Predicting Trends in Dyspnea and Fatigue in Heart Failure Patients' Outcomes

BACKGROUND

Dyspnea and fatigue are distressing symptoms commonly seen in heart failure (HF) patients, and are closely related to patients' disease trajectory of contributes. Identifying the effect of symptom trends on disease outcomes is important to develop effective symptom management interventions in HF patients.

METHODS

One hundred and twenty-two patients were recruited. Dyspnea, fatigue, clinical characteristics, and disease outcomes were measured at the baseline assessment, three months, and 12 months. Latent class growth model and Kaplan-Meier survival analysis were used on dyspnea and fatigue to examine the relationship of disease trajectories and effects on disease outcomes.

RESULTS

A total of 122 patients were examined (mean age 62.8 ± 13.0 yrs; 79% male; 39% NYHA III/IV; 48% preserved systolic function HF). Three groups based on HF patients' dyspnea-fatigue trends were identified as "constant good," "recovery," and "getting worse." The cumulative incidence of a first cardiac event in both dyspnea and fatigue groups yielded similar results. The quality of life score for the getting worse group was significantly higher than that of the constant good and recovery groups. The result of the log-rank test was significant (χ(2) = 8.11, p = 0.017). Post hoc comparison showed that the prognosis status of the constant good group was better than that of the getting worse (p = 0.046) and recovery groups (p = 0.020), while getting worse and recovery groups did not differ in prognosis status (p = 0.30).

CONCLUSIONS

The results demonstrate the value of tracking symptoms over time to determine symptom trajectories as well as severe baseline (even with improvements at follow-ups) or increased fatigue over time were related to a worse event-free survival as compared with low but stable fatigue.

KEY WORDS

Disease outcome; Kaplan-Meier survival analysis; Symptom trajectory.

Reversal of hoarseness with recognition of Ortner syndrome in a patient with severe mitral regurgitation

Loss of voice due to vocal cord paralysis, as in Ortner syndrome, is secondary to left recurrent laryngeal nerve palsy. Cardiovascular cause should be listed as a differential diagnosis of hoarseness and is incumbent upon the diagnostic physician to be familiar with the condition. A 56-year-old male presented to our emergency department with shortness of breath due to severe mitral regurgitation. Incidental finding of aggravating hoarseness during the past six months was suspected to be related to his cardiac condition with hugely dilated left atrium. After an ear nose and throat specialist confirmed left vocal cord paralysis, a cardiac surgeon was consulted for surgical management. The operation consisted of mitral valve repair, tricuspid valve repair, left atrial reduction, and Cox maze procedure. Three days after surgery the patient had noticeable improvement in his voice, and 3 months later he had complete resolution of the hoarseness. Awareness of Ortner syndrome and a search for treatable cause of vocal cord palsy therefore is imperative before the nerve injury becomes irreversible. <Learning objective: Hoarseness in unusual clinical setting (i.e. other than in common cold), should raise suspicion and alert physician to search for primary cause of the symptoms. Ortner syndrome, due to left recurrent laryngeal nerve palsy secondary to cardiovascular disease, is an important differential diagnosis of loss of voice. Comprehensive evaluation and timely intervention allow reversal of the damage to left recurrent laryngeal nerve, whereas delay in diagnosis may lead to permanent nerve injury.>.

MUC1, MUC2 and MUC5AC expression in hepatocellular carcinoma with cardiac metastasis

