Predicting mortality in patients undergoing VA-ECMO after coronary artery bypass grafting: the REMEMBER score

Peripheral cannulation for extracorporeal membrane oxygenation yields superior neurologic outcomes in adult patients who experienced cardiac arrest following cardiac surgery

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest has improved mortality in post-cardiac surgery patients; however, loss of neurologic function remains one of the main and devastating complications. We reviewed our experience with ECPR and investigated the effect of cannulation strategy on neurologic outcome in adult patients who experienced cardiac arrest following cardiac surgery that was managed with ECPR.

METHODS

Patients were categorized by central versus percutaneous peripheral VA-extracorporeal membrane oxygenation (ECMO) cannulation strategy. We reviewed patient records and evaluated in-hospital mortality, cause of death, and neurologic status 72 hours after cannulation.

RESULTS

From January 2010 to September 2019, 44 patients underwent post-cardiac surgery ECPR for cardiac arrest. Twenty-six patients received central cannulation; 18 patients received peripheral cannulation. Mean post-operative day of the cardiac arrest was 3 and 9 days (p = 0.006), and mean time between initiation of CPR and ECMO was 40 ± 24 and 28 ± 22 minutes for central and peripheral cannulation, respectively. After 72 hours of VA-ECMO support, 30% of centrally cannulated patients versus 72% of peripherally cannulated patients attained cerebral performance status 1-2 (p = 0.01). Anoxic brain injury was the cause of death in 26.9% of centrally cannulated and 11.1% of peripherally cannulated patients. Survival to discharge was 31% and 39% for central and peripheral cannulation, respectively.

CONCLUSIONS

Peripheral VA-ECMO allows for continuous CPR and systemic perfusion while obtaining vascular access. Compared to central cannulation, a peripheral cannulation strategy is associated with improved neurologic outcomes and decreased likelihood of anoxic brain death.

Data Science Methods for Nursing-Relevant Patient Outcomes and Clinical Processes: The 2019 Literature Year in Review

Data science continues to be recognized and used within healthcare due to the increased availability of large data sets and advanced analytics. It can be challenging for nurse leaders to remain apprised of this rapidly changing landscape. In this article, we describe our findings from a scoping literature review of papers published in 2019 that use data science to explore, explain, and/or predict 15 phenomena of interest to nurses. Fourteen of the 15 phenomena were associated with at least one paper published in 2019. We identified the use of many contemporary data science methods (eg, natural language processing, neural networks) for many of the outcomes. We found many studies exploring Readmissions and Pressure Injuries. The topics of Artificial Intelligence/Machine Learning Acceptance, Burnout, Patient Safety, and Unit Culture were poorly represented. We hope that the studies described in this article help readers: (1) understand the breadth and depth of data science's ability to improve clinical processes and patient outcomes that are relevant to nurses and (2) identify gaps in the literature that are in need of exploration.

2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-cardiotomy Extracorporeal Life Support in Adult Patients

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.

2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management, and avoidance of complications, appraisal of new approaches and ethics, education, and training.

Urgent coronary artery bypass graft surgery supported by veno-arterial extracorporeal membrane oxygenation: a report of two cases

Mechanical circulatory support (MCS) devices, especially veno-arterial extracorporeal membrane oxygenation (VA-ECMO) devices, are increasingly used to shore complex cardiac procedures in high-risk patients. We are reporting two cases where patients underwent coronary artery bypass grafting (CABG) under support of VA-ECMO in the setting of cardiogenic shock complicating acute myocardial infarction. The patients had different courses, but both survived the initial insult and were weaned successively from VA-ECMO. Our report indicates that VA-ECMO can be used instead of the cardiopulmonary bypass machine (CPB) to support the circulation during CABG surgery in patients with complex coronary anatomy and unstable haemodynamics. Future studies focusing on the long-term outcomes of such patients will probably help to establish the optimal management of this type of patients.

