85 research outputs found
Anticoagulation strategies in Extracorporeal Membrane Oxygenation (ECMO)
No full textExtracorporeal Membrane Oxygenation (ECMO) is an advanced system of short-term mechanical cardiorespiratory support indicated for patients with life-threatening cardiac and/or respiratory failure. The circuit includes the centrifugal pump, the oxygenator, and a closed circuit of cardiopulmonary bypass tubing. Due to the contact of the blood with the artificial surfaces, the use of anticoagulation is mandatory to avoid the formation of clots, reducing the risk of embolism while at the same time minimizing the inflammatory reaction created by the exposure of the blood to the surface of the circuit. Anticoagulants mainly include heparin and its derivatives that differ in molecular weight as well as novel agents that inhibit thrombin formation. Anticoagulation is monitored through various plasma-based laboratory tests and clinical evaluations. Management of anticoagulation in ECMO requires a multidisciplinary approach, involving intensivists, perfusionists, hematologists, and other healthcare professionals, to ensure optimal patient outcomes. While there have been several small studies that have attempted to evaluate the safety and efficacy of various anticoagulation strategies, institutions currently use a variety of independently developed approaches due to a lack of published accepted guidelines based on solid clinical evidence
Minimal invasive extracorporeal circulation should become the standard practice in coronary revascularization surgery†.
No full textWe read with great interest the large-scale network meta-analysis by Kowalewski et al. comparing clinical outcomes of patients undergoing coronary artery bypass grafting (CABG) operated on using minimal invasive extracorporeal circulation (MiECC) or off-pump (OPCAB) with those undergoing surgery on conventional cardiopulmonary bypass (CPB) [1]. The authors actually integrated into single study two recently published meta-analysis comparing MiECC and OPCAB with conventional CPB, respectively [2, 3] into a single study.
According to the results of this study, MiECC and OPCAB are both strongly associated with improved perioperative outcomes following CABG when compared with CABG performed on conventional CPB. The authors conclude that MiECC may represent an attractive compromise between OPCAB and conventional CPB. After carefully reading the whole manuscript, it becomes evident that the role of MiECC is clearly undervalued. Detailed statistical analysis using the surface under the cumulative ranking probabilities indicated that MiECC represented the safer and more effective intervention regarding all-cause mortality and protection from myocardial infarction, cerebral stroke, postoperative atrial fibrillation and renal dysfunction when compared with OPCAB. Even though no significant statistical differences were demonstrated between MiECC and OPCAB, the superiority of MiECC is obvious by the hierarchy of treatments in the probability analysis, which ranked MiECC as the first treatment followed by OPCAB and conventional CPB. Thus, MiECC does not represent a compromise between OPCAB and conventional CPB, but an attractive dominant technique in CABG surgery.
These results are consistent with the largest published meta-analysis by Anastasiadis et al. comparing MiECC versus conventional CPB including a total of 2770 patients. A significant decrease in mortality was observed when MiECC was used, which was also associated with reduced risk of postoperative myocardial infarction and neurological events [4]. Similarly, another recent meta-analysis by Benedetto et al. compared MiECC versus OPCAB and resulted in comparable outcomes between these two surgical techniques [5]. As stated in the text, superiority of MiECC observed in the current network meta-analysis, when compared with OPCAB, could be attributed to the fact that MiECC offers the potential for complete revascularization, whereas OPCAB poses a challenge for unexperienced surgeons; especially when distal marginal branches on the lateral and/or posterior wall of the heart need revascularization. This is reflected by a significantly lower number of distal anastomoses performed in OPCAB when compared with conventional CPB.