Advanced hepatocellular carcinoma is characterized by a poor prognosis, and the choice of therapy is complicated in cases with cardiac metastasis due to the questionable benefits of surgery. Since many studies have indicated that mucin (MUC) expression plays an important role in cancer metastasis and recurrence, we investigated mucin expression in hepatocellular carcinoma patients with cardiac metastasis compared with primary hepatocellular carcinoma to confirm the nature of the malignancy. Over a 6-year period, the expression patterns of MUC1, MUC2 and MUC5AC in tumor samples from hepatocellular carcinoma patients with cardiac metastasis were assessed using immunochemistry. The results were compared with findings from a group characterized by a more favorable prognosis; those with primary hepatocellular carcinoma without recurrence. Pathologic examinations indicated that patients with hepatocellular carcinoma and cardiac metastasis had more vascular invasion (P=0.004) and less section-free zone involvement (P<0.001) than those with primary hepatocellular carcinoma. MUC1 expression was significantly higher in hepatocellular carcinoma with cardiac metastasis (P<0.005). In conclusion, the expression of mucins, especially MUC1, confirms the malignant nature of hepatocellular carcinoma with cardiac metastasis. It is recommended that such patients receive aggressive therapy.

Impact of acute kidney injury on one-year survival after surgery for aortic dissection

BACKGROUND

Surgical treatment is an option for both type A aortic dissection and complicated type B aortic dissection. Acute kidney injury (AKI) influences the disease course after surgery. Our hypothesis was that AKI should be an important prognostic factor for aortic dissection after surgical treatment.

METHODS

Between July 2005 and October 2010, 268 patients (mean age 53 ± 14 years; range, 16 to 88) underwent open surgery for aortic dissection. We reviewed the clinical presentations, surgical variables, and postoperative outcomes to identify the risk factors of death. The 256 patients were divided into groups, with and without AKI, within 24 hours after operation according to the RIFLE (acronym for risk, injury, failure, loss, end stage) criteria.

RESULTS

The in-hospital mortality rate was 17.9%, the 1-year mortality rate was 18.7%, and the major adverse cardiac events rate within 1 year was 29.9%. In multivariate analysis, patients more than 70 years of age (hazard ratio [HR] 2.390, p = 0.029), cardiogenic shock (HR 2.895, p = 0.005), preoperative ventilator use (HR 4.137, p = 0.018), operation at midnight (HR 2.295, p = 0.028), longer bypass time (HR 1.007, p < 0.001), and AKI (HR 2.552, p = 0.041) were clinical predictors of mortality. Kaplan-Meier analysis showed that the survival rate was strongly correlated with the severity of AKI by the RIFLE criteria. The independent predictors of AKI included hypertension (odds ratio 2.340, p = 0.027), sepsis (odds ratio 2.594, p = 0.043), and lower limb malperfusion (odds ratio 4.558, p = 0.022).

CONCLUSIONS

Our study provides outcomes of postoperative aortic dissection. We found that AKI was a predictor of 1-year mortality by using the RIFLE criteria. Factors associated with increased 1-year mortality and AKI should be taken into consideration for surgery and postoperative care.

Predictors of mortality in patients successfully weaned from extracorporeal membrane oxygenation

Purpose

Extracorporeal membrane oxygenation (ECMO) has been utilized for critically ill patients, such as those with life-threatening respiratory failure or post-cardiotomy cardiogenic shock. This study compares the predictive value of Acute Physiology, Age, and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA), and Organ System Failure (OSF) obtained on the first day of ECMO removal, and the Acute Kidney Injury Network (AKIN) stages obtained at 48 hours post-ECMO removal (AKIN_48-hour) in terms of hospital mortality for critically ill patients.

Methods

This study reviewed the medical records of 119 critically ill patients successfully weaned from ECMO at the specialized intensive care unit of a tertiary-care university hospital between July 2006 and October 2010. Demographic, clinical, and laboratory data were collected retrospectively as survival predictors.

Results

Overall mortality rate was 26%. The most common condition requiring ECMO support was cardiogenic shock. By using the areas under the receiver operating characteristic (AUROC) curve, the Sequential Organ Failure Assessment (SOFA) score displayed good discriminative power (AUROC 0.805±0.055, p<0.001). Furthermore, multiple logistic regression analysis indicated that daily urine output on the second day of ECMO removal (UO_{24–48 hour}), mean arterial pressure (MAP), and SOFA score on the day of ECMO removal were independent predictors of hospital mortality. Finally, cumulative survival rates at 6-month follow-up differed significantly (p<0.001) for a SOFA score≤13 relative to those for a SOFA score>13.