Continuous renal replacement therapy in patients treated with extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) is a life‐saving therapy utilized for patients with severe life‐threatening cardiorespiratory failure. Patients treated with ECMO are among the most severely ill encountered in critical care and are at high‐risk of developing multiple organ dysfunction, including acute kidney injury (AKI) and fluid overload. Continuous renal replacement therapy (CRRT) is increasingly utilized inpatients on ECMO to manage AKI and treat fluid overload. The indications for renal replacement therapy for patients on ECMO are similar to those of other critically ill populations; however, there is wide practice variation in how renal supportive therapies are utilized during ECMO. For patients requiring both CRRT and ECMO, CRRT may be connected directly to the ECMO circuit, or CRRT and ECMO may be performed independently. This review will summarize current knowledge of the epidemiology of AKI, indications and timing of CRRT, delivery of CRRT, and the outcomes of patients requiring CRRT with ECMO.

Disseminated Intravascular Coagulation Score Is Related to Short-term Mortality in Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation After Cardiac Surgery

Disseminated intravascular coagulation (DIC) score is associated with short-term mortality in various conditions but has not been studied in postcardiotomy cardiogenic shock (PCS) patients supported with venoarterial extracorporeal membrane oxygenation (VA-ECMO). The objective of this study was to evaluate the relationship between DIC score at day 1 from VA-ECMO initiation and short-term mortality. We included all PCS patients supported with VA-ECMO at the Beijing Anzhen Hospital between January 2015 and December 2018. Multivariable logistic regression analysis was performed to assess the relationship between DIC score at day 1 and in-hospital mortality, and adjust for potential confounding variables. Of 222 PCS patients treated with VA-ECMO, 145 (65%) patients were weaned from VA-ECMO, and median (IQR) ECMO support duration was five (3-6) days. In-hospital mortality was 53%. The median (IQR) DIC score at day 1 was five (4-6). Patients with DIC score ≥5 at day 1 (overt DIC) had higher in-hospital mortality as compared with patients with DIC score <5 (64% vs. 22%; P < 0.001). After adjusting for age, sex, ECMO indication, and peak serum lactate, a one-point rise in DIC score [OR, 2.20; 95% confidence intervals (CI), 1.64-2.95] or DIC score ≥5 at day 1 (OR, 4.98; 95% CI, 2.42-10.24) was associated with an increased risk of in-hospital mortality. The area under the receiver operating characteristic curve for DIC score at day 1 was 0.76 (95% CI, 0.69-0.82). Our study suggests that DIC score at day 1 is associated with short-term mortality in patients undergoing VA-ECMO after cardiac surgery, independent of age, sex, disease characteristics, and severity of illness.

Veno-Arterial Extracorporeal Membrane Oxygenation for Patients Undergoing Heart Transplantation: A 7-Year Experience

Objective: Primary graft dysfunction (PGD) is the leading cause of early death after heart transplantation. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide temporary mechanical circulatory support and time for functional recovery of the transplanted heart. The purpose of this study was to analyze the timing and prognoses of VA-ECMO in patients with severe PGD after heart transplantation. Methods: A total of 130 patients underwent heart transplantation at the Zhongshan Hospital Affiliated with Fudan University between January 2014 and December 2020. All patients received basiliximab immunoinduction and a classic double vena cava anastomosis orthotopic heart transplantation. Among them, 29 patients (22.3%) developed severe PGD in the early postoperative period. VA-ECMO was performed in patients with difficulty weaning from cardiopulmonary bypass (CPB) or postoperative refractory cardiogenic shock. Patients were divided into two groups according to whether or not they were successfully weaned from VA-ECMO (patients who survived for 48 h after weaning and did not need VA-ECMO assistance again). The perioperative clinical data were recorded, and all patients were followed up until discharge. Early outcomes were compared between groups. Results: A total of 29 patients with VA-ECMO support after heart transplantation were included in this study. The proportion of patients receiving VA-ECMO was 22.3% (29/130). Nineteen patients (65.5%) needed VA-ECMO due to difficulty with weaning from CPB, and 10 patients required VA-ECMO for postoperative cardiogenic shock. Nineteen patients (65.5%) were successfully weaned from VA-ECMO. Overall, in-hospital mortality of VA-ECMO support patients was 55.2%. The main causes of death were ventricular fibrillation (four cases), major bleeding (three cases), infection (four cases), and graft failure (five cases). Conclusion: Despite advances in heart transplantation, severe PGD remains a lethal complication after heart transplantation. At present, the treatment for severe PGD after heart transplantation is a challenge. VA-ECMO provides an effective treatment for severe PGD after heart transplantation, which can promote graft function recovery.