Therefore, taking into consideration the literature published up to date, including the results of the current article, we advocate that MiECC should be integrated in the clinical practice guidelines as a state-of-the-art technique and become a standard practice for perfusion in coronary revascularization surgery
2021 MiECTiS focused update on the 2016 position paper for the use of minimal invasive extracorporeal circulation in cardiac surgery
No full textThe landmark 2016 Minimal Invasive Extracorporeal Technologies International Society (MiECTiS) position paper promoted the creation of a common language between cardiac surgeons, anesthesiologists and perfusionists which led to the development of a stable framework that paved the way for the advancement of minimal invasive perfusion and related technologies. The current expert consensus document offers an update in areas for which new evidence has emerged. In the light of published literature, modular minimal invasive extracorporeal circulation (MiECC) has been established as a safe and effective perfusion technique that increases biocompatibility and ultimately ensures perfusion safety in all adult cardiac surgical procedures, including re-operations, aortic arch and emergency surgery. Moreover, it was recognized that incorporation of MiECC strategies advances minimal invasive cardiac surgery (MICS) by combining reduced surgical trauma with minimal physiologic derangements. Minimal Invasive Extracorporeal Technologies International Society considers MiECC as a physiologically-based multidisciplinary strategy for performing cardiac surgery that is associated with significant evidence-based clinical benefit that has accrued over the years. Widespread adoption of this technology is thus strongly advocated to obtain additional healthcare benefit while advancing patient care
Conventional versus minimally invasive extra-corporeal circulation in patients undergoing cardiac surgery: A randomized controlled trial (COMICS)
No full textIntroduction The trial hypothesized that minimally invasive extra-corporeal circulation (MiECC) reduces the risk of serious adverse events (SAEs) after cardiac surgery operations requiring extra-corporeal circulation without circulatory arrest. Methods This is a multicentre, international randomized controlled trial across fourteen cardiac surgery centres including patients aged ≥18 and <85 years undergoing elective or urgent isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR) surgery, or CABG + AVR surgery. Participants were randomized to MiECC or conventional extra-corporeal circulation (CECC), stratified by centre and operation. The primary outcome was a composite of 12 post-operative SAEs up to 30 days after surgery, the risk of which MiECC was hypothesized to reduce. Secondary outcomes comprised: other SAEs; all-cause mortality; transfusion of blood products; time to discharge from intensive care and hospital; health-related quality-of-life. Analyses were performed on a modified intention-to-treat basis. Results The trial terminated early due to the COVID-19 pandemic; 1071 participants (896 isolated CABG, 97 isolated AVR, 69 CABG + AVR) with median age 66 years and median EuroSCORE II 1.24 were randomized (535 to MiECC, 536 to CECC). Twenty-six participants withdrew after randomization, 22 before and four after intervention. Fifty of 517 (9.7%) randomized to MiECC and 69/522 (13.2%) randomized to CECC group experienced the primary outcome (risk ratio = 0.732, 95% confidence interval (95% CI) = 0.556 to 0.962, p = 0.025). The risk of any SAE not contributing to the primary outcome was similarly reduced (risk ratio = 0.791, 95% CI 0.530 to 1.179, p = 0.250). Conclusions MiECC reduces the relative risk of primary outcome events by about 25%. The risk of other SAEs was similarly reduced. Because the trial terminated early without achieving the target sample size, these potential benefits of MiECC are uncertain.Bristol NIHR BRCMedtronic Europe https://doi.org/10.13039/100020192British Heart Foundation https://doi.org/10.13039/501100000274Maquet Europ
Letter re: The COMICS trial: Randomization to MiECC significantly decreases serious adverse events
