Abstract
Purpose
Fulminant myocarditis is uncommon, but life-threatening, and some patients need mechanical circulatory support. This study was performed to evaluate how different types of mechanical circulatory support—biventricular assist device (BiVAD) or left ventricular assist device (LVAD) placement—affect intraoperative hemodynamic status.
Methods
From January 2013 to September 2016, the patients who underwent BiVAD or LVAD placement for fulminant myocarditis were analyzed. The mean arterial pressure (MAP), mean pulmonary arterial pressure, central venous pressure (CVP), vasoactive score, and inotropic score were recorded at five time points: after the induction of anesthesia; at weaning, 30 min after weaning, and 60 min after weaning from cardiopulmonary bypass (CPB); and at the end of surgery. The vasoactive and inotropic scores were calculated as follows: vasoactive score = norepinephrine (µg/kg/min) × 100 + milrinone (µg/kg/min) × 10 + olprinone (µg/kg/min) × 25: inotropic score = dopamine (µg/kg/min) × 1 + dobutamine (µg/kg/min) × 1 + epinephrine (µg/kg/min) × 100.
Results
We enrolled 16 patients of fulminant myocarditis. Ten of them underwent BiVAD placement, and the other underwent LVAD placement. After weaning from CPB, the BiVAD group had a significantly lower MAP but no difference in CVP. The vasoactive score was significantly higher in the BiVAD group at weaning of CPB (p = 0.015), 30 min after weaning (p = 0.004), 60 min after weaning (p = 0.005), and at the end of surgery (p < 0.016).
Conclusion
Patients with BiVAD placement required more vasoactive support to maintain optimal hemodynamic status compared with those with LVAD placement. This result indicates that BiVAD placement was more associated with vasoplegic syndrome.
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References
Cooper LT. Myocarditis. N Engl J Med. 2009;360:1526–38.
Maisch B, Ruppert V, Pankuweit S. Management of fulminant myocarditis: a diagnosis in search of its etiology but with therapeutic options. Curr Heart Fail Rep. 2014;11:166–77.
Aoyama N, Izumi T, Hiramori K, Isobe M, Kawana M, Hiroe M, Hishida H, Kitaura Y, Imaizumi T, Japanese Investigators of Fulminant Myocarditis. National survey of fulminant myocarditis in Japan: therapeutic guidelines and long-term prognosis of using percutaneous cardiopulmonary support for fulminant myocarditis (special report from a scientific committee). Circ J. 2002;66:133–44.
Ting M, Wang CH, Tsao CI, Huang SC, Chi NH, Chou NK, Chen YS, Wang SS. Heart transplantation under mechanical circulatory support for acute fulminant myocarditis with cardiogenic shock: 10 years’ experience of a single center. Transpl Proc. 2016;48:951–5.
Lorusso R, Centofanti P, Gelsomino S, Barili F, Di Mauro M, Orlando P, Botta L, Milazzo F, Actis Dato G, Casabona R, Casali G, Musumeci F, De Bonis M, Zangrillo A, Alfieri O, Pellegrini C, Mazzola S, Coletti G, Vizzardi E, Bianco R, Gerosa G, Massetti M, Caldaroni F, Pilato E, Pacini D, Di Bartolomeo R, Marinelli G, Sponga S, Livi U, Mauro R, Mariscalco G, Beghi C, Miceli A, Glauber M, Pappalardo F, Russo CF, GIROC Investigators. Venoarterial extracorporeal membrane oxygenation for acute fulminant myocarditis in adult patients: a 5-year multi-institutional experience. Ann Thorac Surg. 2016;101:919–26.
Atluri P, Ullery BW, MacArthur JW, Goldstone AB, Fairman AS, Hiesinger W, Acker MA, Woo YJ. Rapid onset of fulminant myocarditis portends a favourable prognosis and the ability to bridge mechanical circulatory support to recovery. Eur J Cardiothorac Surg. 2013;43:379–82.
Grinda JM, Chevalier P, D’Attellis N, Bricourt MO, Berrebi A, Guibourt P, Fabiani JN, Deloche A. Fulminant myocarditis in adults and children: Hence assist device for recovery. Eur J Cardiothorac Surg. 2004;26:1169–73.
Mody KP, Takayama H, Landes E, Yuzefpolskaya M, Colombo PC, Naka Y, Jorde UP, Uriel N. Acute mechanical circulatory support for fulminant myocarditis complicated by cardiogenic shock. J Cardiovasc Transl Res. 2014;7:156–64.
