Reply to Napp et al.

Reply to Napp et al. Extracorporeal membrane oxygenation, Watershed, Cardiogenic shock, Myocardial recovery, Oxygenation We thank Napp et al. [1, 2] for their valuable comments. We agree with every point raised by the authors. Increasing extracorporeal life support (ECLS) speed and thereby left ventricular (LV) afterload might impair myocardial recovery; therefore, ECLS speed is usually set as low as possible but as high as necessary. To clarify our therapeutic strategy in this case, we will give a short description of our management. The patient underwent out-of-hospital cardiopulmonary resuscitation for cardiogenic shock in ventricular fibrillation. After a total of 90-min ongoing cardiopulmonary resuscitation, there was still no return of spontaneous circulation. Therefore, we performed ECLS implantation via femoral cannulation. After initiation of ECLS flow (at 3 l/min), further diagnostic testing was performed including computed tomography and cardiac catheterization. Transthoracic echocardiography revealed a hypertrophic myocardium with severely impaired LV function, leading to the working diagnosis of hypertrophic cardiomyopathy as underlying disease. At this point, the arterial blood pressure line was pulsatile, confirming that antegrade left ventricular ejection was not suppressed by retrograde aortic ECLS flow. However, poor upper body saturation was apparent, as demonstrated in our image [2]. To assure adequate brain saturation, we decided to increase ECLS flow to 4 l/min to immediately stabilize the patient. In situations like this, it is very important to do an intensive workup of the patient to make a highly individualized decision. In case of an absolutely non-contracting left ventricle not capable of ejecting against ECLS flow despite increased inotropic support, we recommend unloading the left ventricle. Unloading strategies include implantation of a permanent LV assist device, Impella implantation, direct LV venting and connection to the venous ECLS cannula, even introduction of a transaortic pigtail catheter or the Rashkind manoeuvre are described in the scientific literature [3]. Alternatively, the arterial cannulation site can be switched from the femoral to the subclavian artery to gain more antegrade flow and improve brain saturation. Nevertheless, in our case, these strategies were not necessary. Mechanical ventilation was increased, allowing for the reduction of ECLS flow without upper body desaturation. LV function improved rapidly, and the ECLS system was already explanted after 2 days. The patient could be weaned from mechanical ventilation after 25 days. She received an implantable converter–defibrillator and was discharged on the 48th postoperative day without neurological deficits. REFERENCES [1] Napp C, Schmitto J, Tongers J, Schäfer A. The short and long term risk of venoarterial ECMO watershed. Eur J Cardiothorac Surg  2018;53:894. [2] Angleitner P, Roggla M, Laufer G, Wiedemann D. Watershed of veno-arterial extracorporeal life support. Eur J Cardiothorac Surg  2016; 50: 785. Google Scholar CrossRef Search ADS PubMed  [3] Meani P, Gelsomino S, Natour E, Johnson DM, Rocca H-PBL, Pappalardo F et al.   Modalities and effects of left ventricle unloading on extracorporeal life support: a review of the current literature. Eur J Heart Fail  2017; 19(suppl 2): 84– 91. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Cardio-Thoracic Surgery Oxford University Press

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Publisher
Oxford University Press
ISSN
1010-7940
eISSN
1873-734X
D.O.I.
10.1093/ejcts/ezx376
Publisher site
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Abstract

Extracorporeal membrane oxygenation, Watershed, Cardiogenic shock, Myocardial recovery, Oxygenation We thank Napp et al. [1, 2] for their valuable comments. We agree with every point raised by the authors. Increasing extracorporeal life support (ECLS) speed and thereby left ventricular (LV) afterload might impair myocardial recovery; therefore, ECLS speed is usually set as low as possible but as high as necessary. To clarify our therapeutic strategy in this case, we will give a short description of our management. The patient underwent out-of-hospital cardiopulmonary resuscitation for cardiogenic shock in ventricular fibrillation. After a total of 90-min ongoing cardiopulmonary resuscitation, there was still no return of spontaneous circulation. Therefore, we performed ECLS implantation via femoral cannulation. After initiation of ECLS flow (at 3 l/min), further diagnostic testing was performed including computed tomography and cardiac catheterization. Transthoracic echocardiography revealed a hypertrophic myocardium with severely impaired LV function, leading to the working diagnosis of hypertrophic cardiomyopathy as underlying disease. At this point, the arterial blood pressure line was pulsatile, confirming that antegrade left ventricular ejection was not suppressed by retrograde aortic ECLS flow. However, poor upper body saturation was apparent, as demonstrated in our image [2]. To assure adequate brain saturation, we decided to increase ECLS flow to 4 l/min to immediately stabilize the patient. In situations like this, it is very important to do an intensive workup of the patient to make a highly individualized decision. In case of an absolutely non-contracting left ventricle not capable of ejecting against ECLS flow despite increased inotropic support, we recommend unloading the left ventricle. Unloading strategies include implantation of a permanent LV assist device, Impella implantation, direct LV venting and connection to the venous ECLS cannula, even introduction of a transaortic pigtail catheter or the Rashkind manoeuvre are described in the scientific literature [3]. Alternatively, the arterial cannulation site can be switched from the femoral to the subclavian artery to gain more antegrade flow and improve brain saturation. Nevertheless, in our case, these strategies were not necessary. Mechanical ventilation was increased, allowing for the reduction of ECLS flow without upper body desaturation. LV function improved rapidly, and the ECLS system was already explanted after 2 days. The patient could be weaned from mechanical ventilation after 25 days. She received an implantable converter–defibrillator and was discharged on the 48th postoperative day without neurological deficits. REFERENCES [1] Napp C, Schmitto J, Tongers J, Schäfer A. The short and long term risk of venoarterial ECMO watershed. Eur J Cardiothorac Surg  2018;53:894. [2] Angleitner P, Roggla M, Laufer G, Wiedemann D. Watershed of veno-arterial extracorporeal life support. Eur J Cardiothorac Surg  2016; 50: 785. Google Scholar CrossRef Search ADS PubMed  [3] Meani P, Gelsomino S, Natour E, Johnson DM, Rocca H-PBL, Pappalardo F et al.   Modalities and effects of left ventricle unloading on extracorporeal life support: a review of the current literature. Eur J Heart Fail  2017; 19(suppl 2): 84– 91. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Journal

European Journal of Cardio-Thoracic SurgeryOxford University Press

Published: Apr 1, 2018

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