TY - JOUR
AU - Takeda,, Koji
AB - Abstract Postcardiotomy shock is a complication after open-heart surgery that may be alleviated with extracorporeal life support (ECLS). Postcardiotomy shock patients on ECLS with prosthetic valves are at a high risk of valve thrombosis. We retrospectively reviewed patients supported with ECLS after the development of postcardiotomy shock at our centre, 90 of which had prosthetic valves. Nine patients developed prosthetic valve thrombosis, an incidence of 10%. Patients who developed prosthetic valve thrombosis were more often supported via central cannulation (78% vs 38%, P = 0.034) and had a higher median initial flow (4.4 vs 3.2 l/min, P = 0.018). Central cannulation was associated with valve thrombosis by multivariable logistic regression (odds ratio 7.56; 95% confidence interval 1.12–149.87). Central cannulation with high flow is thought to reduce intracardiac blood flow, thereby increasing the risk of stasis and thrombus formation. Patients with prosthetic valve thrombosis were treated with anticoagulation or surgical intervention and 4 patients (44%) survived to discharge. Extracorporeal life support, Postcardiotomy shock, Prosthetic valve thrombosis INTRODUCTION Postcardiotomy shock (PCS) is a devastating complication after open-heart surgery with an incidence of 0.5–1% [1]. When pharmacological treatment fails to stabilize PCS patients, mechanical circulatory support is often used in an attempt to maintain end-organ perfusion and to facilitate myocardial recovery [2]. Veno-arterial extracorporeal life support (ECLS) is a mechanical circulatory support device capable of providing temporary cardiopulmonary support. However, ECLS decreases flow through the cardiac chambers that can predispose patients to developing intracardiac stasis and thrombosis, especially in those with prosthetic valves [1–3]. While case reports have documented prosthetic valve thrombosis (PVT) during ECLS, the risk of PVT after PCS remains uncertain [3–5]. This study assessed the incidence and outcomes of PVT in patients with PCS requiring ECLS following valve surgery. METHODS We retrospectively reviewed patients who received ECLS for PCS from January 2007 to July 2019. This study was approved on 2 June 2020 by the Columbia University Medical Center IRB Protocol AAAE1866 (informed consent waived). Baseline characteristics and outcomes data were collected by chart review. Continuous variables were displayed as medians with interquartile ranges and compared using the Mann–Whitney test. Categorical variables were displayed as numbers and percentages and compared using Fisher’s exact test. Factors associated with PVT were assessed by multivariable logistic regression. All statistical analyses were performed using R version 4.0.0. The anticoagulation protocol used during this study period was as follows: protamine was administered in the operating room. When haemostasis was confirmed, intravenous heparin was initiated at a rate of 300 U/h and titrated to an activated partial thromboplastin time of 45–60 s. A dose of 81 mg Aspirin was generally