Duration of Venoarterial Extracorporeal Membrane Oxygenation and Mortality in Postcardiotomy Cardiogenic Shock

OBJECTIVE

The optimal duration of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in patients affected by postcardiotomy cardiogenic shock (PCS) remains controversial. The present study was conducted to investigate the effect of VA-ECMO duration on hospital outcomes.

DESIGN

Retrospective analysis of an international registry.

SETTING

Multicenter study including 19 tertiary university hospitals.

PARTICIPANTS

Between January 2010 and March 2018, data on PCS patients receiving VA-ECMO were retrieved from the multicenter PC-ECMO registry.

INTERVENTIONS

Patients were stratified according to the following different durations of VA-ECMO therapy: ≤three days, four-to-seven days, eight-to-ten days, and >ten days.

MEASUREMENTS AND MAIN RESULTS

A total of 725 patients, with a mean age of 62.9 ± 12.9 years, were included. The mean duration of VA-ECMO was 7.1 ± 6.3 days (range 0-39 d), and 39.4% of patients were supported for ≤three days, 29.1% for four-seven days, 15.3% for eight-ten days, and finally 20.7% for >ten days. A total of 391 (53.9%) patients were weaned from VA-ECMO successfully; however, 134 (34.3%) of those patients died before discharge. Multivariate logistic regression showed that prolonged duration of VA-ECMO therapy (four-seven days: adjusted rate 53.6%, odds ratio [OR] 0.28, 95% confidence interval [CI] 0.18-0.44; eight-ten days: adjusted rate 61.3%, OR 0.51, 95% CI 0.29-0.87; and >ten days: adjusted rate 59.3%, OR 0.49, 95% CI 0.31-0.81) was associated with lower risk of mortality compared with VA-ECMO lasting ≤three days (adjusted rate 78.3%). Patients requiring VA-ECMO therapy for eight-ten days (OR 1.96, 95% CI 1.15-3.33) and >10 days (OR 1.85, 95% CI 1.14-3.02) had significantly greater mortality compared with those on VA-ECMO for 4 to 7 days.

CONCLUSIONS

PCS patients weaned from VA-ECMO after four-seven days of support had significantly less mortality compared with those with shorter or longer mechanical support.

2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.

2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-Cardiotomy Extracorporeal Life Support in Adult Patients

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.

Predicting Survival After VA-ECMO for Refractory Cardiogenic Shock: Validating the SAVE Score

Background

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used increasingly to support patients who are in cardiogenic shock. Due to the risk of complications, prediction models may aid in identifying patients who would benefit most from VA-ECMO. One such model is the Survival After Veno-Arterial Extracorporeal Membrane Oxygenation (SAVE) score. Therefore, we wanted to validate the utility of the SAVE score in a contemporary cohort of adult patients.

Methods

Retrospective data were extracted from electronic health records of 120 patients with cardiogenic shock supported with VA-ECMO between 2011 and 2018. The SAVE score was calculated for each patient to predict survival to hospital discharge. We assessed the SAVE score calibration by comparing predicted vs observed survival at discharge. We assessed discrimination with the area under the receiver operating curve using logistic regression.