Conclusions

Following successful ECMO weaning, the SOFA score proved a reproducible evaluation tool with good prognostic abilities.

Adult bicuspid aortic valve endocarditis with extensive paravalvular invasion attributable to disseminated varicella zoster infection

We report a previously healthy 21-year-old man who developed disseminated varicella zoster infection complicated with encephalitis, acute renal insufficiency, liver dysfunction, and an apparent pustular skin superinfection with Staphylococcus aureus. He later developed an extensively destructive endocarditis affecting a congenital bicuspid aortic valve, accompanied with leaflet perforation, complete atrio-ventricular (AV) block, and invasion of vegetation to both left and right atrium; the endocarditis was attributed to the same skin pathogen, S. aureus. He underwent radical debridement of the aortic valve, membranous ventricular septum, and mitral anterior fibrous trigone, followed by reconstruction of intracardiac defects with 2 autologous pericardial patches and aortic valve replacement. After a permanent pacemaker implantation and 4 weeks of antibiotic treatment, he was discharged after an uneventful postoperative course.

Prognosis of patients on extracorporeal membrane oxygenation plus continuous arteriovenous hemofiltration

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) has been utilized for critically ill patients such as those with life-threatening respiratory failure or post-cardiotomy cardiogenic shock. Patients on ECMO with acute renal failure have high mortality rates. This study identifies specific predictors of hospital mortality for patients receiving ECMO and continuous arteriovenous hemofiltration (CAVH).

METHODS

This study reviewed the medical records of 123 critically ill patients on ECMO plus CAVH at a cardiovascular surgical intensive care unit (CVSICU) at a tertiary care university hospital between March 2003 and August 2010. Patient baseline, clinical, and laboratory data were collected retrospectively as survival predicators.

RESULTS

The overall mortality rate was 85.4%. The most common conditions requiring ECMO plus CAVH were cardiogenic shock and oliguria. The Acute Physiology and Chronic Health Evaluation II (APACHE II) score and organ system failure (OSF) score both indicated good discriminative power (area under the receiver operating characteristic curve [AUROC] 0.812 ± 0.048 and 0.758 ± 0.057, respectively). Multiple logistic regression analysis indicated that age, mean arterial pressure, and OSF score on day 1 of ECMO plus CAVH were independent risk factors for hospital mortality. Cumulative survival rates at the 6-month follow-up differed significantly (p < 0.001) between those with an OSF score ≤ 4 vs. those with an OSF score > 4.

CONCLUSIONS

During ECMO plus CAVH support, both the OSF and APACHE II scores showed good discriminative power in predicting hospital mortality for these patients.

Prognosis of patients on extracorporeal membrane oxygenation: the impact of acute kidney injury on mortality

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) has been utilized for patients in critical condition, such as those with life-threatening respiratory failure or postcardiotomy cardiogenic shock. This study analyzed the outcomes of patients treated with ECMO and identified the relationship between prognosis and the Acute Kidney Injury Network (AKIN) scores obtained at pre-ECMO support (AKIN0-hour); and at post-ECMO support 24 hours (AKIN24-hour) and 48 hours (AKIN48-hour).

METHODS

This study reviewed the medical records of 102 critically ill patients on ECMO support at a specialized intensive care unit at a tertiary care university hospital between March 2002 and January 2008. Demographic, clinical, and laboratory variables were retrospectively collected as survival predicators.

