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2012/09/27 Combine meeting

2012/09/27 Combine meeting. 58 y/o Female DCMP s/p ECMO s/p DFPP s/p LVAD. 林柑 5305996. Brief History. 2006---DCMP 2008---ICD 2010---Heart transplantation waiting list. 58 yo Female. DCMP with arrhythmia status post permanent pacemaker insertion. 2012/07/07 HsinChu H.:

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2012/09/27 Combine meeting

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  1. 2012/09/27 Combine meeting 58 y/o FemaleDCMP s/p ECMO s/p DFPP s/p LVAD 林柑 5305996

  2. Brief History • 2006---DCMP • 2008---ICD • 2010---Heart transplantation waiting list

  3. 58 yo Female DCMP with arrhythmia status post permanent pacemaker insertion. 2012/07/07 HsinChu H.: • unsteady gait and aphasia. Con’s=E4M6Vt • Brain CT: left cerebral subcortical infarction admission 2012/07/07-11: • Progressive dyspnea, oliguria • LVEF=4.6% Pulmonary edema with acute CHF 2012/07/11: Intubation, ECMONTUH

  4. Physical Examination (2012/7/11) Vital Sign: T:36.2 P:64 R:17 BP:108/84 mmHg General appearance: ill Consciousness: E4M6Vt HEENT: grossly normal Eyes: conjunctiva: not pale, sclera: not icteric Pupil Isocoric, light reflex (R/L): +/+, prompt Ears: eardrums not injected. Neck: supple, JVE (-), LAP (-) Chest: symmetric expansion, bil crackles (+), Heart: RHB, no murmur audible Abdomen: soft and flat, no superficial collateral circulations, No tenderness, no rebounding tenderness Bowel sounds: normal active Liver / Spleen: Not palpable Extremities: freely movable, pitting edema (+), cyanosis (-), petechiae (-), rash (-) left femoral ECMO (+)

  5. 2012-7-11 X-ray

  6. 2012/07/12 EKG

  7. 2012/07/16 Cardiac Echo LVEF=14.6% global hypokinesia Moderate MR, TR, PR, Pulmonary Hypertension TRPG=50.7

  8. CAVH on V-A ECMO AKI due to shock related CAVH on ECMO support Waiting for heart transplantation

  9. Lab data Unasyn Tatumcef Donor Crossmatch + 5.4

  10. Cross match  減敏感治療

  11. Desenstitration Order

  12. DFPP Protocol 2A  4A Separator Volume : 1.5 X 30%  10% Extraction Replacement Fluid : Nil

  13. DFPP Course

  14. Treatment Course

  15. Donor Cross match

  16. 問題 • Blood flow ? • Myocardium depression • Fibrinogen consumption • Bleeding • Transfusion • 輸血 • 避免輸血 • 前置作業

  17. Treatment Course in 5CVI 2012/07/14 ECMO+CAVH, on HTx waiting list, PRA(+) 2012/07/25 Start Desensitization Protocol • 7/25 Rituximab 200 mg iv stat with solu-medrol 40 mg st • 7/26 DFPP(2A) with IVIG 7/26, 7/28, 7/30 • 8/1~14 DFPP (4A) with IVIG (QW2,5)  8 courses

  18. Treatment Course in 5CVI • 2012/07/11-8/30: Waiting for Heart Transplantation (ECMO) • ‧Coagulopathy • DFPP + IVIG for desensitization low fibrinogen, bleeding • Thrombus formation s/p emergent evacuation *4 • PRA(+) • VTDC shock (7/29, 8/27,8/28)

  19. 2012/08/30 LVAD implantation OP Method: LVAD THORATEC implantation V cannula: beveled tip against septim through LV apex A cannula: 14mm graft end-to-side anastomosis to AsAo; then wrapped by 20mm Hemashield vascular graft.

