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Ann Thorac Surg 1999;68:655-661
© 1999 The Society of Thoracic Surgeons
a Department of CardioThoracic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
Address reprint requests to Dr Magovern, Allegheny General Hospital, 320 East North Ave, Pittsburgh, PA 15212
e-mail: gmagover{at}aherf.edu
Presented at the Fourth International Conference on Circulatory Support Devices for Severe Cardiac Failure, Houston, TX, Oct 3–5, 1997.
Abstract
Background. A mix of cardiac assist options is necessary to meet the diverse indications for cardiac support in a comprehensive heart failure program. At our institution, an adult extracorporeal membrane oxygenation (ECMO) system comprising a centrifugal pump and hollow fiber membrane oxygenator is used for short-term and temporary cardiac assist.
Methods. Between December 1991 and August 1997, 82 adult cardiac patients were supported on ECMO. Indications for cardiac assist included postcardiotomy cardiogenic shock (PCCS, 55 patients), high-risk cardiology intervention (27 patients), perioperative cardiac graft failure (4 patients), and emergency cardiac resuscitation (6 patients). Data for analysis were collected by prospective completion of standardized ECMO report forms and retrospective review of hospital charts.
Results. The ECMO system was inexpensive to operate, uncomplicated to implant, and adaptable for diverse indications. Survival in PCCS was 20 of 55 patients (36%), with an increased survival rate of 56% (18 of 32 patients) in patients with PCCS after isolated coronary bypass. Catheter-based revascularizations were successfully performed in 26 of 27 (96%) high-acuity patients temporarily supported by ECMO, and 23 of 27 patients (85%) survived to discharge. Survival in the cardiac graft failure group was 2 of 4 (50%). No patient supported on ECMO for cardiac resuscitation survived.
Conclusions. ECMO provides good cardiopulmonary and end-organ support; survival rates are similar to or higher than those seen with centrifugal pump support in comparable patient populations.
Mechanical cardiac assist is an integral component of a multidisciplinary adult heart failure program. For optimum outcomes, a mix of cardiac support options must be available to meet the diverse needs of this large patient population. Indications for cardiac assist include chronic cardiac support and bridge to recovery, bridge to transplant, short-term postcardiotomy cardiogenic shock (PCCS), temporary support for high-risk cardiology interventions, and emergency cardiac resuscitation. In addition, the cardiac surgeon may also be asked to provide circulatory support in such settings as pulmonary embolism, hypothermia, and trauma.
At Allegheny General Hospital, temporary and short-term cardiac assist requirements are met with a flexible, low-cost extracorporeal membrane oxygenation (ECMO) system. The system features rapid deployment capabilities and the enhanced biocompatibility of heparin-coated components (Cormeda Bioactive Surface, Medtronic, Minneapolis, MN) [1].
The Allegheny ECMO system was developed in 1991 after a 12-year experience with the Medtronic BioPump as a PCCS support device [2]. Eighty PCCS patients had ventricular assist using the BioPump during this period, and survival to discharge was 36% (29 of 80 patients). In an effort to reduce the rates of end-organ complications and decrease bleeding, we incorporated the BioPump into an ECMO cardiopulmonary support system. This report describes current utilization patterns and results with this ECMO system at our institution.
Material and methods
Device
Detailed descriptions of the Allegheny ECMO system have been published previously [3]. Briefly, the system comprises a hollow-fiber membrane oxygenator with integral heat exchanger (Maxima; Medtronic, Inc), a centrifugal pump (BioPump; Medtronic, Inc), a Sechrist oxygen/air blender, and a water heater/cooler (Sarns, Minneapolis, MN). All components, including tubing for the arterial-venous loop, are coated with the Carmeda bioactive surface (CBAS).
