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Snipelisky D, Estep JD. Guide to Temporary Mechanical Support in Cardiogenic Shock: Choosing Wisely. Heart Fail Clin 2024; 20:445-454. [PMID: 39216929 DOI: 10.1016/j.hfc.2024.06.010] [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: 09/04/2024]
Abstract
Cardiogenic shock is a multisystem pathology that carries a high mortality rate, and initial pharmacotherapies include the use of vasopressors and inotropes. These agents can increase myocardial oxygen consumption and decrease tissue perfusion that can oftentimes result in a state of refractory cardiogenic shock for which temporary mechanical circulatory support can be considered. Numerous support devices are available, each with its own hemodynamic blueprint. Defining a patient's hemodynamic profile and understanding the phenotype of cardiogenic shock is important in device selection. Careful patient selection incorporating a multidisciplinary team approach should be utilized.
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Affiliation(s)
- David Snipelisky
- Robert and Suzanne Tomsich Department of Cardiology, Section of Heart Failure & Cardiac Transplant Medicine, Cleveland Clinic, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA.
| | - Jerry D Estep
- Robert and Suzanne Tomsich Department of Cardiology, Section of Heart Failure & Cardiac Transplant Medicine, Cleveland Clinic, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA
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2
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Kondo T, Yoshizumi T, Morimoto R, Imaizumi T, Kazama S, Hiraiwa H, Okumura T, Murohara T, Mutsuga M. Predicting survival after Impella implantation in patients with cardiogenic shock: The J-PVAD risk score. Eur J Heart Fail 2024. [PMID: 39300761 DOI: 10.1002/ejhf.3471] [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: 07/08/2024] [Revised: 09/02/2024] [Accepted: 09/04/2024] [Indexed: 09/22/2024] Open
Abstract
AIMS Impella has become a new option for mechanical circulatory support in patients with cardiogenic shock (CS); however, prognostic models for patients after Impella are lacking. We aimed to identify the factors that predict in-hospital mortality in patients with CS requiring Impella and develop a new risk prediction model. METHODS AND RESULTS We utilized the J-PVAD registry, which includes all cases where Impella was implanted in Japan. Two-thirds of the patients in the J-PVAD registry were randomly assigned to the derivation cohort (n = 1701), and the other third was assigned to the validation cohort (n = 850). A backward stepwise logistic regression model was developed to identify factors associated with in-hospital mortality. In the derivation cohort, 956 patients were discharged alive, and 745 patients (43.8%) died during hospitalization. Among 29 candidate variables, 12 were independently associated with in-hospital mortality and were applied as components of the risk model, including age, sex, body mass index, fulminant myocarditis aetiology, cardiac arrest in hospital, baseline veno-arterial extracorporeal membrane oxygenation use, mean arterial pressure, lactate, lactate dehydrogenase, total bilirubin, creatinine, and albumin levels. The comparison of predicted and observed in-hospital mortality according to the 7th quantiles using the J-PVAD risk score showed good calibration. The area under the curve for the J-PVAD risk score was 0.76 (95% confidence interval 0.73-0.78). In the validation cohort, the J-PVAD risk score showed good calibration and discrimination ability. CONCLUSIONS The J-PVAD risk score can be calculated using variables easily obtained in routine clinical practice. It helps the accurate stratification of mortality risk and facilitates clinical decision-making.
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Affiliation(s)
- Toru Kondo
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomo Yoshizumi
- Department of Cardiac surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryota Morimoto
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takahiro Imaizumi
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shingo Kazama
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroaki Hiraiwa
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masato Mutsuga
- Department of Cardiac surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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3
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Erdoğan SB, Bastopcu M, Usca MK, Çakmak AY, Sargın M, Aka S. The Utility of Risk Scores in Postcardiotomy Extracorporeal Membrane Oxygenation. Perfusion 2024; 39:578-584. [PMID: 36705013 DOI: 10.1177/02676591231154741] [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: 01/28/2023]
Abstract
BACKGROUND The use of a venoarterial extracorporeal membrane oxygenation (ECMO) in the postcardiotomy shock setting (PC-ECMO) can be life-saving. Risk stratification for patients under PC-ECMO is currently challenging. The aim of this study was to assess the discriminatory ability of the different available risk scores for mortality in PC-ECMO patients. METHODS Patients aged >18 years undergoing coronary artery bypass, valve surgery, or a combination of these procedures and implanted an ECMO for postcardiotomy shock between January 2017 and June 2022 in a single ELSO registered center were retrospectively included. The STS, Euroscore II, SAVE, modified SAVE, APACHE II, and VIS scores were compared for their discriminatory ability concerning weaning and 30-day survival. RESULTS During the study period, 7342 patients underwent coronary bypass or valve surgery, of whom 109 patients with PC-ECMO were included in the analysis. The Euroscore II and STS scores were not associated significantly with 30-day mortality, whereas the SAVE, the modified SAVE, APACHE II, and VIS scores significantly predicted 30-day mortality. The SAVE and the modified SAVE scores showed moderate discrimination ability with AUCs of 0.672 and 0.695, while the APACHE and VIS scores had a satisfactory discriminatory ability with AUCs of 0.727 and 0.844, respectively. CONCLUSION Currently used risk scores for PC-ECMO patients do not provide satisfactory predictions for weaning and survival. VIS at the 24th hour can be a valuable parameter for risk analysis and prospective studies can investigate novel PC-ECMO risk scoring systems.
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Affiliation(s)
- Sevinç B Erdoğan
- Department of Cardiovascular Surgery, Dr Siyami Ersek Thoracic and Cardiovascular Surgery Research and Training Center, Istanbul, Turkey
| | - Murat Bastopcu
- Department of Cardiovascular Surgery, Dr Siyami Ersek Thoracic and Cardiovascular Surgery Research and Training Center, Istanbul, Turkey
| | - Mehmet Kağan Usca
- Department of Cardiovascular Surgery, Dr Siyami Ersek Thoracic and Cardiovascular Surgery Research and Training Center, Istanbul, Turkey
| | - Arif Yasin Çakmak
- Department of Cardiovascular Surgery, Dr Siyami Ersek Thoracic and Cardiovascular Surgery Research and Training Center, Istanbul, Turkey
| | - Murat Sargın
- Department of Cardiovascular Surgery, Dr Siyami Ersek Thoracic and Cardiovascular Surgery Research and Training Center, Istanbul, Turkey
| | - Serap Aka
- Department of Cardiovascular Surgery, Dr Siyami Ersek Thoracic and Cardiovascular Surgery Research and Training Center, Istanbul, Turkey
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Kalra A, Bachina P, Shou BL, Hwang J, Barshay M, Kulkarni S, Sears I, Eickhoff C, Bermudez CA, Brodie D, Ventetuolo CE, Kim BS, Whitman GJR, Abbasi A, Cho SM. Predicting Acute Brain Injury in Venoarterial Extracorporeal Membrane Oxygenation Patients with Tree-Based Machine Learning: Analysis of the Extracorporeal Life Support Organization Registry. RESEARCH SQUARE 2024:rs.3.rs-3848514. [PMID: 38260374 PMCID: PMC10802703 DOI: 10.21203/rs.3.rs-3848514/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Objective To determine if machine learning (ML) can predict acute brain injury (ABI) and identify modifiable risk factors for ABI in venoarterial extracorporeal membrane oxygenation (VA-ECMO) patients. Design Retrospective cohort study of the Extracorporeal Life Support Organization (ELSO) Registry (2009-2021). Setting International, multicenter registry study of 676 ECMO centers. Patients Adults (≥18 years) supported with VA-ECMO or extracorporeal cardiopulmonary resuscitation (ECPR). Interventions None. Measurements and Main Results Our primary outcome was ABI: central nervous system (CNS) ischemia, intracranial hemorrhage (ICH), brain death, and seizures. We utilized Random Forest, CatBoost, LightGBM and XGBoost ML algorithms (10-fold leave-one-out cross-validation) to predict and identify features most important for ABI. We extracted 65 total features: demographics, pre-ECMO/on-ECMO laboratory values, and pre-ECMO/on-ECMO settings.Of 35,855 VA-ECMO (non-ECPR) patients (median age=57.8 years, 66% male), 7.7% (n=2,769) experienced ABI. In VA-ECMO (non-ECPR), the area under the receiver-operator characteristics curves (AUC-ROC) to predict ABI, CNS ischemia, and ICH was 0.67, 0.67, and 0.62, respectively. The true positive, true negative, false positive, false negative, positive, and negative predictive values were 33%, 88%, 12%, 67%, 18%, and 94%, respectively for ABI. Longer ECMO duration, higher 24h ECMO pump flow, and higher on-ECMO PaO2 were associated with ABI.Of 10,775 ECPR patients (median age=57.1 years, 68% male), 16.5% (n=1,787) experienced ABI. The AUC-ROC for ABI, CNS ischemia, and ICH was 0.72, 0.73, and 0.69, respectively. The true positive, true negative, false positive, false negative, positive, and negative predictive values were 61%, 70%, 30%, 39%, 29% and 90%, respectively, for ABI. Longer ECMO duration, younger age, and higher 24h ECMO pump flow were associated with ABI. Conclusions This is the largest study predicting neurological complications on sufficiently powered international ECMO cohorts. Longer ECMO duration and higher 24h pump flow were associated with ABI in both non-ECPR and ECPR VA-ECMO.
