr 4, s. 452-458Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

OBJECTIVES: Short-term ventricular assist devices are more frequently used in patients with acute cardiogenic shock. The aim of this study was to evaluate its effect on haemodynamic parameters, as well as the short- and long-term outcome and complication rate associated with the device. METHODS: All patients treated with the ImpellaA (R) Recover device at our centre from 2003 to 2014 (n = 66) were included in this study, and follow-up time was 2.9 (+/- 0.4) years. Data were obtained through patient records and the population register. Patient-related factors, preimplantation and early postimplantation haemodynamic and biochemical parameters were analysed. Characteristics of survivors and non-survivors were compared. RESULTS: The device was implanted in 66 patients and 58% (38/66) were alive at 30 days post-implantation. The mean duration of support was 7.4 (+/- 0.8) days. Mean time in the intensive care unit was 24 (+/- 4) days. Following device implantation, patients' cardiac index improved from 2.1 l/min/m(2) (+/- 0.20) to 3.8 l/min/m(2) (+/- 0.20) at Day 7, mixed venous saturation increased from 56% (+/- 2.0) to 68% (+/- 1.2) and diuresis increased from 69 ml/h (+/- 9) at device insertion to 105 ml/h (+/- 19) at Day 7 on support. Central venous pressure, lactate levels and inotropic support decreased on support. No difference between survivors and non-survivors was established. No correlation was established between preimplant parameters and 30-day mortality. CONCLUSIONS: The ImpellaA (R) Recover device improved haemodynamics in patients with acute cardiogenic shock. Still, 30-day mortality remains high and future studies must focus on the optimal timing of placement of the device.

Emneord
Heart failure, Acute cardiogenic shock, Left ventricular assist device
HSV kategori
Identifikatorer
urn:nbn:se:uu:diva-296864 (URN)10.1093/icvts/ivv305 (DOI)000374228700013 ()26763043 (PubMedID)
Tilgjengelig fra: 2016-06-20 Laget: 2016-06-20 Sist oppdatert: 2018-04-12bibliografisk kontrollert
4. Survival after Refractory Cardiogenic Shock is Comparable in Patients with Impella® and Veno-Arterial Extracorporeal Membrane Oxygenation (ECMO) - when Adjusted for SAVE-score
Åpne denne publikasjonen i ny fane eller vindu >>Survival after Refractory Cardiogenic Shock is Comparable in Patients with Impella® and Veno-Arterial Extracorporeal Membrane Oxygenation (ECMO) - when Adjusted for SAVE-score
(engelsk)Manuskript (preprint) (Annet vitenskapelig)
HSV kategori
Identifikatorer
urn:nbn:se:uu:diva-347426 (URN)
Tilgjengelig fra: 2018-04-02 Laget: 2018-04-02 Sist oppdatert: 2018-04-12

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