Echocardiography for adult patients supported with extracorporeal membrane oxygenation

The Simplified Acute Physiology Score II as a Predictor of Mortality in Patients Who Underwent Extracorporeal Membrane Oxygenation for Septic Shock

BACKGROUND

The use of extracorporeal membrane oxygenation (ECMO) for patients with septic shock is controversial. The outcomes are favorable in children but heterogeneous in adults. The present study aimed to analyze the outcomes of adult patients who underwent ECMO for septic shock, and to determine the factors associated with prognosis.

METHODS

We respectively reviewed the medical records of patients who underwent ECMO for septic shock between January 2007 and December 2013. Patients were divided into survivor and nonsurvivor groups based on survival to hospital discharge. The patient characteristics before and during ECMO were compared between the groups. Independent risk factors for mortality were evaluated using multivariate logistic regression, receiver-operating characteristic curves, and Kaplan-Meier analysis.

RESULTS

Twenty-eight patients were treated with venoarterial (n = 21), venovenous (n = 4), or venoarteriovenous (n = 3) mode ECMO. The overall survival rate to hospital discharge was 35.7%. The Simplified Acute Physiology Score II (SAPS II) and prealbumin were predictors of survival to hospital discharge. The optimal cutoff value for SAPS II was 80 (area under the curve 0.80, p = 0.010). Kaplan-Meier survival curves showed that the cumulative survival rate at hospital discharge and at 54-month follow-up was significantly higher among patients with SAPS II of 80 or less compared with patients with SAPS II greater than 80 (66.7% versus 12.5% and 58.3% versus 12.5%, respectively; p = 0.001).

CONCLUSIONS

It is still difficult to conclude whether ECMO should be recommended as therapy for adult patients with septic shock. However, a SAPS II score of 80 or less may be an indicator of favorable outcomes with the use of ECMO.

Veno-arterial extracorporeal membrane oxygenation: an overview of different cannulation techniques

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has known a widespread application over the last decade and is now an effective and valuable therapeutic option in refractory cardiogenic shock of various etiologies. In this subgroup of critically ill and unstable patients in cardiogenic shock, VA-ECMO allows, on the one hand, temporary hemodynamic stabilization with improvement of end-organ function and, on the other hand, gives the time to perform complementary diagnostic exams and to decide the therapeutic strategy in these high-risk candidates for immediate long-term mechanical circulatory support (MCS) implantation. VA-ECMO could also be suggested as a rescue therapeutic option for refractory cardiac arrest. It showed promising results in the specific setting of in-hospital cardiac arrest and survival rates with good neurological outcome are reported between 20% and 40%. Conversely, there are contrasting data in the literature about survival after VA-ECMO for out-of-hospital cardiac arrest, as results are highly dependent on low-flow time. The aim of the present report is to offer an overview of different cannulation techniques of VA-ECMO.

Hemodynamic Transesophageal Echocardiography-Guided Venous-Arterial Extracorporeal Membrane Oxygenation Support in a Case of Giant Cell Myocarditis

Giant cell myocarditis (GCM) is a rare and commonly fatal form of fulminant myocarditis. During the acute phase, while immunosuppressive therapy is initiated, venoarterial extracorporeal membrane oxygenation (VA-ECMO) support is commonly used as a bridge to heart transplantation or recovery. Until recently, conventional transesophageal echocardiography and transthoracic echocardiography were the tools available for hemodynamic assessment of patients on this form of mechanical circulatory support. Nevertheless, both techniques have their limitations. We present a case of a 54-year-old man diagnosed with GCM requiring VA-ECMO support that was monitored under a novel miniaturized transesophageal echocardiography (hTEE) probe recently approved for 72 hours of continuous hemodynamic monitoring. Our case highlights the value of this novel, flexible, and disposable device for hemodynamic monitoring, accurate therapy guidance, and potential VA-ECMO weaning process of patients with this form of severe myocarditis.