BACKGROUND: Immediate initiation of extracorporeal membrane oxygenation (ECMO) has not demonstrated benefit in individuals diagnosed with cardiogenic shock based on the presence of hypotension. The relationship between other hemodynamic or metabolic parameters and clinical outcomes, with or without ECMO, is not fully understood. METHODS: The Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock (ECMO-CS) trial randomly assigned 117 patients diagnosed with cardiogenic shock to 2 groups: immediate initiation of ECMO or early conservative strategy. The present post-hoc analysis investigated the clinical efficacy of immediate ECMO therapy in subgroups with cardiogenic shock-more specific characteristics: low cardiac index, low venous oxygen saturation (SvO2) and high partial carbon dioxide pressure (pCO2) gap. The primary endpoint for this analysis was 1-year all-cause mortality; the secondary endpoint was a composite of mortality or hemodynamic worsening requiring ECMO. RESULTS: Data regarding cardiac index were available for 58 patients. In the subgroup with cardiac index < 2.2 L/min/m2, immediate ECMO initiation was associated with a reduced risk for all-cause death (hazard ratio [HR] 0.48 [95% confidence interval (CI) 0.23-0.99]; p = 0.049; number needed to treat to prevent one death [NNT] 3.6) and composite of all-cause death or hemodynamic worsening (HR 0.30 [95% CI 0.15-0.65]; p = 0.003). Data regarding pCO2 gap were available for 54 patients and, in the subgroup with pCO2 gap > 0.8 kPa, initiation of ECMO was associated with a lower risk for all-cause death (HR 0.43 [95% CI 0.20-0.91]; p = 0.028; NNT 3.5) and the composite endpoint (HR 0.29 [95% CI 0.13-0.62]; p = 0.001). Finally, data regarding SvO2 were available for 95 patients. In the subgroup with SvO2 < 60%, initiation of ECMO was associated with lower risk for all-cause mortality (HR 0.34 [95% CI 0.17-0.67]; p = 0.002; NNT 2.8) and the composite endpoint (HR 0.28 [95% CI 0.14-0.57]; p < 0.001). CONCLUSIONS: Measurement of cardiac index, pCO2 gap and SvO2 could improve the management of cardiogenic shock. The presence of any of the following criteria - low cardiac index, high pCO2 gap and low SvO2 - may indicate a poor prognosis with conservative therapy and a substantial mortality benefit from mechanical circulatory support. TRIAL REGISTRATION: NCT02301819. Retrospectively registered 26 November 2014.

• Klíčová slova
• Cardiogenic shock, Clinical trial, Extracorporeal membrane oxygenation, Therapy,
• MeSH
• kardiogenní šok * terapie   patofyziologie   mortalita   MeSH
• lidé středního věku MeSH
• lidé MeSH
• mimotělní membránová oxygenace * metody   normy   MeSH
• minutový srdeční výdej * fyziologie   MeSH
• oxid uhličitý * krev   analýza   MeSH
• saturace kyslíkem * fyziologie   MeSH
• senioři MeSH
• výsledek terapie MeSH
• Check Tag
• lidé středního věku MeSH
• lidé MeSH
• mužské pohlaví MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• multicentrická studie MeSH
• randomizované kontrolované studie MeSH
• Názvy látek
• oxid uhličitý * MeSH

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is widely used in the treatment of patients experiencing cardiogenic shock (CS). However, increased VA-ECMO blood flow (EBF) may significantly impair left ventricular (LV) performance. The objective of the present study was to assess the effect of VA-ECMO on LV function in acute CS with concomitant severe aortic stenosis (AS) or mitral regurgitation (MR) in a porcine model. Eight female swine (45 kg) underwent VA-ECMO implantation under general anaesthesia and mechanical ventilation. Acute CS was induced by global myocardial hypoxia. Subsequently, severe AS was simulated by obstruction of the aortic valve, while severe MR was induced by mechanical destruction of the mitral valve. Haemodynamic and LV performance variables were measured at different rates of EBF rates (ranging from 1 to 4 L/min), using arterial and venous catheters, a pulmonary artery catheter, and LV pressure-volume catheter. Data are expressed as median (interquartile range). Myocardial hypoxia resulted in declines in cardiac output to 2.7 (1.9-3.1) L/min and LV ejection fraction to 15.2% (10.5-19.3%). In severe AS, increasing EBF from 1 to 4 L/min was associated with a significant elevation in mean arterial pressure (MAP), from 33.5 (24.2-34.9) to 56.0 (51.9-73.3) mmHg (P ˂ 0.01). However, LV volumes (end-diastolic, end-systolic, stroke) remained unchanged, and LV end-diastolic pressure (LVEDP) significantly decreased from 24.9 (21.2-40.0) to 19.1 (15.2-29.0) mmHg (P ˂ 0.01). In severe MR, increasing EBF resulted in a significant elevation in MAP from 49.0 (28.0-53.4) to 72.5 (51.4-77.1) mmHg (P ˂ 0.01); LV volumes remained stable and LVEDP increased from 17.1 (13.7-19.1) to 20.8 (16.3-25.6) mmHg (P ˂ 0.01). Results of this study indicate that the presence of valvular heart disease may alleviate negative effect of VA-ECMO on LV performance in CS. Severe AS fully protected against LV overload, and partial protection was also detected with severe MR, although at the cost of increased LVEDP and, thus, higher risk for pulmonary oedema.