Results

A total of 45% of patients survived to hospital discharge. Survivors had a significantly higher mean SAVE score (–9.3 ± 4.1 in survivors vs –13.1 ± 4.4, respectively; P = 0.001). SAVE score discrimination was adequate (c = 0.77; 95% confidence interval 0.69-0.86; P < 0.001). SAVE score calibration was limited, as observed survival rates for risk classes II-V were higher in our cohort (II: 67% vs 58%; III: 78% vs 42%; IV: 61% vs 30%; and V: 29% vs 18%).

Conclusions

The SAVE score underestimates survival in a contemporary North American cohort of adult patients with cardiogenic shock. Its inaccurate performance could lead to denying ECMO support to patients deemed to be too high risk. Further studies are needed to validate additional predictive models for patients requiring VA-ECMO.

The Validity of SOFA Score to Predict Mortality in Adult Patients with Cardiogenic Shock on Venoarterial Extracorporeal Membrane Oxygenation

Background

Venoarterial ECMO is increasingly used in resuscitation of adult patients with cardiogenic shock with variable mortality reports worldwide. Our objectives were to study the variables associated with hospital mortality in adult patients supported with VA-ECMO and to determine the validity of repeated assessments of those patients by the Sequential Organ Failure Assessment (SOFA) score for prediction of hospital mortality. We retrospectively studied adult patients admitted to the cardiac surgical critical care unit with cardiogenic shock supported with VA-ECMO from January 2015 to August 2019 in our tertiary care hospital.

Results

One hundred and six patients supported with VA-ECMO were included in our study with in-hospital mortality of 56.6%. The mean age of studied patients was 40.2 ± 14.4 years, and the patients were mostly males (69.8%) with a mean BMI of 26.5 ± 7 without statistically significant differences between survivors and nonsurvivors. Presence of CKD, chronic atrial fibrillation, and cardiac surgeries was significantly more frequent in the nonsurvivors group. The nonsurvivors had more frequent AKI (p < 0.001), more haemodialysis use (p < 0.001), more gastrointestinal bleeding (p = 0.039), more ICH (p = 0.006), and fewer ICU days (p = 0.002) compared to the survivors group. The mean peak blood lactate level was 11 ± 3 vs 16.7 ± 3.3, p < 0.001, and the mean lactate level after 24 hours of ECMO initiation was 2.2 ± 0.9 vs 7.9 ± 5.7, p < 0.001, in the survivors and nonsurvivors, respectively. Initial SOFA score ≥13 measured upon ICU admission had a 85% sensitivity and 73.9% specificity for predicting hospital mortality [AUROC = 0.862, 95% CI: 0.791–0.932; p < 0.001] with 81% PPV, 79.1% NPV, and 80.2% accuracy while SOFA score ≥13 at day 3 had 100% sensitivity and 91.3% specificity for predicting mortality with 93.8% PPV, 100% NPV, and 96.2% accuracy [AUROC = 0.995, 95% CI: 0.986–1; p < 0.001]. The ∆1 SOFA (3-1) ≥2 had 95% sensitivity and 93.5% specificity for predicting hospital mortality [AUROC = 0.958, 95% CI: 0.913–1; p < 0.001] with 95% PPV, 93.5% NPV, and 94.3% accuracy. SOFA score ≥15 at day 5 had 98% sensitivity and 100% specificity for predicting mortality with 99% accuracy [AUROC = 0.994, 95% CI: 0.982–1; p < 0.001]. The ∆2 SOFA (5-1) ≥2 had 90% sensitivity and 97.8% specificity for predicting hospital mortality [AUROC = 0.958, 95% CI: 0.909–1; p < 0.001] with 97.8% PPV, 90% NPV, and 94.8% accuracy. Multivariable regression analysis revealed that increasing ∆1 SOFA score (OR = 2.506, 95% CI: 1.681–3.735, p < 0.001) and increasing blood lactate level (OR = 1.388, 95% CI: 1.015–1.898, p = 0.04) were significantly associated with hospital mortality after VA-ECMO support for adults with cardiogenic shock.

