Also Sprach Zarathustra
2018; Elsevier BV; Volume: 156; Issue: 3 Linguagem: Inglês
10.1016/j.jtcvs.2018.03.077
ISSN1097-685X
AutoresEric Howell, Nahush A. Mokadam,
Tópico(s)Acute Myocardial Infarction Research
ResumoCentral MessageWhat was once was thought of as impossible may become possible. We must maintain optimism in cardiothoracic surgery as we break through the next frontier.See Article page e135. What was once was thought of as impossible may become possible. We must maintain optimism in cardiothoracic surgery as we break through the next frontier. See Article page e135. On the shoulders of Friedrich Nietzsche, the composer Richard Strauss was able to create a symphonic masterpiece in his classic tone poem, Also Sprach Zarathustra, which was able to capture the imaginations of generations to follow. In the initial fanfare, entitled “Sunrise,” which was later used in Stanley Kubrich's 1968 classic film 2001: A Space Odyssey, Strauss's orchestral harmony encourages us all to believe in the unachievable and, in doing so, overcome what was previously thought impossible. In the seminal publication “Certain Features of Sudden Obstruction of the Coronary Arteries,” Herrick1Herrick J.B. Certain clinical features of sudden obstruction of the coronary arteries.JAMA. 1912; 59: 2015-2020Crossref Scopus (452) Google Scholar proclaimed in 1912 that in cases of coronary occlusion, “the importance of absolute rest in bed for several days is clear.” Despite its inherently benign nature, Herrick's medical mandate would ultimately shape the sedentary-based history of acute coronary care. Indeed, it wasn't until the development of myocardial reperfusion strategies by Chazov and colleagues2Chazov E.I. Matveeva L.S. Mazaev A.V. Sargin K.E. Sadovskaia G.V. Ruda M.I. [Intracoronary administration of fibrinolysin in acute myocardial infarction] Russian.Ter Arkh. 1976; 48: 8-19PubMed Google Scholar in 1975, more than 6 decades later, that the treatment paradigm of strict bedrest, aspirin, and expectant symptom management gave way to a more aggressive approach of early coronary revascularization and ambulation. Now, within the modern era of cardiopulmonary care, a distinct clinical subgroup of patients who require extracorporeal support for the management of end-stage heart and lung disease have emerged as the newest iteration of Herrick's historic immobility paradox. Despite the fact that both frailty and preoperative deconditioning are well known risk factors for poor patient outcomes, the intrinsic mobility limitations posed by the presence of external life-sustaining cannulas provide a unique set of challenges when it comes to balancing the benefits of preoperative functional optimization with the potentially catastrophic risks of cannula dislodgement or temporary circuit disruption. In this issue of the Journal, Shudo and colleagues3Shudo Y. Kasinpila P. Lee A.M. Rao V.K. Woo Y.J. Ambulating femoral venoarterial extracorporeal membrane oxygenation bridge to heart-lung transplant.J Thorac Cardiovasc Surg. 2018; 156: e135-e137Abstract Full Text Full Text PDF Scopus (11) Google Scholar present the first reported case of ambulatory femorofemoral, venoarterial extracorporeal membrane oxygenation (ECMO) as a bridge to en bloc combined heart-lung transplantation. With an emphasis on the importance of graduated preoperative conditioning strategies and comprehensive multidisciplinary engagement, Shudo and colleagues3Shudo Y. Kasinpila P. Lee A.M. Rao V.K. Woo Y.J. Ambulating femoral venoarterial extracorporeal membrane oxygenation bridge to heart-lung transplant.J Thorac Cardiovasc Surg. 2018; 156: e135-e137Abstract Full Text Full Text PDF Scopus (11) Google Scholar describe the successful use of ambulatory mobilization in a patient who underwent percutaneous femoral cannulation for venoarterial ECMO as a bridge to heart-lung transplantation. According to this experience, a femoral cannulation strategy should not be viewed as an absolute contraindication to early mobilization in patients on venoarterial ECMO support. Although on an admittedly less dramatic scale than Nietzsche's philosophy and Strauss's masterpiece, Shudo and colleagues' experience and success with ambulatory venoarterial ECMO3Shudo Y. Kasinpila P. Lee A.M. Rao V.K. Woo Y.J. Ambulating femoral venoarterial extracorporeal membrane oxygenation bridge to heart-lung transplant.J Thorac Cardiovasc Surg. 2018; 156: e135-e137Abstract Full Text Full Text PDF Scopus (11) Google Scholar highlights what can be considered the beginning of a new era for ambulatory extracorporeal support. Just as in the evolution in the management of myocardial infarction, we as a field are now progressing in extracorporeal support and experiencing our own will to power of what should be obvious to all of us. As we look forward, additional challenges must be faced, such as the creation of a reproducible cannula fixation system, the development of a structured functional rehabilitation program, and a more comprehensive patient cohort to ensure the reproducibility of this ambulatory method. Like the musical score in C major, this case report, too, is optimistic. Ambulating femoral venoarterial extracorporeal membrane oxygenation bridge to heart-lung transplantThe Journal of Thoracic and Cardiovascular SurgeryVol. 156Issue 3PreviewEn bloc heart-lung transplantation (EBHLT) represents definitive therapy for end-stage cardiopulmonary failure.1 However, patients may critically decompensate while awaiting suitable donor organs. In these cases, venoarterial extracorporeal membrane oxygenation (VA-ECMO) may be used as salvage therapy to mitigate end-organ dysfunction and potentially serve as a bridge to transplantation. Although multiple cannulation configurations have been used, femoral access is sometimes most optimal. However, femoral cannulation historically limited mobility, which is of significant concern in patients with preexisting physical deconditioning due to strained physiologic reserve. Full-Text PDF Open Archive
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