added on POD1. RESULTS The annual incidence of PCS requiring ECLS at our centre is ∼1.3%. A total of 152 patients received ECLS for PCS during the study period. Ninety had prosthetic valves and 9 developed PVT (10%). In the remaining 62 patients, 3 (5%) developed intracardiac thrombosis. Patient characteristics and outcomes are displayed in Tables 1 and 2. Eight PVT patients had bioprosthetic valves (2 aortic, 3 mitral, 1 tricuspid, 1 pulmonic, 1 with both aortic and mitral and 1 with both aortic and pulmonic). One patient had a mechanical aortic valve. PVT was incidentally found by follow-up echocardiogram in 5 patients and 4 were detected via a loss in pulsatility in the arterial line that was confirmed on echocardiogram. PVT patients were more often supported via central cannulation (78% vs 38%, P = 0.034) and had a higher median initial ECLS flow (4.4 vs 3.2 l/min, P < 0.018). Logistic regression analysis showed that central cannulation and initial ECLS flow were associated with PVT by univariable analysis [odds ratio (OR) 5.53; 95% confidence interval (CI) 1.24–38.78 and OR 2.18; 95% CI 1.11–4.67, respectively]. Multivariable analysis showed that central cannulation was significantly associated with PVT (OR 7.56; 95% CI 1.12–149.87). Table 1: Baseline and intraoperative characteristics in patients who underwent ECLS for PCS Patient demographics . Non-thrombosed (n = 81) . Thrombosed (n = 9) . P-value . Age (years) 65.5 (55.0–74.0) 66.0 (42.0–77.0) 0.90 Male gender 59 (48) 56 (5) 1.00 Body mass index (kg/m2) 28.7 (24.8–31.4) 29.1 (24.4–33.4) 0.56 Coronary artery disease 51 (41) 56 (5) 1.00 Congestive heart failure 59 (48) 44 (4) 0.49 Dyslipidaemia 54 (44) 56 (5) 1.00 Diabetes mellitus 27 (22) 11 (1) 0.44 Hypertension 75 (61) 56 (5) 0.24 Atrial fibrillation 46 (37) 44 (4) 1.00 Chronic kidney disease 40 (32) 33 (3) 1.00 Reoperation 61.0 (49) 56 (5) 0.73 Prosthetic valve characteristics  tAVR 58 (47) 33 (3) 0.18  mAVR 7 (6) 11 (1) 0.50  tMVR 42 (34) 44 (4) 1.00  mMVR 9 (7) 0 (0) 1.00  tTVR 17 (14) 11 (1) 1.00  mTVR 4 (3) 0 (0) 1.00  tPVR 4 (3) 22 (2) 0.076  mPVR 1 (1) 0 (0) 1.00 Operative characteristics  Cardiopulmonary bypass time (min) 229 (158–318) 215 (176– 316) 0.87  Aortic cross-clamp time (min) 133 (100–202) 107 (94–154) 0.37  Initial ECLS flow (l/min) 3.2 (2.7–4.2) 4.4 (3.6–5.1) 0.018  Time from ECLS start to anticoagulation start (days) 1.2 (0.7–2.3) 0.6 (0.5–2.2) 0.48  aPTT during ECLS support (s) 43 (38–47) 46 (42–52) 0.23  Cumulative duration of heparinization (days) 4.3 (2.2–7.4) 3.7 (2.7–5.2) 0.21  Time on heparin with subtherapeutic aPTT (<45 s) (days) 4.0 (2.5–5.0) 2.7 (2.0–3.5) 0.089  Length of ECLS support (days) 4.8 (3.3–8.5) 5.2 (3.6–6.0) 0.61  Central cannulation 38 (31) 78 (7) 0.034  Surgical vent 6 (5) 11 (1) 0.40  Impella use 2 (2) 0 (0) 1.00  HIT positive, treated with argatroban 1 (1) 11 (1) 0.19 Patient demographics . Non-thrombosed (n = 81) . Thrombosed (n = 9) . P-value . Age (years) 65.5 (55.0–74.0) 66.0 (42.0–77.0) 0.90 Male gender 59 (48) 56 (5) 1.00 Body mass index (kg/m2) 28.7 (24.8–31.4) 29.1 (24.4–33.4) 0.56 