Conclusion

The use of VA-ECMO in adult patients with cardiogenic shock is still associated with high mortality. Serial evaluation of those patients with SOFA score during the first few days of ECMO support is a good predictor of hospital mortality. Increase in SOFA score after 48 hours and hyperlactataemia are significantly associated with increased hospital mortality.

Clinical predictors of in-hospital mortality in venoarterial extracorporeal membrane oxygenation

INTRODUCTION

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is utilized as a life-saving procedure and bridge to myocardial recovery for patients in refractory cardiogenic shock. Despite technical advancements, VA-ECMO retains high mortality. This study aims to identify the clinical predictors of in-hospital mortality after VA-ECMO to improve risk stratification for this tenuous patient population.

METHODS

The REgistry for Cardiogenic Shock: Utility and Efficacy of Device Therapy database is a multicenter, observational registry of ECMO patients. From 2013 to 2018, 789 patients underwent VA-ECMO. Bivariate analysis was performed on more than 300 variables regarding their association with in-hospital mortality. Logistic regression analyses were performed with variables chosen based upon clinical and statistical significance in the bivariate analysis. Tests were considered significant at a two-sided P < .05.

RESULTS

Although 63.5% patients were successfully weaned from VA-ECMO, in-hospital mortality was 57.9%. Nonsurvivors were older (P < .0001), had higher body mass index (P = .01), higher rates of hypertension (P = .02), coronary artery disease (P = .02), chronic obstructive pulmonary disease (P = .02), chronic liver disease (P = .008), percutaneous coronary intervention (P = .02), and surgical revascularization (P = .02). Multivariate predictors for in-hospital mortality include older age (odds ratio [OR], 1.019; P = .007), cardiac arrest (OR, 2.76; P = .006), chronic liver disease (OR, 8.87; P = .04), elevated total bilirubin (OR, 1.093; P < .0001), and the presence of a left ventricular vent (OR, 2.018; P = .03). Pre-ECMO sinus rhythm was protective (OR, 0.374; P = .006).

CONCLUSIONS

In a large study of recent VA-ECMO patients, in-hospital mortality remains significant, but acceptable given the severe pathology manifested in this population. Identification of pre-ECMO predictors of mortality helps stratify high-risk patients when deciding on ECMO placement, prolonged support, and prognosis.

Risk factors for agitation and hyperactive delirium in adult postcardiotomy patients with extracorporeal membrane oxygenation support: an observational study

BACKGROUND

Agitation and delirium in critically ill patients after cardiac surgery carry poor in-hospital prognosis. Identifying risk factors may promote its prevention and management. Accordingly, this study aimed to evaluate the incidence of agitation and hyperactive delirium in postcardiotomy patients during the extracorporeal membrane oxygenation support and to identify the risk factors for its development.

METHODS

This single center, retrospective study was conducted at Beijing Anzhen Hospital, Capital Medical University. Data were extracted from the prospective institutional registry database of extracorporeal membrane oxygenation patients. Univariate and multivariate logistic regression analyses were performed to predict risk factors.

RESULTS

A total of 170 consecutive adult patients underwent extracorporeal membrane oxygenation in our hospital from January 2016 to December 2017. Ninety-four patients were included in the final analysis. The incidence of agitation and hyperactive delirium was 35% in our population of extracorporeal membrane oxygenation-supported postcardiotomy patients. Agitation and delirium usually occurred within the first 3 days of extracorporeal membrane oxygenation. Multivariable analysis showed that history of previous stroke (without preoperative cognitive dysfunction; odds ratio, 4.425, 95% confidence interval: 1.171-16.716; p = 0.028) and mean arterial pressure reduction (before extracorporeal membrane oxygenation initiation) ⩾ 49 mmHg (odds ratio, 7.570, 95% confidence interval: 2.366-24.219, p = 0.001) were independent risk factors for agitation and hyperactive delirium during extracorporeal membrane oxygenation support. The areas under the receiver operating characteristic curve for the prediction of agitation and hyperactive delirium was 0.704 (95% confidence interval 0.589-0.820, p = 0.001). There was more severe arrhythmia in the agitation patients.