  20. Post-OP Course (2012/8/30) 2012/08/30 14:00 • Thoratec blood flow: 6L/min • CVP:24 mmHg, BP:45/42(43) mmHg • Dopamine :9.4 µg/Kg/min Levophed: 1.63 µg/Kg/min, Isuprel : 0.2 µg/Kg/min 2012/08/30 18:00 • BP↓ (48/41mmHg), device alarm: no flow • EKG: bradycardia • Lab: Hyperkalemia(K6.18)with metabolic cidosis (pH=7.05) • s/p correction: BP 169/97, PH 7.546, K 2.90 • Start CVVH

  21. Post-OP Course (2012/8/30) 2012/08/30-31 0:00 • BP drop ↓77/52mmHg VAD alarm(+): poor drainage CVP 27  12  volume challenge! Dop+Isuprel+Levophed+ DC shock*2CPR-> on ECMO

  22. 2012/8/30-31 ABG: lactate↑

  23. Treatment Course in 5CVI 2012/08/31 Pupil dilatation, E1M1Vt BP:50/30mmHg Discuss with family about poor prognosis • 2012/09/02 • Remove ECMO and Thoratec, the pt expired at 11:10AM

  24. 問題 • Blood flow ? • Myocardium depression • Fibrinogen consumption • Bleeding • Transfusion • 輸血 • 避免輸血 • 前置作業

  25. The decrease of patient blood volume was induced by an oncotic pressure drop due to albumin loss and often resulted in a pressure drop.

  26. ECMO + DFPP

  27. Intraoperative plasmapheresis and Cellcept induction • Peri-operative alemtuzumab(Campath-1H) and plasmapheresis for high-PRA positive lymphocyte crossmatch heart transplant: a strategy to shorten left ventricular device support. • Department of surgery, University of Texas Medical Branch, Galveston. • J Heart Lung Transplant. 2008 Sep;27(9): 1036-9. • Mortality and morbidity in pre-sensitized pediatric heart transplant recipients with a positive donor crossmatch utilizing peri-operative plasmapheresis and cytolytic therapy. • Department of Pediatrics, Washington University school of Medicine. • J Heart Lung Transplant. 2007 Sep;26(9): 876-82. • Pediatric cardiac transplantation in children with high panel reactive antibody. • The Congenital Heart institute of Florida, All children’s Hospital, University of South Florida. • Ann Thorac Surg. 2004 Nov;78(5):1703-9

  28. Protocol • 3-volume exchange in 60-100 min, depending on the patient’s body size. • Repaid removal of calcium and heparin sulfate during pheresis. • The timing of the institution of CPB and pheresis is determined by the expected arrival of the donor heart.

  29. Ann ThoracSurg 2011;92:1428-34

  30. NTUH Plasma exchange during CPB

  31. 移除目標為IgG: 2A或3A (can remove Immunoglobulins while allowing Albumin to be returned) 移除目標為IgM: 4A或5A 移除目標為LDL: 5A (can remove LDL while allowing Albumin and HDL to be returned)

  32. 楊正智order

  33. 楊正智DFPP

  34. 4/18 plasma exchange in OR

  35. LVAD (Thoratec Heartmate VE) • Pulsatile, LV assist Only. • Fixed rate / Chamber filled (asynchrony) • Initiated with flow 2.2L/min/m2, LAP 10-15mmHg • Bridge to Heart Transplantation.

  36. Manual Of Perioperative Care In Adult Cardiac Surgery Ch11 p.479

  37. Contraindication • Reasonable chance of recovery? • Age, medical condition, RV function, • Comorbidities ( neurologic, pulmonary, renal, hepatic) • Other medical issues ( infection, vascular disease, DM…)

  38. Post-LVAD management • Adequate tissue perfusion • Assessed by mixed Venous oxygen saturation • Decrease myocardial demand • Vasoactive medication only for RV function or increased SVR to keep MAP>75mmHg • “vasodilatory shock”

  39. Complication • Mediastinal bleeding, tamponade (60%) • Manifested by inadequate drainage into the device. • Previous coagulopathy, fibrinolysis, plt dysfxn. • Mediastinitis and Sepsis (40-50%) • Device related. • Resistant organism. • Malignant ventricular arrhythmia • LVAD flow↓ • Foster thrombus formation • RV failure (20%)  iNO • Thromboembolism (20%)

  40. Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) trial; N=280. • The 1-year survival after LVAD implantation was 56%; in-hospital mortality after LVAD surgery was 27%. • The most important determinants: • poor nutrition • hematological abnormalities • end-organ or right ventricular dysfunction • lack of inotropic support Circulation. 2007 Jul 31;116(5):497-505. Epub 2007 Jul 16

  41. Preoperative RV dysfunction correlated well with postoperative worsening RV dysfunction. • deviation of interventricular septum towards the LV, which eliminates the septal contribution to right heart contractility. Neragi-Miandoab et al. Journal of Cardiothoracic Surgery 2012, 7:60a

  42. Operative mortality of 46% for a score >5. 12% for a scoreto <=5. J ThoracCardiovascSurg 2003;125:855-62

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