RESULTS

The overall mortality rate was 57.8%. The most common condition requiring ECMO support was cardiogenic shock. Goodness-of-fit was good for AKIN0-hour, AKIN24-hour, and AKIN48-hour criteria. The AKIN0-hour, AKIN24-hour, and AKIN48-hour scoring systems also had excellent areas under the receiver operating characteristic curve (0.804±0.046, 0.811±0.045, and 0.858±0.040, respectively). Furthermore, multiple logistic regression analysis indicated that AKIN48-hour, age, and Glasgow Coma Scale score on the first day of intensive care unit admission were independent risk factors for hospital mortality. Finally, cumulative survival rates at 6-month follow-up after hospital discharge differed significantly (p<0.05) for AKIN48-hour stage 0 versus AKIN48-hour stages 1, 2, and 3; and AKIN48-hour stage 1 and 2 versus AKIN48-hour stage 3.

CONCLUSIONS

During ECMO support, the AKIN48-hour scoring system proved to be a reproducible evaluation tool with excellent prognostic abilities for these patients.

Transforming growth factor-β and oxidative stress mediate tachycardia-induced cellular remodelling in cultured atrial-derived myocytes

AIMS

Atrial fibrillation (AF), a common tachyarrhythmia in clinical practice, is associated with increased oxidative stress. Structural remodelling in atrial myocytes, including myofibril degradation, is an important characteristic of AF. However, the mechanism underlying AF-induced cellular structural remodelling remains unclear. The aim of this study was to investigate the role of oxidative stress and related factors in tachycardia-induced atrial structural remodelling.

METHODS AND RESULTS

Cultured atrial-derived myocytes (HL-1 cell line) were subjected to electrical stimulation. Immunofluorescence and immunoblotting were used to evaluate oxidative stress, myofibril degradation, and transforming growth factor-β (TGF-β) expression. Tachypacing in HL-1 cells induced TGF-β expression, pronounced oxidative stress including up-regulation of NADPH oxidases (Nox2/4), and myofibril degradation. Oxidative stress scavenger, NADPH oxidase inhibitors, and small-interfering RNAs for Nox2/4 blocked tachypacing-induced myofibril degradation, suggesting that Nox-derived oxidative stress may lead to tachycardia-induced myofibril degradation. Blockade of TGF-β signalling by neutralizing TGF-β antibodies attenuated myofibril loss in response to tachypacing, implicating autocrine and/or paracrine roles for TGF-β in such effects. Tachypacing also induced the activation of p-Smad3 (an effective mediator of TGF-β) and small-interfering RNAs for Nox2/4 attenuated its activation, supporting a crosstalk between both signalling pathways. Furthermore, TGF-β expression, oxidative stress, and myofibril loss were greater in the atria of patients with AF than those with sinus rhythm.

CONCLUSIONS

Rapid activation in atrial myocytes promotes myofibril degradation through autocrine/paracrine TGF-β signalling and increased oxidative stress. These findings provide an important mechanistic insight into AF-related structural remodelling.

Traumatic pericardial effusion: impact of diagnostic and surgical approaches

INTRODUCTION

In trauma patients with chest injuries, traumatic pericardial effusion is an important scenario to consider because of its close linkage to cardiac injury. Even with advances in imaging, diagnosis remains a challenge and use of which surgical approach is controversial. This study reviews the treatment algorithm, surgical outcomes, and predictors of mortality for traumatic pericardial effusion.

PATIENTS AND METHODS

Information on demographics, mechanisms of trauma, injury scores, diagnostic tools, surgical procedures, associated injuries, and hospital events were collected retrospectively from a tertiary trauma center.