No full textMinimally invasive extracorporeal circulation versus conventional cardiopulmonary bypass in patients undergoing cardiac surgery (MiECS): Rationale and design of a multicentre randomised trial
No full textIntroduction The ultimate answer to the question whether minimal invasive extracorporeal circulation (MiECC) represents the optimal perfusion technique in contemporary clinical practice remains elusive. The present study is a real-world study that focuses on specific perfusion-related clinical outcomes after cardiac surgery that could potentially be favourably affected by MiECC and thereby influence the future clinical practice. Methods The MiECS study is an international, multi-centre, two-arm randomized controlled trial. Patients undergoing elective or urgent coronary artery bypass grafting (CABG), aortic valve replacement (AVR) or combined procedure (CABG + AVR) using extracorporeal circulation will be randomized to MiECC or contemporary conventional cardiopulmonary bypass (cCPB). Use of optimized conventional circuits as controls is acceptable. The study design includes a range of features to prevent bias and is registered at clinicaltrials.gov (NCT05487612). Results The primary outcome is a composite of postoperative serious adverse events that could be related to perfusion technique occurring up to 30 days postoperatively. Secondary outcomes include use of blood products, ICU and hospital length of stay (30 days) as well as health-related quality of life (30 and 90 days). Conclusions The MiECS trial has been designed to overcome perceived limitation of previous trials of MiECC. Results of the proposed study could affect current perfusion practice towards advancement of patient care
MiECC should not be restricted to selected patients and experienced teams. A MiECTiS rebuttal to 2024 EACTS/EACTAIC/EBCP guidelines on patient blood management
No full textStudy on the transformation of haematopoietic stem cells to cardiomyocytes in long term liquid culture
No full textThe aim of the study is to investigate the ability of bone marrow mesenchymal stem cells to differentiate toward cardiomyocytes in ligand culture. Bone marrow samples were aspirated from 30 patients undergoing open heart surgery. Mesenchymal stem cells were isolated and expanded in culture. Second passaged cells were treated with 10μΜ 5-azacytidine. Immunophenotype was detected with flow cytometry. Morphology was analyzed with contrast and electron microscopy. Vimentin and myosin heavy chain production were analyzed by immunohistochemistry. Expression of α-cardiac actin, b-myosin heavy chain and troponin-T was also analyzed with molecular studies. In treated cells, multiple myofilaments were detected that were positive immunohistochemically to myosin heavy chain. All studied genes were also expressed. In untreated cells not expanded in culture, all myocardial markers were negative.Σκοπός της παρούσας μελέτης αποτελεί η διερεύνηση της ικανότητας των αρχέγονων μεσεγχυματικών κυττάρων του μυελού των οστών να μετατρέπονται σε μυοκαρδιακά κύτταρα του μυελού των οστών να μετατρέπονται σε μυοκαρδιακά κύτταρα σε σύστημα υγρής καλλιέργειας. Δείγματα μυελού ελήφθησαν από 30 ασθενείς οι οποίοι υποβλήθηκαν σε χειρουργική επέμβαση ανοικτής καρδιάς. Τα μεσεγχυματικά βλαστικά κύτταρα απομονώθηκαν και τοποθετήθηκαν σε καλλιέργεια. Μετά τη δεύτερη ανακαλλιέργεια έγινε επίδραση 10μ.Μ 5-αζακυτιδίνης. Ο ανοσοφαινότυπος προσδιορίστηκε με κυτταρομετρία ροής. Η μελέτη της μορφολογίας διενεργήθηκε με το ανάστροφο καθώς και με το ηλεκτρονικό μικροσκόπιο. Πραγματοποιήθηκε ανοσοϊστοχημικός έλεγχος της βιμεντίνης και της βαριάς αλύσου της μυοσίνης. Μελετήθηκε παράλληλα η έκφραση των γονιδίων της α-καρδιακής ακτίνης και της β-βαριάς αλύσου της μυοσίνης και της τροπονίνης-Τ. Στα κύτταρα που υποβλήθηκαν στην επίδραση ανιχνεύτηκαν πολυάριθμα ινίδια, τα οποία ήταν θετικά με ανοσοϊστοχημεία στη βαριά άλυσο μυοσίνης. Παράλληλα διαπιστώθηκε έκφραση των υπό μελέτη γονιδίων. Αντίθετα, σε κύτταρα πολύ δεν υποβλήθηκαν σε καλλιέργεια, δε διαπιστώθηκε έκφραση μυοκαρδιακών δεικτών
Minimal invasive Extra-Corporeal Circulation (MiECC): a revolutionary evolution in perfusion
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