Coronary artery disease 51 (41) 56 (5) 1.00 Congestive heart failure 59 (48) 44 (4) 0.49 Dyslipidaemia 54 (44) 56 (5) 1.00 Diabetes mellitus 27 (22) 11 (1) 0.44 Hypertension 75 (61) 56 (5) 0.24 Atrial fibrillation 46 (37) 44 (4) 1.00 Chronic kidney disease 40 (32) 33 (3) 1.00 Reoperation 61.0 (49) 56 (5) 0.73 Prosthetic valve characteristics  tAVR 58 (47) 33 (3) 0.18  mAVR 7 (6) 11 (1) 0.50  tMVR 42 (34) 44 (4) 1.00  mMVR 9 (7) 0 (0) 1.00  tTVR 17 (14) 11 (1) 1.00  mTVR 4 (3) 0 (0) 1.00  tPVR 4 (3) 22 (2) 0.076  mPVR 1 (1) 0 (0) 1.00 Operative characteristics  Cardiopulmonary bypass time (min) 229 (158–318) 215 (176– 316) 0.87  Aortic cross-clamp time (min) 133 (100–202) 107 (94–154) 0.37  Initial ECLS flow (l/min) 3.2 (2.7–4.2) 4.4 (3.6–5.1) 0.018  Time from ECLS start to anticoagulation start (days) 1.2 (0.7–2.3) 0.6 (0.5–2.2) 0.48  aPTT during ECLS support (s) 43 (38–47) 46 (42–52) 0.23  Cumulative duration of heparinization (days) 4.3 (2.2–7.4) 3.7 (2.7–5.2) 0.21  Time on heparin with subtherapeutic aPTT (<45 s) (days) 4.0 (2.5–5.0) 2.7 (2.0–3.5) 0.089  Length of ECLS support (days) 4.8 (3.3–8.5) 5.2 (3.6–6.0) 0.61  Central cannulation 38 (31) 78 (7) 0.034  Surgical vent 6 (5) 11 (1) 0.40  Impella use 2 (2) 0 (0) 1.00  HIT positive, treated with argatroban 1 (1) 11 (1) 0.19 Data presented as % (n) for categorical variables and median (interquartile range) for continuous variables. a PTT: activated partial thromboplastin time; ECLS: extracorporeal life support; HIT: heparin-induced thrombocytopaenia; mAVR: mechanical aortic valve; mMVR: mechanical mitral valve; mPVR: mechanical pulmonic valve; mTVR: mechanical tricuspid valve; PCS: postcardiotomy shock; tAVR: tissue aortic valve; tMVR: tissue mitral valve; tPVR: tissue pulmonic valve; tTVR: tissue tricuspid valve. Open in new tab Table 1: Baseline and intraoperative characteristics in patients who underwent ECLS for PCS Patient demographics . Non-thrombosed (n = 81) . Thrombosed (n = 9) . P-value . Age (years) 65.5 (55.0–74.0) 66.0 (42.0–77.0) 0.90 Male gender 59 (48) 56 (5) 1.00 Body mass index (kg/m2) 28.7 (24.8–31.4) 29.1 (24.4–33.4) 0.56 Coronary artery disease 51 (41) 56 (5) 1.00 Congestive heart failure 59 (48) 44 (4) 0.49 Dyslipidaemia 54 (44) 56 (5) 1.00 Diabetes mellitus 27 (22) 11 (1) 0.44 Hypertension 75 (61) 56 (5) 0.24 Atrial fibrillation 46 (37) 44 (4) 1.00 Chronic kidney disease 40 (32) 33 (3) 1.00 Reoperation 61.0 (49) 56 (5) 0.73 Prosthetic valve characteristics  tAVR 58 (47) 33 (3) 0.18  mAVR 7 (6) 11 (1) 0.50  tMVR 42 (34) 44 (4) 1.00  mMVR 9 (7) 0 (0) 1.00  tTVR 17 (14) 11 (1) 1.00  mTVR 4 (3) 0 (0) 1.00  tPVR 4 (3) 22 (2) 0.076  mPVR 1 (1) 0 (0) 1.00 Operative characteristics  Cardiopulmonary bypass time (min) 229 (158–318) 215 (176– 316) 0.87  Aortic cross-clamp time (min) 133 (100–202) 107 (94–154) 0.37  Initial ECLS flow (l/min) 3.2 (2.7–4.2) 4.4 (3.6–5.1) 0.018  Time from ECLS start to anticoagulation start (days) 1.2 (0.7–2.3) 0.6 (0.5–2.2) 0.48  aPTT during ECLS support (s) 43 (38–47) 46 (42–52) 0.23  Cumulative duration of heparinization (days) 4.3 (2.2–7.4) 3.7 (2.7–5.2) 