RESULTS

Between June 2003 and December 2009, 31 patients (23 males and 8 females) with a median age of 31 (range 16-77), who had undergone surgical drainage of pericardial effusion were enrolled in the study. Blunt trauma accounted for 27 (87.1%) insults, and penetrating injury accounted for 4 (12.9%). Patients were diagnosed by Focused Assessment with Sonography for Trauma (FAST) (8 patients), computerized tomography (7 patients), echocardiography (9 patients), and incidentally during surgery (7 patients). Notably, sixteen (51.7%) patients required surgical repair for traumatic cardiac ruptures, including 6 (19.6%) with pericardial defects who presented initially with hemothorax. The surgical approaches were subxiphoid in 8 patients (25.8%), thoracotomy in 7 (22.6%), and sternotomy in 19 (61.2%), including 3 conversions from thoracotomy. The survival to discharge rate was 77.4% (24/31). Concomitant cardiac repair, associated pericardial defects, and initial surgical approach did not affect survival, but the need for massive transfusion, cardiopulmonary cerebral resuscitation (CPCR), trauma score, and incidental discovery at surgery all had a significant impact on the outcome.

CONCLUSIONS

Precise diagnoses of traumatic pericardial effusions are still challenging and easily omitted even with FAST, repeat cardiac echo and CT. The number of patients with traumatic pericardial effusion requiring surgical repair is high. Standardized therapeutic protocol, different surgical approaches have not impact on survival. Correct identification, prompt drainage, and preparedness for concomitant cardiac repair seem to be the key to better outcomes.

Using extracorporeal life support to resuscitate adult postcardiotomy cardiogenic shock: treatment strategies and predictors of short-term and midterm survival

BACKGROUND

Postcardiotomy extracorporeal life support (ECLS) is a resource-demanding therapy with varied results among institutions. An organized protocol was necessary to improve the effectiveness of this therapy.

METHODS AND RESULTS

A total of 110 patients received ECLS due to refractory postcardiotomy cardiogenic shock between January 2003 and June 2009, and were eligible for inclusion in this retrospective study. Preoperative, perioperative, and postoperative variables were collected, including the European system for cardiac operative risk evaluation (EuroSCORE) and markers of ECLS-related organ injuries. All variables were analyzed for possible associations with mortality in hospital, and after hospital discharge. The mean age, additive EuroSCORE, and left ventricular ejection fraction (LVEF) for all patients was 60 (+/-14) years, 9 (+/-6), and 43% (+/-20%) respectively. Sixty-seven patients were weaned from ECLS and 46 survived to hospital discharge. The mean duration of ECLS support was 143 h (+/-112 h). Multivariate analysis revealed that an age of >60 years, a necessity for postoperative continuous arteriovenous hemofiltration, a maximal serum total bilirubin >6 mg/dL, and a need for ECLS support for >110 h were independent predictors of in-hospital mortality. In addition, persistent heart failure with LVEF <30% was an independent predictor of mortality after hospital discharge. A risk-predicting score for in-hospital mortality associated with postcardiotomy ECLS was developed for clinical application.

CONCLUSION

Based on the abovementioned findings, a comprehensive protocol for postcardiotomy ECLS was designed. The primary objective was to achieve adequate hemodynamics within the first 24h of initiating ECLS. Other objectives of the protocol included a consistent approach to safe anticoagulation while on ECLS, a process to make decisions within 7 days of initiating ECLS, and patient follow-up after hospital discharge.

Prediction of major complications after isolated coronary artery bypass grafting: the CGMH experience

BACKGROUND

The in-hospital mortality of coronary artery bypass grafting (CABG) is low but can be significant if catastrophic complications occur. To increase the safety of CABG, we aimed to establish a predictive model of major postoperative complications that incorporated patient characteristics and operative strategies.

METHODS

A retrospective study was performed which included all consecutive patients receiving isolated CABG from August 2006 to February 2008 (n = 319). Patient characteristics were quantified by the additive EuroSCORE. Operative strategies were classified as cardioplegic arrest, on-pump beating, and off-pump.

