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Tarzia, Vincenzo (2015) Extracorporeal membrane oxygenation(ECMO) in refractory cardiogenic shock: impact of acute versus chronic etiology on outcome. [Tesi di dottorato]

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Abstract (inglese)

Refractory cardiogenic shock (CS) is a condition that continues to have a very high mortality despite advances in medical therapy. Conventional treatment typically comprises inotrope infusions, vasopressors and intra-aortic-balloon-pump (IABP). When circulatory instability is refractory to these treatments, mechanical circulatory support represents the only hope for survival, as indicated by current guidelines. As most of these patients present with critical circulatory instability requiring urgent or emergent therapy, the chosen mechanical assistance should be rapidly and easily implanted. For this reason ExtraCorporeal Membrane Oxygenation (ECMO) represents the ideal “bridge-to-life” and increasingly it is used to keep the patient alive while the optimal therapeutic management is determined (bridge-to-decision). Management may then follow one of three courses: “bridge-to-recovery”: patient recovery, and weaning from ECMO; “bridge-to-transplant”: direct heart transplantation; “bridge-to-bridge”: placement of ventricular-assist-device or total artificial longer-term support. There have been several large reports on the use of ECMO as a mechanical support in post-cardiotomy patients but relatively few, mostly small case-series focusing on its role in primary acute cardiogenic shock outside of the post-cardiotomy setting.
We present the results of our centre’s experience (Padova) in the treatment of primary acute cardiogenic shock with the PLS-Quadrox ECMO system (Maquet) as a bridge to decision. Furthermore, we evaluated the impact of etiology on patient outcomes by comparing acute primary refractory CS secondary to acute myocardial infarction (AMI), myocarditis, pulmonary embolism (PE) and post-partum cardiomyopathy (PPCM) with acute decompensation of a chronic cardiomyopathy, including dilated cardiomyopathy (DCM), ischemic cardiomyopathy (ICM) and grown-up-congenital-heart-diseases (GUCHD). We also analyzed whether duration and magnitude of support may predict weaning and survival.
Materials and Methods. Between January 2009 and March 2013, we implanted a total of 249 ECMO; in this study we focused on 64 patients where peripheral ECMO was the treatment for primary cardiogenic shock. Thirty-seven cases (58%) were “acute” (Group A-PCS: mostly acute myocardial infarction, 39%), while twenty-seven (42%) had an exacerbation of “chronic” heart failure (Group C-PCS: dilated cardiomyopathy 30%, post-ischemic cardiomyopathy 9%, congenital 3%).
Results. In group C-PCS, 23 patients were bridged to a LVAD (52%) or heart transplantation (33%). In group A-PCS, ECMO was used as bridge-to-transplantation in 3 patients (8%), bridge-to-bridge in 9 (24%), and bridge-to-recovery in 18 patients (49%). One patient in both groups was bridged to conventional surgery. Recovery of cardiac function was achieved only in group A-PCS (18 vs 0 pts, p=0.0001). Mean-flow during support ≤60% of the theoretical flow (BSA*2.4) was a predictor of successful weaning (p=0.02). Average duration of ECMO support was 8.9 ±9 days. Nine patients (14%) died during support; 30-day overall survival was 80% (51/64 pts); 59% of patients were discharged, in whom survival at 48 months was 90%. Better survival was observed in patients supported for 8 days or less (74% vs 36%, p=0.002).
Conclusions. In “chronic” heart-failure ECMO represents a bridge to VAD or heart-transplantation, while in “acute” settings it offers a considerable chance of recovery, often representing the only required therapy.

Abstract (italiano)