0.21  Time on heparin with subtherapeutic aPTT (<45 s) (days) 4.0 (2.5–5.0) 2.7 (2.0–3.5) 0.089  Length of ECLS support (days) 4.8 (3.3–8.5) 5.2 (3.6–6.0) 0.61  Central cannulation 38 (31) 78 (7) 0.034  Surgical vent 6 (5) 11 (1) 0.40  Impella use 2 (2) 0 (0) 1.00  HIT positive, treated with argatroban 1 (1) 11 (1) 0.19 Patient demographics . Non-thrombosed (n = 81) . Thrombosed (n = 9) . P-value . Age (years) 65.5 (55.0–74.0) 66.0 (42.0–77.0) 0.90 Male gender 59 (48) 56 (5) 1.00 Body mass index (kg/m2) 28.7 (24.8–31.4) 29.1 (24.4–33.4) 0.56 Coronary artery disease 51 (41) 56 (5) 1.00 Congestive heart failure 59 (48) 44 (4) 0.49 Dyslipidaemia 54 (44) 56 (5) 1.00 Diabetes mellitus 27 (22) 11 (1) 0.44 Hypertension 75 (61) 56 (5) 0.24 Atrial fibrillation 46 (37) 44 (4) 1.00 Chronic kidney disease 40 (32) 33 (3) 1.00 Reoperation 61.0 (49) 56 (5) 0.73 Prosthetic valve characteristics  tAVR 58 (47) 33 (3) 0.18  mAVR 7 (6) 11 (1) 0.50  tMVR 42 (34) 44 (4) 1.00  mMVR 9 (7) 0 (0) 1.00  tTVR 17 (14) 11 (1) 1.00  mTVR 4 (3) 0 (0) 1.00  tPVR 4 (3) 22 (2) 0.076  mPVR 1 (1) 0 (0) 1.00 Operative characteristics  Cardiopulmonary bypass time (min) 229 (158–318) 215 (176– 316) 0.87  Aortic cross-clamp time (min) 133 (100–202) 107 (94–154) 0.37  Initial ECLS flow (l/min) 3.2 (2.7–4.2) 4.4 (3.6–5.1) 0.018  Time from ECLS start to anticoagulation start (days) 1.2 (0.7–2.3) 0.6 (0.5–2.2) 0.48  aPTT during ECLS support (s) 43 (38–47) 46 (42–52) 0.23  Cumulative duration of heparinization (days) 4.3 (2.2–7.4) 3.7 (2.7–5.2) 0.21  Time on heparin with subtherapeutic aPTT (<45 s) (days) 4.0 (2.5–5.0) 2.7 (2.0–3.5) 0.089  Length of ECLS support (days) 4.8 (3.3–8.5) 5.2 (3.6–6.0) 0.61  Central cannulation 38 (31) 78 (7) 0.034  Surgical vent 6 (5) 11 (1) 0.40  Impella use 2 (2) 0 (0) 1.00  HIT positive, treated with argatroban 1 (1) 11 (1) 0.19 Data presented as % (n) for categorical variables and median (interquartile range) for continuous variables. a PTT: activated partial thromboplastin time; ECLS: extracorporeal life support; HIT: heparin-induced thrombocytopaenia; mAVR: mechanical aortic valve; mMVR: mechanical mitral valve; mPVR: mechanical pulmonic valve; mTVR: mechanical tricuspid valve; PCS: postcardiotomy shock; tAVR: tissue aortic valve; tMVR: tissue mitral valve; tPVR: tissue pulmonic valve; tTVR: tissue tricuspid valve. Open in new tab Table 2: Characteristics, interventions employed and outcomes in 9 patients who developed prosthetic valve thrombosis after ECLS for PCS Patient . Age/gender . Type of surgery . Vasoactive agents at ECLS insertion . LVEF (%) . RV function . LV unloading . Thrombosed valve . Intervention . Outcome . 