RESULTS

Four major complications were identified to be connected to the in-hospital mortality: (1) requirement of mechanical circulatory supports > 72 h (odds ratio [OR] 28.9, 95% confidence interval [CI] 6.0-139.9), (2) requirement of mechanical ventilator supports > 72 h (OR 9.5., 95%, CI 2.2- 42.7), (3) acute renal failure requiring dialysis (OR 9.2, 95% CI 2.2-38.3), (4) major gastrointestinal complications (OR 5.4., 95% CI 1.1-26.7). An increase of additive EuroSCORE (OR 1.2, 95% CI 1.1-1.4) and the cardioplegic strategy (OR 2.7, 95% CI 1.2-6.0) were independent risk factors for major complications. The probability of one or more major complication was > 50% for patients receiving cardioplegic CABG with an additive EuroSCORE > 8.

CONCLUSION

Dependence on the mechanical ventilator or circulatory supports > 72 h, acute renal failure requiring dialysis, and major gastrointestinal complications were major complications of CABG. The individual risk of having at least one of these complications could be predicted by the patient's preoperative EuroSCORE and operative strategy. A surgical plan tailored by institutional experiences on specific risk factors and aggressive therapeutic plans for major complications are helpful in improving the overall results of CABG.

Blunt traumatic cardiac rupture: therapeutic options and outcomes

INTRODUCTION

Cardiac rupture following blunt thoracic trauma is rarely encountered by clinicians, since it commonly causes death at the scene. With advances in traumatology, blunt cardiac rupture had been increasingly disclosed in various ways. This study reviews our experience of patients with suspected blunt traumatic cardiac rupture and proposes treatment protocols for the same.

METHODS

This is a 5-year retrospective study of trauma patients confirmed with blunt traumatic cardiac rupture admitted to a university-affiliated tertiary trauma referral centre. The following information was collected from the patients: age, sex, mechanism of injury, initial effective diagnostic tool used for diagnosing blunt cardiac rupture, location and size of the cardiac injury, associated injury and injury severity score (ISS), reversed trauma score (RTS), survival probability of trauma and injury severity scoring (TRISS), vital signs and biochemical lab data on arrival at the trauma centre, time elapsed from injury to diagnosis and surgery, surgical details, hospital course and final outcome.

RESULTS

The study comprised 8 men and 3 women with a median age of 39 years (range: 24-73 years) and the median follow-up was 5.5 months (range: 1-35 months). The ISS, RTS, and TRISS scores of the patients were 32.18+/-5.7 (range: 25-43), 6.267+/-1.684 (range: 2.628-7.841), and 72.4+/-25.6% (range: 28.6-95.5%), respectively. Cardiac injuries were first detected using focused assessment with sonography for trauma (FAST) in 4 (36.3%) patients, using transthoracic echocardiography in 3 (27.3%) patients, chest CT in 1 (9%) patient, and intra-operatively in 3 (27.3%) patients. The sites of cardiac injury comprised the superior vena cava/right atrium junction (n=4), right atrial auricle (n=1), right ventricle (n=4), left ventricular contusion (n=1), and diffuse endomyocardial dissection over the right and left ventricles (n=1). Notably, 2 had pericardial lacerations presenting as a massive haemothorax, which initially masked the cardiac rupture. The in-hospital mortality was 27.3% (3/11) with 1 intra-operative death, 1 multiple organ failure, and 1 death while waiting for cardiac transplantation. Another patient with morbid neurological defects died on the thirty-third postoperative day; the overall survival was 63.6% (7/11). Compared with the surviving patients, the fatalities had higher RTS and TRISS scores, serum creatinine levels, had received greater blood transfusions, and had a worse preoperative conscious state.

CONCLUSIONS

We proposed a protocol combining various diagnostic tools, including FAST, CT, transthoracic echocardiography, and TEE, to manage suspected blunt traumatic cardiac rupture. Pericardial defects can mask the cardiac lesion and complicate definite cardiac repair. Comorbid trauma, particularly neurological injury, may have an impact on the survival of such patients, despite timely repair of the cardiac lesions.

Extracorporeal life support in post-traumatic respiratory distress patients

BACKGROUND

Extracorporeal life support (ECLS) has been applied successfully to patients with acute cardiopulmonary failure. However, ECLS remains controversial for traumatized patients who are prone to bleeding.