CONCLUSION

Our results suggest that the prevalence of agitation and hyperactive delirium in postcardiotomy patients with extracorporeal membrane oxygenation support is high. In addition, previous stroke and severe mean arterial pressure reduction before extracorporeal membrane oxygenation initiation is predictive of agitation and hyperactive delirium.

Survival following venoarterial extracorporeal membrane oxygenation in postcardiotomy cardiogenic shock adults

BACKGROUND

Studies reporting long-term outcomes of venoarterial extracorporeal membrane oxygenation-treated coronary artery bypass grafting patients are scarce. The objective of this study was to examine the survival outcomes and identify mortality risk factors for coronary artery bypass grafting patients who received venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock.

METHODS

Data from 121 consecutive venoarterial extracorporeal membrane oxygenation-treated coronary artery bypass grafting patients at the Beijing Anzhen Hospital between January 2012 and December 2016 were analyzed. Multivariable Cox regression modeling was used to identify factors independently associated with 36-month mortality.

RESULTS

Seventy-seven patients (64%) could be weaned from venoarterial extracorporeal membrane oxygenation, 56 patients (46%) survived to hospital discharge, and 41 patients (34%) survived to 36 months. Older age (hazard ratio, 1.06; 95% confidence interval [CI], 1.03-1.10; p < 0.001), left main coronary artery disease (hazard ratio, 1.64; 95% CI, 1.04-2.59; p < 0.001), and vasoactive inotropic score (hazard ratio, 1.09; 95% CI, 1.02-1.16; p = 0.011) were independent risk factors associated with 36-month mortality. The area under the receiver operating characteristic curve for the logistic regression model, which was constructed with three pre-extracorporeal membrane oxygenation parameters-age ⩾ 60 years, left main coronary artery disease, and vasoactive inotropic score > 60-was 0.87 (95% CI, 0.81-0.94). Age and left main coronary artery disease significantly increased the discriminatory performance of Sepsis-related Organ Failure Assessment score (0.79 vs. 0.91, p = 0.025).

CONCLUSIONS

Older age, left main coronary artery disease, and vasoactive inotropic score were associated with 36-month mortality in coronary artery bypass grafting patients who received venoarterial extracorporeal membrane oxygenation.

Survival following venoarterial extracorporeal membrane oxygenation in postcardiotomy cardiogenic shock adults

Background:

Studies reporting long-term outcomes of venoarterial extracorporeal membrane oxygenation–treated coronary artery bypass grafting patients are scarce. The objective of this study was to examine the survival outcomes and identify mortality risk factors for coronary artery bypass grafting patients who received venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock.

Methods:

Data from 121 consecutive venoarterial extracorporeal membrane oxygenation–treated coronary artery bypass grafting patients at the Beijing Anzhen Hospital between January 2012 and December 2016 were analyzed. Multivariable Cox regression modeling was used to identify factors independently associated with 36-month mortality.

Results:

Seventy-seven patients (64%) could be weaned from venoarterial extracorporeal membrane oxygenation, 56 patients (46%) survived to hospital discharge, and 41 patients (34%) survived to 36 months. Older age (hazard ratio, 1.06; 95% confidence interval [CI], 1.03-1.10; p < 0.001), left main coronary artery disease (hazard ratio, 1.64; 95% CI, 1.04-2.59; p < 0.001), and vasoactive inotropic score (hazard ratio, 1.09; 95% CI, 1.02-1.16; p = 0.011) were independent risk factors associated with 36-month mortality. The area under the receiver operating characteristic curve for the logistic regression model, which was constructed with three pre–extracorporeal membrane oxygenation parameters—age ⩾ 60 years, left main coronary artery disease, and vasoactive inotropic score > 60—was 0.87 (95% CI, 0.81-0.94). Age and left main coronary artery disease significantly increased the discriminatory performance of Sepsis-related Organ Failure Assessment score (0.79 vs. 0.91, p = 0.025).