Cannulation is via a transthoracic or femoral approach depending upon the indication for use and individual patient characteristics. The right atrial to aortic loop is accomplished using a 46/36F two-stage cannula (Research Medical, Midvale, UT) and a 22F right-angle catheter (Research Medical). Biomedicus catheters (19–22F) are used to establish the femoral venoarterial loop. For patients who fail to separate from cardiopulmonary bypass after open heart surgery, institution of ECMO may be facilitated by using the previously inserted cardiopulmonary bypass catheters. Cannulation for temporary support during catheter-based procedures is accomplished via a standard cutdown technique for controlled access to the femoral vessels.
Anticoagulation
In open heart surgery patients placed on ECMO after failure to wean from cardiopulmonary bypass, heparin is reversed with protamine after ECMO is instituted. Protamine dosage in this setting is normally reduced by about 25% compared with normal post-open heart dosages. For other indications, heparinization is begun before cannulation.
During assist, bolus injections of heparin are used to maintain an activated clotting time (ACT) of > 160 seconds during full flow (an ACT of > 180–190 seconds is maintained in patients with artificial valves). A continuous heparin drip is used to achieve an ACT of > 200 seconds during significant reductions in pump flow, as during weaning trails.
Patient management
Patients are ventilated with a volume-controlled ventilator at an inspired oxygen fraction of 50% or less. Respiratory rate is set to eight/min or less with a tidal volume of 10 mL/kg and a positive end-expiratory pressure of 5 cm H2O. Ventilator settings are adjusted to maintain peak airway pressures of less than 35 cm H2O. An oxygen/air blender (Sechrist Industries, Anaheim, CA) is used to ventilate the membrane oxygenator.
Flow rates for the BioPump and membrane oxygenator are maintained at a 1:1 ratio to ensure efficient oxygenator function. Membrane changes are performed every 48 hours, or sooner if evidence of decreased permeability occurs. Low-dose inotropes are used during the support period to maintain contractility and reduce interventricular blood stasis. An intraaortic balloon pump (IABP) is inserted in most patients to reduce afterload, improve coronary perfusion, and to add a pulsatile component to the circulation. Specific details of our patient management protocol have been previously documented [4].
Weaning from assist
Ventricular function is monitored at the bedside by echocardiography and by visual inspection of the heart in patients without sternal closure. Formal weaning trials are normally not initiated during the first 24 hours of ECMO support. During the weaning, trial pump flow is gradually decreased to less than 1 L/min for no more than 2 minutes. Full flow is promptly reinstituted if evidence of poor ejection is noted. As ventricular recovery progresses, BioPump flow is gradually reduced. The ECMO system is removed when a weaning trial demonstrates native cardiac index exceeding 2.2 L/min.
Data collection and analysis
Data collection in cardiac surgery patients was performed during the support period using standardized forms to record details of patient medical history, hospital course, laboratory, hemodynamic, and ECMO system function variables. Data on patients from the cardiology service were collected retrospectively by review of hospital charts. 
2 and Student’s t tests were used to compare population variables as appropriate. Data are expressed as mean ± standard error of the mean unless otherwise noted.
Patient population: PCCS
Between December 1991 and August 1997, 8,300 patients underwent open-heart surgery at Allegheny General Hospital. Approximately 60 patients met the criteria for PCCS cardiac assist (1%). Of these, 55 patients were placed on the Allegheny ECMO system. Mean age of the ECMO-supported patients was 62 ± 1.4 years of age (range 34–79 years), and 24 (44%) were female.
Surgical procedure included isolated coronary artery bypass graft (CABG) in 36 patients, mitral valve repair or replacement in 8 patients, aortic valve replacement in 6 patients, the Ross procedure in 1 patient, ventricular septal defect (VSD) repair with CABG in 2 patients, and thoracic aorta repair in 2 patients. Seventeen patients had emergency procedures, 26 patients had urgent procedures (stable but hospitalized), and 12 patients had elective procedures (same-day admit). Nineteen procedures were redo sternotomies.