PATIENTS AND METHODS

From March 2004 to October 2007, nine patients with post-traumatic respiratory distress refractory to ventilator support were treated with ECLS. Mean patient age was 35.1+/-9.7 (range, 18-47) years, average injury severity score (ISS) was 44.56+/-4.93 (range, 35-50), and Sequential Organ Failure Assessment score (SOFA) score was 12.1+/-3.67 (range, 7-16). Before ECLS, all patients had received thoracic interventions, including four lung resections, with a mean PaO(2) of 49.04+/-9.82 (range, 31-64) mmHg and PaCO(2) of 66.4+/-15.72 (range, 45-86) mmHg. Seven patients were supported in standard veno-venous mode, and the other two were initially supported in veno-arterial mode due to hemodynamic instability.

RESULTS

Median interval from trauma to ECLS was 33 (range, 4-384) h, and median duration of ECLS was 145 (range, 69-456) h. Six (66.7%) patients received additional surgeries during ECLS. One died of sepsis from occult colon rupture and the other of acute liver failure, 6 and 13 days respectively after trauma. Seven (77.8%) patients were weaned and discharged.

CONCLUSIONS

Using ECLS to resuscitate traumatic respiratory distress proved to be safe and effective when conventional therapies had been exhausted. Early deployment of ECLS to preserve systemic organ perfusion, aggressive treatment of coexisting injuries and tailored anticoagulation protocols are crucial to a successful outcome.

Continuous renal replacement therapy combined with extracorporeal membrane oxygenation in advanced cardiac failure patients

Acute renal failure during extracorporeal membrane oxygenation (ECMO) support is associated with extremely high mortality. This report describes treatment of myocardial dysfunction in one 48-year-old and one 11-year-old patient. Venoarterial ECMO was required to support myocardial dysfunction. Continuous venovenous hemodialysis was performed for acute renal failure with pulmonary edema and oliguria. Both patients survived following treatment with venoarterial ECMO combined with continuous venovenous hemodialysis.

Impact of preexisting organ dysfunction on extracorporeal life support for non-postcardiotomy cardiopulmonary failure

BACKGROUND

Extracorporeal life support (ECLS) is associated with a high mortality rate in patients with preexisting multiple organ failure. To achieve better outcomes of ECLS in this high risk group, an understanding of the real impact of preexisting organ dysfunction on ECLS-associated mortality is necessary.

METHODS

From January 2003 to March 2007, a total of 45 patients (mean age: 48 years) were placed on ECLS for acute cardiopulmonary failure and survived longer than 24h. The medical records of these 45 patients were retrospectively reviewed. The indications for ECLS were acute respiratory distress syndrome (n=23), acute myocarditis (n=10) and acute myocardial infarction (n=12). Organ failure was assessed based on the Sequential Organ Failure Assessment (SOFA) score, which was calculated daily until ECLS termination. The demographic variables, SOFA score variables, and ECLS-related complications, including renal dialysis, severe brain damage and limb ischemia, were analysed.

RESULTS

Twenty-seven patients (60%) were weaned from ECLS and 21 (47%) survived to discharge. Multivariate analysis revealed that the necessity of renal dialysis was an independent risk factor associated with failure to wean and non-survival, and the necessity of cardiopulmonary resuscitation (CPR) before ECLS was an independent risk factor for non-survival. Preexisting organ dysfunction, quantified by the pre-ECLS SOFA score, was predictive of survival to discharge. A pre-ECLS SOFA score greater than 14 predicted mortality in this study.

CONCLUSIONS

SOFA score is a practical assessment tool and is predictive of ECLS-associated mortality in non-postcardiotomy patients. Patients having cardiac arrest requiring CPR or acute renal failure requiring dialysis before ECLS may have inferior ECLS outcomes.