1 41/M Redo AVR, hemiarch NE 0.11 ADH 0.07 EPI 0.07 Mil 0.25 10–15 Severely decreased IABP mAVR AC Survived 2 71/M Aortic root replacement, CABG Sudden cardiac arrest 10–15 Severely decreased No tAVR Emergency thrombectomy Death 3 33/M Redo PVR Sudden cardiac arrest 10–15 Severely decreased No tPVR Redo PVR Survived 4 83/F AVR, MVR, CABG NE 0.15 ADH 0.07 EPI 0.09 55 Severely decreased No tAVR, tMVR AC Death 5 42/F Redo aortic root replacement, CABG, PVR NE 0.23 ADH 0.07 Mil 0.25 60 Severely decreased No tAVR, tPVR Redo PVR Death 6 77/M MVR, TVr NE 0.24 ADH 0.1 EPI 0.12 20 Severely decreased No tMVR AC Death 7 54/F MVR NE 0.18 ADH 0.1 EPI 0.03 Mil 0.25 20 Severely decreased IABP tMVR AC Survived 8 66/M TVR, ASD closure NE 0.11 ADH 0.08 DB 10 EPI 0.03 20 Severely decreased No tTVR AC Death 9 85/F MVR NE 0.03 ADH 0.03 DB 5 Mil 0.25 20 Normal Surgical LV apical vent tMVR AC Survived Patient . Age/gender . Type of surgery . Vasoactive agents at ECLS insertion . LVEF (%) . RV function . LV unloading . Thrombosed valve . Intervention . Outcome . 1 41/M Redo AVR, hemiarch NE 0.11 ADH 0.07 EPI 0.07 Mil 0.25 10–15 Severely decreased IABP mAVR AC Survived 2 71/M Aortic root replacement, CABG Sudden cardiac arrest 10–15 Severely decreased No tAVR Emergency thrombectomy Death 3 33/M Redo PVR Sudden cardiac arrest 10–15 Severely decreased No tPVR Redo PVR Survived 4 83/F AVR, MVR, CABG NE 0.15 ADH 0.07 EPI 0.09 55 Severely decreased No tAVR, tMVR AC Death 5 42/F Redo aortic root replacement, CABG, PVR NE 0.23 ADH 0.07 Mil 0.25 60 Severely decreased No tAVR, tPVR Redo PVR Death 6 77/M MVR, TVr NE 0.24 ADH 0.1 EPI 0.12 20 Severely decreased No tMVR AC Death 7 54/F MVR NE 0.18 ADH 0.1 EPI 0.03 Mil 0.25 20 Severely decreased IABP tMVR AC Survived 8 66/M TVR, ASD closure NE 0.11 ADH 0.08 DB 10 EPI 0.03 20 Severely decreased No tTVR AC Death 9 85/F MVR NE 0.03 ADH 0.03 DB 5 Mil 0.25 20 Normal Surgical LV apical vent tMVR AC Survived AC: anticoagulation; ADH: vasopressin (unit/min); ASD: atrial septal defect; AVR: aortic valve replacement; CABG: coronary artery bypass grafting; DB: dobutamine (μg/kg/min); ECLS: extracorporeal life support; EPI: epinephrine (μg/kg/min); IABP: intra aortic balloon pump; LV: left ventricular; LVEF: left ventricular ejection fraction; mAVR: mechanical aortic valve; Mil: milrinone (μg/kg/min); MVR: mitral valve replacement; NE: norepinephrine (μg/kg/min); PCS: postcardiotomy shock; PVR: pulmonic valve replacement; RV: right ventricular; tAVR: tissue aortic valve; tMVR: tissue mitral valve; tPVR: tissue pulmonic valve; tTVR: tissue tricuspid valve; TVr: tricuspid valve repair; TVR: tricuspid valve replacement. Open in new tab Table 2: Characteristics, interventions employed and outcomes in 9 patients who developed prosthetic valve thrombosis after ECLS for PCS Patient . Age/gender . Type of surgery . Vasoactive agents at ECLS insertion . LVEF (%) . RV function . LV unloading . Thrombosed valve . Intervention . Outcome . 1 41/M Redo AVR, hemiarch NE 0.11 ADH 0.07 EPI 0.07 Mil 0.25 10–15 Severely decreased IABP mAVR AC Survived 2 71/M Aortic root replacement, CABG Sudden cardiac arrest 10–15 Severely decreased No tAVR Emergency thrombectomy Death 3 33/M Redo PVR Sudden cardiac arrest 10–15 Severely decreased No tPVR Redo PVR Survived 4 83/F AVR, MVR, CABG NE 0.15 ADH 0.07 EPI 0.09 55 Severely decreased No tAVR, tMVR AC Death 5 42/F Redo aortic root replacement, CABG, PVR NE 0.23 ADH 0.07 Mil 0.25 60 Severely decreased No tAVR, tPVR Redo PVR Death 6 77/M MVR, TVr NE 0.24 ADH 