ECMO support was initiated at the time of surgery in 32 patients and 1 to 48 h after surgery in 23 patients. Cannulation was via the femoral venoarterial route in 13 patients and via a right atrial to aortic loop in 42 patients.
Patient population: cardiac graft failure
From December 1987 to August 1997, 111 patients had cardiac transplant at Allegheny General Hospital, and 7 of these required support for graft failure in the immediate posttransplant period. Four of these patients were supported on the Allegheny ECMO system. Mean age of these patients was 57 ± 2 years, and 1 was female. The indication for cardiac transplant was ischemic cardiomyopathy in all patients, and all patients had evidence of moderate levels of reversible pulmonary hypertension before transplant. Three patients were hospitalized on inotropic therapy at the time of transplant and 1 was awaiting transplant at home.
Patient population: cardiology intervention support
Twenty-seven patients underwent planned catheter-based coronary revascularization procedures with ECMO support during the period between October 1994 and May 1996. Mean age of the patients was 73.5 ± 2.1 years (range 52–95 years) and 6 were female (23%). Indication for ECMO-supported intervention was refractory unstable angina or congestive heart failure in a patient judged to be at high risk due to left ventricular dysfunction or increased comorbidity burden. Major comorbid conditions in this population included lung disease, end-stage renal disease, peripheral vascular disease, advanced age, morbid obesity, constrictive pericarditis, and terminal mediastinal cancer. Revascularization procedures included balloon dilatation, atherectomy, and stent placement. An average of 1.6 vessels per patient were revascularized, including left main coronary artery revascularization in 12 patients.
Patient population: emergency cardiac resuscitation
The cardiac surgery service was consulted for emergency implantation of ECMO in 6 patients who had sudden cardiac collapse in the catheterization laboratory (5 patients) or medical intensive care unit (1 patient). Mean age of the patients was 59.3 ± 4.3 years, and 3 (50%) were female. All patients had undergone an extensive resuscitation protocol before institution of ECMO and neurologic function was uncertain in all but 1 patient, who was documented to be neurologically intact.
Results
PCCS population
Mean length of assist was 41.9 ± 3.1 hours (range 8–137 hours). Length of assist for survivors was 37.3 ± 12.7 hours in survivors and 44.8 ± 4.6 hours in nonsurvivors. Mean flow on ECMO was similar in survivors and nonsurvivors (Fig 1) and in patients cannulated via the femoral versus the transthoracic loop (Fig 2).
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Complications in survivors included renal failure managed medically (no dialysis) in 2 patients (2 of 20 patients, 10%), stroke (2 patients, 10%), transient neurological symptomology (5 patients, 25%), and major sternal infection (2 patients, 10%).
Respiratory complications in survivors included refractory ventilator dependence in 1 patient. Six additional patients required tracheostomy before ventilator wean (35%). Mean time to extubation was 13 days (range 14–41 days). Mechanical ventilation was prolonged in these patients primarily due to an increased rate of respiratory infection after separation from ECMO (14 of 20 patients, 70%).
Six of 13 patients (48%) with femoral cannulation for ECMO required reoperation for femoral vessel repair. Two of these 6 patients were survivors.
Mean length of stay in the intensive care unit, including time on ECMO support, was 16.7 ± 2.0 days (range 6–33 days). Total postoperative length of stay averaged 38.8 ± 7.2 days (13–161 days).
Bleeding was noted in all PCCS ECMO patients. The average number of units of red blood cells, fresh frozen plasma, and platelets administered was 29 ± 2, 19 ± 2, and 36 ± 4 units, respectively. Survivors received slightly fewer units of red blood cells (23 ± 3 vs 33 ± 3 units), fresh frozen plasma (13 ± 3 vs 23 ± 3 units), and platelets (30 ± 5 vs 40 ± 6 units) in comparison with nonsurvivors). Bleeding was manageable in all patients.