Lo shock cardiogeno refrattario è una condizione gravata da alta mortalità nonostante i progressi nella terapia medica. Il trattamento convenzionale comprende infusione di inotropi, vasopressori, e contropulsazione aortica (intra-aortic-balloon-pump – IABP). Quando l’instabilità emodinamica è refrattaria a questi trattamenti, il supporto meccanico al circolo rappresenta la sola possibilità di sopravvivenza, come indicato dalle attuali linee guida. Tuttavia, poichè la maggior parte di questi pazienti si presenta con severa instabilità emodinamica che richiede un intervento urgente o emergente, l’assistenza meccanica scelta dovrebbe essere impiantabile in maniera rapida e semplice. Per questa ragione, l’ExtraCorporeal Membrane Oxygenation (ECMO) rappresenta l’ideale “bridge-to-life”, che sempre più viene usato per supportare le funzioni vitali in attesa che il programma terapeutico ottimale venga stabilito (bridge-to-decision). L’iter terapeutico può poi seguire tre diversi percorsi: “bridge-to-recovery”: il paziente recupera una funzione cardiocircolatoria tale da permettere lo svezzamento dall’ECMO; “bridge-to-transplant”: il paziente viene sottoposto a trapianto cardiaco; “bridge-to-bridge”: il paziente viene trattato con impianto di un’assistenza ventricolare o di un cuore artificiale totale. Sono state riportate diverse ampie casistiche sull’uso dell’ ECMO come supporto meccanico in pazienti con shock dopo intervento cardiochirurgico (“post-cardiotomy”), ma relativamente poche serie, e limitate a pochi casi, focalizzate sul ruolo dell’ECMO nello shock cardiogeno primario (non post-cardiotomico).
In questo studio si presenta l’esperienza del centro di Padova nel trattamento dello shock cardiogeno primario con il sistema ECMO PLS-Quadrox (Maquet) come bridge-to-decision.
In particolare, la ricerca proposta si prefigge di valutare l’impatto della differente eziologia sull'outcome dei pazienti, paragonando gli shock cardiogeni primari “acuti”, secondari ad infarto miocardico acuto, miocardite, embolia polmonare e cardiomiopatia post-partum, con scompensi acuti di cardiomiopatie “croniche”, includendo cardiomiopatie dilatative primitive, post-ischemiche, e cardiopatie congenite dell’adulto. Si è infine analizzato se la durata e l’entità del supporto possano predire la chance di sopravvivenza e di svezzamento.
Materiali e metodi. Tra Gennaio 2009 e Marzo 2013, sono stati impiantati con ECMO un totale di 249 pazienti, di questi 64 erano affetti da shock cardiogeno "primario" (52 uomini e 12 donne, di 50±16 anni di età) e sono stati trattati con supporto ECMO periferico. Trentasette casi (58%) sono stati classificati come "acuti" (Gruppo A, Acuti, IMA 39%, miocardite 6%, embolia polmonare 8%, post-partum 2%), mentre i rimanenti 27 (42%) shock erano insorti in un quadro di scompenso cardiaco "cronico" (Gruppo B, Cronici, cardiomiopatia dilatativa primitiva 30%, cardiomiopatia dilatativa post-ischemica 9%, patologie congenite 3%).
Risultati della ricerca. Nel gruppo con scompenso cardiaco cronico (Gruppo B), 23 pazienti sono stati trattati con impianto o di assistenza ventricolare sinistra (52%) o trapianto cardiaco ortotopico (33%). Nel gruppo con scompenso cardiaco acuto (Gruppo A), l' ECMO è stato usato come ponte a trapianto in 3 pazienti (8%), come ponte ad impianto di assistenza ventricolare sinistra in 9 pazienti (24%) e come ponte al recupero della propria funzionalità cardiaca in 18 pazienti (49%).
Un solo paziente in ogni gruppo è stato trattato con chirurgia tradizionale. Il recupero della funzionalità cardiaca si è osservato solo all'interno del Gruppo A (18 vs. 0 pazienti, p=0,0001). E' stato visto che mantenere un flusso medio di supporto ≤60% del flusso teorico (BSA*2,4) costituisce un predittore positivo di svezzamento dal dispositivo (p=0,02). Globalmente, la durata media del supporto ECMO è stata di 8,9±9 giorni. Nove pazienti (14%) sono deceduti durante il supporto ECMO; la sopravvivenza globale a 30 giorni è stata dell' 80% (5/64 pazienti); il 59% dei pazienti è stato dimesso dall’ ospedale e, tra questi, la sopravvivenza a 48 mesi è stata del 90%, senza differenze significative nei due gruppi. La sopravvivenza migliore si è osservata in quei pazienti che hanno necessitato di supporto ECMO per un periodo inferiore o uguale ad 8 giorni (74% vs. 36%, P=0,002).
In conclusione nei pazienti con shock cardiogeno refrattario nell'ambito di uno scompenso cardiaco cronico l'ECMO rappresenta un dispositivo-ponte verso l'impianto di assistenza ventricolare sinistra o verso trapianto cardiaco. Nei pazienti con shock refrattario dovuto ad eziologia acuta, invece, tale supporto offre sostanziali chance di recovery, costituendo spesso l'unica terapia necessaria.

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Tipo di EPrint:Tesi di dottorato
Relatore:Gerosa, Gino
Dottorato (corsi e scuole):Ciclo 27 > scuole 27 > SCIENZE MEDICHE, CLINICHE E SPERIMENTALI > SCIENZE CARDIOVASCOLARI
Data di deposito della tesi:03 Febbraio 2015
Anno di Pubblicazione:02 Febbraio 2015
Parole chiave (italiano / inglese):Extracorporeal Membrane Oxygenation (ECMO); Shock Cardiogeno; Supporto Meccanico al Circolo / Extracorporeal Membrane Oxygenation (ECMO); Cardiogenic Shock; Mechanical Circulatory Support
Settori scientifico-disciplinari MIUR:Area 06 - Scienze mediche > MED/23 Chirurgia cardiaca
Struttura di riferimento:Dipartimenti > Dipartimento di Scienze Cardiologiche, Toraciche e Vascolari
Codice ID:8019
Depositato il:10 Nov 2015 11:29
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III CAPITOLO Cerca con Google

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