0.1 EPI 0.12 20 Severely decreased No tMVR AC Death 7 54/F MVR NE 0.18 ADH 0.1 EPI 0.03 Mil 0.25 20 Severely decreased IABP tMVR AC Survived 8 66/M TVR, ASD closure NE 0.11 ADH 0.08 DB 10 EPI 0.03 20 Severely decreased No tTVR AC Death 9 85/F MVR NE 0.03 ADH 0.03 DB 5 Mil 0.25 20 Normal Surgical LV apical vent tMVR AC Survived Patient . Age/gender . Type of surgery . Vasoactive agents at ECLS insertion . LVEF (%) . RV function . LV unloading . Thrombosed valve . Intervention . Outcome . 1 41/M Redo AVR, hemiarch NE 0.11 ADH 0.07 EPI 0.07 Mil 0.25 10–15 Severely decreased IABP mAVR AC Survived 2 71/M Aortic root replacement, CABG Sudden cardiac arrest 10–15 Severely decreased No tAVR Emergency thrombectomy Death 3 33/M Redo PVR Sudden cardiac arrest 10–15 Severely decreased No tPVR Redo PVR Survived 4 83/F AVR, MVR, CABG NE 0.15 ADH 0.07 EPI 0.09 55 Severely decreased No tAVR, tMVR AC Death 5 42/F Redo aortic root replacement, CABG, PVR NE 0.23 ADH 0.07 Mil 0.25 60 Severely decreased No tAVR, tPVR Redo PVR Death 6 77/M MVR, TVr NE 0.24 ADH 0.1 EPI 0.12 20 Severely decreased No tMVR AC Death 7 54/F MVR NE 0.18 ADH 0.1 EPI 0.03 Mil 0.25 20 Severely decreased IABP tMVR AC Survived 8 66/M TVR, ASD closure NE 0.11 ADH 0.08 DB 10 EPI 0.03 20 Severely decreased No tTVR AC Death 9 85/F MVR NE 0.03 ADH 0.03 DB 5 Mil 0.25 20 Normal Surgical LV apical vent tMVR AC Survived AC: anticoagulation; ADH: vasopressin (unit/min); ASD: atrial septal defect; AVR: aortic valve replacement; CABG: coronary artery bypass grafting; DB: dobutamine (μg/kg/min); ECLS: extracorporeal life support; EPI: epinephrine (μg/kg/min); IABP: intra aortic balloon pump; LV: left ventricular; LVEF: left ventricular ejection fraction; mAVR: mechanical aortic valve; Mil: milrinone (μg/kg/min); MVR: mitral valve replacement; NE: norepinephrine (μg/kg/min); PCS: postcardiotomy shock; PVR: pulmonic valve replacement; RV: right ventricular; tAVR: tissue aortic valve; tMVR: tissue mitral valve; tPVR: tissue pulmonic valve; tTVR: tissue tricuspid valve; TVr: tricuspid valve repair; TVR: tricuspid valve replacement. Open in new tab Six patients were treated with anticoagulation and 3 patients underwent surgical intervention following recognition of PVT. Four PVT patients (44%) survived to discharge. Echocardiogram prior to discharge in patient 1 showed a peak aortic valve gradient of 18 mmHg, mean gradient 8 mmHg, trace aortic insufficiency and no detectable thrombus. Patient 7 had a peak mitral valve gradient of 16 mmHg, mean gradient 8 mmHg, trace mitral regurgitation and no detectable thrombus. Patient 9 had a peak mitral valve gradient of 32 mmHg, mean gradient 17 mmHg and mild mitral valve regurgitation, though the patient clinically improved. DISCUSSION Reducing intracardiac stasis is essential to preventing PVT in PCS patients on ECLS because non-mobile prosthetic valve leaflets are prone to thrombosis. Based on our results, central cannulation may contribute to the development of PVT. Central cannulation is generally required in patients needing increased haemodynamic support due to severely