Evidence of platelet destruction and hemolysis were also common. Changes in platelet count could not be shown to correlate with centrifugal pump speed; however, a definitive analysis of this relationship was hindered by the complexity of the setting and the relatively small number of patients. Platelet counts and pump speed over the initial 48 hours of support are shown in Figure 3. Maximum plasma hemoglobin levels per patients ranged from 40 to 220 G/dL in survivors and 40 to 390 G/dL in nonsurvivors. Mean serum glutamic-pyruvic transaminase (SGPT) levels were elevated but stable (191 ± 111 IU/L at insertion, 174 ± 121 IU/L at 48 hours), indicating no new onset of hepatic insult. Mean serum creatinine remained normal in survivors and were slightly elevated in nonsurvivors. Seven patients required dialysis after institution of ECMO support; none of these patients survived.
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Mean length of assist was 37.9 ± 8.1 hours. Twenty-five patients were weaned from assist, and 18 of the 32 patients (56%) in this group survived to discharge.
Group 2 ECMO after valve surgery
Fifteen patients were supported on ECMO after surgery for: mitral valve repair (3 patients), mitral valve replacement (5 patients), aortic valve replacement (6 patients), or the Ross procedure (1 patient). Three patients (2 mitral valve repair and 1 mitral valve replacement, 20%) had emergent procedures. Mean age of the patients was 62.1 ± 3.7 years and 9 (60%) were female. ECMO was placed during the primary procedure in 9 patients and 1 to 18 h postsurgery in 6 patients.
Mean length of assist was 45.8 ± 8.2 hours. As expected, bleeding was increased in this group. Mean units of blood products transfused was 46 ± 5 units of packed red blood cells, 30 ± 6 units of fresh frozen plasma, and 54 ± 11 units of platelets. Ten patients were weaned from the device, and 2 patients, both with aortic valve replacement, survived (13%).
Group 3 ECMO after cardiotomy and prolonged cardiac arrest
Six patients had ECMO placed after cardiotomy complicated by prolonged cardiac arrest events outside the operating room. Three patients had salvage cardiac operations (2 CABG, 1 thoracic aorta repair) within 1 hour after cardiac arrest, and none of these could be weaned from cardiopulmonary bypass; ECMO was instituted in these patients with the hope that preoperative neurologic insult might prove to be manageable if cardiac function recovered. Three additional patients had ECMO placed after prolonged arrest events occurring 1 h to 2 days after technically successful cardiac surgery (2 CABG, 1 thoracic aorta repair).
All patients were male and the mean age in this group was 57.2 ± 5 years. Mean length of assist was 35.6 ± 6.6 hours. No patient in this group survived to discharge. Limited or no evidence of significant neurologic function was noted during ECMO support. Only 1 patient had sufficient cardiac recovery to permit wean from ECMO; however, he succumbed to biventricular failure and brainstem injury.
Group 4 ECMO after surgery for VSD repair
Two patients, a 52-year-old man and a 71-year-old woman, underwent emergency surgery for VSD repair and required ECMO support upon separation from cardiopulmonary bypass. Acute inferior myocardial infarction had been diagnosed in both patients. One patient with severe preoperative right heart failure failed to respond to ECMO support and died on postoperative day 1. The second patient had intraoperative evidence of adequate but depressed left and right ventricular function, and developed severe right heart failure during the support period due to residual flow through the VSD. He died after reoperative VSD repair on postoperative day 4.
PCCS mortality summary
Distribution of key clinical variables in survivors and nonsurvivors is presented in Table 2. No factor demonstrated significant association with survival after PCCS and ECMO support other than isolated CABG as surgical procedure.
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Three patients were successfully weaned from ECMO; 2 of these were discharged to home. Length of ECMO support in the 2 discharged patients was 36 and 41 hours. One of these patients had prolonged mechanical ventilation and was discharged 49 days after transplant. The second survivor had no additional complications and returned home on postoperative day 13. One nonsurvivor died of refractory cardiac failure after 100 hours of ECMO support. The fourth patient was successfully weaned from support after 18 hours of ECMO assist and 72 hours of isolated right ventricular support with the BioPump. This patient had a long, complicated postoperative course and died from multiple system failure 46 days after transplant.