• MeSH
• aortální stenóza * MeSH
• funkce levé komory srdeční fyziologie   MeSH
• hypoxie MeSH
• kardiogenní šok terapie   MeSH
• mimotělní membránová oxygenace * metody   MeSH
• mitrální insuficience * terapie   MeSH
• prasata MeSH
• zvířata MeSH
• Check Tag
• ženské pohlaví MeSH
• zvířata MeSH
• Publikační typ
• časopisecké články MeSH
• práce podpořená grantem MeSH

Despite advanced therapies, the mortality of patients with myocardial infarction (MI) complicated by cardiogenic shock (CS) remains around 50%. Mechanical complications of MI are rare nowadays but associated with high mortality in patients who present with CS. Different treatment strategies and mechanical circulatory support (MCS) devices have been increasingly used to improve the grim prognosis of refractory CS. This article discusses current evidence regarding the use of MCS in MI complicated by CS, ventricular septal rupture, free wall rupture and acute mitral regurgitation. Device selection should be tailored according to the cause and severity of CS. Early MCS initiation and multidisciplinary team cooperation is mandatory for good results. MCS associated bleeding remains a major complication and an obstacle to better outcomes. Ongoing prospective randomized trials will improve current knowledge regarding MCS indications, timing, and patient selection in the coming years.

• Publikační typ
• časopisecké články MeSH

Extracorporeal membrane oxygenation (ECMO) has been used increasingly for both respiratory and cardiac failure in adult patients. Indications for ECMO use in cardiac failure include severe refractory cardiogenic shock, refractory ventricular arrhythmia, active cardiopulmonary resuscitation for cardiac arrest, and acute or decompensated right heart failure. Evidence is emerging to guide the use of this therapy for some of these indications, but there remains a need for additional evidence to guide best practices. As a result, the use of ECMO may vary widely across centers. The purpose of this document is to highlight key aspects of care delivery, with the goal of codifying the current use of this rapidly growing technology. A major challenge in this field is the need to emergently deploy ECMO for cardiac failure, often with limited time to assess the appropriateness of patients for the intervention. For this reason, we advocate for a multidisciplinary team of experts to guide institutional use of this therapy and the care of patients receiving it. Rigorous patient selection and careful attention to potential complications are key factors in optimizing patient outcomes. Seamless patient transport and clearly defined pathways for transition of care to centers capable of providing heart replacement therapies (e.g., durable ventricular assist device or heart transplantation) are essential to providing the highest level of care for those patients stabilized by ECMO but unable to be weaned from the device. Ultimately, concentration of the most complex care at high-volume centers with advanced cardiac capabilities may be a way to significantly improve the care of this patient population.

• Klíčová slova
• Cardiac arrest, Cardiac failure, Critical care networks, Extracorporeal life support, Extracorporeal membrane oxygenation, Hospital organization, Mechanical circulatory support, Position article,
• MeSH
• dospělí MeSH
• kardiogenní šok * MeSH
• lidé MeSH
• mimotělní membránová oxygenace * MeSH
• podpůrné srdeční systémy MeSH
• srdeční selhání * terapie   MeSH
• transplantace srdce MeSH
• Check Tag
• dospělí MeSH
• lidé MeSH
• Publikační typ
• časopisecké články MeSH

INTRODUCTION: Veno-arterial extracorporeal life support (ECLS) is increasingly being used to treat rapidly progressing or severe cardiogenic shock. However, it has been repeatedly shown that increased afterload associated with ECLS significantly diminishes left ventricular (LV) performance. The objective of the present study was to compare LV function and coronary flow during standard continuous-flow ECLS support and electrocardiogram (ECG)-synchronized pulsatile ECLS flow in a porcine model of cardiogenic shock. METHODS: Sixteen female swine (mean body weight 45 kg) underwent ECLS implantation under general anesthesia and artificial ventilation. Subsequently, acute cardiogenic shock, with documented signs of tissue hypoperfusion, was induced by initiating global myocardial hypoxia. Hemodynamic cardiac performance variables and coronary flow were then measured at different rates of continuous or pulsatile ECLS flow (ranging from 1 L/min to 4 L/min) using arterial and venous catheters, a pulmonary artery catheter, an LV pressure-volume loop catheter, and a Doppler coronary guide-wire. RESULTS: Myocardial hypoxia resulted in declines in mean cardiac output to 1.7±0.7 L/min, systolic blood pressure to 64±22 mmHg, and LV ejection fraction (LVEF) to 22±7%. Synchronized pulsatile flow was associated with a significant reduction in LV end-systolic volume by 6.2 mL (6.7%), an increase in LV stroke volume by 5.0 mL (17.4%), higher LVEF by 4.5% (18.8% relative), cardiac output by 0.37 L/min (17.1%), and mean arterial pressure by 3.0 mmHg (5.5%) when compared with continuous ECLS flow at all ECLS flow rates (P<0.05). At selected ECLS flow rates, pulsatile flow also reduced LV end-diastolic pressure, end-diastolic volume, and systolic pressure. ECG-synchronized pulsatile flow was also associated with significantly increased (7% to 22%) coronary flow at all ECLS flow rates. CONCLUSION: ECG-synchronized pulsatile ECLS flow preserved LV function and coronary flow compared with standard continuous-flow ECLS in a porcine model of cardiogenic shock.

• MeSH
• elektrokardiografie metody   MeSH
• funkce levé komory srdeční fyziologie   MeSH
• hemodynamika MeSH
• kardiogenní šok patologie   patofyziologie   terapie   MeSH
• koronární cévy patofyziologie   MeSH
• koronární cirkulace fyziologie   MeSH
• mimotělní membránová oxygenace metody   MeSH
• modely nemocí na zvířatech * MeSH
• prasata * MeSH
• pulzatilní průtok fyziologie   MeSH
• resuscitační péče metody   MeSH
• zvířata MeSH
• Check Tag
• ženské pohlaví MeSH
• zvířata MeSH
• Publikační typ
• časopisecké články MeSH
• práce podpořená grantem MeSH