Conclusions:

Older age, left main coronary artery disease, and vasoactive inotropic score were associated with 36-month mortality in coronary artery bypass grafting patients who received venoarterial extracorporeal membrane oxygenation.

ECMO in cardiogenic shock and bridge to heart transplant

Purpose

The aim of this review is to discuss the role of extracorporeal membrane oxygenation (ECMO) in cardiogenic shock and its use to bridge patients to heart transplantation.

Methods and results

Consideration of published literature reveals indications for ECMO in cardiogenic shock and tools for patient selection, adequate evidence of its efficacy, its advantages when compared with other temporary mechanical circulatory support devices and details of its use as a bridge to decision, bridge to recovery, bridge to bridge (durable ventricular assist device) and bridge to heart transplant.

Conclusion

ECMO is invaluable in treating patients with medically refractory profound cardiogenic shock and allows for cardiac recovery or planning for permanent heart replacement treatments.

Predictors for unsuccessful weaning from venoarterial extracorporeal membrane oxygenation in patients undergoing coronary artery bypass grafting

Background:

Studies reporting risk factors associated with unsuccessful weaning for coronary artery bypass grafting patients on venoarterial extracorporeal membrane oxygenation are scarce. This study was designed to identify factors associated with unsuccessful weaning from venoarterial extracorporeal membrane oxygenation.

Methods:

Data from 166 coronary artery bypass grafting patients supported with venoarterial extracorporeal membrane oxygenation at the Beijing Anzhen Hospital between February 2004 and March 2017 were retrospectively analyzed. Multivariable logistic regression was performed using bootstrapping methodology to identify factors independently associated with unsuccessful weaning from venoarterial extracorporeal membrane oxygenation.

Results:

A total of 106 patients (64%) could be weaned from venoarterial extracorporeal membrane oxygenation, and 74 patients (45%) were alive at hospital discharge. The 30-day and 60-day survival rates after ECMO weaning were 72% and 70%, respectively. Pre-existing hypertension (odds ratio, 2.54; 95% confidence interval, 1.16-5.56; p = 0.02), serum creatinine (+1 μmol/L; odds ratio, 1.008; 95% confidence interval, 1.003-1.013; p = 0.001), and serum lactate (+1 mmol/L; odds ratio, 1.17; 95% confidence interval, 1.08-1.26; p = 0.001) were independent risk factors associated with unsuccessful weaning from venoarterial extracorporeal membrane oxygenation. Higher platelet count was protective (+1 × 109/L; odds ratio, 0.992; 95% confidence interval, 0.986-0.998; p = 0.011). The area under the receiver operating characteristic curve 0.81 (95% confidence interval, 0.75-0.88) for the logistic regression model was better than those for the survival after VA-ECMO score (p = 0.002), EuroSCORE (p < 0.001), and the prEdictioN of Cardiogenic shock OUtcome foR Acute myocardial infarction patients salvaGed by VA-ECMO scores (p = 0.02) in this population. The pRedicting mortality in patients undergoing venoarterial Extracorporeal MEMBrane oxygenation after coronary artEry bypass gRafting (0.76; 95% confidence interval, 0.68-0.83; p = 0.29) and sepsis-related organ failure assessment score (0.77; 95% confidence interval, 0.70-0.85; p = 0.46) exhibited good performances similar to the logistic regression model.

Conclusion:

Pre-existing hypertension, serum creatinine, serum lactate, and low platelet count were independent predictors for unsuccessful weaning from venoarterial extracorporeal membrane oxygenation in patients undergoing coronary artery bypass grafting.

Venoarterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock: Lifeline of Modern Day CICU

Cardiogenic shock (CS) portends an extremely high mortality of nearly 50% during index hospitalization. Prompt diagnoses of CS, its underlying etiology, and efficient implementation of treatment modalities, including mechanical circulatory support (MCS), are critical especially in light of such high predicted mortality. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides the most comprehensive cardiopulmonary support in critically ill patients and hence has seen a steady increase in its utilization over the past decade. Hence, a good understanding of VA-ECMO, its role in treatment of CS, especially when compared with other temporary MCS devices, and its complications are vital for any critical care cardiologist. Our review of VA-ECMO aims to provide the same.

Early prediction of transition to durable mechanical circulatory support in patients undergoing peripheral veno-arterial extracorporeal membrane oxygenation for critical cardiogenic shock

Peripheral veno-arterial extracorporeal membrane oxygenation (pVA-ECMO) has gained increasing value in the management of patients with critical cardiogenic shock (cCS), allowing time for myocardial recovery. Failure of myocardial recovery has life-altering consequences: transition to durable mechanical circulatory support (dMCS), urgent heart transplantation, or withdrawal of support. Clinical factors controlling myocardial recovery under these circumstances remain largely unknown. Using a retrospective cohort, we developed a model for early prediction of transition to dMCS in patients undergoing pVA-ECMO for cCS. To promote myocardial recovery, our clinical management centered around left ventricular pressure unloading, that is, targeting pulmonary capillary wedge pressures (PCWP) ≤18 mm Hg. We collected demographic data, laboratory findings, inotrope use, and two-dimensional transthoracic echocardiography measurements, all limited to the first 72h of pVA-ECMO (D1-3). Out of 70 patients who were alive after pVA-ECMO, 27 patients underwent implantation of dMCS. There was no significant difference in survival to hospital discharge between patients with or without transition to dMCS. Ejection fraction_D1-3 (per 10% increase, OR 0.37 [0.17-0.79]) and amount of inotropic support_D1-3 (OR 4.77 [1.6-14.18]) but neither myocardial wall tension nor PCWP emerged as significant predictors of transition to dMCS. Optimism-corrected c-index (0.90 [0.89-0.90]) revealed an excellent discriminative ability of our model. In summary, our model for early prediction of transition to dMCS in patients with cCS undergoing pVA-ECMO identifies indicators of inotropic state as relevant factors. Absence of markers for myocardial oxygen consumption or left ventricular pressure loading allows us to hypothesize sufficient cardiac unloading in our cohort with PCWP-targeted management.

Hurdles to Cardioprotection in the Critically Ill

Cardiovascular disease is the largest contributor to worldwide mortality, and the deleterious impact of heart failure (HF) is projected to grow exponentially in the future. As heart transplantation (HTx) is the only effective treatment for end-stage HF, development of mechanical circulatory support (MCS) technology has unveiled additional therapeutic options for refractory cardiac disease. Unfortunately, despite both MCS and HTx being quintessential treatments for significant cardiac impairment, associated morbidity and mortality remain high. MCS technology continues to evolve, but is associated with numerous disturbances to cardiac function (e.g., oxidative damage, arrhythmias). Following MCS intervention, HTx is frequently the destination option for survival of critically ill cardiac patients. While effective, donor hearts are scarce, thus limiting HTx to few qualifying patients, and HTx remains correlated with substantial post-HTx complications. While MCS and HTx are vital to survival of critically ill cardiac patients, cardioprotective strategies to improve outcomes from these treatments are highly desirable. Accordingly, this review summarizes the current status of MCS and HTx in the clinic, and the associated cardiac complications inherent to these treatments. Furthermore, we detail current research being undertaken to improve cardiac outcomes following MCS/HTx, and important considerations for reducing the significant morbidity and mortality associated with these necessary treatment strategies.