ECMO support for cardiology intervention
Mean length of ECMO support for the 27 patients was 100.1 ± 10.7 minutes (range 46–306 minutes). One patient had an additional 20 hours of ECMO support for hemodynamic instability due to significant blood loss during the revascularization procedure. Eighteen patients were extubated in the catheterization laboratory, 6 patients were extubated within 24 hours of the procedure, and 2 patients remained on mechanical ventilation for 48 hours after the procedure. One patient required prolonged ventilator support and was extubated 4 days after leaving the cardiac laboratory. All patients were observed in the intensive care unit for at least 12 hours. Mean intensive care unit stay was 3.1 ± 0.5 days (range 1–13 days).
Complications after ECMO-supported cardiology intervention were modest in this high-risk population and included significant bleeding at the cannulation site in 1 patient, reoperation for femoral vessel repair in 6 patients, heart block requiring permanent pacer in 1 patient, mild myocardial infarction in 2 patients, and low cardiac output in 3 patients. One revascularization procedure was considered to be technically unsuccessful and the patient was discharged on medical management. Four patients died before discharge (15%). Cause of death was cardiac arrest in 2 patients and recurrent heart failure in 2 patients. Mean length of stay after revascularization was 8.5 ± 1.1 days (range 2–23 days). Three patients were discharged to a rehabilitation facility.
ECMO support for emergency cardiac resuscitation
Mean length of support in this population was 43.2 ± hours (range 3–76 hours). One patient underwent emergency balloon revascularization of the left main coronary artery after cardiac arrest and placement of ECMO. Only 1 patient had evidence of significant neurologic function while on ECMO, but none developed sufficient cardiac function to permit separation from support. No patient in this group survived. Cause of death was cardiogenic shock in all 6 patients.
Comment
Temporary and short-term cardiac assist will continue to be required for management of cardiac failure in a wide variety of applications. Evaluation of assist devices in these settings is difficult due to unstable status of the patient before most implantations and increased acuity in this patient population. Unlike the majority of cardiac transplant candidates who become eligible for chronic assist/bridge to transplant, the short-term assist patient usually presents with an increased comorbidity burden and acute ischemic end-organ insult and hemodynamic instability. Determining the safety and efficacy of cardiac assist devices for this complex patient population will not be an easy process.
The ideal strategy for short-term cardiac assist will combine low cost, adaptability to diverse applications and patient requirements, and feature rapid and easy deployment. The ECMO system used at Allegheny General has demonstrated these criteria in 5 years of use. Overall survival rates in ECMO-supported PCCS equal those in our experience with the Medtronic BioPump, and in selected patient populations, ECMO support appears to increase survival. The flexibility and patient control afforded by uncomplicated implantation and full cardiopulmonary assist makes ECMO an attractive choice for a heart failure program.
The rate of complications in the PCCS population is high, as expected in this critically ill patient group. The ECMO system appears to provide good cardiopulmonary and end-organ support, however, and serious complications directly attributable to the support device are rare. The advantages of employing heparin-coated components in the assist system have not been convincingly demonstrated. Although only 1 of our patients has had a documented embolic event (transient cerebrovascular accident [CVA] in a patient who survived to discharge), evidence of clot formation on a small number of cannula tips and on echocardiographic images have led us to reinstitute low level heparinization during support, as well as low-dose inotropic support to maintain ventricular contractility. Platelet destruction and hemolysis continue to be seen in most patients, although significant hepatic and renal dysfunction do not appear to develop as a consequence of these processes.
A recently published series of PCCS patients supported on a similar ECMO system at the Cleveland Clinic provides an interesting contrast with our experience [5]. Overall mortality in the Cleveland Clinic series (including 22 patients referenced in an addendum to the paper) was the same as ours (36%). The primary differences between the two patient populations are significantly younger age (47.3 ± 16.4 years, Cleveland vs 62 ± 1.4 years, AGH; p < 0.001) and preponderance of femoral cannulation (74%, Cleveland vs 24% AGH, p < 0.001). Possibly due to the younger age of the Cleveland group, conversion to bridge to transplant was accomplished in 4 of their patients with three successful transplants. We consider bridge to transplant to be an option for ECMO-supported patients who fail to exhibit cardiac recovery, however, in our PCCS population only 1 patient has met the standard criteria for acceptance into a transplant program. This 60-year-old man with ventricular failure after aortic valve replacement for aortic stenosis maintained good end-organ function during 48 hours of ECMO support and was provisionally accepted for transplant. His family refused permission for further treatment according to previously expressed patient directives and he died after separation from support.
At Allegheny, femoral cannulation for ECMO support is used primarily for temporary and emergency support applications. In PCCS patients, our preference is to employ transthoracic cannulation to increase available flow volume. Figure 2 illustrates mean flow volumes over the first 48 hours of ECMO support. Flow via femoral cannulation appears to equal that available via the transthoracic route, although it is difficult to assess flow differences due to the large interpatient variability. A factor not evident from the graph is our observation that the flow values in the femoral group were likely to be near the maximum available, whereas flow rates in the transthoracic group usually had the capacity to be increased if needed. These findings are certainly influenced by the age of our patient population, and the increased occurrence of clinical and subclinical peripheral vascular disease in an older patient population.
Femoral cannulation confers the potential for sternal closure during support, but significant benefits from this option are not apparent in most patients. Allegheny cardiothoracic surgeons have had considerable experience with postcardiotomy open chest management [6]. Thoracic access for cardiac observation and meticulous control of bleeding are important advantages with this approach, especially over short (2–3 days) support periods.
Complications at the femoral cannulation site are also increased in older and higher acuity patients. In our experience, 6 of 13 PCCS patients with femoral cannulation (48%) and 6 of 27 cardiology support patients (22%) required intervention for femoral vessel repair, embolectomy, or hematoma. Significant bleeding at the femoral cannulation site was noted in one debilitated patient cannulated for balloon angioplasty, and this patient required subsequent femoral vessel repair. Of the 12 patients with femoral cannulation site complications, 7 survived to discharge. Cannulation site complications were not related to cause of death in the 5 nonsurvivors. This source of increased postprocedure morbidity remains a concern in selection of cannulation approach in our patients.
During our 5 years of experience with the Allegheny ECMO system, we have expanded the indications for use of this cardiac assist approach. ECMO support for high-risk cardiology intervention has proved to be reliable and highly successful for management of this complex and difficult patient population. We have not been successful in employing ECMO support for patients with prolonged cardiac arrest. The majority of these patients have suffered significant neurologic insult in conjunction with cardiac collapse, and this complicates the decision to attempt cardiac salvage.
An interesting group of ECMO-supported patients is the cardiac graft failure population. Cardiac graft failure in our experience is most often related to refractory pulmonary hypertension. ECMO support appears to be more successful in this setting when compared with our experience with BioPump support in perioperative graft failure. Three patients had biventricular assist with BioPump after cardiac transplant without successful reversal of graft failure. One patient died on assist and 2 patients required retransplant for separation from assist (1 retransplanted patient survived to discharge). In contrast, 3 of 4 cardiac transplant patients supported on ECMO regained sufficient graft function to be weaned from support (2 survivors). These numbers are certainly too small to be conclusive; increased survival for this population is best approached through preoperative intervention and patient selection with an emphasis on assessing the reversibility of pulmonary hypertension. ECMO support, however, might be a promising therapy for early graft failure due to medically refractory pulmonary hypertension.
In the PCCS population, it is clear that delineation of patient-related and device-related factors affecting survival will be a long process. We do not know what the maximum achievable salvage rate is in this setting. In addition, it is possible that current advances in myocardial protection techniques have reduced the number of potential PCCS survivors by preventing this complication in all but the most compromised patients. Our observations to date suggest that patients with more acute myocardial insult, such as that seen in ischemic cardiac disease, may be more likely to respond to short-term cardiopulmonary assist.
Bleeding complications and hemolysis continue to be a concern with adult ECMO systems. At this time, no innovative strategies for reducing these problems have been developed. Close control of anticoagulation and bleeding sites will continue to be essential.
In summary ECMO has been shown to be a viable option for short-term assist in the adult cardiac failure patient. Variability in etiology and duration of failure, as well as in overall patient acuity, complicate evaluation of results, but survival is clearly increased in high mortality settings. Further refinements in methods and technology are needed to overcome persistent problems with blood-contacting components.
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M. Massetti, M. Tasle, O. Le Page, R. Deredec, G. Babatasi, D. Buklas, S. Thuaudet, P. Charbonneau, M. Hamon, G. Grollier, et al. Back from Irreversibility: Extracorporeal Life Support for Prolonged Cardiac Arrest Ann. Thorac. Surg., January 1, 2005; 79(1): 178 - 183. [Abstract] [Full Text] [PDF]
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N. Doll, B. Kiaii, M. Borger, J. Bucerius, K. Kramer, D. V. Schmitt, T. Walther, and F. W. Mohr Five-Year results of 219 consecutive patients treated with extracorporeal membrane oxygenation for refractory postoperative cardiogenic shock Ann. Thorac. Surg., January 1, 2004; 77(1): 151 - 157. [Abstract] [Full Text] [PDF]
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S. Christiansen, S. Brose, L. Demircan, and R. Autschbach A new right ventricular assist device for right ventricular support Eur J Cardiothorac Surg, November 1, 2003; 24(5): 834 - 836. [Abstract] [Full Text] [PDF]
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N. Moazami and P. M. McCarthy Temporary Circulatory Support Card. Surg. Adult, January 1, 2003; 2(2003): 495 - 520. [Full Text]
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N. G. Smedira, N. Moazami, C. M. Golding, P. M. McCarthy, C. Apperson-Hansen, E. H. Blackstone, and D. M. Cosgrove III Clinical experience with 202 adults receiving extracorporeal membrane oxygenation for cardiac failure: Survival at five years J. Thorac. Cardiovasc. Surg., July 1, 2001; 122(1): 92 - 102. [Abstract] [Full Text] [PDF]
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N. G. Smedira and E. H. Blackstone Postcardiotomy mechanical support: risk factors and outcomes Ann. Thorac. Surg., March 1, 2001; 71(2007): S60 - S66. [Abstract] [Full Text] [PDF]
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F. D. Pagani, K. D. Aaronson, F. Swaniker, and R. H. Bartlett The use of extracorporeal life support in adult patients with primary cardiac failure as a bridge to implantable left ventricular assist device Ann. Thorac. Surg., March 1, 2001; 71(2007): S77 - S81. [Abstract] [Full Text] [PDF]
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J. A. Magovern, M. J. Sussman, A. H. Goldstein, G. W. Szydlowski, E. B. Savage, and S. Westaby Clinical results with the AB-180 left ventricular assist device Ann. Thorac. Surg., March 1, 2001; 71(2007): S121 - S124. [Abstract] [Full Text] [PDF]
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F. D. Pagani, K. D. Aaronson, D. B. Dyke, S. Wright, F. Swaniker, and R. H. Bartlett Assessment of an extracorporeal life support to LVAD bridge to heart transplant strategy Ann. Thorac. Surg., December 1, 2000; 70(6): 1977 - 1985. [Abstract] [Full Text] [PDF]
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