diminished native cardiac function. In fact, patients with PVT received higher flow, which reduces intracardiac flow and increases the risk of stasis. Many patients requiring central cannulation also experience significant blood loss. These factors may contribute to the higher rate of PVT. A compromise must be made between the risk of intracardiac stasis that accompanies central cannulation with higher ECLS flow and the need to maintain adequate haemodynamic support in order to avoid PVT. We try to prevent intracardiac stasis by maintaining partial ECLS flow (60–80% of total cardiac output) and by using inotropes, inhaled nitric oxide and intra aortic balloon pumps (IABP) to maintain ventricular ejection. Whenever feasible, we monitor haemodynamics with a pulmonary artery catheter, aiming for an arterial pulsatility >10 mmHg, central venous pressure <16 mmHg and mixed venous saturation >60 mmHg. Some methods of ventricular unloading may facilitate PVT by reducing transprosthetic blood flow. ECLS can unload the right ventricle, which may reduce pulsatile blood flow through tricuspid or pulmonary valve prostheses. Left atrial, pulmonary artery and direct left ventricular venting may reduce flow through mitral and aortic valve prostheses. Impella is another unloading option, though it requires fluoroscopy, which is often unavailable in the PCS situation at our centre. We favour IABPs in this setting, though further study is needed to determine the optimal unloading strategy. Despite these efforts, PVT can still occur when the ventricles are unable to maintain pulsatility. In these cases, we use temporary biventricular assist devices to maintain pulmonary arterial system blood flow. Limitations The results of this single-centre retrospective study may not be applicable to other centres, like with our lack of experience with Impella. Due to the small number of PVT events, conclusions from the multivariable logistic regression analysis should be interpreted with caution, evidenced by the wide CI of the OR. Conflict of interest: none declared. Reviewer information Interactive CardioVascular and Thoracic Surgery thanks Themistokles Chamogeorgakis and Evgenij V. Potapov for their contribution to the peer-review process of this article. REFERENCES 1 Lorusso R , Raffa GM , Alenizy K , Sluijpers N , Makhoul M , Brodie D et al. Structured review of post-cardiotomy extracorporeal membrane oxygenation: part 1—adult patients . J Heart Lung Transplant 2019 ; 38 : 1125 – 43 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Fukuhara S , Takeda K , Garan AR , Kurlansky P , Hastie J , Naka Y et al. 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Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Prosthetic valve thrombosis during extracorporeal life support for postcardiotomy shock
JO - Interactive CardioVascular and Thoracic Surgery
DO - 10.1093/icvts/ivaa125
DA - 2020-10-01
UR - https://www.deepdyve.com/lp/oxford-university-press/prosthetic-valve-thrombosis-during-extracorporeal-life-support-for-X2ApWDL0V2
SP - 573
EP - 575
VL - 31
IS - 4
DP - DeepDyve
ER -