Lieberman EB, Hutchins GM, Herskowitz A, Rose NR, Baughman KL. Clinicopathologic description of myocarditis. J Am Coll Cardiol. 1991;18:1617–26.
Garcia RU, Walters HL, Delius RE, Aggarwal S. Vasoactive Inotropic Score (VIS) as biomarker of short-term outcomes in adolescents after cardiothoracic surgery. Pediatr Cardiol. 2016;37:271–7.
Maeda T, Toda K, Kamei M, Miyata S, Ohnishi Y. Impact of preoperative extracorporeal membrane oxygenation on vasoactive inotrope score after implantation of left ventricular assist device. Springerplus. 2015;30:821.
Gaies MG, Jeffries HE, Niebler RA, Pasquali SK, Donohue JE, Yu S, Gall C, Rice TB, Thiagarajan RR. Vasoactive-inotropic score is associated with outcome after infant cardiac surgery: an analysis from the Pediatric Cardiac Critical Care Consortium and Virtual PICU System Registries. Pediatr Crit Care Med. 2014;15:529–37.
Lambden S, Creagh-Brown BC, Hunt J, Summers C, Forni LG. Definitions and pathophysiology of vasoplegic shock. Crit Care. 2018;22:174.
Carrel T, Englberger L, Mohacsi P, Neidhart P, Schmidli J. Low systemic vascular resistance after cardiopulmonary bypass: incidence, etiology, and clinical importance. J Card Surg. 2000;15:347–53.
Tecson KM, Lima B, Lee AY, Raza FS, Ching G, Lee CH, Felius J, Baxter RD, Still S, Collier JDG, Hall SA, Joseph SM. Determinants and outcomes of vasoplegia following left ventricular assist device implantation. J Am Heart Assoc. 2018;7:e008377.
Millar JE, Fanning JP, McDonald CI, McAuley DF, Fraser JF. The inflammatory response to extracorporeal membrane oxygenation (ECMO): a review of the pathophysiology. Crit Care. 2016;20:387.
McILwain RB, Timpa JG, Kurundkar AR, Holt DW, Kelly DR, Hartman YE, Neel ML, Karnatak RK, Schelonka RL, Anantharamaiah GM, Killingsworth CR, Maheshwari A. Plasma concentrations of inflammatory cytokines rise rapidly during ECMO-related SIRS due to the release of preformed stores in the intestine. Lab Investig. 2010;90:128–39.
Colson PH, Bernard C, Struck J, Morgenthaler NG, Albat B, Guillon G. Post cardiac surgery vasoplegia is associated with high preoperative copeptin plasma concentration. Crit Care. 2011;15:R255.
Hajjar LA, Vincent JL, Barbosa Gomes Galas FR, Rhodes A, Landoni G, Osawa EA, Melo RR, Sundin MR, Grande SM, Gaiotto FA, Pomerantzeff PM, Dallan LO, Franco RA, Nakamura RE, Lisboa LA, de Almeida JP, Gerent AM, Souza DH, Gaiane MA, Fukushima JT, Park CL, Zambolim C, Rocha Ferreira GS, Strabelli TM, Fernandes FL, Camara L, Zeferino S, Santos VG, Piccioni MA, Jatene FB, Costa Auler JO Jr, Filho RK. Vasopressin versus norepinephrine in patients with vasoplegic shock after cardiac surgery: the VANCS randomized controlled trial. Anesthesiology. 2017;126:85–93.
Catena E, Paino R, Milazzo F, Colombo T, Marianeschi S, Lanfranconi M, Aresta F, Bruschi G, Russo C, Vitali E. Mechanical circulatory support for patients with fulminant myocarditis: the role of echocardiography to address diagnosis, choice of device, management, and recovery. J Cardiothorac Vasc Anesth. 2009;23:87–94.
Tschöpe C, Van Linthout S, Klein O, Mairinger T, Krackhardt F, Potapov EV, Schmidt G, Burkhoff D, Pieske B, Spillmann F. Mechanical unloading by fulminant myocarditis: LV-IMPELLA, ECMELLA, BI-PELLA, and PROPELLA concepts. J Cardiovasc Transl Res. 2018. https://doi.org/10.1007/s12265-018-9820-2
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Ezaka, M., Maeda, T. & Ohnishi, Y. Intraoperative vasoplegic syndrome in patients with fulminant myocarditis on ventricular assist device placement. J Anesth 33, 304–310 (2019). https://doi.org/10.1007/s00540-019-02625-5
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DOI: https://doi.org/10.1007/s00540-019-02625-5