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Affiliation(s)
| | | | | | | | | | | | - Isaac Sears
- Warren Alpert Medical School of Brown University
| | | | | | | | | | - Bo Soo Kim
- Johns Hopkins University School of Medicine
| | | | - Adeel Abbasi
- Warren Alpert Medical School of Brown University
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5
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Snipelisky D, Estep JD. Guide to Temporary Mechanical Support in Cardiogenic Shock: Choosing Wisely. Cardiol Clin 2023; 41:583-592. [PMID: 37743080 DOI: 10.1016/j.ccl.2023.06.004] [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: 09/26/2023]
Abstract
Cardiogenic shock is a multisystem pathology that carries a high mortality rate, and initial pharmacotherapies include the use of vasopressors and inotropes. These agents can increase myocardial oxygen consumption and decrease tissue perfusion that can oftentimes result in a state of refractory cardiogenic shock for which temporary mechanical circulatory support can be considered. Numerous support devices are available, each with its own hemodynamic blueprint. Defining a patient's hemodynamic profile and understanding the phenotype of cardiogenic shock is important in device selection. Careful patient selection incorporating a multidisciplinary team approach should be utilized.
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Affiliation(s)
- David Snipelisky
- Robert and Suzanne Tomsich Department of Cardiology, Section of Heart Failure & Cardiac Transplant Medicine, Cleveland Clinic, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA.
| | - Jerry D Estep
- Robert and Suzanne Tomsich Department of Cardiology, Section of Heart Failure & Cardiac Transplant Medicine, Cleveland Clinic, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA
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6
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Stephens AF, Šeman M, Diehl A, Pilcher D, Barbaro RP, Brodie D, Pellegrino V, Kaye DM, Gregory SD, Hodgson C. ECMO PAL: using deep neural networks for survival prediction in venoarterial extracorporeal membrane oxygenation. Intensive Care Med 2023; 49:1090-1099. [PMID: 37548758 PMCID: PMC10499722 DOI: 10.1007/s00134-023-07157-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 07/01/2023] [Indexed: 08/08/2023]
Abstract
PURPOSE Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a complex and high-risk life support modality used in severe cardiorespiratory failure. ECMO survival scores are used clinically for patient prognostication and outcomes risk adjustment. This study aims to create the first artificial intelligence (AI)-driven ECMO survival score to predict in-hospital mortality based on a large international patient cohort. METHODS A deep neural network, ECMO Predictive Algorithm (ECMO PAL) was trained on a retrospective cohort of 18,167 patients from the international Extracorporeal Life Support Organisation (ELSO) registry (2017-2020), and performance was measured using fivefold cross-validation. External validation was performed on all adult registry patients from 2021 (N = 5015) and compared against existing prognostication scores: SAVE, Modified SAVE, and ECMO ACCEPTS for predicting in-hospital mortality. RESULTS Mean age was 56.8 ± 15.1 years, with 66.7% of patients being male and 50.2% having a pre-ECMO cardiac arrest. Cross-validation demonstrated an inhospital mortality sensitivity and precision of 82.1 ± 0.2% and 77.6 ± 0.2%, respectively. Validation accuracy was only 2.8% lower than training accuracy, reducing from 75.5% to 72.7% [99% confidence interval (CI) 71.1-74.3%]. ECMO PAL accuracy outperformed the ECMO ACCEPTS (54.7%), SAVE (61.1%), and Modified SAVE (62%) scores. CONCLUSIONS ECMO PAL is the first AI-powered ECMO survival score trained and validated on large international patient cohorts. ECMO PAL demonstrated high generalisability across ECMO regions and outperformed existing, widely used scores. Beyond ECMO, this study highlights how large international registry data can be leveraged for AI prognostication for complex critical care therapies.
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Affiliation(s)
- Andrew F Stephens
- Cardio-Respiratory Engineering and Technology Laboratory, Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, Australia.
- Lab 2, Level 2, Victorian Heart Hospital, 631 Blackburn Road, Melbourne, 3800, Australia.
| | - Michael Šeman
- Cardio-Respiratory Engineering and Technology Laboratory, Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Cardiology, Alfred Health, Melbourne, Australia
| | - Arne Diehl
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Australia
| | - David Pilcher
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Australia
| | - Ryan P Barbaro
- Pediatric Critical Care Medicine, and the Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI, USA
| | - Daniel Brodie
- Intensive Care Unit, Columbia University Irving Medical Centre, New York, NY, USA
| | - Vincent Pellegrino
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, Melbourne, Australia
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Shaun D Gregory
- Cardio-Respiratory Engineering and Technology Laboratory, Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, Australia
| | - Carol Hodgson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia
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7
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Koziol KJ, Isath A, Rao S, Gregory V, Ohira S, Van Diepen S, Lorusso R, Krittanawong C. Extracorporeal Membrane Oxygenation (VA-ECMO) in Management of Cardiogenic Shock. J Clin Med 2023; 12:5576. [PMID: 37685643 PMCID: PMC10488419 DOI: 10.3390/jcm12175576] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/13/2023] [Accepted: 08/17/2023] [Indexed: 09/10/2023] Open
Abstract
Cardiogenic shock is a critical condition of low cardiac output resulting in insufficient systemic perfusion and end-organ dysfunction. Though significant advances have been achieved in reperfusion therapy and mechanical circulatory support, cardiogenic shock continues to be a life-threatening condition associated with a high rate of complications and excessively high patient mortality, reported to be between 35% and 50%. Extracorporeal membrane oxygenation can provide full cardiopulmonary support, has been increasingly used in the last two decades, and can be used to restore systemic end-organ hypoperfusion. However, a paucity of randomized controlled trials in combination with high complication and mortality rates suggest the need for more research to better define its efficacy, safety, and optimal patient selection. In this review, we provide an updated review on VA-ECMO, with an emphasis on its application in cardiogenic shock, including indications and contraindications, expected hemodynamic and echocardiographic findings, recommendations for weaning, complications, and outcomes. Furthermore, specific emphasis will be devoted to the two published randomized controlled trials recently presented in this setting.
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Affiliation(s)
- Klaudia J. Koziol
- School of Medicine, New York Medical College and Westchester Medical Center, Valhalla, NY 10595, USA
| | - Ameesh Isath
- Department of Cardiology, Westchester Medical Center, Valhalla, NY 10595, USA
| | - Shiavax Rao
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD 21218, USA
| | - Vasiliki Gregory
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD 21218, USA
| | - Suguru Ohira
- Division of Cardiothoracic Surgery, New York Medical College and Westchester Medical Center, Valhalla, NY 10595, USA
| | - Sean Van Diepen
- Division of Cardiology and Critical Care, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, 6202 AZ Maastricht, The Netherlands
| | - Chayakrit Krittanawong
- Cardiology Division, NYU Langone Health and NYU School of Medicine, New York, NY 10016, USA
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8
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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: 24] [Impact Index Per Article: 24.0] [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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9
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Predictive models in extracorporeal membrane oxygenation (ECMO): a systematic review. Syst Rev 2023; 12:44. [PMID: 36918967 PMCID: PMC10015918 DOI: 10.1186/s13643-023-02211-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 03/02/2023] [Indexed: 03/16/2023] Open
Abstract
PURPOSE Extracorporeal membrane oxygenation (ECMO) has been increasingly used in the last years to provide hemodynamic and respiratory support in critically ill patients. In this scenario, prognostic scores remain essential to choose which patients should initiate ECMO. This systematic review aims to assess the current landscape and inform subsequent efforts in the development of risk prediction tools for ECMO. METHODS PubMed, CINAHL, Embase, MEDLINE and Scopus were consulted. Articles between Jan 2011 and Feb 2022, including adults undergoing ECMO reporting a newly developed and validated predictive model for mortality, were included. Studies based on animal models, systematic reviews, case reports and conference abstracts were excluded. Data extraction aimed to capture study characteristics, risk model characteristics and model performance. The risk of bias was evaluated through the prediction model risk-of-bias assessment tool (PROBAST). The protocol has been registered in Open Science Framework ( https://osf.io/fevw5 ). RESULTS Twenty-six prognostic scores for in-hospital mortality were identified, with a study size ranging from 60 to 4557 patients. The most common candidate variables were age, lactate concentration, creatinine concentration, bilirubin concentration and days in mechanical ventilation prior to ECMO. Five out of 16 venous-arterial (VA)-ECMO scores and 3 out of 9 veno-venous (VV)-ECMO scores had been validated externally. Additionally, one score was developed for both VA and VV populations. No score was judged at low risk of bias. CONCLUSION Most models have not been validated externally and apply after ECMO initiation; thus, some uncertainty whether ECMO should be initiated still remains. It has yet to be determined whether and to what extent a new methodological perspective may enhance the performance of predictive models for ECMO, with the ultimate goal to implement a model that positively influences patient outcomes.
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10
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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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11
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Char S, Fried J, Melehy A, Mehta S, Ning Y, Kurlansky P, Takeda K. Clinical efficacy of direct or indirect left ventricular unloading during venoarterial extracorporeal membrane oxygenation for primary cardiogenic shock. J Thorac Cardiovasc Surg 2023; 165:699-707.e5. [PMID: 34243933 PMCID: PMC8683567 DOI: 10.1016/j.jtcvs.2021.06.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 05/31/2021] [Accepted: 06/04/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Left ventricular (LV) distention is a feared complication in patients receiving venoarterial (VA) extracorporeal membrane oxygenation (ECMO). LV unloading can be achieved indirectly with intra-aortic balloon pump (IABP) or directly with an Impella device (Abiomed, Danvers, Mass). We sought to assess the clinical and hemodynamic effects of IABP and Impella devices on patients supported with VA ECMO. METHODS We conducted a retrospective review of VA ECMO patients at our institution from January 2015 to June 2020. Patients were categorized as either ECMO alone or ECMO with LV unloading. LV unloading was characterized as either ECMO with IABP or ECMO with Impella. We recorded baseline characteristics, survival, complications, and hemodynamic changes associated with device initiation. RESULTS During the study, 143 patients received ECMO alone whereas 140 received ECMO with LV unloading (68 ECMO with IABP, 72 ECMO with Impella). ECMO with Impella patients had a higher incidence of bleeding events compared with ECMO alone or ECMO with IABP (52.8% vs 37.1% vs 17.7%; P < .0001). Compared with ECMO alone, ECMO with IABP patients had better survival at 180 days (log rank P = .005) whereas survival in ECMO with Impella patients was not different (log rank P = .66). In a multivariable Cox hazard analysis, age (hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.00-1.03; P = .015), male sex (HR, 0.54; 95% CI, 0.38-0.80; P = .002), baseline lactate (HR, 1.06; 95% CI, 1.02-1.11; P = .004), baseline creatinine (HR, 1.06; 95% CI, 1.00-1.11; P = .032), need for extracorporeal membrane oxygenation-cardiopulmonary resuscitation (HR, 2.09; 95% CI, 1.40-3.39; P = .001), and presence of pre-ECMO IABP (HR, 0.45; 95% CI, 0.25-0.83; P = .010) were associated with reduced mortality. There was no significant difference in hemodynamic changes in the ECMO with IABP versus ECMO with Impella cohorts. CONCLUSIONS Concomitant support with IABP might help reduce morbidity and improve 180-day survival in patients receiving VA ECMO for cardiogenic shock.
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Affiliation(s)
- Steven Char
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, NY
| | - Justin Fried
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Andrew Melehy
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, NY
| | - Sanket Mehta
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, NY
| | - Yuming Ning
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University Medical Center, New York, NY
| | - Paul Kurlansky
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, NY; Center for Innovation and Outcomes Research, Department of Surgery, Columbia University Medical Center, New York, NY
| | - Koji Takeda
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, NY.
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12
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Pladet LCA, Barten JMM, Vernooij LM, Kraemer CVE, Bunge JJH, Scholten E, Montenij LJ, Kuijpers M, Donker DW, Cremer OL, Meuwese CL. Prognostic models for mortality risk in patients requiring ECMO. Intensive Care Med 2023; 49:131-141. [PMID: 36600027 PMCID: PMC9944134 DOI: 10.1007/s00134-022-06947-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/28/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE To provide an overview and evaluate the performance of mortality prediction models for patients requiring extracorporeal membrane oxygenation (ECMO) support for refractory cardiocirculatory or respiratory failure. METHODS A systematic literature search was undertaken to identify studies developing and/or validating multivariable prediction models for all-cause mortality in adults requiring or receiving veno-arterial (V-A) or veno-venous (V-V) ECMO. Estimates of model performance (observed versus expected (O:E) ratio and c-statistic) were summarized using random effects models and sources of heterogeneity were explored by means of meta-regression. Risk of bias was assessed using the Prediction model Risk Of BiAS Tool (PROBAST). RESULTS Among 4905 articles screened, 96 studies described a total of 58 models and 225 external validations. Out of all 58 models which were specifically developed for ECMO patients, 14 (24%) were ever externally validated. Discriminatory ability of frequently validated models developed for ECMO patients (i.e., SAVE and RESP score) was moderate on average (pooled c-statistics between 0.66 and 0.70), and comparable to general intensive care population-based models (pooled c-statistics varying between 0.66 and 0.69 for the Simplified Acute Physiology Score II (SAPS II), Acute Physiology and Chronic Health Evaluation II (APACHE II) score and Sequential Organ Failure Assessment (SOFA) score). Nearly all models tended to underestimate mortality with a pooled O:E > 1. There was a wide variability in reported performance measures of external validations, reflecting a large between-study heterogeneity. Only 1 of the 58 models met the generally accepted Prediction model Risk Of BiAS Tool criteria of good quality. Importantly, all predicted outcomes were conditional on the fact that ECMO support had already been initiated, thereby reducing their applicability for patient selection in clinical practice. CONCLUSIONS A large number of mortality prediction models have been developed for ECMO patients, yet only a minority has been externally validated. Furthermore, we observed only moderate predictive performance, large heterogeneity between-study populations and model performance, and poor methodological quality overall. Most importantly, current models are unsuitable to provide decision support for selecting individuals in whom initiation of ECMO would be most beneficial, as all models were developed in ECMO patients only and the decision to start ECMO had, therefore, already been made.
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Affiliation(s)
- Lara C A Pladet
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Jaimie M M Barten
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lisette M Vernooij
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Carlos V Elzo Kraemer
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen J H Bunge
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Intensive Care, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Erik Scholten
- Department of Intensive Care Medicine, Sint Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Leon J Montenij
- Department of Intensive Care Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Marijn Kuijpers
- Department of Intensive Care Medicine, Isala Hospital Zwolle, Zwolle, The Netherlands
| | - Dirk W Donker
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.,Cardiovascular and Respiratory Physiology, TechMed Center, University of Twente, Enschede, the Netherlands
| | - Olaf L Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christiaan L Meuwese
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Intensive Care, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
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Hemodynamic Effect of Pulsatile on Blood Flow Distribution with VA ECMO: A Numerical Study. Bioengineering (Basel) 2022; 9:bioengineering9100487. [PMID: 36290455 PMCID: PMC9598990 DOI: 10.3390/bioengineering9100487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/20/2022] [Accepted: 09/09/2022] [Indexed: 11/20/2022] Open
Abstract
The pulsatile properties of arterial flow and pressure have been thought to be important. Nevertheless, a gap still exists in the hemodynamic effect of pulsatile flow in improving blood flow distribution of veno-arterial extracorporeal membrane oxygenation (VA ECMO) supported by the circulatory system. The finite-element models, consisting of the aorta, VA ECMO, and intra-aortic balloon pump (IABP) are proposed for fluid-structure interaction calculation of the mechanical response. Group A is cardiogenic shock with 1.5 L/min of cardiac output. Group B is cardiogenic shock with VA ECMO. Group C is added to IABP based on Group B. The sum of the blood flow of cardiac output and VA ECMO remains constant at 4.5 L/min in Group B and Group C. With the recovery of the left ventricular, the flow of VA ECMO declines, and the effective blood of IABP increases. IABP plays the function of balancing blood flow between left arteria femoralis and right arteria femoralis compared with VA ECMO only. The difference of the equivalent energy pressure (dEEP) is crossed at 2.0 L/min to 1.5 L/min of VA ECMO. PPI’ (the revised pulse pressure index) with IABP is twice as much as without IABP. The intersection with two opposing blood generates the region of the aortic arch for the VA ECMO (Group B). In contrast to the VA ECMO, the blood intersection appears from the descending aorta to the renal artery with VA ECMO and IABP. The maximum time-averaged wall shear stress (TAWSS) of the renal artery is a significant difference with or not IABP (VA ECMO: 2.02 vs. 1.98 vs. 2.37 vs. 2.61 vs. 2.86 Pa; VA ECMO and IABP: 8.02 vs. 6.99 vs. 6.62 vs. 6.30 vs. 5.83 Pa). In conclusion, with the recovery of the left ventricle, the flow of VA ECMO declines and the effective blood of IABP increases. The difference between the equivalent energy pressure (EEP) and the surplus hemodynamic energy (SHE) indicates the loss of pulsation from the left ventricular to VA ECMO. 2.0 L/min to 1.5 L/min of VA ECMO showing a similar hemodynamic energy loss with the weak influence of IABP.
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Bruyneel A, Larcin L, Tack J, Van Den Bulke J, Pirson M. Association between nursing cost and patient outcomes in intensive care units: A retrospective cohort study of Belgian hospitals. Intensive Crit Care Nurs 2022; 73:103296. [PMID: 35871959 DOI: 10.1016/j.iccn.2022.103296] [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: 03/29/2022] [Revised: 06/07/2022] [Accepted: 06/28/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Hospitals with better nursing resources report more favourable patient outcomes with almost no difference in cost as compared to those with worse nursing resources. The aim of this study was to assess the association between nursing cost per intensive care unit bed and patient outcomes (mortality, readmission, and length of stay). METHODOLOGY This was a retrospective cohort study using data collected from the intensive care units of 17 Belgian hospitals from January 01 to December 31, 2018. Hospitals were dichotomized using median annual nursing cost per bed. A total of 18,235 intensive care unit stays were included in the study with 5,664 stays in the low-cost nursing group and 12,571 in the high-cost nursing group. RESULTS The rate of high length of stay outliers in the intensive care unit was significantly lower in the high-cost nursing group (9.2% vs 14.4%) compared to the low-cost nursing group. Intensive care unit readmission was not significantly different in the two groups. Mortality was lower in the high-cost nursing group for intensive care unit (9.9% vs 11.3%) and hospital (13.1% vs 14.6%) mortality. The nursing cost per intensive care bed was different in the two groups, with a median [IQR] cost of 159,387€ [140,307-166,690] for the low-cost nursing group and 214,032€ [198,094-230,058] for the high-cost group. In multivariate analysis, intensive care unit mortality (OR = 0.80, 95% CI: 0.69-0.92, p < 0.0001), in-hospital mortality (OR = 0.82, 95% CI: 0.72-0.93, p < 0.0001), and high length of stay outliers (OR = 0.48, 95% CI: 0.42-0.55, p < 0.0001) were lower in the high-cost nursing group. However, there was no significant effect on intensive care readmission between the two groups (OR = 1.24, 95% CI: 0.97-1.51, p > 0.05). CONCLUSIONS This study found that higher-cost nursing per bed was associated with significantly lower intensive care unit and in-hospital mortality rates, as well as fewer high length of stay outliers, but had no significant effect on readmission to the intensive care unit. .
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Affiliation(s)
- Arnaud Bruyneel
- Health Economics, Hospital Management and Nursing Research Dept, School of Public Health, Université Libre de Bruxelles, Belgium; CHU Tivoli, La Louvière, Belgium. https://twitter.com/@ArnaudBruyneel
| | - Lionel Larcin
- Research Centre for Epidemiology, Biostatistics and Clinical Research, School of Public Health, Université Libre de Bruxelles, Belgium
| | - Jérôme Tack
- Health Economics, Hospital Management and Nursing Research Dept, School of Public Health, Université Libre de Bruxelles, Belgium; Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Belgium
| | - Julie Van Den Bulke
- Health Economics, Hospital Management and Nursing Research Dept, School of Public Health, Université Libre de Bruxelles, Belgium
| | - Magali Pirson
- Health Economics, Hospital Management and Nursing Research Dept, School of Public Health, Université Libre de Bruxelles, Belgium
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15
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Tehrani BN, Damluji AA, Batchelor WB. Acute Myocardial Infarction and Cardiogenic Shock Interventional Approach to Management in the Cardiac Catheterization Laboratories. Curr Cardiol Rev 2022; 18:e251121198293. [PMID: 34823461 PMCID: PMC9413732 DOI: 10.2174/1573403x17666211125090929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 07/07/2021] [Accepted: 07/28/2021] [Indexed: 11/22/2022] Open
Abstract
Despite advances in early reperfusion and a technologic renaissance in the space of Mechanical Circulatory Support (MCS), Cardiogenic Shock (CS) remains the leading cause of in-hospital mortality following Acute Myocardial Infarction (AMI). Given the challenges inherent to conducting adequately powered randomized controlled trials in this time-sensitive, hemodynamically complex, and highly lethal syndrome, treatment recommendations have been derived from AMI patients without shock. In this review, we aimed to (1) examine the pathophysiology and the new classification system for CS; (2) provide a comprehensive, evidence-based review for best practices for interventional management of AMI-CS in the cardiac catheterization laboratory; and (3) highlight the concept of how frailty and geriatric syndromes can be integrated into the decision process and where medical futility lies in the spectrum of AMI-CS care. Management strategies in the cardiac catheterization laboratory for CS include optimal vascular access, periprocedural antithrombotic therapy, culprit lesion versus multi-vessel revascularization, selective utilization of hemodynamic MCS tailored to individual shock hemometabolic profiles, and management of cardiac arrest. Efforts to advance clinical evidence for patients with CS should be concentrated on (1) the coordination of multi-center registries; (2) development of pragmatic clinical trials designed to evaluate innovative therapies; (3) establishment of multidisciplinary care models that will inform quality care and improve clinical outcomes.
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Affiliation(s)
- Behnam N Tehrani
- Interventional Cardiology, INOVA Heart and Vascular Institute, Virginia, VA 22042, United States
| | - Abdulla A Damluji
- Interventional Cardiology, INOVA Heart and Vascular Institute, Virginia, VA 22042, United States.,Department of Medicine, Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Wayne B Batchelor
- Interventional Cardiology, INOVA Heart and Vascular Institute, Virginia, VA 22042, United States
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16
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Plazak ME, Grazioli A, Powell EK, Menne AR, Bathula AL, Madathil RJ, Krause EM, Deatrick KB, Mazzeffi MA. Precannulation International Normalized Ratio is Independently Associated With Mortality in Veno-Arterial Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2021; 36:1092-1099. [PMID: 34330572 DOI: 10.1053/j.jvca.2021.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/03/2021] [Accepted: 07/05/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To explore whether precannulation international normalized ratio (INR) is associated with in-hospital mortality in venoarterial extracorporeal membrane oxygenation (VA-ECMO) patients. DESIGN A retrospective, observational cohort study. SETTING A quaternary care academic medical center. PARTICIPANTS Patients with cardiogenic shock on VA-ECMO for >24 hours. INTERVENTIONS None, observational study. MEASUREMENTS AND MAIN RESULTS A total of 188 patients who were on VA-ECMO were included over three years. Patients were stratified into three groups based on their pre-ECMO INR: INR <1.5, INR 1.5 to 1.8, and INR >1.8. For all patients, demographics, comorbidities, and ECMO details were recorded. The study's primary outcome was in-hospital mortality and secondary outcomes included major bleeding, minor bleeding, allogeneic transfusion, ischemic stroke, intracranial hemorrhage, acute renal failure, acute liver failure, gastrointestinal bleeding, intensive care unit and hospital lengths of stay. A multivariate logistic regression was used to determine whether precannulation INR was associated independently with in-hospital mortality. In-hospital mortality differed significantly by INR group (51.6% INR >1.8 v 42.3% INR 1.5-1.8 v 24.3% INR <1.5; p = 0.004). In a multivariate logistic regression model, precannulation INR >1.8 was associated independently with an increased odds of mortality (odds ratio, 2.48; 95% confidence interval, 1.05-6.04) after controlling for sex, Survival after VA- ECMO score, and ECMO indication. An INR within 1.5 to 1.8 did not confer an increased mortality risk. CONCLUSIONS An INR >1.8 before VA-ECMO cannulation is associated independently with in-hospital mortality. Precannulation INR should be considered by clinicians so that ECMO resources can be better allocated and risks of organ failure and intracranial hemorrhage can be better understood.
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Affiliation(s)
- Michael E Plazak
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD
| | - Alison Grazioli
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Elizabeth K Powell
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Ashley R Menne
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Allison L Bathula
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD
| | - Ronson J Madathil
- Department of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Eric M Krause
- Department of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Kristopher B Deatrick
- Department of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD.
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17
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Gao S, Liu G, Yan S, Lou S, Gao G, Hu Q, Zhang Q, Qi J, Yan W, Wang Q, Wang J, Ji B. Outcomes from adult veno-arterial extracorporeal membrane oxygenation in a cardiovascular disease center from 2009 to 2019. Perfusion 2021; 37:235-241. [PMID: 33588661 DOI: 10.1177/0267659121993365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) is an imperative short-term cardiopulmonary support device now. We aimed to provide a single-center experience of veno-arterial (V-A) ECMO management and identify the risk factors of in-hospital mortality. METHODS We conducted a retrospective review of adult patients who received V-A ECMO between 2009 and 2019 in a cardiovascular disease center. The risk factor analysis of in-hospital mortality was conducted. RESULTS The study reviewed 236 patients, with an overall survival rate of 68.2%. The survivors' blood lactate concentration is significantly lower than non-survivors [7.4 (7.8) vs 11.1 (9.7), p = 0.002]. Patients who received heart transplantation were with higher in-hospital survival rate. Survivors developed less hepatic dysfunction, acute kidney injury and myocardial damage [23 (14.3%) vs 19 (25.3%), p = 0.039; 81 (50.3%) vs 51 (68%), p = 0.011; 24 (14.9%) vs 22 (29.3%), p = 0.009, respectively], with higher rate of continuous renal replacement therapy (CRRT) [56 (34.8%) vs 53 (70.7%), p < 0.001]. Fewer survivors' 24 hours and total chest drainage was over 1000 mL, and the rate of re-exploration as well as red blood cell and platelet transfusion were lower in survivors. In multivariate analysis, female, pre-ECMO blood lactate concentration, hyperlipidemia, CRRT, and 24 hours chest drainage ⩾ 1000 mL were risk factors of early mortality. CONCLUSIONS By providing a general description of V-A ECMO practice at a single-center in China. Post-heart transplant graft failure was associated with numerically, the greatest survival in our practice. Furthermore, female sex, pre-ECMO blood lactate concentration, hyperlipidemia, CRRT, and high blood loss in chest drains are predictors of mortality in patients who undergo V-A ECMO.
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Affiliation(s)
- Sizhe Gao
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Gang Liu
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Shujie Yan
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Song Lou
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Guodong Gao
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Qiang Hu
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Qiaoni Zhang
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Jiachen Qi
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Weidong Yan
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Qian Wang
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Jian Wang
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
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18
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Kim D, Na SJ, Cho YH, Chung CR, Jeon K, Suh GY, Park TK, Lee JM, Song YB, Hahn JY, Choi JH, Choi SH, Gwon HC, Ahn JH, Carriere KC, Yang JH. Predictors of Survival to Discharge After Successful Weaning From Venoarterial Extracorporeal Membrane Oxygenation in Patients With Cardiogenic Shock. Circ J 2020; 84:2205-2211. [PMID: 33041291 DOI: 10.1253/circj.cj-20-0550] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND This study identified predictors of hospital mortality after successful weaning of patients with cardiogenic shock off venoarterial (VA) extracorporeal membrane oxygenation (ECMO) support. METHODS AND RESULTS Adult patients who received peripheral VA ECMO from January 2012 to April 2017 were reviewed retrospectively. After excluding patients who died on ECMO support, predictors for survival to discharge were investigated in patients who were successfully weaned off ECMO. Of 191 patients successfully weaned off ECMO, 143 (74.9%) survived to discharge. The prevalence of a history of stroke and coronary artery disease, as well as ECMO-related complications, including newly developed stroke and sepsis, was a higher in patients who did not survive to discharge than in those who did. On the day of ECMO weaning, Sequential Organ Failure Assessment score and serum lactate were higher in patients who did not survive to discharge, although there was no significant difference in blood pressure and the use of vasoactive drugs between the 2 groups. On multivariable analysis, stroke and sepsis during ECMO support, a lower Glasgow Coma Scale and acute kidney injury requiring continuous renal replacement therapy after weaning were significant predictors for in-hospital mortality. CONCLUSIONS Complications that occurred during ECMO and the presence of extracardiac organ dysfunction after weaning were associated with in-hospital mortality in patients with cardiogenic shock who were successfully weaned off ECMO.
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Affiliation(s)
- Donghoon Kim
- Department of Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Soo Jin Na
- Department of Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Gee Young Suh
- Department of Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Taek Kyu Park
- Division of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Joo Myung Lee
- Division of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Young Bin Song
- Division of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Joo-Yong Hahn
- Division of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Jin-Ho Choi
- Division of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Seung-Hyuk Choi
- Division of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Joong Hyun Ahn
- Biostatistics and Clinical Epidemiology Center, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Keumhee C Carriere
- Biostatistics and Clinical Epidemiology Center, Samsung Medical Center, Sungkyunkwan University School of Medicine
- Department of Mathematical and Statistical Sciences, University of Alberta
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
- Division of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
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19
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Mihama T, Bahatyrevich N, Cavarocchi N, Hirose H. Outcomes of end-organ function and survival with veno-arterial extracorporeal membrane oxygenation. Perfusion 2020; 36:808-813. [PMID: 33198559 DOI: 10.1177/0267659120969288] [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: 11/16/2022]
Abstract
INTRODUCTION Extracorporeal Membrane Oxygenation (ECMO) is a temporary therapy option for refractory cardiac or respiratory failure. Preliminary study suggests that ECMO aids in the recovery of end-organ function by maintaining systemic perfusion. METHODS A retrospective IRB approved database research and chart review was performed on patients initiated on veno-arterial (VA-) ECMO between September 2010 and April 2019. End-organ injury markers were compared between the pre-ECMO period, defined as markers recorded before ECMO initiation, and the pre-decannulation period, defined as markers prior to ECMO decannulation. Data was expressed with mean ± standard deviation, or median [quartile 1, quartile 3] and compared between Pre-ECMO and per-decannulation period. RESULTS Among the 159 VA-ECMO patients, 100 patients (63%) survived ECMO with mean ECMO duration 10 ± 7 days. Within the survival group, 78 patients (49%) weaned to recovery, and 22 patients (14%) weaned off to durable implantable devices. Compared to the pre-ECMO period, the pre-decannulation period significantly improved in pH (7.23 ± 0.19 vs. 7.40 ± 0.09; p < 0.001) and lactate (5.5 [2.3, 9.0] vs. 1.6 [0.9, 2.3]; p < 0.001), and serum creatinine (1.4 [1.1, 2.1] vs. 1.1 [0.8, 1.7]; p < 0.001). Significant changes were noted in ventilation parameters as well, such as FiO2 (100 [100, 100] vs. 50 [50, 50]; p < 0.001), PaO2 (88 [62, 135], 126 [87, 162]; p < 0.001) and PEEP (8.0 [5.0, 12.0] vs. 5.0 [5.0, 8.0]; p < 0.001). CONCLUSION Maintaining perfusion with VA-ECMO utilization on indicated patients demonstrated improvements in end-organ functions. Survival rates of VA-ECMO patients were also optimistic.
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Affiliation(s)
- Toru Mihama
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | | | - Hitoshi Hirose
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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20
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Yellow Means Caution: Correlations Between Liver Injury and Mortality with the Use of VA-ECMO. ASAIO J 2020; 65:812-818. [PMID: 30312207 DOI: 10.1097/mat.0000000000000895] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Abnormalities in markers of liver injury after venoarterial extracorporeal membrane oxygenation (VA-ECMO) initiation are of unclear distribution and clinical significance. This study included all consecutive adult patients from a single institution who underwent VA-ECMO cannulation between May 2012 and September 2016 and had liver function panels drawn during their admission (n = 223). Data points include: age, sex, body mass index, diagnosis, duration of ECMO cannulation, duration of hospitalization, pre-ECMO cardiac arrest, central nervous system (CNS) injury, the presence of chronic kidney disease or acute renal failure, renal replacement therapy utilization, lactate levels, duration of pre-ECMO intubation, admission and peak bilirubin/aspartate aminotransferase (AST)/alanine aminotransferase (ALT)/alkaline phosphatase (ALP) levels, and time to peak bilirubin/AST/ALT/ALP in relation to cannulation. Multivariate Poisson regression analyses were performed to determine associations with mortality. In-hospital mortality was 66%. Serum bilirubin elevation appeared to significantly correlate continuously with mortality. Other markers of liver injury were not significant in final multivariate models. As a univariate factor, no patient survived with a total serum bilirubin greater than 30 mg/dl, and specificity for 90% mortality was crossed at 11 mg/dl. Mortality was also significantly associated with the presence of CNS injury and elevation of lactic acid levels. Postcannulation liver injury is significantly associated with increased mortality and total serum bilirubin appears to be a biomarker of considerable clinical significance.
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21
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Ahmed T, Chahal D, Madathil RJ, Kaczorowski D, Gupta A. Percutaneous Coronary Intervention (PCI) Strategies under Hemodynamic Support for Cardiogenic Shock: A Single-Center Experience with Two Patients. Case Rep Cardiol 2020; 2020:6260239. [PMID: 32550026 PMCID: PMC7275241 DOI: 10.1155/2020/6260239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/28/2020] [Accepted: 03/28/2020] [Indexed: 11/27/2022] Open
Abstract
We describe two cases of profound cardiogenic shock complicating acute myocardial infarction (CSAMI) requiring mechanical circulatory support (MCS) with venoarterial extracorporeal membrane oxygenation (VA-ECMO) allowing complex, high-risk, and staged percutaneous interventions with successful decannulation but with unfortunate outcomes.
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Affiliation(s)
- Talha Ahmed
- University of Maryland Medical Center Midtown Campus, USA
| | - Diljon Chahal
- University of Maryland Medical Center, School of Medicine, USA
| | | | | | - Anuj Gupta
- University of Maryland Medical Center, School of Medicine, USA
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22
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Predicting Survival After Extracorporeal Membrane Oxygenation by Using Machine Learning. Ann Thorac Surg 2020; 110:1193-1200. [PMID: 32454016 DOI: 10.1016/j.athoracsur.2020.03.128] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/26/2020] [Accepted: 03/31/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) undoubtedly saves many lives, but it is associated with a high degree of patient morbidity, mortality, and resource use. This study aimed to develop a machine learning algorithm to augment clinical decision making related to VA-ECMO. METHODS Patients supported by VA-ECMO at a single institution from May 2011 to October 2018 were retrospectively reviewed. Laboratory values from only the initial 48 hours of VA-ECMO support were used. Data were split into 70% for training, 15% for validation, and 15% withheld for testing. Feature importance was estimated, and dimensionality reduction techniques were used. A deep neural network was trained to predict survival to discharge, and the final model was assessed using the independent testing cohort. Model performance was compared with that of the SAVE (Survival After Veno-arterial ECMO) score by using a receiver operator characteristic curve. RESULTS Of the 282 eligible adult patients who were undergoing VA-ECMO, 117 (41%) survived to discharge. A total of 1.96 million laboratory values were extracted from the electronic medical record, from which 270 different summary variables were derived for each patient. The most important variables in predicting the primary outcome included lactate, age, total bilirubin, and creatinine. For the testing cohort, the final model achieved 82% overall accuracy and a greater area under the curve than the SAVE score (0.92 vs 0.65; P = .01) in predicting survival to discharge. CONCLUSIONS This proof of concept study demonstrates the potential for machine learning models to augment clinical decision making for patients undergoing VA-ECMO. Further development with multi-institutional data is warranted.
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Magoon R, Shri I, Kohli JK, Kashav R. SOFA Scoring in VA-ECMO: Plenty to Ponder! J Cardiothorac Vasc Anesth 2020; 34:2844-2845. [PMID: 32418833 DOI: 10.1053/j.jvca.2020.02.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 02/26/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Rohan Magoon
- Department of Cardiac Anesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), New Delhi, India; Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, India
| | - Iti Shri
- Department of Cardiac Anesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), New Delhi, India; Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, India
| | - Jasvinder Kaur Kohli
- Department of Cardiac Anesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), New Delhi, India; Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, India
| | - Ramesh Kashav
- Department of Cardiac Anesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), New Delhi, India; Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, India
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Ayers B, Wood K, Melvin A, Prasad S, Gosev I. MELD-XI is predictive of mortality in venoarterial extracorporeal membrane oxygenation. J Card Surg 2020; 35:1275-1282. [PMID: 32340073 DOI: 10.1111/jocs.14578] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a life-saving method of supporting critically ill patients. However, it is expensive and associated with high morbidity and mortality, making early predictive outcome modeling extremely valuable. The model for end-stage liver disease-excluding international normalized ratio (MELD-XI) scoring system has been shown to have prognostic value in other critically ill patient populations. MATERIALS AND METHODS A single-center retrospective review was performed for all adult patients managed on VA-ECMO from May 2011 to January 2018 (n = 247). Patients were included in the study if MELD-XI scores could be calculated during the first 48 hours on ECMO (n = 187). Receiver operating characteristic curve analysis was performed for MELD-XI in regard to in-hospital mortality. RESULTS Of the 187 patients, 74 (40%) patients had MELD-XI less than 14 (low-risk) and 113 (60%) had a MELD-XI of 14 or greater (high-risk). The cohorts did not differ significantly in terms of patient characteristics or indication for ECMO. The high-risk MELD-XI group had significantly greater mortality during index hospitalization compared to the low-risk group (74% vs 39%; P < .0001). Quartile stratification demonstrated progressively worse prognosis associated with higher MELD-XI scores; the fourth quartile showed a ninefold increased risk of mortality compared to the first quartile (P < .001). The AUC for predicting index hospitalization mortality was 0.69 (95% CI, 0.62-0.77) with a Youden index (J) of 0.36 and optimized cutoff of 12.98. CONCLUSIONS These findings suggest that the MELD-XI scoring system can be applied to the VA-ECMO patient population early in their course of ECMO as a prognostic tool to aid in complex clinical decision making.
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Affiliation(s)
- Brian Ayers
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York
| | - Katherine Wood
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York
| | - Amber Melvin
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York
| | - Sunil Prasad
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York
| | - Igor Gosev
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York
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What Is the Optimal Blood Pressure on Veno-Arterial Extracorporeal Membrane Oxygenation? Impact of Mean Arterial Pressure on Survival. ASAIO J 2020; 65:336-341. [PMID: 29762229 DOI: 10.1097/mat.0000000000000824] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Blood pressure management is crucial for patients on veno-arterial extracorporeal membrane oxygenation (VA ECMO). Lower pressure can lead to end-organ malperfusion, whereas higher pressure may compete with ECMO flow and cardiac output. The impact of mean arterial pressure (MAP) on outcomes of patients on VA ECMO was evaluated. Patients who were supported on VA ECMO from September 2010 to March 2016 were retrospectively analyzed for average MAP throughout their course on ECMO, excluding the first and last day. Survival and complications observed during ECMO were investigated by classifying patients into groups based on their average MAP. A total of 116 patients were identified. Average MAP was significantly higher in patients who survived to discharge (82 ± 5.6 vs. 78 ± 5.5 mm Hg, p = 0.0003). There was a positive association between MAP and survival. Survival was best with MAP higher than 90 mm Hg (71%) and worst with MAP less than 70 mm Hg, where no patient survived. MAP was an independent predictor of survival to discharge by multivariate analysis (odds ratio 1.17, p = 0.013). Vasopressors were used more frequently in patients with lower pressure (coefficient -3.14, p = 0.005) without affecting survival (odds ratio 0.95, p = 0.95). Although the MAP did not affect the probability of strokes or bleeding complications, patients with a higher MAP had a lower incidence of kidney injury (p = 0.007). In conclusion, survival of patients on VA ECMO was significantly greater with a higher MAP, without being affected by prolonged vasopressor use.
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Worku B, Gaudino M, Avgerinos D, Ramasubbu K, Gambardella I, Gulkarov I, Khin S. A comparison of existing risk prediction models in patients undergoing venoarterial extracorporeal membrane oxygenation. Heart Lung 2020; 49:599-604. [PMID: 32234259 DOI: 10.1016/j.hrtlng.2020.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/01/2020] [Accepted: 03/05/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Patients undergoing consideration for venoarterial extracorporeal membrane oxygenation (VA-ECMO) require an immediate risk profile assessment in the setting of incomplete information. A number of survival prediction models for critically ill patients and patients undergoing elective cardiac surgery or institution of VA-ECMO support have been designed. We assess the ability of these models to predict outcomes in a cohort of patients undergoing institution of VA-ECMO for cardiogenic shock or cardiac arrest. METHODS Fifty-one patients undergoing institution of VA-ECMO support were retrospectively analyzed. APACHE II, SOFA, SAPS II, Encourage, SAVE, and ACEF scores were calculated. Their ability to predict outcomes were assessed. RESULTS Indications for ECMO support included postcardiotomy shock (25%), ischemic etiologies (39%), and other etiologies (36%). Pre-ECMO arrest occurred in 73% and 41% of patients underwent cannulation during arrest. Survival to discharge was 39%. Three survival prediction model scores were significantly higher in nonsurvivors to discharge than surivors; the Encourage score (25.4 vs 20; p = .04), the APACHE II score (23.6 vs 19.2; p = .05), and the ACEF score (3.1 vs 1.8; p = .03). In ROC analysis, the ACEF score demonstrated the greatest predictive ability with an AUC of 0.7. CONCLUSIONS A variety of survival prediction model scores designed for critically ill ICU and VA-ECMO patients demonstrated modest discriminatory ability in the current cohort of patients. The ACEF score, while not designed to predict survival in critically ill patients, demonstrated the best discriminatory ability. Furthermore, it is the simplest to calculate, an advantage in the emergent setting.
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Affiliation(s)
- Berhane Worku
- Department of Cardiothoracic Surgery, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, 11215, USA; Department of Cardiothoracic Surgery, New York Presbyterian Weil Cornell Medical Center, New York, NY, 10021, USA.
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, New York Presbyterian Weil Cornell Medical Center, New York, NY, 10021, USA
| | - Dimitrios Avgerinos
- Department of Cardiothoracic Surgery, New York Presbyterian Weil Cornell Medical Center, New York, NY, 10021, USA
| | - Kumudha Ramasubbu
- Department of Medicine, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, 11215, USA
| | - Ivancarmine Gambardella
- Department of Cardiothoracic Surgery, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, 11215, USA; Department of Cardiothoracic Surgery, New York Presbyterian Weil Cornell Medical Center, New York, NY, 10021, USA
| | - Iosif Gulkarov
- Department of Cardiothoracic Surgery, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, 11215, USA; Department of Cardiothoracic Surgery, New York Presbyterian Weil Cornell Medical Center, New York, NY, 10021, USA
| | - Sandi Khin
- Department of Medicine, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, 11215, USA
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Nagy Á, Holndonner-Kirst E, Eke C, Kertai MD, Fazekas L, Benke K, Pólos M, Szabolcs Z, Hartyánszky I, Gál J, Merkely B, Székely A. Model for end-stage liver disease scores in veno-arterial extracorporeal membrane oxygenation. Int J Artif Organs 2020; 43:684-691. [PMID: 32098569 DOI: 10.1177/0391398820906538] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Veno-arterial extracorporeal membrane oxygenation is a valuable therapeutic approach in patients with severe heart failure due to different etiologies. Current prognosis with veno-arterial extracorporeal membrane oxygenation is unsatisfactory, and the risk stratification is still challenging. Therefore, we aimed to evaluate the predictive value of different baseline model for end-stage liver disease scores for survival in patients with veno-arterial extracorporeal membrane oxygenation. METHODS We conducted an observational, retrospective study of consecutive veno-arterial extracorporeal membrane oxygenation-treated patients between January 2012 and August 2018. The four types of model for end-stage liver disease scores-model for end-stage liver disease, international normalized ratio-excluded model for end-stage liver disease, modified model for end-stage liver disease, and model for end-stage liver disease with sodium-were calculated preoperatively. Veno-arterial extracorporeal membrane oxygenation was used based on the four clinical indications: primer graft failure after heart transplantation, weaning failure from cardiopulmonary bypass, acute myocardial infarction with refractory cardiogenic shock, and bridge to transplantation or bridge to candidacy. The primary endpoint of the study was overall mortality. The secondary endpoint was in-hospital mortality. We performed univariable and multivariable Cox regression analyses. RESULTS Data from 135 patients were analyzed. The median follow-up was 952 days (interquartile range = 417-1555 days). In-hospital mortality was 62.2%, and overall mortality was 71.1%. The multivariable Cox regression analysis is adjusted for indication, and the survival after veno-arterial extracorporeal membrane oxygenation score showed that the following scores were associated with overall mortality: model for end-stage liver disease (hazard ratio = 1.04; 95% confidence interval = 1.01-1.07; p = 0.016), modified model for end-stage liver disease (hazard ratio = 1.04; 95% confidence interval = 1.01-1.06; p = 0.006), and model for end-stage liver disease with sodium (hazard ratio = 1.05; 95% confidence interval = 1.02-1.08; p = 0.001). CONCLUSION Model for end-stage liver disease, modified model for end-stage liver disease, and model for end-stage liver disease with sodium scores could be useful in the risk stratification of veno-arterial extracorporeal membrane oxygenation treatment in varying clinical indications.
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Affiliation(s)
- Ádám Nagy
- Károly Rácz School of PhD Studies, Semmelweis University, Budapest, Hungary
| | - Enikő Holndonner-Kirst
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Csaba Eke
- Károly Rácz School of PhD Studies, Semmelweis University, Budapest, Hungary
| | - Miklós D Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Levente Fazekas
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Kálmán Benke
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Miklós Pólos
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zoltán Szabolcs
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | - János Gál
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Andrea Székely
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
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Kwak J, Majewski MB, Jellish WS. Extracorporeal Membrane Oxygenation: The New Jack-of-All-Trades? J Cardiothorac Vasc Anesth 2020; 34:192-207. [DOI: 10.1053/j.jvca.2019.09.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 09/03/2019] [Accepted: 09/20/2019] [Indexed: 11/11/2022]
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Akin S, Caliskan K, Soliman O, Muslem R, Guven G, van Thiel RJ, Struijs A, Gommers D, Zijlstra F, Bakker J, Dos Reis Miranda D. A novel mortality risk score predicting intensive care mortality in cardiogenic shock patients treated with veno-arterial extracorporeal membrane oxygenation. J Crit Care 2019; 55:35-41. [PMID: 31689611 DOI: 10.1016/j.jcrc.2019.09.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/16/2019] [Accepted: 09/16/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Mortality after veno-arterial extracorporeal membrane oxygenation (VA-ECMO) implantation remains a major problem in patients with cardiogenic shock. Our objective was to assess the utility of the SOFA score in combination with markers of right ventricular (RV) dysfunction in predicting mortality in the ICU. MATERIALS AND METHODS Data were retrospectively obtained from all adult patients (n=103) who were treated with VA-ECMO between November 2004 and January 2016. The primary outcome of this study was ICU mortality after VA-ECMO implantation. Using the clinical, demographic and echocardiographic data, we developed a novel mortality risk score, the SOFA-RV score, which combine RV-function to the SOFA score at the time of VA-ECMO implantation. RESULTS Out of 103 patients, 37 (36%) died in the ICU. The median duration of VA-ECMO support was 7 days [IQR 4-11], mean age 49 ± 16 years, and 54% were male. SOFA-RV score has an AUC of 0.70, and was significantly better than SOFA alone (AUC of 0.57) in predicting ICU mortality. In addition, SAVE and MELD scores were not able to predict ICU mortality. CONCLUSION Adding RV-function to the existing SOFA score improves significantly the prediction of ICU mortality in patients on VA-ECMO. Dedicated evaluation of RV function in patients with VA-ECMO is therefore recommended.
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Affiliation(s)
- Sakir Akin
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Intensive Care, Haga Teaching Hospital, The Hague, the Netherlands.
| | - Kadir Caliskan
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Osama Soliman
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Rahatullah Muslem
- Department of Cardiothoracic surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Goksel Guven
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Robert J van Thiel
- Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Ard Struijs
- Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Diederik Gommers
- Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Felix Zijlstra
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Jan Bakker
- Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Division of Pulmonary, Allergy, and Critical Care, Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, USA; Department of Pulmonary and Critical Care, Langone Medical Center, New York University, New York, USA; Department of Intensive Care, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Dinis Dos Reis Miranda
- Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Biancari F, Dalén M, Fiore A, Ruggieri VG, Saeed D, Jónsson K, Gatti G, Zipfel S, Perrotti A, Bounader K, Loforte A, Lechiancole A, Pol M, Spadaccio C, Pettinari M, Ragnarsson S, Alkhamees K, Mariscalco G, Welp H. Multicenter study on postcardiotomy venoarterial extracorporeal membrane oxygenation. J Thorac Cardiovasc Surg 2019; 159:1844-1854.e6. [PMID: 31358340 DOI: 10.1016/j.jtcvs.2019.06.039] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 05/28/2019] [Accepted: 06/17/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aim of this study was to identify the risk factors associated with early mortality after postcardiotomy venoarterial extracorporeal membrane oxygenation. METHODS This is an analysis of the postcardiotomy extracorporeal membrane oxygenation registry, a retrospective multicenter cohort study including 781 patients aged more than 18 years who required venoarterial extracorporeal membrane oxygenation for cardiopulmonary failure after cardiac surgery from 2010 to 2018 at 19 cardiac surgery centers. RESULTS After a mean venoarterial extracorporeal membrane oxygenation therapy of 6.9 ± 6.2 days, hospital and 1-year mortality were 64.4% and 67.2%, respectively. Hospital mortality after venoarterial extracorporeal membrane oxygenation therapy for more than 7 days was 60.5% (P = .105). Centers that had treated more than 50 patients with postcardiotomy venoarterial extracorporeal membrane oxygenation had a significantly lower hospital mortality than lower-volume centers (60.7% vs 70.7%, adjusted odds ratio, 0.58; 95% confidence interval, 0.41-0.82). The postcardiotomy extracorporeal membrane oxygenation score was derived by assigning a weighted integer to each independent pre-venoarterial extracorporeal membrane oxygenation predictors of hospital mortality as follows: female gender (1 point), advanced age (60-69 years, 2 points; ≥70 years, 4 points), prior cardiac surgery (1 point), arterial lactate 6.0 mmol/L or greater before venoarterial extracorporeal membrane oxygenation (2 points), aortic arch surgery (4 points), and preoperative stroke/unconsciousness (5 points). The hospital mortality rates according to the postcardiotomy extracorporeal membrane oxygenation score was 0 point, 45.6%; 1 point, 40.5%; 2 points, 51.1%; 3 points, 57.8%; 4 points, 70.7%; 5 points, 68.3%; 6 points, 77.5%; and 7 points or more, 89.7% (P < .0001). CONCLUSIONS Age, female gender, prior cardiac surgery, preoperative acute neurologic events, aortic arch surgery, and increased arterial lactate were associated with increased risk of early mortality after postcardiotomy venoarterial extracorporeal membrane oxygenation. Center experience with postcardiotomy venoarterial extracorporeal membrane oxygenation may contribute to improved results.
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Affiliation(s)
- Fausto Biancari
- Heart Center, Turku University Hospital and Department of Surgery, University of Turku, Turku, Finland; Department of Surgery, University of Oulu, Oulu, Finland.
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, Department of Cardiac Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Antonio Fiore
- Department of Cardiothoracic Surgery, Henri Mondor University Hospital, AP-HP, Paris-Est University, Créteil, France
| | - Vito G Ruggieri
- Division of Cardiothoracic and Vascular Surgery, Robert Debré University Hospital, Reims, France
| | - Diyar Saeed
- Cardiovascular Surgery, University Hospital of Duesseldorf, Dusseldorf, Germany
| | - Kristján Jónsson
- Department of Cardiac Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Giuseppe Gatti
- Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy
| | | | - Andrea Perrotti
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Antonio Loforte
- Department of Cardiothoracic, Transplantation and Vascular Surgery, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | | | - Marek Pol
- Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Matteo Pettinari
- Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | | | | | - Giovanni Mariscalco
- Department of Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester, Leicester, United Kingdom
| | - Henryk Welp
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
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Lee HS, Kim HS, Lee SH, Lee SA, Hwang JJ, Park JB, Kim YH, Moon HJ, Lee WS. Clinical implications of the initial SAPS II in veno-arterial extracorporeal oxygenation. J Thorac Dis 2019; 11:68-83. [PMID: 30863575 DOI: 10.21037/jtd.2018.12.20] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Prediction of survival and weaning probability in VA ECMO (veno-arterial extracorporeal membrane oxygenation) patients could be of great benefit for real-time decision making on VA ECMO initiation in critical ill patients. We investigated whether the SAPS II score would be a real-time determinant for VA ECMO initiation and could be a predictor of survival and weaning probability in patients on VA ECMO. Methods Between January 1, 2010 and December 31, 2014, VA ECMO was carried out on 135 adult patients suffering from primary cardiogenic shock. To avoid selection bias, we excluded respiratory failure patients treated with VV or other types of ECMO. Successful VA ECMO weaning was defined as weaning, followed by stable survival for more than 48 hours. Survival after VA ECMO was defined as successful weaning and treatment of the underlying medical condition, followed by discharge without any further events. Results A total of 135 patients consisted of 41 women and 94 men, with a mean age of 59.4±16.5 years. Fifty-three patients had successful weaning, and 35 survived and were discharged uneventfully. Compared to the non-survivors, the survivors showed a lower SAPS II (67.77±20.79 vs. 90.29±13.31, P<0.001), a lower SOFA score (12.63±3.49 vs. 15.33±2.28, P<0.001), a lower predicted death rate (71.12±30.51 vs. 94.00±9.36, P<0.001), a higher initial ipH (7.14±0.22 vs. 6.98±0.15, P<0.001), and a lower initial lactate level (7.09±4.93 vs. 12.11±4.84, P<0.001). The average duration of hospital stay in the successful vs. failed weaning groups was 33.43±27.41 vs. 6.35±8.71 days, and the average duration of ICU stay in the successful vs. failed weaning groups was 20.60±16.88 vs. 5.39±5.95 days. By multivariate logistic regression analysis of initial parameters for VA ECMO assistance, the simplified acute physiology score II (SAPS II) (OR =1.1019, P=0.0389), ipH (OR =0.0010, P=0.0452), and hospital stay (OR =0.8140, P=0.001) had an association with in-hospital mortality on VA ECMO. The initial SAPS II score [area under the curve (AUC) =0.821] demonstrated significantly superior prediction of VA ECMO mortality than age (AUC =0.697), SOFA score (AUC =0.701), ipH (AUC =0.551), and the other parameters. By multivariable CoX regression analysis of survival, only the SAPS II score proved to have statistical significance (hazard ratio, 1.0423; 95% CI, 1.0083-1.0775; P=0.01). Conclusions Although the precise predictive scoring systems for VA ECMO still remains one of the most difficult challenges to ECMO physicians, the SAPS II score could provide valuable information on prognosis to patient himself, family members and caretakers, and might help physicians increase the survival rate and might avoid a waste of healthcare resources.
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Affiliation(s)
- Hee Sung Lee
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Hallym University, Hallym University Dongtan Medical Center, Gyeonggi-do, Republic of Korea
| | - Hyoung Soo Kim
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Hallym University, Hallym University Medical Center. Gyeonggi-do, Republic of Korea
| | - Sun Hee Lee
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Hallym University, Hallym University Medical Center. Gyeonggi-do, Republic of Korea
| | - Song Am Lee
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Seoul Hospital, Seoul, Republic of Korea
| | - Jae Joon Hwang
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Seoul Hospital, Seoul, Republic of Korea
| | - Jae Bum Park
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Seoul Hospital, Seoul, Republic of Korea
| | - Yo Han Kim
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Chungju Hospital, Chungju-si, Chungbuk, Republic of Korea
| | - Hyoung Ju Moon
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Chungju Hospital, Chungju-si, Chungbuk, Republic of Korea
| | - Woo Surng Lee
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Chungju Hospital, Chungju-si, Chungbuk, Republic of Korea
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He P, Zhang S, Hu B, Wu W. Retrospective study on the effects of the prognosis of patients treated with extracorporeal membrane oxygenation combined with continuous renal replacement therapy. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:455. [PMID: 30603643 DOI: 10.21037/atm.2018.11.12] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Patients undergoing extracorporeal membrane oxygenation (ECMO) treatment often have severe fluid overload and electrolyte imbalances and may even suffer acute kidney injury (AKI). It is often necessary to use continuous renal replacement therapy (CRRT). In this study, we aimed to retrospectively analyze the prognosis of patients treated with ECMO combined with CRRT and to find the independent factors that affect the survival rate. Methods There were 32 patients who were treated with ECMO combined with CRRT in our hospital from January 2007 to December 2017 who were analyzed. All of the patients were divided into a survival group and death group. The clinical indicators and biochemical indexes of the two groups were observed, and their differences were compared. Multivariate logistic regression analysis was carried out to determine the independent risk factors. Results The fluid balance at ECMO day 3, SOFA score and lactate at CRRT initiation, sequential organ failure assessment (SOFA) score at ECMO weaning, CRRT duration, ECMO to CRRT interval, mechanical ventilation (MV) duration, length of ICU, and overall hospital length of stay were statistically significant (P<0.05). The clinical biochemical indexes at CRRT initiation and ECMO weaning [serum creatinine, pH, white blood cell (WBC), hemoglobin (Hb), bilirubin]; patient's age, gender and BMI; and the fluid balance at ECMO days 1 and 7 were not statistically significance (P>0.05). The fluid balance at ECMO day 3 and lactate at CRRT initiation by multivariable logistic regression analysis were independent risk factors affecting patient prognosis. Conclusions The fluid balance at ECMO day 3 and lactate at CRRT initiation are the prognosis independent risk factors for ECMO + CRRT patients.
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Affiliation(s)
- Ping He
- Cardiothoracic Surgery Department, Southwest Hospital, The Third Military Medical University, Chongqing 400038, China
| | - Shixin Zhang
- Cardiothoracic Surgery Department, Southwest Hospital, The Third Military Medical University, Chongqing 400038, China
| | - Bingyang Hu
- Department of Clinical Medicine, North Sichuan Medical College, Nanchong 637000, China
| | - Wei Wu
- Cardiothoracic Surgery Department, Southwest Hospital, The Third Military Medical University, Chongqing 400038, China
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Fux T, Holm M, Corbascio M, Lund LH, van der Linden J. VA‐ECMO Support in Nonsurgical Patients With Refractory Cardiogenic Shock: Pre‐Implant Outcome Predictors. Artif Organs 2018; 43:132-141. [DOI: 10.1111/aor.13331] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/26/2018] [Accepted: 06/22/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Thomas Fux
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
- Division of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
| | - Manne Holm
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
| | - Matthias Corbascio
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
- Heart and Vascular Theme Karolinska University Hospital Stockholm Sweden
| | - Lars H. Lund
- Department of Medicine Karolinska Institutet Stockholm Sweden
- Heart and Vascular Theme Karolinska University Hospital Stockholm Sweden
| | - Jan van der Linden
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
- Division of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
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Wang L, Wang H, Hou X. Clinical Outcomes of Adult Patients Who Receive Extracorporeal Membrane Oxygenation for Postcardiotomy Cardiogenic Shock: A Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth 2018; 32:2087-2093. [DOI: 10.1053/j.jvca.2018.03.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Indexed: 12/12/2022]
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35
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Rao P, Khalpey Z, Smith R, Burkhoff D, Kociol RD. Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock and Cardiac Arrest. Circ Heart Fail 2018; 11:e004905. [DOI: 10.1161/circheartfailure.118.004905] [Citation(s) in RCA: 184] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Prashant Rao
- Sarver Heart Center, University of Arizona, Tucson (P.R.)
| | - Zain Khalpey
- Division of Cardiothoracic Surgery, Department of Surgery, University of Arizona, Tucson (Z.K.)
| | - Richard Smith
- Artificial Heart and Perfusion Programs, Banner University Medical Center, Tucson, AZ (R.S.)
| | - Daniel Burkhoff
- Cardiovascular Research Foundation, Columbia University Medical Center, New York, NY (D.B.)
| | - Robb D. Kociol
- Advanced Heart Failure and Mechanical Circulatory Support Program, University of Massachusetts Memorial Medical Center, Worcester (R.D.K.)
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Biancari F, Perrotti A, Dalén M, Guerrieri M, Fiore A, Reichart D, Dell’Aquila AM, Gatti G, Ala-Kokko T, Kinnunen EM, Tauriainen T, Chocron S, Airaksinen JK, Ruggieri VG, Brascia D. Meta-Analysis of the Outcome After Postcardiotomy Venoarterial Extracorporeal Membrane Oxygenation in Adult Patients. J Cardiothorac Vasc Anesth 2018; 32:1175-1182. [DOI: 10.1053/j.jvca.2017.08.048] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Indexed: 02/02/2023]
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Chen M, Evans A, Gutsche J. Post-cardiotomy Shock Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2018; 32:2094-2095. [PMID: 30049522 DOI: 10.1053/j.jvca.2018.05.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Martin Chen
- Department of Anesthesia and Institute of Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Adam Evans
- Departments of Cardiothoracic Surgery and Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA
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Lactate and lactate clearance as valuable tool to evaluate ECMO therapy in cardiogenic shock. J Crit Care 2017; 42:35-41. [DOI: 10.1016/j.jcrc.2017.06.022] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Revised: 06/20/2017] [Accepted: 06/22/2017] [Indexed: 01/10/2023]
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39
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Fux T, Holm M, Corbascio M, van der Linden J, Lund LH. Pre-Implant Outcome Predictors in Patients With Refractory Cardiogenic Shock Supported With VA-ECMO. J Am Coll Cardiol 2017; 70:2094-2096. [DOI: 10.1016/j.jacc.2017.08.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/11/2017] [Accepted: 08/13/2017] [Indexed: 10/18/2022]
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40
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Factors associated with mortality risk in critical care patients treated with veno-arterial extracorporeal membrane oxygenation. Heart Lung 2017; 46:137-142. [PMID: 28318620 DOI: 10.1016/j.hrtlng.2017.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 01/13/2017] [Accepted: 02/09/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To identify factors associated with mortality in patients treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and to validate the discrimination of the risk assessment tools to predict mortality. BACKGROUND VA-ECMO is a rescue therapy for patients with life-threatening cardiac failure, but mortality remains high. METHODS In this retrospective study, we reviewed the medical records of adult patients who underwent VA-ECMO in an intensive care unit of a university hospital, between 2009 and 2013. RESULTS VA-ECMO was performed in 89 patients, with a median duration of 116 h. The survival rate until hospital discharge was 27%. The pre-ECMO simplified acute physiology score (SAPS) II and diabetes mellitus were significant predictors of hospital mortality. The optimal prognostic SAPS II score was 81 overall, 80 in patients with diabetes, and 84 in those without diabetes. CONCLUSIONS Our findings indicate that high pre-ECMO SAPS II score and diabetes are risk factors for mortality in patients who undergo VA-ECMO.
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Delmas C, Conil JM, Sztajnic S, Georges B, Biendel C, Dambrin C, Galinier M, Minville V, Fourcade O, Silva S, Marcheix B. Early Prediction of 3-month Survival of Patients in Refractory Cardiogenic Shock and Cardiac Arrest on Extracorporeal Life Support. Indian J Crit Care Med 2017; 21:138-145. [PMID: 28400684 PMCID: PMC5363102 DOI: 10.4103/ijccm.ijccm_32_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background: Extracorporeal life support (ECLS) holds the promise of significant improvement of the survival of patient in refractory cardiogenic shock (CS) or cardiac arrest (CA). Nevertheless, it remains to be shown to which extent these highly invasive supportive techniques could improve long-term patient's outcome. Methods: The outcomes of 82 adult ECLS patients at our institution between January 2012 and December 2013 were retrospectively analyzed. Results: Patients were essentially men (64.7%) and are 54 years old. Preexisting ischemic (53.7%) and dilated cardiomyopathy (14.6%) were frequent. ECLS indications were shared equally between CA and CS. ECLS-specific adverse effects as hemorrhage (30%) and infection (50%) were frequent. ECLS was effective for 43 patients (54%) with recovery for 35 (43%), 5 (6%) heart transplant, and 3 (4%) left ventricular assist device support. Mortality rate at 30 days was 59.8%, but long-term and 3-month survival rates were similar of 31.7%. Initial plasma lactate levels >5.3 mmol/L and glomerular filtration rate <43 ml/min/1.73 m2 were significantly associated with 3-month mortality (risk ratio [RR] 2.58 [1.21–5.48]; P = 0.014; RR 2.10 [1.1–4]; P = 0.024, respectively). Long-term follow-up had shown patients paucisymptomatic (64% New York Heart Association 1–2) and autonomic (activities of daily living [ADL] score 6 ± 1.5). Conclusion: In case of refractory CA or CS, lactates and renal function at ECLS initiation could serve as outcome predictor for risk stratification and ECLS indication.
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Affiliation(s)
- Clément Delmas
- