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Hohri Y, Zhao Y, Takayama H, Vinogradsky AV, Kurlansky P, Fried J, Takeda K. Relationship between indexed surgery and postcardiotomy extracorporeal life support outcomes. Perfusion 2024:2676591241271984. [PMID: 39088311 DOI: 10.1177/02676591241271984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
Abstract
OBJECTIVES Veno-arterial extracorporeal life support (V-A ECLS) is increasingly being utilized for postcardiotomy shock (PCS), though data describing the relationship between type of indexed operation and outcomes are limited. This study compared V-A ECLS outcomes across four major cardiovascular surgical procedures. METHODS This was a single-center retrospective study of patients who required V-A ECLS for PCS between 2015 and 2022. Patients were stratified by the type of indexed operation, which included aortic surgery (AoS), coronary artery bypass grafting (CABG), valve surgery (Valve), and combined CABG and valve surgery (CABG + Valve). Factors associated with postoperative outcomes were assessed using logistic regression. RESULTS Among 149 PCS patients who received V-A ECLS, there were 35 AoS patients (23.5%), 29 (19.5%) CABG patients, 59 (39.6%) Valve patients, and 26 (17.4%) CABG + Valve patients. Cardiopulmonary bypass times were longest in the AoS group (p < 0.01). Regarding causes of PCS, AoS patients had a greater incidence of ventricular failure, while the CABG group had a higher incidence of ventricular arrhythmia (p = 0.04). Left ventricular venting was most frequently utilized in the Valve group (p = 0.07). In-hospital mortality was worst among CABG + Valve patients (p < 0.01), and the incidence of acute kidney injury was highest in the AoS group (p = 0.03). In multivariable logistic regression, CABG + Valve surgery (odds ratio (OR) 4.20, 95% confidence interval 1.30-13.6, p = 0.02) and lactate level at ECLS initiation (OR, 1.17; 95% CI, 1.06-1.29; p < 0.01) were independently associated with mortality. CONCLUSIONS We demonstrate that indications, management, and outcomes of V-A ECLS for PCS vary by type of indexed cardiovascular surgery.
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Affiliation(s)
- Yu Hohri
- Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY, USA
| | - Yanling Zhao
- Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY, USA
| | - Hiroo Takayama
- Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY, USA
| | - Alice V Vinogradsky
- Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY, USA
| | - Paul Kurlansky
- Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY, USA
| | - Justin Fried
- Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Koji Takeda
- Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY, USA
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Laimoud M, Machado P, Lo MG, Maghirang MJ, Hakami E, Qureshi R. The absolute lactate levels versus clearance for prognostication of post-cardiotomy patients on veno-arterial ECMO. ESC Heart Fail 2024. [PMID: 38979681 DOI: 10.1002/ehf2.14910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 04/17/2024] [Accepted: 04/19/2024] [Indexed: 07/10/2024] Open
Abstract
AIMS Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a life-saving procedure for supporting patients with cardiogenic shock after cardiac surgery. This work aimed to analyse the impact of changes in blood lactate levels on the survival of patients on post-cardiotomy ECMO (PC-ECMO) and whether lactate clearance (LC) performs better than absolute lactate levels. METHODS AND RESULTS We retrospectively analysed the data of adult patients who received PC-ECMO at our centre between 2016 and 2022. The primary outcome was the in-hospital mortality rate. Arterial lactate levels were measured at ECMO initiation, peak and 12 and 24 h after VA-ECMO support. LC was calculated at 12 and 24 h. Out of 2368 patients who received cardiac surgeries, 152 (median age, 48 years; 57.9% of them were men) received PC-ECMO. Of them, 48 (31.6%) survived and were discharged, while 104 (68.4%) died during the index hospitalization. Non-survivors had higher frequencies of atrial fibrillation (41.35% vs. 12.5%, P < 0.001), chronic kidney disease (26.9% vs. 6.3%, P = 0.004), prolonged cardiopulmonary bypass (237 vs. 192 min, P = 0.016) and aortic cross-clamping times (160 vs. 124 min, P = 0.04) than survivors. Non-survivors had a significantly higher median Sequential Organ Failure Assessment (SOFA) score at ECMO initiation (13.5 vs. 9, P < 0.001) and a lower median Survival After Veno-arterial ECMO (SAVE) score (-3 vs. 3, P < 0.001) with higher SAVE classes (P < 0.001) than survivors. After 12 h of VA-ECMO support, the blood lactate level was negatively correlated with LC in survivors (r = -0.755, P < 0.001) and non-survivors (r = -0.601, P < 0.001). After 24 h, the same negative correlation was identified between survivors (r = -0.764, P < 0.001) and non-survivors (r = -0.847, P < 0.001). Blood lactate levels measured at 12 h to determine hospital mortality [>8.2 mmol/L, area under the receiver operating characteristic curve (AUROC): 0.868] and 24 h (>2.6 mmol/L, AUROC: 0.896) had the best performance, followed by LC-T12 (<21.94%, AUROC: 0.807), LC-T24 (<40.3%, AUROC: 0.839) and peak blood lactate (>14.35 mmol/L, AUROC: 0.828). The initial pre-ECMO blood lactate (>6.25 mmol/L, AUROC: 0.731) had an acceptable ability to discriminate mortality but was less than the following measurements and clearance. Kaplan-Meier curves demonstrated that LC of <21.94% at T12 h and <40.3% at T24 h was associated with decreased survival (log-rank P < 0.001). Cox proportional hazards regression analysis for mortality revealed that LC of <21.94% at T12 h had an adjusted hazard ratio (HR) of 2.73 [95% confidence interval (CI): 1.64-5.762, P < 0.001] and LC of <40.3% at T24 h had an adjusted HR of 1.98 (95% CI: 1.46-4.173, P < 0.001). The predictors of hospital mortality after PC-ECMO were the lactate level at 12 h [odds ratio (OR): 1.67, 95% CI: 1.121-2.181, P = 0.001], initial SOFA score (OR: 1.593, 95% CI: 1.15-2.73, P < 0.001), initial blood lactate (OR: 1.21, 95% CI: 1.016-1.721, P = 0.032) and atrial fibrillation (OR: 6.17, 95% CI: 2.37-57.214, P = 0.003). Bivariate models using lactate levels and clearance at the same points revealed that blood lactate levels performed better than the clearance percentage. CONCLUSIONS Serial measurements of arterial blood lactate and LC help in obtaining early prognostic guidance in adult patients supported by VA-ECMO after cardiac surgery. Absolute lactate levels, compared with LC at the same time points, demonstrated better performance in differentiating mortality.
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Affiliation(s)
- Mohamed Laimoud
- Department of Cardiovascular Critical Care, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- Department of Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Patricia Machado
- Department of Cardiovascular Nursing, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Michelle Gretchen Lo
- Department of Cardiovascular Nursing, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mary Jane Maghirang
- Department of Cardiovascular Nursing, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Emad Hakami
- Department of Cardiovascular Nursing, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Rehan Qureshi
- Department of Cardiovascular Critical Care, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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3
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Crowley J. Predicting Survival on ECMO: The "Right" Parameters. Circ Heart Fail 2024; 17:e012008. [PMID: 38979606 DOI: 10.1161/circheartfailure.124.012008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Affiliation(s)
- Jerome Crowley
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Clinical Instructor in Anesthesia, Harvard Medical School, Boston
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D'Errico Ramirez A, Ruggieri VG. Mitral bioprosthesis early dysfunction treated with transapical valvuloplasty during V-A ECMO. Perfusion 2024:2676591241260860. [PMID: 38884199 DOI: 10.1177/02676591241260860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
We report the case of a 61-year-old male who had complications with a mitral valve (MV) bioprosthesis replacement by post-cardiotomy shock leading to VA ECMO implantation. The patient suffered early bioprosthetic valve failure owing to early thrombosis. The complication was successfully treated with a MV bioprosthesis transapical balloon valvuloplasty that restored normal leaflet mobility.
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Affiliation(s)
| | - Vito Giovanni Ruggieri
- Division of Thoracic and Cardiovascular Surgery, CHU Reims, Reims, France
- Université de Reims Champagne Ardenne (URCA), Reims, France
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Keller SP, Whitman GJR, Grant MC. Temporary Mechanical Circulatory Support after Cardiac Surgery. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00387-2. [PMID: 38955616 DOI: 10.1053/j.jvca.2024.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 05/30/2024] [Accepted: 06/11/2024] [Indexed: 07/04/2024]
Abstract
Postcardiotomy shock in the cardiac surgical patient is a highly morbid condition characterized by profound myocardial impairment and decreased systemic perfusion inadequate to meet end-organ metabolic demand. Postcardiotomy shock is associated with significant morbidity and mortality. Poor outcomes motivate the increased use of mechanical circulatory support (MCS) to restore perfusion in an effort to prevent multiorgan injury and improve patient survival. Despite growing acceptance and adoption of MCS for postcardiotomy shock, criteria for initiation, clinical management, and future areas of clinical investigation remain a topic of ongoing debate. This article seeks to (1) define critical cardiac dysfunction in the patient after cardiotomy, (2) provide an overview of commonly used MCS devices, and (3) summarize the relevant clinical experience for various MCS devices available in the literature, with additional recognition for the role of MCS as a part of a modified approach to the cardiac arrest algorithm in the cardiac surgical patient.
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Affiliation(s)
- Steven P Keller
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Glenn J R Whitman
- Department of Surgery, Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael C Grant
- Department of Surgery, Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Anesthesiology and Critical Care Medicine, Divisions of Cardiac Anesthesia and Surgical Critical, The Johns Hopkins University School of Medicine, Baltimore, MD.
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6
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Bunge JJH, Mariani S, Meuwese C, van Bussel BCT, Di Mauro M, Wiedeman D, Saeed D, Pozzi M, Loforte A, Boeken U, Samalavicius R, Bounader K, Hou X, Buscher H, Salazar L, Meyns B, Herr D, Matteucci S, Sponga S, MacLaren G, Russo C, Formica F, Sakiyalak P, Fiore A, Camboni D, Raffa GM, Diaz R, Wang IW, Jung JS, Belohlavek J, Pellegrino V, Bianchi G, Pettinari M, Barbone A, Garcia JP, Shekar K, Whitman GJR, Gommers D, Dos Reis Miranda D, Lorusso R. Characteristics and Outcomes of Prolonged Venoarterial Extracorporeal Membrane Oxygenation After Cardiac Surgery: The Post-Cardiotomy Extracorporeal Life Support (PELS-1) Cohort Study. Crit Care Med 2024:00003246-990000000-00344. [PMID: 38856631 DOI: 10.1097/ccm.0000000000006349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
OBJECTIVES Most post-cardiotomy (PC) extracorporeal membrane oxygenation (ECMO) runs last less than 7 days. Studies on the outcomes of longer runs have provided conflicting results. This study investigates patient characteristics and short- and long-term outcomes in relation to PC ECMO duration, with a focus on prolonged (> 7 d) ECMO. DESIGN Retrospective observational cohort study. SETTING Thirty-four centers from 16 countries between January 2000 and December 2020. PATIENTS Adults requiring post PC ECMO between 2000 and 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Characteristics, in-hospital, and post-discharge outcomes were compared among patients categorized by ECMO duration. Survivors and nonsurvivors were compared in the subgroup of patients with ECMO duration greater than 7 days. The primary outcome was in-hospital mortality. Two thousand twenty-one patients were included who required PC ECMO for 0-3 days (n = 649 [32.1%]), 4-7 days (n = 776 [38.3%]), 8-10 days (n = 263 [13.0%]), and greater than 10 days (n = 333 [16.5%]). There were no major differences in the investigated preoperative and procedural characteristics among ECMO duration groups. However, the longer ECMO duration category was associated with multiple complications including bleeding, acute kidney injury, arrhythmias, and sepsis. Hospital mortality followed a U-shape curve, with lowest mortality in patients with ECMO duration of 4-7 days (n = 394, 50.8%) and highest in patients with greater than 10 days ECMO support (n = 242, 72.7%). There was no significant difference in post-discharge survival between ECMO duration groups. In patients with ECMO duration greater than 7 days, age, comorbidities, valvular diseases, and complex procedures were associated with nonsurvival. CONCLUSIONS Nearly 30% of PC ECMO patients were supported for greater than 7 days. In-hospital mortality increased after 7 days of support, especially in patients undergoing valvular and complex surgery, or who had complications, although the long-term post-discharge prognosis was comparable to PC ECMO patients with shorter support duration.
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Affiliation(s)
- Jeroen J H Bunge
- Department of Intensive Care Adults, Erasmus MC, Rotterdam, The Netherlands
- Deparment of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Silvia Mariani
- Cardio-Thoracic Surgery Department and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Christiaan Meuwese
- Department of Intensive Care Adults, Erasmus MC, Rotterdam, The Netherlands
- Deparment of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Bas C T van Bussel
- Department of Intensive Care Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | | | - Dominik Wiedeman
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Department of Cardiac Surgery, University Hospital St. Pölten, St. Pölten, Austria
| | - Diyar Saeed
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Matteo Pozzi
- Department of Cardiac Surgery, Louis Pradel Cardiologic Hospital, Lyon, France
| | - Antonio Loforte
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Deparment of Surgical Sciences, University of Turin, Turin, Italy
| | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Duesseldorf, Germany
| | - Robertas Samalavicius
- II Department of Anesthesiology, Centre of Anesthesia, Intensive Care and Pain Management, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hergen Buscher
- Department of Intensive Care Medicine, Center of Applied Medical Research, St Vincent's Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Leonardo Salazar
- Department of Cardiology, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven and Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Daniel Herr
- Departments of Medicine and Surgery, University of Maryland, Baltimore, MD
| | - Sacha Matteucci
- SOD Cardiochirurgia Ospedali Riuniti "Umberto I-Lancisi-Salesi" Università Politecnica delle Marche, Ancona, Italy
| | - Sandro Sponga
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Claudio Russo
- Cardiac Surgery Unit, Cardiac Thoracic and Vascular Department, Niguarda Hospital, Milan, Italy
| | - Francesco Formica
- Department of Medicine and Surgery, Cardiac Surgery Clinic, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy
| | - Pranya Sakiyalak
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Antonio Fiore
- Department of Cardio-Thoracic Surgery, University Hospital Henri-Mondor, Créteil, Paris, France
| | - Daniele Camboni
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Rodrigo Diaz
- ECMO Unit, Centro Cardiovascular Red Salud Santiago and Hospital San Juan de Dios, Santiago, Chile
| | - I-Wen Wang
- Division of Cardiac Surgery, Memorial Healthcare System, Hollywood, FL
| | - Jae-Seung Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, South Korea
| | - Jan Belohlavek
- 2nd Department of Internal Medicine, Cardiovascular Medicine General Teaching Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Vin Pellegrino
- Intensive Care Unit, The Alfred Hospital, Melbourne, VIC, Australia
| | - Giacomo Bianchi
- Ospedale del Cuore Fondazione Toscana "G. Monasterio," Massa, Italy
| | - Matteo Pettinari
- Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Alessandro Barbone
- Cardiac Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - José P Garcia
- IU Health Advanced Heart & Lung Care, Indiana University Methodist Hospital, Indianapolis, IN
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
| | | | - Diederik Gommers
- Department of Intensive Care Adults, Erasmus MC, Rotterdam, The Netherlands
| | | | - Roberto Lorusso
- Cardio-Thoracic Surgery Department and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
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Mihu MR, El Banayosy AM, Harper MD, Cain K, Maybauer MO, Swant LV, Brewer JM, Schoaps RS, Sharif A, Benson C, Freno DR, Bell MT, Chaffin J, Elkins CC, Vanhooser DW, El Banayosy A. Comparing Outcomes of Post-Cardiotomy Cardiogenic Shock Patients: On-Site Cannulation vs. Retrieval for V-A ECMO Support. J Clin Med 2024; 13:3265. [PMID: 38892975 PMCID: PMC11172433 DOI: 10.3390/jcm13113265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 05/24/2024] [Accepted: 05/27/2024] [Indexed: 06/21/2024] Open
Abstract
Background: Post-cardiotomy cardiogenic shock (PCCS) remains a life-threatening complication after cardiac surgery. Extracorporeal membrane oxygenation (ECMO) represents the mainstay of mechanical circulatory support for PCCS; however, its availability is limited to larger experienced centers, leading to a mismatch between centers performing cardiac surgery and hospitals offering ECMO management beyond cannulation. We sought to evaluate the outcomes and complications of PCCS patients requiring veno-arterial (V-A) ECMO cannulated at our hospital compared to those cannulated at referral hospitals. Methods: A retrospective analysis of PCCS patients requiring V-A ECMO was conducted between October 2014 to December 2022. Results: A total of 121 PCCS patients required V-A ECMO support, of which 62 (51%) patients were cannulated at the referring institutions and retrieved (retrieved group), and 59 (49%) were cannulated at our hospital (on-site group). The baseline demographics and pre-ECMO variables were similar between groups, except retrieved patients had higher lactic acid levels (retrieved group: 8.5 mmol/L ± 5.8 vs. on-site group: 6.6 ± 5; p = 0.04). Coronary artery bypass graft was the most common surgical intervention (51% in the retrieved group vs. 47% in the on-site group). There was no difference in survival-to-discharge rates between the groups (45% in the retrieved group vs. 51% in the on-site group; p = 0.53) or in the rate of patient-related complications. Conclusions: PCCS patients retrieved on V-A ECMO can achieve similar outcomes as those cannulated at experienced centers. An established network in a hub-and-spoke model is critical for the PCCS patients managed at hospitals without ECMO abilities to improve outcomes.
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Affiliation(s)
- Mircea R. Mihu
- Specialty Critical Care, Advanced Cardiac Care and Acute Circulatory Support, Nazih Zuhdi Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK 73112, USA (R.S.S.)
- Department of Medicine, Oklahoma State University Health Science Center, Tulsa, OK 74077, USA
| | - Ahmed M. El Banayosy
- Specialty Critical Care, Advanced Cardiac Care and Acute Circulatory Support, Nazih Zuhdi Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK 73112, USA (R.S.S.)
| | - Michael D. Harper
- Department of Surgical Critical Care, MedStar Washington Hospital Center, Washington, DC 20010, USA
| | - Kaitlyn Cain
- Specialty Critical Care, Advanced Cardiac Care and Acute Circulatory Support, Nazih Zuhdi Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK 73112, USA (R.S.S.)
| | - Marc O. Maybauer
- Department of Anesthesiology, Division of Critical Care Medicine, College of Medicine, University of Florida, Gainesville, FL 32610, USA
- Department of Anesthesiology and Intensive Care Medicine, Philipps University, 35043 Marburg, Germany
- Critical Care Research Group, The Prince Charles Hospital, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Laura V. Swant
- Specialty Critical Care, Advanced Cardiac Care and Acute Circulatory Support, Nazih Zuhdi Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK 73112, USA (R.S.S.)
| | - Joseph M. Brewer
- Specialty Critical Care, Advanced Cardiac Care and Acute Circulatory Support, Nazih Zuhdi Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK 73112, USA (R.S.S.)
| | - Robert S. Schoaps
- Specialty Critical Care, Advanced Cardiac Care and Acute Circulatory Support, Nazih Zuhdi Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK 73112, USA (R.S.S.)
| | - Ammar Sharif
- Specialty Critical Care, Advanced Cardiac Care and Acute Circulatory Support, Nazih Zuhdi Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK 73112, USA (R.S.S.)
| | - Clayne Benson
- Specialty Critical Care, Advanced Cardiac Care and Acute Circulatory Support, Nazih Zuhdi Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK 73112, USA (R.S.S.)
| | - Daniel R. Freno
- Department of Cardio-Thoracic Surgery, Integris Heart Hospital, Integris Baptist Medical Center, Oklahoma City, OK 73112, USA
| | - Marshall T. Bell
- Department of Cardio-Thoracic Surgery, Integris Heart Hospital, Integris Baptist Medical Center, Oklahoma City, OK 73112, USA
| | - John Chaffin
- Department of Cardio-Thoracic Surgery, Integris Heart Hospital, Integris Baptist Medical Center, Oklahoma City, OK 73112, USA
| | - Charles C. Elkins
- Department of Cardio-Thoracic Surgery, Integris Heart Hospital, Integris Baptist Medical Center, Oklahoma City, OK 73112, USA
| | - David W. Vanhooser
- Department of Cardio-Thoracic Surgery, Integris Heart Hospital, Integris Baptist Medical Center, Oklahoma City, OK 73112, USA
| | - Aly El Banayosy
- Specialty Critical Care, Advanced Cardiac Care and Acute Circulatory Support, Nazih Zuhdi Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK 73112, USA (R.S.S.)
- Department of Medicine, Oklahoma State University Health Science Center, Tulsa, OK 74077, USA
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8
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Mariani S, Ravaux JM, van Bussel BCT, De Piero ME, van Kruijk SMJ, Schaefer AK, Wiedemann D, Saeed D, Pozzi M, Loforte A, Boeken U, Samalavicius R, Bounader K, Hou X, Bunge JJH, Buscher H, Salazar L, Meyns B, Mazzeffi MA, Matteucci S, Sponga S, Sorokin V, Russo C, Formica F, Sakiyalak P, Fiore A, Camboni D, Raffa GM, Diaz R, Wang IW, Jung JS, Belohlavek J, Pellegrino V, Bianchi G, Pettinari M, Barbone A, Garcia JP, Shekar K, Whitman GJR, Lorusso R. Features and outcomes of female and male patients requiring postcardiotomy extracorporeal life support. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00435-5. [PMID: 38762034 DOI: 10.1016/j.jtcvs.2024.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/08/2024] [Accepted: 04/30/2024] [Indexed: 05/20/2024]
Abstract
OBJECTIVES Although cardiogenic shock requiring extracorporeal life support after cardiac surgery is associated with high mortality, the impact of sex on outcomes of postcardiotomy extracorporeal life support remains unclear with conflicting results in the literature. We compare patient characteristics, in-hospital outcomes, and overall survival between females and males requiring postcardiotomy extracorporeal life support. METHODS This retrospective, multicenter (34 centers), observational study included adults requiring postcardiotomy extracorporeal life support between 2000 and 2020. Preoperative, procedural, and extracorporeal life support characteristics, complications, and survival were compared between females and males. Association between sex and in-hospital survival was investigated through mixed Cox proportional hazard models. RESULTS This analysis included 1823 patients (female: 40.8%; median age: 66.0 years [interquartile range, 56.2-73.0 years]). Females underwent more mitral valve surgery (females: 38.4%, males: 33.1%, P = .019) and tricuspid valve surgery (feamales: 18%, males: 12.4%, P < .001), whereas males underwent more coronary artery surgery (females: 45.9%, males: 52.4%, P = .007). Extracorporeal life support implantation was more common intraoperatively in feamales (females: 64.1%, females: 59.1%) and postoperatively in males (females: 35.9%, males: 40.9%, P = .036). Ventricular unloading (females: 25.1%, males: 36.2%, P < .001) and intra-aortic balloon pumps (females: 25.8%, males: 36.8%, P < .001) were most frequently used in males. Females had more postoperative right ventricular failure (females: 24.1%, males: 19.1%, P = .016) and limb ischemia (females: 12.3%, males: 8.8%, P = .23). In-hospital mortality was 64.9% in females and 61.9% in males (P = .199) with no differences in 5-year survival (females: 20%, 95% CI, 17-23; males: 24%, 95% CI, 21-28; P = .069). Crude hazard ratio for in-hospital mortality in females was 1.12 (95% CI, 0.99-1.27; P = .069) and did not change after adjustments. CONCLUSIONS This study demonstrates that female and male patients requiring postcardiotomy extracorporeal life support have different preoperative and extracorporeal life support characteristics, as well as complications, without a statistical difference in in-hospital and 5-year survivals.
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Affiliation(s)
- Silvia Mariani
- Cardiovascular Research Institute Maastricht, University of Maastricht, Maastricht, The Netherlands; Cardiac Surgery Unit, Cardio-Thoracic and Vascular Department, Fondazione IRCCS San Gerardo, Monza, Italy.
| | - Justine Mafalda Ravaux
- Cardiovascular Research Institute Maastricht, University of Maastricht, Maastricht, The Netherlands; Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Bas C T van Bussel
- Cardiovascular Research Institute Maastricht, University of Maastricht, Maastricht, The Netherlands; Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Maria Elena De Piero
- Cardiovascular Research Institute Maastricht, University of Maastricht, Maastricht, The Netherlands
| | - Sander M J van Kruijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Diyar Saeed
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Matteo Pozzi
- Department of Cardiac Surgery, Louis Pradel Cardiologic Hospital, Lyon, France
| | - Antonio Loforte
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Duesseldorf, Germany
| | - Robertas Samalavicius
- II Department of Anesthesiology, Centre of Anesthesia, Intensive Care and Pain management, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jeroen J H Bunge
- Department of Intensive Care Adults, Erasmus MC, Rotterdam, The Netherlands; Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Hergen Buscher
- Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, New South Wales, Australia; St Vincent's Centre for Applied Medical Research, University of New South Wales, Sidney, New South Wales, Australia
| | - Leonardo Salazar
- Department of Cardiology, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Michael A Mazzeffi
- Departments of Medicine and Surgery, University of Maryland, Baltimore, Md
| | - Sacha Matteucci
- Cardiac Surgery Unit, Cardiovascular Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Sandro Sponga
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Vitaly Sorokin
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Claudio Russo
- Cardiac Surgery Unit, Cardiac Thoracic and Vascular Department, Niguarda Hospital, Milan, Italy
| | - Francesco Formica
- Cardiac Surgery Unit, Cardio-Thoracic and Vascular Department, Fondazione IRCCS San Gerardo, Monza, Italy; Department of Medicine and Surgery, University of Parma, Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy
| | - Pranya Sakiyalak
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Antonio Fiore
- Department of Cardio-Thoracic Surgery, University Hospital Henri-Mondor, Créteil, France
| | - Daniele Camboni
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Rodrigo Diaz
- ECMO Unit, Departamento de Anestesia, Clínica Las Condes, Las Condes, Santiago, Chile
| | - I-Wen Wang
- Division of Cardiac Surgery, Memorial Healthcare System, Hollywood, Fla
| | - Jae-Seung Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, South Korea
| | - Jan Belohlavek
- 2nd Department of Internal Medicine, Cardiovascular Medicine General Teaching Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Vin Pellegrino
- Intensive Care Unit, Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
| | - Giacomo Bianchi
- Department of Adult Cardiac Surgery, Ospedale del Cuore Fondazione Toscana "G. Monasterio," Massa, Italy
| | - Matteo Pettinari
- Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Alessandro Barbone
- Cardiac Surgery Unit, Cardiovascular Department, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - José P Garcia
- Division of Cardiothoracic Surgery, Department of Surgery, IU Health Advanced Heart & Lung Care, Indiana University Methodist Hospital, Indianapolis, Ind
| | - Kiran Shekar
- Intensive Care Unit, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia
| | - Glenn J R Whitman
- Division of Cardiac Surgery, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Roberto Lorusso
- Cardiovascular Research Institute Maastricht, University of Maastricht, Maastricht, The Netherlands; Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Maastricht, The Netherlands
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Casali D. Bridging Heartbeats: The Promise of Extracorporeal Cardiopulmonary Resuscitation in Pediatric Cardiac Critical Care. Crit Care Med 2024; 52:666-668. [PMID: 38483223 DOI: 10.1097/ccm.0000000000006128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Affiliation(s)
- Diego Casali
- Department of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
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Lüsebrink E, Binzenhöfer L, Hering D, Villegas Sierra L, Schrage B, Scherer C, Speidl WS, Uribarri A, Sabate M, Noc M, Sandoval E, Erglis A, Pappalardo F, De Roeck F, Tavazzi G, Riera J, Roncon-Albuquerque R, Meder B, Luedike P, Rassaf T, Hausleiter J, Hagl C, Zimmer S, Westermann D, Combes A, Zeymer U, Massberg S, Schäfer A, Orban M, Thiele H. Scrutinizing the Role of Venoarterial Extracorporeal Membrane Oxygenation: Has Clinical Practice Outpaced the Evidence? Circulation 2024; 149:1033-1052. [PMID: 38527130 DOI: 10.1161/circulationaha.123.067087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for temporary mechanical circulatory support in various clinical scenarios has been increasing consistently, despite the lack of sufficient evidence regarding its benefit and safety from adequately powered randomized controlled trials. Although the ARREST trial (Advanced Reperfusion Strategies for Patients with Out-of-Hospital Cardiac Arrest and Refractory Ventricular Fibrillation) and a secondary analysis of the PRAGUE OHCA trial (Prague Out-of-Hospital Cardiac Arrest) provided some evidence in favor of VA-ECMO in the setting of out-of-hospital cardiac arrest, the INCEPTION trial (Early Initiation of Extracorporeal Life Support in Refractory Out-of-Hospital Cardiac Arrest) has not found a relevant improvement of short-term mortality with extracorporeal cardiopulmonary resuscitation. In addition, the results of the recently published ECLS-SHOCK trial (Extracorporeal Life Support in Cardiogenic Shock) and ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock) discourage the routine use of VA-ECMO in patients with infarct-related cardiogenic shock. Ongoing clinical trials (ANCHOR [Assessment of ECMO in Acute Myocardial Infarction Cardiogenic Shock, NCT04184635], REVERSE [Impella CP With VA ECMO for Cardiogenic Shock, NCT03431467], UNLOAD ECMO [Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO, NCT05577195], PIONEER [Hemodynamic Support With ECMO and IABP in Elective Complex High-risk PCI, NCT04045873]) may clarify the usefulness of VA-ECMO in specific patient subpopulations and the efficacy of combined mechanical circulatory support strategies. Pending further data to refine patient selection and management recommendations for VA-ECMO, it remains uncertain whether the present usage of this device improves outcomes.
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Affiliation(s)
- Enzo Lüsebrink
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Leonhard Binzenhöfer
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Daniel Hering
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Laura Villegas Sierra
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany and DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Germany (B.S.)
| | - Clemens Scherer
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Walter S Speidl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria (W.S.S.)
| | - Aitor Uribarri
- Cardiology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain. CIBER-CV (A.U.)
| | - Manel Sabate
- Interventional Cardiology Department, Hospital Clinic, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain (M.S.)
| | - Marko Noc
- Center for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia (M.N.)
| | - Elena Sandoval
- Department of Cardiovascular Surgery, Hospital Clínic, Barcelona, Spain (E.S.)
| | - Andrejs Erglis
- Latvian Centre of Cardiology, Paul Stradins Clinical University Hospital, Riga, Latvia (A.E.)
| | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy (F.P.)
| | - Frederic De Roeck
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium (F.D.R.)
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia Intensive Care, Fondazione IRCCS Policlinico San Matteo, Italy (G.T.)
| | - Jordi Riera
- Intensive Care Department, Vall d'Hebron University Hospital, and SODIR, Vall d'Hebron Research Institute, Barcelona, Spain (J.R.)
| | - Roberto Roncon-Albuquerque
- Department of Intensive Care Medicine, São João University Hospital Center, UnIC@RISE and Department of Surgery and Physiology, Faculty of Medicine of Porto, Portugal (R.R.-A.)
| | - Benjamin Meder
- Department of Cardiology, Angiology, and Pneumology, University Hospital Heidelberg, Germany (B.M.)
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen (P.L., T.R.)
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen (P.L., T.R.)
| | - Jörg Hausleiter
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Christian Hagl
- Department of Cardiac Surgery, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Germany (C.H.)
| | - Sebastian Zimmer
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, Germany (S.Z.)
| | - Dirk Westermann
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Germany (D.W.)
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France, and Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France (A.C.)
| | - Uwe Zeymer
- Klinikum der Stadt Ludwigshafen and Institut für Herzinfarktforschung, Ludwigshafen am Rhein, Germany (U.Z.)
| | - Steffen Massberg
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Andreas Schäfer
- Department of Cardiology and Angiology, Hannover Medical School, Germany (A.S.)
| | - Martin Orban
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Department of Internal Medicine/Cardiology and Leipzig Heart Science, Germany (H.T.)
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Geetha S, Verma N, Chakole V. A Comprehensive Review of Extra Corporeal Membrane Oxygenation: The Lifeline in Critical Moments. Cureus 2024; 16:e53275. [PMID: 38435953 PMCID: PMC10905309 DOI: 10.7759/cureus.53275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 01/31/2024] [Indexed: 03/05/2024] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) has evolved into a pivotal intervention in critical care, offering a lifeline for patients facing severe respiratory or cardiac failure. This review provides a comprehensive exploration of ECMO, spanning its definition and historical background to its contemporary advancements and ongoing impact in critical care. The versatility of ECMO in addressing diverse critical conditions, careful patient selection criteria, and the nuanced management of complications are discussed. Advances in technology, including miniaturization, novel circuit designs, and the integration of remote monitoring, showcase the evolving landscape of ECMO. The review underscores the ongoing impact of ECMO in improving survival rates, enhancing mobility, and enabling remote expertise. As a symbol of hope and innovation, ECMO's lifesaving potential is evident in its ability to navigate the complexities of critical care and redefine the boundaries of life support interventions.
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Affiliation(s)
- Sindhu Geetha
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Neeta Verma
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Vivek Chakole
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Krasivskyi I, Großmann C, Aswadi W, Ivanov B, Gerfer S, Gaisendrees C, Elderia A, Mihaylova M, Eghbalzadeh K, Deppe AC, Sabashnikov A, Rahmanian PB, Mader N, Wahlers T, Djordjevic I. Impact of thrombocytopenia on short-term outcomes in patients undergoing mobile extracorporeal membrane oxygenation support. Perfusion 2023:2676591231224635. [PMID: 38146253 DOI: 10.1177/02676591231224635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023]
Abstract
INTRODUCTION The prolonged use of extracorporeal membrane oxygenation (ECMO) support is associated with increased consumption of platelets and hemolysis. The prognostic impact of thrombocytopenia prior to and during ECMO support on patient's short-, mid- and long-term outcomes has been critically evaluated and discussed over the last years. However, only few data have been published on thrombocytopenia caused by mobile ECMO support. The aim of this study was to evaluate the impact of thrombocytopenia on short-term outcomes and predictors of in-hospital mortality in patients supported by mobile ECMO for transportation and subsequent weaning in a tertiary centre. METHODS This retrospective single-centre study analyzed a total of 117 patients requiring mobile veno-arterial (va) ECMO support and subsequent transportation from referral hospitals to our department from January 2015 until December 2021. A total of 15 patients had to be excluded from the analysis for missing data regarding baseline platelet count. Patients were divided into two groups: thrombocytopenia group (<130 × 109/L, n = 44) and non-thrombocytopenia group (≥130 × 109/L, n = 58). The primary outcome was in-hospital mortality. Secondary outcomes were successful ECMO-weaning, and the incidence of associated complications (bleeding, acute hepatic failure, acute renal failure, dialysis, and septic shock). RESULTS The dialysis rate before ECMO initiation was significantly higher (p = .041) in the thrombocytopenia group compared to the non-thrombocytopenia group. The rates of bleeding complications (p = .032) and limb ischemia (p = .003) were significantly higher in patients with low platelet count. Moreover, complication rates of acute hepatic failure (p < .001), acute renal failure (p < .001) and dialysis (p = .033) were significantly higher in the thrombocytopenia group. Also, in-hospital mortality was significantly higher (p = .002) in patients with low platelet count before initiation of ECMO support. CONCLUSION Based on the results of the present study, patients with thrombocytopenia prior to mobile vaECMO support may be at significantly higher risk for associated complications and short-term mortality.
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Affiliation(s)
- Ihor Krasivskyi
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Clara Großmann
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Wasil Aswadi
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Borko Ivanov
- Department of Cardiothoracic Surgery, Helios Hospital Siegburg, Siegburg, Germany
| | - Stephen Gerfer
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Christopher Gaisendrees
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Ahmed Elderia
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Mariya Mihaylova
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Antje-Christin Deppe
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Parwis Baradaran Rahmanian
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Navid Mader
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Ilija Djordjevic
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
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Celińska-Spodar M, Załęska Kocięcka M, Kowalik I, Kołsut P, Sitkowska-Rysiak E, Szymański J, Stępińska J. Troponin T and Survival following Cardiac Surgery in Patients Supported with Extracorporeal Membrane Oxygenation for Post-Cardiotomy Shock. Diagnostics (Basel) 2023; 14:45. [PMID: 38201354 PMCID: PMC10802831 DOI: 10.3390/diagnostics14010045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/11/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND While troponin is an established biomarker of cardiac injury, its prognostic significance in post-cardiotomy cardiogenic shock patients supported by venoarterial extracorporeal membrane oxygenation (PCCS-VA-ECMO) remains unclear. OBJECTIVE This study aimed to assess the correlation between early post-operative troponin T levels and both short-term and long-term mortality outcomes in this cohort. METHODS We evaluated 1457 troponin T measurements from 102 PCCS-VA-ECMO patients treated from 2013 to 2018 at a specialized cardio-surgical and transplantation center. Emphasis was placed on troponin concentrations at 24-48 h post-surgery, post-VA-ECMO implantation, and peak troponin levels in relation to VA-ECMO weaning, as well as 90-day and one-year mortality. RESULTS No significant association was observed between troponin T levels post-VA-ECMO implantation and 90-day mortality (median: 1338 ng/L for overall, 1529 ng/L for survivors vs. 1294 ng/L for non-survivors; p = 0.146) or between peak troponin levels and 90-day mortality (median: 3583 ng/L for overall, 3337 ng/L for survivors vs. 3666 ng/L for non-survivors; p = 0.709). Comprehensive multivariate models showed no correlation between troponin levels and various mortality endpoints. Notably, age, procedure urgency, type, LVEF pre-surgery, Euroscore II, prior cardiac arrest, and VA-ECMO duration were not linked with troponin release. Hemodiafiltration emerged as the strongest mortality risk factor [HR 2.4]. CONCLUSIONS Isolated early Troponin T release and peak troponin T were not associated, while organ complications were linked with VA-ECMO weaning or short- and long-term prognosis. The results underscore the multi-organ implications of PCCS in determining survival.
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Affiliation(s)
- Małgorzata Celińska-Spodar
- Department of Anaesthesiology and Intensive Care, The National Institute of Cardiology, 04-628 Warsaw, Poland
| | - Marta Załęska Kocięcka
- Department of Mechanical Circulatory Support and Transplantation, Department of Heart Failure and Transplantology, The National Institute of Cardiology, 04-628 Warsaw, Poland
| | - Ilona Kowalik
- Clinical Research Support Center, The National Institute of Cardiology, 04-628 Warsaw, Poland
| | - Piotr Kołsut
- Department of Cardiac Surgery and Transplantation, The National Institute of Cardiology, 04-628 Warsaw, Poland
| | - Ewa Sitkowska-Rysiak
- Department of Anaesthesiology and Intensive Care, The National Institute of Cardiology, 04-628 Warsaw, Poland
| | - Jarosław Szymański
- Department of Cardiac Surgery and Transplantation, The National Institute of Cardiology, 04-628 Warsaw, Poland
| | - Janina Stępińska
- Department of Cardiac Intensive Care, The National Institute of Cardiology, 04-628 Warsaw, Poland
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Salha A, Chowdhury T, Singh S, Luyt J, Harky A. Optimizing Outcomes in Extracorporeal Membrane Oxygenation Postcardiotomy in Pediatric Population. J Pediatr Intensive Care 2023; 12:245-255. [PMID: 37970139 PMCID: PMC10631840 DOI: 10.1055/s-0041-1731682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/29/2021] [Indexed: 10/20/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a rapidly emerging advanced life support technique used in cardiorespiratory failure refractory to other treatments. There has been an influx in the number of studies relating to ECMO in recent years, as the technique becomes more popular. However, there are still significant gaps in the literature including complications and their impacts and methods to predict their development. This review evaluates the available literature on the complications of ECMO postcardiotomy in the pediatric population. Areas explored include renal, cardiovascular, hematological, infection, neurological, and hepatic complications. Incidence, risk factors and potential predictors, and scoring systems for the development of these complications have been evaluated.
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Affiliation(s)
- Ahmad Salha
- Department of Medicine, St George's Hospital Medical School, London, United Kingdom
| | - Tasnim Chowdhury
- Department of Medicine, St George's Hospital Medical School, London, United Kingdom
| | - Saloni Singh
- School of Medicine, University of Central Lancashire, Preston, United Kingdom
| | - Jessica Luyt
- Department of Paediatric Intensive Care, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - Amer Harky
- Department of Cardiac Surgery, Alder Hey Children Hospital, Liverpool, United Kingdom
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
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Mariani S, Wang IW, van Bussel BCT, Heuts S, Wiedemann D, Saeed D, van der Horst ICC, Pozzi M, Loforte A, Boeken U, Samalavicius R, Bounader K, Hou X, Bunge JJH, Buscher H, Salazar L, Meyns B, Herr D, Matteucci S, Sponga S, Ramanathan K, Russo C, Formica F, Sakiyalak P, Fiore A, Camboni D, Raffa GM, Diaz R, Jung JS, Belohlavek J, Pellegrino V, Bianchi G, Pettinari M, Barbone A, Garcia JP, Shekar K, Whitman G, Lorusso R. The importance of timing in postcardiotomy venoarterial extracorporeal membrane oxygenation: A descriptive multicenter observational study. J Thorac Cardiovasc Surg 2023; 166:1670-1682.e33. [PMID: 37201778 DOI: 10.1016/j.jtcvs.2023.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/05/2023] [Accepted: 04/22/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVES Postcardiotomy extracorporeal membrane oxygenation (ECMO) can be initiated intraoperatively or postoperatively based on indications, settings, patient profile, and conditions. The topic of implantation timing only recently gained attention from the clinical community. We compare patient characteristics as well as in-hospital and long-term survival between intraoperative and postoperative ECMO. METHODS The retrospective, multicenter, observational Postcardiotomy Extracorporeal Life Support (PELS-1) study includes adults who required ECMO due to postcardiotomy shock between 2000 and 2020. We compared patients who received ECMO in the operating theater (intraoperative) with those in the intensive care unit (postoperative) on in-hospital and postdischarge outcomes. RESULTS We studied 2003 patients (women: 41.1%; median age: 65 years; interquartile range [IQR], 55.0-72.0). Intraoperative ECMO patients (n = 1287) compared with postoperative ECMO patients (n = 716) had worse preoperative risk profiles. Cardiogenic shock (45.3%), right ventricular failure (15.9%), and cardiac arrest (14.3%) were the main indications for postoperative ECMO initiation, with cannulation occurring after (median) 1 day (IQR, 1-3 days). Compared with intraoperative application, patients who received postoperative ECMO showed more complications, cardiac reoperations (intraoperative: 19.7%; postoperative: 24.8%, P = .011), percutaneous coronary interventions (intraoperative: 1.8%; postoperative: 3.6%, P = .026), and had greater in-hospital mortality (intraoperative: 57.5%; postoperative: 64.5%, P = .002). Among hospital survivors, ECMO duration was shorter after intraoperative ECMO (median, 104; IQR, 67.8-164.2 hours) compared with postoperative ECMO (median, 139.7; IQR, 95.8-192 hours, P < .001), whereas postdischarge long-term survival was similar between the 2 groups (P = .86). CONCLUSIONS Intraoperative and postoperative ECMO implantations are associated with different patient characteristics and outcomes, with greater complications and in-hospital mortality after postoperative ECMO. Strategies to identify the optimal location and timing of postcardiotomy ECMO in relation to specific patient characteristics are warranted to optimize in-hospital outcomes.
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Affiliation(s)
- Silvia Mariani
- Cardio-Thoracic Surgery Department, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht (CAIRM), Maastricht, The Netherlands.
| | - I-Wen Wang
- Division of Cardiac Surgery, Memorial Healthcare System, Hollywood, Calif
| | - Bas C T van Bussel
- Department of Intensive Care Medicine, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Samuel Heuts
- Cardio-Thoracic Surgery Department, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht (CAIRM), Maastricht, The Netherlands
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Diyar Saeed
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Matteo Pozzi
- Department of Cardiac Surgery, Louis Pradel Cardiologic Hospital, Lyon, France
| | - Antonio Loforte
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Duesseldorf, Germany
| | - Robertas Samalavicius
- II Department of Anesthesiology, Centre of Anesthesia, Intensive Care and Pain management, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Beijing, China
| | - Jeroen J H Bunge
- Department of Intensive Care Adults, Erasmus MC, Rotterdam, The Netherlands
| | - Hergen Buscher
- Department of Intensive Care Medicine, Center of Applied Medical Research, St Vincent's Hospital, Darlinghurst, Australia
| | - Leonardo Salazar
- Department of Cardiology, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, and Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Daniel Herr
- Departments of Medicine and Surgery, University of Maryland, Baltimore, Md
| | - Sacha Matteucci
- SOD Cardiochirurgia Ospedali Riuniti 'Umberto I-Lancisi-Salesi' Università Politecnica delle Marche, Ancona, Italy
| | - Sandro Sponga
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Kollengode Ramanathan
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Claudio Russo
- Cardiac Surgery Unit, Cardiac Thoracic and Vascular Department, Niguarda Hospital, Milan, Italy
| | - Francesco Formica
- Department of Medicine and Surgery, Cardiac Surgery Clinic, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy, and Department of Medicine and Surgery, University of Parma, Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy
| | - Pranya Sakiyalak
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand
| | - Antonio Fiore
- Department of Cardio-Thoracic Surgery, University Hospital Henri-Mondor, Créteil, Paris, France
| | - Daniele Camboni
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
| | - Rodrigo Diaz
- ECMO Unit, Departamento de Anestesia, Clínica Las Condes, Santiago, Chile
| | - Jae-Seung Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, South Korea
| | - Jan Belohlavek
- 2nd Department of Internal Medicine, Cardiovascular Medicine General Teaching Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Vin Pellegrino
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia
| | - Giacomo Bianchi
- Ospedale del Cuore Fondazione Toscana "G. Monasterio", Massa, Italy
| | - Matteo Pettinari
- Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | | | - José P Garcia
- IU Health Advanced Heart & Lung Care, Indiana University Methodist Hospital, Indianapolis, Ind
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia
| | - Glenn Whitman
- Cardiac Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Md
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht (CAIRM), Maastricht, The Netherlands
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Corujo Rodriguez A, Richter E, Ibekwe SO, Shah T, Faloye AO. Postcardiotomy Shock Syndrome: A Narrative Review of Perioperative Diagnosis and Management. J Cardiothorac Vasc Anesth 2023; 37:2621-2633. [PMID: 37806929 DOI: 10.1053/j.jvca.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/29/2023] [Accepted: 09/09/2023] [Indexed: 10/10/2023]
Abstract
Postcardiotomy shock (PCS) is generally described as the inability to separate from cardiopulmonary bypass due to ineffective cardiac output after cardiotomy, which is caused by a primary cardiac disorder, resulting in inadequate tissue perfusion. Postcardiotomy shock occurs in 0.5% to 1.5% of contemporary cardiac surgery cases, and is accompanied by an in-hospital mortality of approximately 67%. In the last 2 decades, the incidence of PCS has increased, likely due to the increased age and baseline morbidity of patients requiring cardiac surgery. In this narrative review, the authors discuss the epidemiology and pathophysiology of PCS, the rationale and evidence behind the initiation, continuation, escalation, and discontinuation of mechanical support devices in PCS, and the anesthetic implications.
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Affiliation(s)
| | - Ellen Richter
- Department of Anesthesiology, Emory University, Atlanta, GA
| | | | - Tina Shah
- Department of Anesthesiology, Emory University, Atlanta, GA
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17
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Mariani S, Schaefer AK, van Bussel BCT, Di Mauro M, Conci L, Szalkiewicz P, De Piero ME, Heuts S, Ravaux J, van der Horst ICC, Saeed D, Pozzi M, Loforte A, Boeken U, Samalavicius R, Bounader K, Hou X, Bunge JJH, Buscher H, Salazar L, Meyns B, Herr D, Matteucci S, Sponga S, MacLaren G, Russo C, Formica F, Sakiyalak P, Fiore A, Camboni D, Raffa GM, Diaz R, Wang IW, Jung JS, Belohlavek J, Pellegrino V, Bianchi G, Pettinari M, Barbone A, Garcia JP, Whitman G, Shekar K, Wiedemann D, Lorusso R. On-Support and Postweaning Mortality in Postcardiotomy Extracorporeal Membrane Oxygenation. Ann Thorac Surg 2023; 116:1079-1089. [PMID: 37414384 DOI: 10.1016/j.athoracsur.2023.05.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/24/2023] [Accepted: 05/30/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Postcardiotomy venoarterial extracorporeal membrane oxygenation (VA ECMO) is characterized by discrepancies between weaning and survival-to-discharge rates. This study analyzes the differences between postcardiotomy VA ECMO patients who survived, died on ECMO, or died after ECMO weaning. Causes of death and variables associated with mortality at different time points are investigated. METHODS The retrospective, multicenter, observational Postcardiotomy Extracorporeal Life Support Study (PELS) includes adults requiring postcardiotomy VA ECMO between 2000 and 2020. Variables associated with on-ECMO mortality and postweaning mortality were modeled using mixed Cox proportional hazards, including random effects for center and year. RESULTS In 2058 patients (men, 59%; median age, 65 years; interquartile range [IQR], 55-72 years), weaning rate was 62.7%, and survival to discharge was 39.6%. Patients who died (n = 1244) included 754 on-ECMO deaths (36.6%; median support time, 79 hours; IQR, 24-192 hours), and 476 postweaning deaths (23.1%; median support time, 146 hours; IQR, 96-235.5 hours). Multiorgan (n = 431 of 1158 [37.2%]) and persistent heart failure (n = 423 of 1158 [36.5%]) were the main causes of death, followed by bleeding (n = 56 of 754 [7.4%]) for on-ECMO mortality and sepsis (n = 61 of 401 [15.4%]) for postweaning mortality. On-ECMO death was associated with emergency surgery, preoperative cardiac arrest, cardiogenic shock, right ventricular failure, cardiopulmonary bypass time, and ECMO implantation timing. Diabetes, postoperative bleeding, cardiac arrest, bowel ischemia, acute kidney injury, and septic shock were associated with postweaning mortality. CONCLUSIONS A discrepancy exists between weaning and discharge rate in postcardiotomy ECMO. Deaths occurred during ECMO support in 36.6% of patients, mostly associated with unstable preoperative hemodynamics. Another 23.1% of patients died after weaning in association with severe complications. This underscores the importance of postweaning care for postcardiotomy VA ECMO patients.
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Affiliation(s)
- Silvia Mariani
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands.
| | | | - Bas C T van Bussel
- Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands; Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Michele Di Mauro
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Luca Conci
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Philipp Szalkiewicz
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Maria Elena De Piero
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Samuel Heuts
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Justine Ravaux
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Iwan C C van der Horst
- Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands; Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Diyar Saeed
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Matteo Pozzi
- Department of Cardiac Surgery, Louis Pradel Cardiologic Hospital, Lyon, France
| | - Antonio Loforte
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Duesseldorf, Germany
| | - Robertas Samalavicius
- II Department of Anesthesiology, Centre of Anesthesia, Intensive Care and Pain Management, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jeroen J H Bunge
- Department of Intensive Care Adults, Erasmus MC, Rotterdam, the Netherlands; Department of Cardiology, Erasmus MC, Rotterdam, the Netherlands
| | - Hergen Buscher
- Department of Intensive Care Medicine, Center of Applied Medical Research, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Leonardo Salazar
- Department of Cardiology, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Daniel Herr
- Department of Medicine, University of Maryland, Baltimore, Maryland; Department of Surgery, University of Maryland, Baltimore, Maryland
| | - Sacha Matteucci
- Struttura Organizzativa Dipartimentale Cardiochirurgia, Ospedali Riuniti 'Umberto I - Lancisi - Salesi' Università Politecnica delle Marche, Ancona, Italy
| | - Sandro Sponga
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Claudio Russo
- Cardiac Surgery Unit, Cardiac Thoracic and Vascular Department, Niguarda Hospital, Milan, Italy
| | - Francesco Formica
- Cardiac Surgery Unit, San Gerardo Hospital, Monza, Italy; Cardiac Surgery Unit, Department of Medicine and Surgery, University Hospital of Parma, University of Parma, Parma, Italy
| | - Pranya Sakiyalak
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Antonio Fiore
- Department of Cardio-Thoracic Surgery, University Hospital Henri-Mondor, Créteil, Paris, France
| | - Daniele Camboni
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Rodrigo Diaz
- ECMO Unit, Departamento de Anestesia, Clínica Las Condes, Las Condes, Santiago, Chile
| | - I-Wen Wang
- Division of Cardiac Surgery, Memorial Healthcare System, Hollywood, Florida
| | - Jae-Seung Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Jan Belohlavek
- Second Department of Internal Medicine, Cardiovascular Medicine General Teaching Hospital, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Vin Pellegrino
- Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Giacomo Bianchi
- Ospedale del Cuore, Fondazione Toscana "G. Monasterio," Massa, Italy
| | - Matteo Pettinari
- Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Alessandro Barbone
- Cardiac Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - José P Garcia
- IU Health Advanced Heart & Lung Care, Indiana University Methodist Hospital, Indianapolis, Indiana
| | - Glenn Whitman
- Cardiac Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Maryland
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
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18
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Kakuturu J, Dhamija A, Chan E, Lagazzi L, Thibault D, Badhwar V, Hayanga JWA. Mortality and cost of post-cardiotomy extracorporeal support in the United States. Perfusion 2023; 38:1468-1477. [PMID: 35930658 DOI: 10.1177/02676591221117355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has been used increasingly for cardiopulmonary rescue. Despite recent advances however, post-cardiotomy shock (PCS)-ECMO survival remains comparatively poor. We sought to evaluate outcomes and define factors that predict in-hospital mortality. METHODS We used the Nationwide Inpatient Sample (NIS) to evaluate adult hospitalizations with a primary procedure code for coronary artery bypass grafting (CABG), and/or valve procedures performed between 2013 and 2018, which also required post cardiotomy ECMO support. Patient-related factors and hospital costs were evaluated to identify those associated with in-hospital mortality. RESULTS There were 1,247,835 admissions for cardiac surgical procedures during the study period. Post-cardiotomy shock-ECMO support was provided in 4475 (0.3%) within the study cohort. A total of 2000 (44.7%) hospitalizations involved isolated valvular procedures, 1700 (38.0%) isolated CABG, and 775 (17.3%) involved a combination of both. Overall, in-hospital mortality was 42.1% (n = 1880). Factors significantly associated with in-hospital mortality included patients with multiple comorbidities (> 7) and those undergoing combination of valve and CABG procedures. Only 26.6% of those who survived to discharge, were discharged home independently. CONCLUSION Survival to independent home discharge is rare following PCS-ECMO. Its high mortality is associated with multiple comorbidities and combination of CABG and valve surgery.
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Affiliation(s)
- Jahnavi Kakuturu
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Ankit Dhamija
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Ernest Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Luigi Lagazzi
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Dylan Thibault
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - J W A Hayanga
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
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Sommer W, Arif R, Kremer J, Al Maisary S, Verch M, Tochtermann U, Karck M, Meyer AL, Warnecke G. Temporary circulatory support with surgically implanted microaxial pumps in postcardiotomy cardiogenic shock following coronary artery bypass surgery. JTCVS OPEN 2023; 15:252-260. [PMID: 37808068 PMCID: PMC10556953 DOI: 10.1016/j.xjon.2023.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/14/2023] [Accepted: 06/20/2023] [Indexed: 10/10/2023]
Abstract
Objectives Patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (CABG) surgery may develop postcardiotomy cardiogenic shock. In these cases, implantation of an Impella 5.0 or 5.5 microaxial pump offers full hemodynamic support while simultaneously unloading of the left ventricle. Methods Preoperative, perioperative, and postoperative data of all patients receiving postoperative support with an Impella 5.0 or 5.5 after CABG surgery between September 2017 and October 2022 were retrospectively collected. Cohort built-up was performed according to the timing of Impella implantation, either simultaneous during CABG surgery or delayed. Results A total of n = 42 patients received postoperative Impella support, of whom 27 patients underwent simultaneous Impella implantation during CABG surgery and 15 patients underwent delayed Impella therapy. Preoperative left ventricular ejection fraction was similarly low in both groups (26.7 ± 0.7% vs 24.8 ± 11.3%; P = .32). In the delayed cohort, Impella implantation was performed after a median of 1 (1; 2) days after CABG surgery. Survival after 30 days (75.6% vs 47.6%, P = .04) and 1 year (69.4% vs 29.8%, P = .03) was better in the cohort receiving simultaneous Impella implantation. Conclusions The combined advantages of hemodynamic support and LV unloading with microaxial pumps may lead to a favorable survival in patients with left ventricular failure following CABG surgery. Early implantation during the initial surgery shows a trend toward a more favorable survival as compared with patients receiving delayed support.
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Affiliation(s)
- Wiebke Sommer
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Rawa Arif
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Jamila Kremer
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Sameer Al Maisary
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus Verch
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Ursula Tochtermann
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Anna L. Meyer
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
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20
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Akbik B, Chou LCP, Gorthi J. Extracorporeal Membrane Oxygenation in Postcardiotomy Cardiogenic Shock. Methodist Debakey Cardiovasc J 2023; 19:66-73. [PMID: 37547900 PMCID: PMC10402824 DOI: 10.14797/mdcvj.1256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 06/15/2023] [Indexed: 08/08/2023] Open
Abstract
Postcardiotomy extracorporeal membrane oxygenation (PC-ECMO), the most frequent indication for ECMO in the United States, is increasingly used as the first-line mechanical circulatory support in patients who are refractory to conventional treatment. Despite increasing use of PC-ECMO, limited evidence is available regarding its safety, efficacy, and optimal timing for initiation and weaning. The decision to use PC-ECMO often is made in the absence of robust clinical data, leading to variability in patient selection, management, and outcomes across different institutions. This article summarizes current evidence on ECMO use in postcardiotomy cardiogenic shock and discusses its potential benefits, management, complications, and outcomes.
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Affiliation(s)
- Bassel Akbik
- Center for Critical Care, Houston Methodist, Houston, Texas, US
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21
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Mariani S, Heuts S, van Bussel BCT, Di Mauro M, Wiedemann D, Saeed D, Pozzi M, Loforte A, Boeken U, Samalavicius R, Bounader K, Hou X, Bunge JJH, Buscher H, Salazar L, Meyns B, Herr D, Matteucci MLS, Sponga S, MacLaren G, Russo C, Formica F, Sakiyalak P, Fiore A, Camboni D, Raffa GM, Diaz R, Wang I, Jung J, Belohlavek J, Pellegrino V, Bianchi G, Pettinari M, Barbone A, Garcia JP, Shekar K, Whitman GJR, Lorusso R. Patient and Management Variables Associated With Survival After Postcardiotomy Extracorporeal Membrane Oxygenation in Adults: The PELS-1 Multicenter Cohort Study. J Am Heart Assoc 2023; 12:e029609. [PMID: 37421269 PMCID: PMC10382118 DOI: 10.1161/jaha.123.029609] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 05/25/2023] [Indexed: 07/10/2023]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) has been increasingly used for postcardiotomy cardiogenic shock, but without a concomitant reduction in observed in-hospital mortality. Long-term outcomes are unknown. This study describes patients' characteristics, in-hospital outcome, and 10-year survival after postcardiotomy ECMO. Variables associated with in-hospital and postdischarge mortality are investigated and reported. Methods and Results The retrospective international multicenter observational PELS-1 (Postcardiotomy Extracorporeal Life Support) study includes data on adults requiring ECMO for postcardiotomy cardiogenic shock between 2000 and 2020 from 34 centers. Variables associated with mortality were estimated preoperatively, intraoperatively, during ECMO, and after the occurrence of any complications, and then analyzed at different time points during a patient's clinical course, through mixed Cox proportional hazards models containing fixed and random effects. Follow-up was established by institutional chart review or contacting patients. This analysis included 2058 patients (59% were men; median [interquartile range] age, 65.0 [55.0-72.0] years). In-hospital mortality was 60.5%. Independent variables associated with in-hospital mortality were age (hazard ratio [HR], 1.02 [95% CI, 1.01-1.02]) and preoperative cardiac arrest (HR, 1.41 [95% CI, 1.15-1.73]). In the subgroup of hospital survivors, the overall 1-, 2-, 5-, and 10-year survival rates were 89.5% (95% CI, 87.0%-92.0%), 85.4% (95% CI, 82.5%-88.3%), 76.4% (95% CI, 72.5%-80.5%), and 65.9% (95% CI, 60.3%-72.0%), respectively. Variables associated with postdischarge mortality included older age, atrial fibrillation, emergency surgery, type of surgery, postoperative acute kidney injury, and postoperative septic shock. Conclusions In adults, in-hospital mortality after postcardiotomy ECMO remains high; however, two-thirds of those who are discharged from hospital survive up to 10 years. Patient selection, intraoperative decisions, and ECMO management remain key variables associated with survival in this cohort. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03857217.
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Affiliation(s)
- Silvia Mariani
- Cardio‐Thoracic Surgery Department and Cardiovascular Research Institute MaastrichtMaastrichtthe Netherlands
| | - Samuel Heuts
- Cardio‐Thoracic Surgery Department and Cardiovascular Research Institute MaastrichtMaastrichtthe Netherlands
| | - Bas C. T. van Bussel
- Department of Intensive Care Medicine and Cardiovascular Research Institute MaastrichtMaastrichtthe Netherlands
| | - Michele Di Mauro
- Cardio‐Thoracic Surgery Department and Cardiovascular Research Institute MaastrichtMaastrichtthe Netherlands
| | - Dominik Wiedemann
- Department of Cardiac SurgeryMedical University of ViennaViennaAustria
| | - Diyar Saeed
- Department of Cardiac SurgeryLeipzig Heart CenterLeipzigGermany
| | - Matteo Pozzi
- Department of Cardiac Surgery, Louis Pradel Cardiologic HospitalLyonFrance
| | - Antonio Loforte
- Division of Cardiac SurgeryIstituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliero–Universitaria di BolognaBolognaItaly
- Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Udo Boeken
- Department of Cardiac Surgery, Medical FacultyHeinrich Heine UniversityDuesseldorfGermany
| | - Robertas Samalavicius
- II Department of Anesthesiology, Centre of Anesthesia, Intensive Care and Pain ManagementVilnius University Hospital Santariskiu KlinikosVilniusLithuania
| | - Karl Bounader
- Division of Cardiothoracic and Vascular SurgeryPontchaillou University HospitalRennesFrance
| | - Xiaotong Hou
- Center for Cardiac Intensive CareBeijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical UniversityBeijingChina
| | - Jeroen J. H. Bunge
- Department of Intensive Care AdultsErasmus Medical CenterRotterdamthe Netherlands
| | - Hergen Buscher
- Department of Intensive Care Medicine, Center of Applied Medical ResearchSt Vincent’s HospitalDarlinghursNew South WalesAustralia
- University of New South WalesSydneyAustralia
| | - Leonardo Salazar
- Department of Cardiology, Fundación Cardiovascular de ColombiaBucaramangaColombia
| | - Bart Meyns
- Department of Cardiac SurgeryUniversity Hospitals Leuven and Department of Cardiovascular Sciences, University of LeuvenLeuvenBelgium
| | - Daniel Herr
- Departments of Medicine and SurgeryUniversity of MarylandBaltimoreMD
| | - Marco L. Sacha Matteucci
- Struttura Organizzativa Dipartimentale di CardiochirurgiaOspedali Riuniti ‘Umberto I–Lancisi‐Salesi’ Università Politecnica delle MarcheAnconaItaly
| | - Sandro Sponga
- Division of Cardiac Surgery, Cardiothoracic DepartmentUniversity Hospital of UdineUdineItaly
| | - Graeme MacLaren
- Cardiothoracic Intensive Care UnitNational University Heart Centre, National University HospitalSingaporeSingapore
| | - Claudio Russo
- Cardiac Surgery Unit, Cardiac Thoracic and Vascular Department, Niguarda HospitalMilanItaly
| | - Francesco Formica
- Department of Medicine and Surgery, Cardiac Surgery Clinic, San Gerardo HospitalUniversity of Milano‐BicoccaMonzaItaly
- Department of Medicine and SurgeryUniversity of Parma, Cardiac Surgery Unit, University Hospital of ParmaParmaItaly
| | - Pranya Sakiyalak
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
| | - Antonio Fiore
- Department of Cardio‐Thoracic SurgeryUniversity Hospital Henri‐Mondor, CréteilParisFrance
| | - Daniele Camboni
- Department of Cardiothoracic SurgeryUniversity Medical Center RegensburgRegensburgGermany
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic TransplantationIstituti di Ricovero e Cura a Carattere Scientifico ‐ Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione)PalermoItaly
| | - Rodrigo Diaz
- Extracorporeal Membrane Oxygenation Unit, Departamento de AnestesiaClínica Las Condes, Las CondesSantiagoChile
| | - I‐wen Wang
- Division of Cardiac Surgery, Memorial Healthcare SystemHollywoodFL
| | - Jae‐Seung Jung
- Department of Thoracic and Cardiovascular SurgeryKorea University Anam HospitalSeoulSouth Korea
| | - Jan Belohlavek
- 2nd Department of Internal Medicine, Cardiovascular Medicine General Teaching Hospital and 1st Faculty of MedicineCharles University in PraguePragueCzech Republic
| | - Vin Pellegrino
- Intensive Care Unit, The Alfred HospitalMelbourneVictoriaAustralia
| | - Giacomo Bianchi
- Ospedale del Cuore Fondazione Toscana "G. Monasterio"MassaItaly
| | - Matteo Pettinari
- Department of Cardiovascular Surgery, Ziekenhuis Oost‐LimburgGenkBelgium
| | - Alessandro Barbone
- Cardiac Surgery UnitIstituto di Ricovero e Cura a Carattere Scientifico Humanitas Research HospitalRozzanoMilanItaly
| | - José P. Garcia
- Indiana University Health Advanced Heart and Lung Care, Indiana University Methodist HospitalIndianapolisIN
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles HospitalBrisbaneAustralia
| | | | - Roberto Lorusso
- Cardio‐Thoracic Surgery Department and Cardiovascular Research Institute MaastrichtMaastrichtthe Netherlands
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Lazcano-Diaz EA, Hurtado Belizario KSA, Riveros-Nina D, Pérez-Manjarrez A, Manzur-Sandoval D, Baeza-Herrera L, Rojas-Velasco G. [North-south syndrome, a complication of circulatory assistance with Veno-Arterial ECMO. A case report.]. ARCHIVOS PERUANOS DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR 2023; 4:114-117. [PMID: 38046226 PMCID: PMC10688409 DOI: 10.47487/apcyccv.v4i3.300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 09/20/2023] [Indexed: 12/05/2023]
Abstract
We present the case of a 34-year-old male patient with a history of Marfan syndrome who was admitted to the emergency room for acute aortic regurgitation secondary to aneurysmal dilation of the ascending thoracic aorta. In the postoperative period, post-cardiotomy cardiogenic shock was documented, so circulatory support was initiated with peripheral Veno-Arterial ECMO, which developed hypoxemia due to bacterial pneumonia and data compatible with North-South syndrome. We present a review, non-conventional cannulation strategies and a diagnostic alternative for this entity.
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Affiliation(s)
- Emmanuel Adrián Lazcano-Diaz
- Terapia Intensiva cardiovascular, Instituto Nacional de Cardiología «Ignacio Chávez», Ciudad de México, México. Terapia Intensiva cardiovascular Instituto Nacional de Cardiología «Ignacio Chávez» Ciudad de México México
| | - Karla Sue América Hurtado Belizario
- Terapia Intensiva cardiovascular, Instituto Nacional de Cardiología «Ignacio Chávez», Ciudad de México, México. Terapia Intensiva cardiovascular Instituto Nacional de Cardiología «Ignacio Chávez» Ciudad de México México
| | - Daniel Riveros-Nina
- Terapia Intensiva cardiovascular, Instituto Nacional de Cardiología «Ignacio Chávez», Ciudad de México, México. Terapia Intensiva cardiovascular Instituto Nacional de Cardiología «Ignacio Chávez» Ciudad de México México
| | - Aldo Pérez-Manjarrez
- Terapia Intensiva cardiovascular, Instituto Nacional de Cardiología «Ignacio Chávez», Ciudad de México, México. Terapia Intensiva cardiovascular Instituto Nacional de Cardiología «Ignacio Chávez» Ciudad de México México
| | - Daniel Manzur-Sandoval
- Terapia Intensiva cardiovascular, Instituto Nacional de Cardiología «Ignacio Chávez», Ciudad de México, México. Terapia Intensiva cardiovascular Instituto Nacional de Cardiología «Ignacio Chávez» Ciudad de México México
| | - Luis Baeza-Herrera
- Terapia Intensiva cardiovascular, Instituto Nacional de Cardiología «Ignacio Chávez», Ciudad de México, México. Terapia Intensiva cardiovascular Instituto Nacional de Cardiología «Ignacio Chávez» Ciudad de México México
| | - Gustavo Rojas-Velasco
- Terapia Intensiva cardiovascular, Instituto Nacional de Cardiología «Ignacio Chávez», Ciudad de México, México. Terapia Intensiva cardiovascular Instituto Nacional de Cardiología «Ignacio Chávez» Ciudad de México México
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23
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Raman J, Saxena P, Dobrilovic N. ECMO as a bridge to cardiac surgery: stabilizing unstable patients for a definitive procedure. Indian J Thorac Cardiovasc Surg 2023; 39:63-72. [PMID: 37525716 PMCID: PMC10387022 DOI: 10.1007/s12055-023-01523-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 08/02/2023] Open
Abstract
Introduction Extracorporeal membrane oxygenation (ECMO) in adults has been used in post-cardiotomy patients who decline hemodynamically. Cardiogenic shock in patients with potential surgically correctable cardiac conditions are at significantly higher risk for post-operative morbidity and mortality. We present experience with a pre-emptive approach of ECMO institution pre-operatively to stabilize patients with cardiogenic shock. Materials and methods This study expands on a pilot study with a group of twenty patients who were supported with ECMO pre-operatively in different institutions over a period between 2011 and 2021. The patients presented with cardiogenic shock. Peripheral veno-arterial (VA) ECMO support was used in all the patients. Cardiac surgery was performed via median sternotomy utilizing the in situ ECMO cannulae to institute cardiopulmonary bypass (CPB). Results Seventeen patients were weaned off ECMO support following a mean duration of support of 156 h. Fifteen patients survived to discharge. The 30-day mortality and in-hospital mortality were 25% (expected 67% by European System for Cardiac Operative Risk Evaluation (EuroSCORE) II). The causes of mortality included persistent bleeding in 2 patients due to liver dysfunction, and one with low platelet counts. The other two had multi-organ failure. Conclusions Variable period of pre-operative ECMO support provides hemodynamic stability and may prevent or reverse the multi-organ dysfunction if instituted on time in patients presenting with cardiogenic shock. This strategy allows cardiac surgery to be performed with acceptable risk.
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Affiliation(s)
- Jai Raman
- Department of Cardiothoracic Surgery, St Vincent’s Hospital, University of Melbourne, Fitzroy, Australia
| | - Pankaj Saxena
- Department of Cardiothoracic Surgery, Townsville University Hospital, Townsville, QLD Australia
| | - Nikola Dobrilovic
- Section of Cardiac Surgery, Evanston Northshore Health System, Chicago, IL USA
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24
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Salter BS, Gross CR, Weiner MM, Dukkipati SR, Serrao GW, Moss N, Anyanwu AC, Burkhoff D, Lala A. Temporary mechanical circulatory support devices: practical considerations for all stakeholders. Nat Rev Cardiol 2023; 20:263-277. [PMID: 36357709 PMCID: PMC9649020 DOI: 10.1038/s41569-022-00796-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/23/2022] [Indexed: 11/12/2022]
Abstract
Originally intended for life-saving salvage therapy, the use of temporary mechanical circulatory support (MCS) devices has become increasingly widespread in a variety of clinical settings in the contemporary era. Their use as a short-term, prophylactic support vehicle has expanded to include procedures in the catheterization laboratory, electrophysiology suite, operating room and intensive care unit. Accordingly, MCS device design and technology continue to develop at a rapid pace. In this Review, we describe the functionality, indications, management and complications associated with temporary MCS, together with scenario-specific utilization, goal-directed development and bioengineering of future devices. We address various considerations for the use of temporary MCS devices in both prophylactic and rescue scenarios, with input from stakeholders from various cardiovascular specialties, including interventional and heart failure cardiology, electrophysiology, cardiothoracic anaesthesiology, critical care and cardiac surgery.
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Affiliation(s)
- Benjamin S Salter
- Department of Anaesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Caroline R Gross
- Department of Anaesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Menachem M Weiner
- Department of Anaesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Srinivas R Dukkipati
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gregory W Serrao
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai, New York, NY, USA
| | - Noah Moss
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai, New York, NY, USA
| | - Anelechi C Anyanwu
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Anuradha Lala
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai, New York, NY, USA
- Department of Population Health Science and Policy, Mount Sinai, New York, NY, USA
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25
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Heart Lung Transplant 2023; 42:e1-e64. [PMID: 36805198 DOI: 10.1016/j.healun.2022.10.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 10/28/2022] [Indexed: 02/08/2023] Open
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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26
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Mariani S, van Bussel BCT, Ravaux JM, Roefs MM, De Piero ME, Di Mauro M, Willers A, Segers P, Delnoij T, van der Horst ICC, Maessen J, Lorusso R. Variables associated with in-hospital and postdischarge outcomes after postcardiotomy extracorporeal membrane oxygenation: Netherlands Heart Registration Cohort. J Thorac Cardiovasc Surg 2023; 165:1127-1137.e14. [PMID: 36229294 DOI: 10.1016/j.jtcvs.2022.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/25/2022] [Accepted: 08/30/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Extracorporeal membrane oxygenation (ECMO) for postcardiotomy cardiogenic shock has been increasingly used without concomitant mortality reduction. This study aims to investigate determinants of in-hospital and postdischarge mortality in patients requiring postcardiotomy ECMO in the Netherlands. METHODS The Netherlands Heart Registration collects nationwide prospective data from cardiac surgery units. Adults receiving intraoperative or postoperative ECMO included in the register from January 2013 to December 2019 were studied. Survival status was established through the national Personal Records Database. Multivariable logistic regression analyses were used to investigate determinants of in-hospital (3 models) and 12-month postdischarge mortality (4 models). Each model was developed to target specific time points during a patient's clinical course. RESULTS Overall, 406 patients (67.2% men, median age, 66.0 years [interquartile range, 55.0-72.0 years]) were included. In-hospital mortality was 51.7%, with death occurring in a median of 5 days (interquartile range, 2-14 days) after surgery. Hospital survivors (n = 196) experienced considerable rates of pulmonary infections, respiratory failure, arrhythmias, and deep sternal wound infections during a hospitalization of median 29 days (interquartile range, 17-51 days). Older age (odds ratio [OR], 1.02; 95% CI, 1.0-1.04) and preoperative higher body mass index (OR, 1.08; 95% CI, 1.02-1.14) were associated with in-hospital death. Within 12 months after discharge, 35.1% of hospital survivors (n = 63) died. Postoperative renal failure (OR, 2.3; 95% CI, 1.6-4.9), respiratory failure (OR, 3.6; 95% CI, 1.3-9.9), and re-thoracotomy (OR, 2.9; 95% CI, 1.3-6.5) were associated with 12-month postdischarge mortality. CONCLUSIONS In-hospital and postdischarge mortality after postcardiotomy ECMO in adults remains high in the Netherlands. ECMO support in patients with higher age and body mass index, which drive associations with higher in-hospital mortality, should be carefully considered. Further observations suggest that prevention of re-thoracotomies, renal failure, and respiratory failure are targets that may improve postdischarge outcomes.
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Affiliation(s)
- Silvia Mariani
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.
| | - Bas C T van Bussel
- Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands; Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Justine M Ravaux
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Maaike M Roefs
- Netherlands Heart Registration, Utrecht, The Netherlands
| | - Maria Elena De Piero
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Michele Di Mauro
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Anne Willers
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Patrique Segers
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Thijs Delnoij
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Iwan C C van der Horst
- Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands; Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jos Maessen
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands; Netherlands Heart Registration, Utrecht, The Netherlands
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
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27
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Card Fail 2023; 29:304-374. [PMID: 36754750 DOI: 10.1016/j.cardfail.2022.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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28
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Massol J, Simon-Tillaux N, Tohme J, Hariri G, Dureau P, Duceau B, Belin L, Hajage D, De Rycke Y, Charfeddine A, Lebreton G, Combes A, Bouglé A. Levosimendan in patients undergoing extracorporeal membrane oxygenation after cardiac surgery: an emulated target trial using observational data. Crit Care 2023; 27:51. [PMID: 36750852 PMCID: PMC9906922 DOI: 10.1186/s13054-023-04328-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/21/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Retrospective cohorts have suggested that levosimendan may facilitate the weaning of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). We therefore studied this clinical question by emulating a randomized trial with observational data. METHODS All patients with refractory postcardiotomy cardiogenic shock and assisted with VA-ECMO, admitted to a surgical intensive care unit at La Pitié-Salpêtrière Hospital between 2016 and 2019, were eligible. To avoid immortal-time bias, we emulated a target trial sequentially comparing levosimendan administration versus no levosimendan administration in patients treated with VA-ECMO. The primary outcome was time to successful ECMO weaning. The secondary outcomes were 30-day and 1-year mortality. We performed a multivariable analysis to adjust for confounding at baseline. RESULTS Two hundred and thirty-nine patients were included in the study allowing building a nested trials cohort of 1434 copies of patients. No association of levosimendan treatment and VA-ECMO weaning was found (HR = 0.91, [0.57; 1.45], p = 0.659 in multivariable analysis), or 30-day mortality (OR = 1.03, [0.52; 2.03], p = 0.940) and 1-year mortality (OR = 1.00, [0.53; 1.89], p = 0.999). CONCLUSIONS Using the emulated target trial framework, this study did not find any association of levosimendan treatment and ECMO weaning success after postcardiotomy cardiogenic shock. However, the population of interest remains heterogeneous and subgroups might benefit from levosimendan.
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Affiliation(s)
- Julien Massol
- grid.411439.a0000 0001 2150 9058Department of Anesthesiology and Critical Care Medicine, La Pitié-Salpêtrière University Hospital, 47-83 Boulevard de L’Hôpital, 75013 Paris, France
| | - Noémie Simon-Tillaux
- grid.411439.a0000 0001 2150 9058Department of Anesthesiology and Critical Care Medicine, La Pitié-Salpêtrière University Hospital, 47-83 Boulevard de L’Hôpital, 75013 Paris, France
| | - Joanna Tohme
- grid.411439.a0000 0001 2150 9058Department of Anesthesiology and Critical Care Medicine, La Pitié-Salpêtrière University Hospital, 47-83 Boulevard de L’Hôpital, 75013 Paris, France
| | - Geoffroy Hariri
- grid.411439.a0000 0001 2150 9058Department of Anesthesiology and Critical Care Medicine, La Pitié-Salpêtrière University Hospital, 47-83 Boulevard de L’Hôpital, 75013 Paris, France
| | - Pauline Dureau
- grid.411439.a0000 0001 2150 9058Department of Anesthesiology and Critical Care Medicine, La Pitié-Salpêtrière University Hospital, 47-83 Boulevard de L’Hôpital, 75013 Paris, France
| | - Baptiste Duceau
- grid.411439.a0000 0001 2150 9058Department of Anesthesiology and Critical Care Medicine, La Pitié-Salpêtrière University Hospital, 47-83 Boulevard de L’Hôpital, 75013 Paris, France
| | - Lisa Belin
- grid.411439.a0000 0001 2150 9058Department of Anesthesiology and Critical Care Medicine, La Pitié-Salpêtrière University Hospital, 47-83 Boulevard de L’Hôpital, 75013 Paris, France
| | - David Hajage
- grid.411439.a0000 0001 2150 9058Department of Anesthesiology and Critical Care Medicine, La Pitié-Salpêtrière University Hospital, 47-83 Boulevard de L’Hôpital, 75013 Paris, France
| | - Yann De Rycke
- grid.411439.a0000 0001 2150 9058Department of Anesthesiology and Critical Care Medicine, La Pitié-Salpêtrière University Hospital, 47-83 Boulevard de L’Hôpital, 75013 Paris, France
| | - Ahmed Charfeddine
- grid.411439.a0000 0001 2150 9058Department of Anesthesiology and Critical Care Medicine, La Pitié-Salpêtrière University Hospital, 47-83 Boulevard de L’Hôpital, 75013 Paris, France
| | - Guillaume Lebreton
- grid.411439.a0000 0001 2150 9058Department of Anesthesiology and Critical Care Medicine, La Pitié-Salpêtrière University Hospital, 47-83 Boulevard de L’Hôpital, 75013 Paris, France
| | - Alain Combes
- grid.411439.a0000 0001 2150 9058Department of Anesthesiology and Critical Care Medicine, La Pitié-Salpêtrière University Hospital, 47-83 Boulevard de L’Hôpital, 75013 Paris, France
| | - Adrien Bouglé
- Department of Anesthesiology and Critical Care Medicine, La Pitié-Salpêtrière University Hospital, 47-83 Boulevard de L'Hôpital, 75013, Paris, France.
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29
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Swedzky F, Barbagelata A, Perrone S, Kaplinsky E, Ducharme A. Emerging concepts in heart failure management and treatment: circulatory support with extracorporeal membrane oxygenation (ECMO). Drugs Context 2023; 12:dic-2022-7-7. [PMID: 36660011 PMCID: PMC9828876 DOI: 10.7573/dic.2022-7-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 12/02/2022] [Indexed: 01/04/2023] Open
Abstract
Circulatory support with extracorporeal membrane oxygenation (ECMO) is being increasingly used in several critical situations but evidence of its impact on outcomes is inconsistent. Understanding of the specific indications and appropriate timing of implantation of this technology might lead to improved results. Indeed, the line between success and futility may be sometimes very thin when facing a patient in critical condition. New techniques with lighter, simpler and effective devices are being developed. Hence, ECMO has become an accessible technology that is being increasingly used outside of the operating room by heart failure specialists, critical care cardiologists and intensivists. Proper timing of utilization and choice of device may lead to better outcomes. We herein aim to improve this knowledge gap by conducting a literature review to provide simple information, evidence-based indications and a practical approach for cardiologists who may encounter acutely ill adult patients that may be ECMO candidates. This article is part of the Emerging concepts in heart failure management and treatment Special Issue: https://www.drugsincontext.com/special_issues/emerging-concepts-in-heart-failure-management-and-treatment.
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Affiliation(s)
- Federico Swedzky
- University of Montreal, Montreal’s Heart Institute, Montreal, Quebec, Canada
| | - Alejandro Barbagelata
- Catholic University of Argentine, Buenos Aires, Argentina,Sanatorio Fleni, Buenos Aires, Argentina
| | - Sergio Perrone
- Catholic University of Argentine, Buenos Aires, Argentina,Duke University School of Medicine, Durham, NC, USA
| | - Edgardo Kaplinsky
- Cardiology Unit, Medicine Department, Hospital Municipal de Badalona, Badalona, Spain
| | - Anique Ducharme
- University of Montreal, Montreal’s Heart Institute, Montreal, Quebec, Canada
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30
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Kiuchi N, Seino Y, Yamamoto M, Katagiri S, Takagi S, Nomura T, Suzuki T. Postoperative prosthetic mitral valve occlusion due to left atrial thrombus during veno-arterial extracorporeal membrane oxygenation: a case report. JA Clin Rep 2022; 8:93. [PMID: 36471130 PMCID: PMC9723070 DOI: 10.1186/s40981-022-00586-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/27/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Anticoagulation using heparin is generally used to prevent thrombus formation during mechanical circulatory support, such as veno-arterial extracorporeal membrane oxygenation (VA-ECMO). However, during the early period following cardiac surgery, anticoagulation becomes more difficult due to the greater risk of critical bleeding complications. CASE PRESENTATION A 71-year-old man presented with acute prosthetic valve occlusion caused by left atrial thrombus formation and bioprosthetic valve thrombosis during peripheral VA-ECMO following mitral valve replacement (MVR) despite continuous heparin administration and loading of antiplatelet agents. The VA-ECMO flow rate decreased 10 h after the intensive care unit (ICU) admission after MVR. Exploratory transesophageal echocardiography (TEE) examination revealed a left atrial thrombus, prosthetic valve obstruction by the thrombus, and an intrapericardial hematoma. CONCLUSIONS Intracardiac thrombus formation might occur during VA-ECMO despite appropriate anticoagulation and loading of antiplatelet agents. Exploratory TEE examination was helpful in the detection of intra-atrial thrombus formation after cardiac surgery and surgical decision-making.
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Affiliation(s)
- Naoto Kiuchi
- grid.260969.20000 0001 2149 8846Department of Anesthesiology, Nihon University School of Medicine, 30-1 Kamicho Oyaguchi, Itabashi-ku, Tokyo, Japan
| | - Yusuke Seino
- grid.410818.40000 0001 0720 6587Department of Intensive Care Medicine, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan ,grid.412764.20000 0004 0372 3116Department of Anesthesiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Japan
| | - Mai Yamamoto
- grid.260969.20000 0001 2149 8846Department of Anesthesiology, Nihon University School of Medicine, 30-1 Kamicho Oyaguchi, Itabashi-ku, Tokyo, Japan
| | - Seidai Katagiri
- grid.260969.20000 0001 2149 8846Department of Anesthesiology, Nihon University School of Medicine, 30-1 Kamicho Oyaguchi, Itabashi-ku, Tokyo, Japan
| | - Shunichi Takagi
- grid.260969.20000 0001 2149 8846Department of Anesthesiology, Nihon University School of Medicine, 30-1 Kamicho Oyaguchi, Itabashi-ku, Tokyo, Japan
| | - Takeshi Nomura
- grid.410818.40000 0001 0720 6587Department of Intensive Care Medicine, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan
| | - Takahiro Suzuki
- grid.260969.20000 0001 2149 8846Department of Anesthesiology, Nihon University School of Medicine, 30-1 Kamicho Oyaguchi, Itabashi-ku, Tokyo, Japan
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Milne B, Gilbey T, Kunst G. Perioperative Management of the Patient at High-Risk for Cardiac Surgery-Associated Acute Kidney Injury. J Cardiothorac Vasc Anesth 2022; 36:4460-4482. [PMID: 36241503 DOI: 10.1053/j.jvca.2022.08.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/27/2022] [Accepted: 08/22/2022] [Indexed: 11/11/2022]
Abstract
Acute kidney injury (AKI) is one of the most common major complications of cardiac surgery, and is associated with increased morbidity and mortality. Cardiac surgery-associated AKI has a complex, multifactorial etiology, including numerous factors such as primary cardiac dysfunction, hemodynamic derangements of cardiac surgery and cardiopulmonary bypass, and the possibility of a large volume of blood transfusion. There are no truly effective pharmacologic therapies for the management of AKI, and, therefore, anesthesiologists, intensivists, and cardiac surgeons must remain vigilant and attempt to minimize the risk of developing renal dysfunction. This narrative review describes the current state of the scientific literature concerning the specific aspects of cardiac surgery-associated AKI, and presents it in a chronological fashion to aid the perioperative clinician in their approach to this high-risk patient group. The evidence was considered for risk prediction models, preoperative optimization, and the intraoperative and postoperative management of cardiac surgery patients to improve renal outcomes.
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Affiliation(s)
- Benjamin Milne
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research Academic Clinical Fellow, King's College London, London, United Kingdom
| | - Tom Gilbey
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research Academic Clinical Fellow, King's College London, London, United Kingdom
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular Medicine and Metabolic Medicine and Sciences, King's College London, British Heart Foundation Centre of Excellence, Faculty of Life Sciences and Medicine, London, United Kingdom.
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Jaidka AK, De S, Drullinsky D, Nagpal AD, Chu MWA. Prophylactic LVAD for high-risk patients undergoing cardiac surgery. J Card Surg 2022; 37:5120-5129. [PMID: 36413687 DOI: 10.1111/jocs.17222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/26/2022] [Accepted: 10/29/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Postcardiotomy cardiogenic shock (PCS) is associated with poor prognosis. Medical therapy with afterload reduction, contractility optimization and systemic vasopressors often fails, and mechanical support is required. The aim of this study was to propose a strategy of prophylactic left ventricular assist device (LVAD) for high-risk patients undergoing cardiac surgery. METHODS Between 2013 and 2019, 12 consecutive patients at high risk for PCS underwent cardiac surgery (valve surgery and/or coronary artery bypass grafting) with preplanned, prophylactic implantation of LVAD (CentriMag or Rotaflow). We reviewed patient characteristics and outcomes. RESULTS Eight patients underwent a valve corrective surgery and seven patients underwent coronary artery bypass grafting. Eleven of 12 patients had successful LVAD insertion, support and wean, and survival to hospital discharge. Left ventricular function was stable perioperatively and improved at follow-up. Patients required low doses of inotropic support and no patients required extracorporeal membranous oxygenation. Major complications included, prolonged mechanical ventilation (n = 7), intra-aortic balloon pump (n = 1), temporary dialysis (n = 2), stroke (n = 1), bleeding requiring reoperation (n = 3), infection requiring mediastinal washout (n = 1). At a mean follow-up of, 660 ± 460.6 days all patients had either NYHA Class 1 (n = 6) or 2 (n = 4). There were two late mortalities (after 1 year). CONCLUSIONS Prophylactic LVAD is a viable technique in select cardiac surgery patients who are high-risk for postcardiotomy shock. Further prospective study is warranted.
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Affiliation(s)
- Atul K Jaidka
- Department of Medicine, London Health Sciences Centre, Division of Cardiology, Western University, London, Ontario, Canada
| | - Sabe De
- Department of Medicine, London Health Sciences Centre, Division of Cardiology, Western University, London, Ontario, Canada
| | - David Drullinsky
- Department of Surgery, London Health Sciences Centre, Division of Cardiac Surgery, Western University, London, Ontario, Canada
| | - Atul Dave Nagpal
- Department of Surgery, London Health Sciences Centre, Division of Cardiac Surgery, Western University, London, Ontario, Canada.,Department of Medicine, London Health Sciences Centre, Division of Critical Care, Western University, London, Ontario, Canada
| | - Michael W A Chu
- Department of Surgery, London Health Sciences Centre, Division of Cardiac Surgery, Western University, London, Ontario, Canada
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Pérez Vela JL, Llanos Jorge C, Duerto Álvarez J, Jiménez Rivera JJ. Clinical management of postcardiotomy shock in adults. Med Intensiva 2022; 46:312-325. [PMID: 35570187 DOI: 10.1016/j.medine.2022.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/14/2021] [Accepted: 08/21/2021] [Indexed: 06/15/2023]
Abstract
Postcardiotomy cardiogenic shock represents the most serious expression of low cardiac output syndrome after cardiac surgery. Although infrequent, it is a relevant condition due to its specific and complex pathophysiology and important morbidity-mortality. The diagnosis requires a high index of suspicion and multimodal hemodynamic monitoring, where echocardiography and the pulmonary arterial catheter play a main role. Early and multidisciplinary management should focus on the management of postoperative or mechanical complications and the optimization of determinants of cardiac output through fluid therapy or diuretic treatments, inotropic drugs and vasopressors/vasodilators and, in the absence of a response, early mechanical circulatory support. The aim of this paper is to review and update the pathophysiology, diagnosis and management of postcardiotomy cardiogenic shock.
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Affiliation(s)
- J L Pérez Vela
- Servicio de Medicina Intensiva, Hospital Universitario Doce de Octubre, Madrid, Spain.
| | - C Llanos Jorge
- Servicio de Medicina Intensiva, Hospital Quirónsalud Tenerife, Santa Cruz de Tenerife, Spain
| | - J Duerto Álvarez
- Servicio de Medicina Intensiva, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - J J Jiménez Rivera
- Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Canarias, San Cristóbal de La Laguna, Santa Cruz de Tenerife, Spain
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Perioperative incidence of ECMO and IABP on 5901 mitral valve surgery procedures. J Cardiothorac Surg 2022; 17:38. [PMID: 35300722 PMCID: PMC8928683 DOI: 10.1186/s13019-022-01790-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/12/2022] [Indexed: 11/28/2022] Open
Abstract
Background Report the incidence and results of peri-operative extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pump (IABP) of patients undergoing mitral valve surgery (MVS) through right mini-thoracotomy (RT) and conventional full sternotomy (FS) for a period of 6 years from eleven tertiary Cardiac Surgery Institutes of GVM Care & Research Italia. Methods From January 2016 to November 2021, a total of 5901 consecutive patients underwent MVS through RT and FS. The primary outcome of the study was the mortality and incidence of low cardiac output syndrome (LCOS) treated with intra-aortic balloon pump (IABP) with or without inotropic support and the incidence of Postcardiotomy Cardiogenic Shock (PCS) treated with Veno-arterial (VA) Extracorporeal Membrane Oxygenation (ECMO) on patients undergoing mitral valve surgery (MVS) through right mini-thoracotomy (RT) versus conventional full sternotomy (FS). Results The mean age was 66 ± 15 years, 3389 patients underwent in RT approach 2512 in FS, 3081 (52%) patients were male and 2.3% had previous cardiac operations. Cardiopulmonary bypass time was 93 min for RT and 81 min for FS and cross clamp time 75 min for RT and 63 min for FS for mitral valve repair. Incidence of perioperative IABP for the treatment of low cardiac output was reported on 99 patients (1.6%), 51 for RT (1.5%), 35% used inotropic support (adrenaline and milrinone) and 48 in FS (1.9), 28% use inotropic support, 21 patients died after IABP (3 RT and 18 FS). Incidence of perioperative VA-ECMO for the PCS treatment was 13 and 4 with IABP, 9 RT (0.2%) and 4 FS approach (0.15%), 12 patients died after VA-ECMO. Conclusion Minimally invasive mitral valve surgery is a safe and reproducible approach associated with low mortality and morbidity. ECMO and IABP incidence for the treatment of PCS was 0.2% and for Low cardiac output syndrome (LCOS) was 1.6% in elective mitral valve surgery is very low. The patients that use the perioperative IABP in minimally invasive mitral valve surgery (MIMVS) trough RT reported a reduced mortality compared to FS in relation to the operative risk and surgical technique. Low incidence of VA-ECMO was found in RT and FS approach, only one patient survived after VA-ECMO after minimally invasive mitral valve surgery.
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Condello I, Lorusso R, Santarpino G, Di Bari N, Fiore F, Moscarelli M, Calafiore AM, Speziale G, Nasso G. Perioperative incidence of ECMO and IABP on 5901 mitral valve surgery procedures. J Cardiothorac Surg 2022. [PMID: 35300722 DOI: 10.1186/s13019-022-01790-1.pmid:35300722;pmcid:pmc8928683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Report the incidence and results of peri-operative extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pump (IABP) of patients undergoing mitral valve surgery (MVS) through right mini-thoracotomy (RT) and conventional full sternotomy (FS) for a period of 6 years from eleven tertiary Cardiac Surgery Institutes of GVM Care & Research Italia. METHODS From January 2016 to November 2021, a total of 5901 consecutive patients underwent MVS through RT and FS. The primary outcome of the study was the mortality and incidence of low cardiac output syndrome (LCOS) treated with intra-aortic balloon pump (IABP) with or without inotropic support and the incidence of Postcardiotomy Cardiogenic Shock (PCS) treated with Veno-arterial (VA) Extracorporeal Membrane Oxygenation (ECMO) on patients undergoing mitral valve surgery (MVS) through right mini-thoracotomy (RT) versus conventional full sternotomy (FS). RESULTS The mean age was 66 ± 15 years, 3389 patients underwent in RT approach 2512 in FS, 3081 (52%) patients were male and 2.3% had previous cardiac operations. Cardiopulmonary bypass time was 93 min for RT and 81 min for FS and cross clamp time 75 min for RT and 63 min for FS for mitral valve repair. Incidence of perioperative IABP for the treatment of low cardiac output was reported on 99 patients (1.6%), 51 for RT (1.5%), 35% used inotropic support (adrenaline and milrinone) and 48 in FS (1.9), 28% use inotropic support, 21 patients died after IABP (3 RT and 18 FS). Incidence of perioperative VA-ECMO for the PCS treatment was 13 and 4 with IABP, 9 RT (0.2%) and 4 FS approach (0.15%), 12 patients died after VA-ECMO. CONCLUSION Minimally invasive mitral valve surgery is a safe and reproducible approach associated with low mortality and morbidity. ECMO and IABP incidence for the treatment of PCS was 0.2% and for Low cardiac output syndrome (LCOS) was 1.6% in elective mitral valve surgery is very low. The patients that use the perioperative IABP in minimally invasive mitral valve surgery (MIMVS) trough RT reported a reduced mortality compared to FS in relation to the operative risk and surgical technique. Low incidence of VA-ECMO was found in RT and FS approach, only one patient survived after VA-ECMO after minimally invasive mitral valve surgery.
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Affiliation(s)
- Ignazio Condello
- Department of Cardiac Surgery, Perfusion Service, Anthea Hospital, GVM Care and Research, Via Camillo Rosalba 35/37, 70124, Bari, Italy.
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Giuseppe Santarpino
- Department of Cardiac Surgery, Perfusion Service, Anthea Hospital, GVM Care and Research, Via Camillo Rosalba 35/37, 70124, Bari, Italy
- Department of Cardiac Surgery, Paracelsus Medical University, Nuremberg, Germany
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Nicola Di Bari
- Division of Cardiac Surgery, Dipartimento Di Emergenza E Trapianti Di Organo (D.E.T.O.), University of Bari, Bari, Italy
| | - Flavio Fiore
- Department of Cardiac Surgery, Perfusion Service, Anthea Hospital, GVM Care and Research, Via Camillo Rosalba 35/37, 70124, Bari, Italy
| | - Marco Moscarelli
- Department of Cardiac Surgery, Perfusion Service, Anthea Hospital, GVM Care and Research, Via Camillo Rosalba 35/37, 70124, Bari, Italy
| | - Antonio Maria Calafiore
- Department of Cardiac Surgery, Perfusion Service, Anthea Hospital, GVM Care and Research, Via Camillo Rosalba 35/37, 70124, Bari, Italy
| | - Giuseppe Speziale
- Department of Cardiac Surgery, Perfusion Service, Anthea Hospital, GVM Care and Research, Via Camillo Rosalba 35/37, 70124, Bari, Italy
| | - Giuseppe Nasso
- Department of Cardiac Surgery, Perfusion Service, Anthea Hospital, GVM Care and Research, Via Camillo Rosalba 35/37, 70124, Bari, Italy
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6523883. [DOI: 10.1093/ejcts/ezac056] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 12/12/2021] [Accepted: 01/24/2022] [Indexed: 11/13/2022] Open
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 61:1178-1185. [DOI: 10.1093/ejcts/ezac035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 12/07/2021] [Accepted: 01/15/2022] [Indexed: 11/14/2022] Open
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Cho HJ, Choi I, Kwak Y, Kim DW, Habimana R, Jeong IS. The Outcome of Post-cardiotomy Extracorporeal Membrane Oxygenation in Neonates and Pediatric Patients: A Systematic Review and Meta-Analysis. Front Pediatr 2022; 10:869283. [PMID: 35547551 PMCID: PMC9083359 DOI: 10.3389/fped.2022.869283] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Post-cardiotomy extracorporeal membrane oxygenation (PC-ECMO) is a known rescue therapy for neonates and pediatric patients who failed to wean from cardiopulmonary bypass (CPB) or who deteriorate in intensive care unit (ICU) due to various reasons such as low cardiac output syndrome (LCOS), cardiac arrest and respiratory failure. We conducted a systematic review and meta-analysis to assess the survival in neonates and pediatric patients who require PC-ECMO and sought the difference in survivals by each indication for PC-ECMO. DESIGN Systematic review and meta-analysis. SETTING Multi-institutional analysis. PARTICIPANTS Neonates and pediatric patients who requires PC- ECMO. INTERVENTIONS ECMO after open-heart surgery. RESULTS Twenty-six studies were included in the analysis with a total of 186,648 patients and the proportion of the population who underwent PC-ECMO was 2.5% (2,683 patients). The overall pooled proportion of survival in this population was 43.3% [95% Confidence interval (CI): 41.3-45.3%; I 2: 1%]. The survival by indications of PC-ECMO were 44.6% (95% CI: 42.6-46.6; I 2: 0%) for CPB weaning failure, 47.3% (95% CI: 39.9-54.7%; I 2: 5%) for LCOS, 37.6% (95% CI: 31.0-44.3%; I 2: 32%) for cardiac arrest and 47.7% (95% CI: 32.5-63.1%; I 2: 0%) for respiratory failure. Survival from PC-ECMO for single ventricle or biventricular physiology, was reported by 12 studies. The risk ratio (RR) was 0.74 for survival in patients with single ventricle physiology (95% CI: 0.63-0.86; I 2: 40%, P < 0.001). Eight studies reported on the survival after PC-ECMO for genetic conditions. The RR was 0.93 for survival in patients with genetic condition (95% CI: 0.52-1.65; I 2: 65%, P = 0.812). CONCLUSIONS PC-ECMO is an effective modality to support neonates and pediatric patients in case of failed CPB weaning and deterioration in ICU. Even though ECMO seems to improve survival, mortality and morbidity remain high, especially in neonates and pediatric patients with single ventricle physiology. Most genetic conditions alone should not be considered a contraindication to ECMO support, further studies are needed to determine which genetic abnormalities are associated with favorable outcome.
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Affiliation(s)
- Hwa Jin Cho
- Division of Pediatric Cardiology and Cardiac Critical Care, Department of Pediatrics, Chonnam National University Children's Hospital and Medical School, Gwangju, South Korea.,Cardiovascular and Respiratory Research Team, Chonnam National University Hospital, Gwangju, South Korea
| | - Insu Choi
- Division of Pediatric Cardiology and Cardiac Critical Care, Department of Pediatrics, Chonnam National University Children's Hospital and Medical School, Gwangju, South Korea
| | - Yujin Kwak
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital and Medical School, Gwangju, South Korea
| | - Do Wan Kim
- Cardiovascular and Respiratory Research Team, Chonnam National University Hospital, Gwangju, South Korea.,Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital and Medical School, Gwangju, South Korea
| | - Reverien Habimana
- Cardiovascular and Respiratory Research Team, Chonnam National University Hospital, Gwangju, South Korea.,Department of Biomedical Sciences, College of Medicine, Chonnam National University Graduate School, Gwangju, South Korea
| | - In-Seok Jeong
- Cardiovascular and Respiratory Research Team, Chonnam National University Hospital, Gwangju, South Korea.,Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital and Medical School, Gwangju, South Korea
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Cavayas YA, Noly PE, Singh G, Lamarche Y. Controversies in extracorporeal membrane oxygenation: Immediate versus watchful waiting for venoarterial extracorporeal membrane oxygenation venting. JTCVS OPEN 2021; 8:70-76. [PMID: 36004177 PMCID: PMC9390622 DOI: 10.1016/j.xjon.2021.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/15/2021] [Indexed: 11/30/2022]
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Stein LH, Silvestry SC. Algorithmic management of postcardiotomy shock with mechanical support: Bring a map, a plan, and your parachute—and know how to use all three. JTCVS OPEN 2021; 8:55-65. [PMID: 36004058 PMCID: PMC9390719 DOI: 10.1016/j.xjon.2021.10.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 10/28/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Louis H. Stein
- Northern Department of Cardiothoracic Surgery, RWJ-Barnabas Health, Newark, NJ
- Address for reprints: Louis H. Stein, MD, PhD, Newark-Beth Israel Medical Center, 201 Lyons Ave, Suite G5, Newark, NJ 07112.
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Bowles C, Hiesinger W. Postcardiotomy shock extracorporeal membrane oxygenation: Peripheral or central? JTCVS OPEN 2021; 8:66-69. [PMID: 36004095 PMCID: PMC9390509 DOI: 10.1016/j.xjon.2021.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/18/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Cayley Bowles
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - William Hiesinger
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
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Schaefer AK, Distelmaier K, Riebandt J, Goliasch G, Bernardi MH, Zimpfer D, Laufer G, Wiedemann D. Access site complications of postcardiotomy extracorporeal life support. J Thorac Cardiovasc Surg 2021; 164:1546-1558.e8. [PMID: 34949456 DOI: 10.1016/j.jtcvs.2021.09.074] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/29/2021] [Accepted: 09/10/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the influence of primary arterial access in patients receiving peripheral postcardiotomy extracorporeal life support on associated complications and outcome. METHODS Of 573 consecutive patients requiring PC-ECLS between 2000 and 2019 at a single center, 436 were included in a retrospective analysis and grouped according to primary arterial extracorporeal life support access site. Survival and rate of access-site-related complications with special emphasis on fatal/disabling stroke were compared. RESULTS The axillary artery was cannulated in 250 patients (57.3%), whereas the femoral artery was used as primary arterial access in 186 patients (42.6%). There was no significant difference in 30-day (axillary: 62%; femoral: 64.7%; P = .561) and 1-year survival (axillary: 42.5%; femoral: 44.8%; P = .657). Cerebral computed tomography-confirmed stroke with a modified ranking scale ≥4 was significantly more frequent in the axillary group (axillary: n = 28, 11.2%; femoral: n = 4, 2.2%; P = .0003). Stroke localization was right hemispheric (n = 20; 62.5%); left hemispheric (n = 5; 15.6%), bilateral (n = 5; 15.6%), or infratentorial (n = 2; 6.25%). Although no difference in major cannulation site bleeding was observed, cannulation site change for bleeding was more frequent in the axillary group (axillary: n = 13; 5.2%; femoral: n = 2; 1.1%; P = .03). Clinically apparent limb ischemia was significantly more frequent in the femoral group (axillary: n = 12, 4.8%; femoral: n = 31, 16.7%; P < .0001). CONCLUSIONS Although survival did not differ, surgeons should be aware of access-site-specific complications when choosing peripheral PC-ECLS access. Although lower rates of limb ischemia and the advantage of antegrade flow seem beneficial for axillary cannulation, the high incidence of right hemispheric strokes in axillary artery cannulation should be considered.
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Affiliation(s)
| | - Klaus Distelmaier
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Julia Riebandt
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Georg Goliasch
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Martin H Bernardi
- Cardiac Thoracic Vascular Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Günther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.
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Zarragoikoetxea I, Pajares A, Moreno I, Porta J, Koller T, Cegarra V, Gonzalez A, Eiras M, Sandoval E, Sarralde J, Quintana-Villamandos B, Vicente Guillén R. Documento de consenso SEDAR/SECCE sobre el manejo de ECMO. CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Pérez Vela J, Llanos Jorge C, Duerto Álvarez J, Jiménez Rivera J. Manejo clínico del shock poscardiotomía en pacientes adultos. Med Intensiva 2021. [DOI: 10.1016/j.medin.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Zaaqoq AM, Pottash M, Ahlstrom E, Brodie D. Postcardiotomy Extracorporeal Membrane Oxygenation: Narrative Review Navigating the Ethical Issues. J Cardiothorac Vasc Anesth 2021; 36:2628-2635. [PMID: 34763977 DOI: 10.1053/j.jvca.2021.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/18/2021] [Accepted: 10/08/2021] [Indexed: 11/11/2022]
Abstract
Postcardiotomy shock (PCS) is an uncommon and life-threatening surgical complication. Extracorporeal membrane oxygenation (ECMO) is the first line of mechanical circulatory support for treating PCS when medical therapies are insufficient. Reaching a "therapeutic ceiling" or a "bridge to nowhere" is a common clinical scenario in which medical avenues for recovery have been exhausted. These situations pose emotional and ethical challenges for patients, their surrogates, and clinicians. To shed light on these ethically challenging situations in PCS and potential approaches, the authors conducted a narrative review of the literature. Publications were utilized to describe current trends in the diagnosis and management of the patient with PCS, with particular emphasis on the therapeutic ceiling for life support. Most of the recommendations came from practice parameters or expert opinions to support specific interventions. The authors proposed a stepwise multidisciplinary approach to reduce PCS-associated ethical and emotional challenges. Their proposed algorithm was based on the likelihood of the need for ECMO support based on the mortality risk stratification of cardiac surgery. They suggested focused discussions around the commencement of ECMO or other life-sustaining therapies-ideally preoperatively at the time of consent-through shared decision-making and, subsequently, proactive multidisciplinary education and updates to the surrogate decision-makers relying on realistic prognosis and consideration of the patient wishes during the ECMO run.
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Affiliation(s)
- Akram M Zaaqoq
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Georgetown University, Washington, DC; Department of Medicine, MedStar Washington Hospital Center, Georgetown University, Washington, DC.
| | - Michael Pottash
- Department of Medicine, MedStar Washington Hospital Center, Georgetown University, Washington, DC; Division of Palliative Medicine, MedStar Washington Hospital Center, Georgetown University, Washington, DC
| | - Eric Ahlstrom
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Georgetown University, Washington, DC; Department of Medicine, MedStar Washington Hospital Center, Georgetown University, Washington, DC
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York
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Zarragoikoetxea I, Pajares A, Moreno I, Porta J, Koller T, Cegarra V, Gonzalez AI, Eiras M, Sandoval E, Aurelio Sarralde J, Quintana-Villamandos B, Vicente Guillén R. SEDAR/SECCE ECMO management consensus document. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:443-471. [PMID: 34535426 DOI: 10.1016/j.redare.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 12/14/2020] [Indexed: 06/13/2023]
Abstract
ECMO is an extracorporeal cardiorespiratory support system whose use has been increased in the last decade. Respiratory failure, postcardiotomy shock, and lung or heart primary graft failure may require the use of cardiorespiratory mechanical assistance. In this scenario perioperative medical and surgical management is crucial. Despite the evolution of technology in the area of extracorporeal support, morbidity and mortality of these patients continues to be high, and therefore the indication as well as the ECMO removal should be established within a multidisciplinary team with expertise in the area. This consensus document aims to unify medical knowledge and provides recommendations based on both the recent bibliography and the main national ECMO implantation centres experience with the goal of improving comprehensive patient care.
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Affiliation(s)
- I Zarragoikoetxea
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain.
| | - A Pajares
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - I Moreno
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - J Porta
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - T Koller
- Servicio de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - V Cegarra
- Servicio de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - A I Gonzalez
- Servicio de Anestesiología y Reanimación, Hospital Puerta de Hierro, Madrid, Spain
| | - M Eiras
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario de Santiago, La Coruña, Spain
| | - E Sandoval
- Servicio de Cirugía Cardiovascular, Hospital Clínic de Barcelona, Barcelona, Spain
| | - J Aurelio Sarralde
- Servicio de Cirugía Cardiovascular, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - B Quintana-Villamandos
- Servicio de Anestesiología y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - R Vicente Guillén
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Cole SP, Martinez-Acero N, Peterson A, Von Homeyer P, Gebhardt B, Nicoara A. Imaging for Temporary Mechanical Circulatory Support Devices. J Cardiothorac Vasc Anesth 2021; 36:2114-2131. [PMID: 34740543 DOI: 10.1053/j.jvca.2021.09.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 09/04/2021] [Accepted: 09/20/2021] [Indexed: 11/11/2022]
Abstract
Heart failure is an important cause of mortality and morbidity in the world. Changes in organ allocation for solid thoracic (lung and heart) transplantation has increased the number of patients on mechanical circulatory support. Temporary mechanical support devices include devices tht support the circulation directly or indirectly such as extracorporeal membrane oxygenation (ECMO) and temporary support for right-sided failure, left-sided failure or biventricular failure. Most often, these devices are placed percutaneously and require either guidance with echocardiography, continuous radiography (fluoroscopy) or both. Furthermore, these devices need imaging in the intensive care unit to confirm continued accurate placement. This review contains the imaging views and nuances of the temporary assist devices (including ECMO) at the time of placement and the complications that can be associated with each individual device.
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Affiliation(s)
- Sheela Pai Cole
- Clinical Professor, Department of Anesthesiology, Perioperative and Pain medicine, Stanford University, Palo Alto, CA 94305.
| | - Natalia Martinez-Acero
- Associate Physician, Cardiac Anesthesiology and Critical Care, Kaiser Permanente, Santa Clara, CA.
| | - Ashley Peterson
- Clinical Assistant Professor, Department of Anesthesiology, Perioperative and Pain medicine, Stanford University, Palo Alto, CA 94305.
| | - Peter Von Homeyer
- Associate Professor, Department of Anesthesiology, University of Washington, Seattle, WA 98195.
| | | | - Alina Nicoara
- Associate Professor, Department of Anesthesiology, Duke University, Raleigh, NC 27708.
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Management of Extracorporeal Membrane Oxygenation for Postcardiotomy Cardiogenic Shock. Anesthesiology 2021; 135:497-507. [PMID: 34259811 DOI: 10.1097/aln.0000000000003876] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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A Standardized Approach Improves Outcomes of Extracorporeal Membrane Oxygenation for Postcardiotomy Shock. ASAIO J 2021; 67:1119-1124. [PMID: 34225277 DOI: 10.1097/mat.0000000000001369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Postcardiotomy shock (PCS) has historically been associated with substantial morbidity and mortality. Mortality at discharge is reportedly more than 60%. We investigated the outcomes of our standardized approach to veno-arterial extracorporeal membrane oxygenation (ECMO) management for PCS. We retrospectively reviewed 60 consecutive PCS patients who required ECMO following major cardiac surgery from January 2017 to September 2019. Index surgery included CABG (n = 10), valve (n = 23), valve and CABG (n = 12), root surgery (n = 10), and other (n = 5). Median lactate level, systolic blood pressure, and mean pulmonary artery pressure before ECMO were 4.0 mmol/L, 80 mm Hg, and 29 mm Hg, respectively. Fifty-nine patients (98%) were on two vasopressors, and 54 (90%) were on at least two inotropes. Vasoactive-Inotropic Score was 30 (IQR, 25-49). Eighty percent of patients received peripheral ECMO. Median ECMO flow index was 1.61 (IQR, 1.4-2.0) L/min/m2. Anticoagulation was not given in 12 (20%) patients during ECMO support. Major adverse events included chest re-exploration (15%), stroke (6.7%), renal replacement therapy (22%), and limb ischemia (5%). In-hospital mortality was 33%. This study suggests that a standardized approach with a dedicated ECMO team is feasible and may improve outcomes of PCS.
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Kowalewski M, Zieliński K, Brodie D, MacLaren G, Whitman G, Raffa GM, Boeken U, Shekar K, Chen YS, Bermudez C, D’Alessandro D, Hou X, Haft J, Belohlavek J, Dziembowska I, Suwalski P, Alexander P, Barbaro RP, Gaudino M, Mauro MD, Maessen J, Lorusso R. Venoarterial Extracorporeal Membrane Oxygenation for Postcardiotomy Shock-Analysis of the Extracorporeal Life Support Organization Registry. Crit Care Med 2021; 49:1107-1117. [PMID: 33729722 PMCID: PMC8217275 DOI: 10.1097/ccm.0000000000004922] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Refractory postcardiotomy cardiogenic shock complicating cardiac surgery yields nearly 100% mortality when untreated. Use of venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock has increased worldwide recently. The aim of the current analysis was to outline the trends in use, changing patient profiles, and in-hospital outcomes including complications in patients undergoing venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock. DESIGN Analysis of extracorporeal life support organization registry from January 2010 to December 2018. SETTING Multicenter worldwide registry. PATIENTS Seven-thousand one-hundred eighty-five patients supported with venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock. INTERVENTIONS Venoarterial extracorporeal membrane oxygenation. MEASUREMENTS AND MAIN RESULTS Hospital death, weaning from extracorporeal membrane oxygenation, hospital complications. Mortality predictors were assessed by multivariable logistic regression. Propensity score matching was performed for comparison of peripheral and central cannulation for extracorporeal membrane oxygenation. A significant trend toward more extracorporeal membrane oxygenation use in recent years (coefficient, 0.009; p < 0.001) was found. Mean age was 56.3 ± 14.9 years and significantly increased over time (coefficient, 0.513; p < 0.001). Most commonly, venoarterial extracorporeal membrane oxygenation was instituted after coronary artery bypass surgery (26.8%) and valvular surgery (25.6%), followed by heart transplantation (20.7%). Overall, successful extracorporeal membrane oxygenation weaning was possible in 4,520 cases (56.4%), and survival to hospital discharge was achieved in 41.7% of cases. In-hospital mortality rates remained constant over time (coefficient, -8.775; p = 0.682), whereas complication rates were significantly reduced (coefficient, -0.009; p = 0.003). Higher mortality was observed after coronary artery bypass surgery (65.4%), combined coronary artery bypass surgery with valve (68.4%), and aortic (69.6%) procedures than other indications. Lower mortality rates were observed in heart transplantation recipients (46.0%). Age (p < 0.001), central cannulation (p < 0.001), and occurrence of complications while on extracorporeal membrane oxygenation were independently associated with poorer prognosis. CONCLUSIONS The analysis confirmed increased use of venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock. Mortality rates remained relatively constant over time despite a decrease in complications, in the setting of supporting older patients.
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Affiliation(s)
- Mariusz Kowalewski
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
- Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland
- Thoracic Research Centre, Collegium Medicum, Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | | | - Daniel Brodie
- Center for Acute Respiratory Failure and Department of Medicine, Columbia University College of Physicians & Surgeons/New York-Presbyterian Hospital, New York, NY, USA
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Hospital, Singapore
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | | | - Udo Boeken
- Department of Cardiac Surgery, University of Dusseldorf, Dusseldorf, Germany
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia
| | - Yih-Sharng Chen
- Cardiovascular Surgery & Pediatric Cardiovascular Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Christian Bermudez
- Department of Cardiothoracic Surgery, Jefferson University, Philadelphia, PA, USA
| | - David D’Alessandro
- Cardio-Thoracic Surgery Dept., Massachusetts Medical Centre, Boston, MA, USA
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, P.R. of China
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Jan Belohlavek
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University, Prague, and General University Hospital, Prague, Czech Republic
| | - Inga Dziembowska
- Department of Pathophysiology, Faculty of Pharmacy, Collegium Medicum, Nicolaus Copernicus University, Toruń, Poland
| | - Piotr Suwalski
- Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Peta Alexander
- Department of Cardiology, Boston Children’s Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Ryan P Barbaro
- Department of Pediatrics, C.S. Mott Children’s Hospital, University of Michigan Ann Arbor, Michigan, USA
| | - Mario Gaudino
- Department of Cardio-Thoracic Surgery, Well Cornell Medicine, New York, NY, USA
| | - Michele Di Mauro
- Cardiac Surgery Unit, University Hospital, University of Chieti, Chieti, Italy
| | - Jos Maessen
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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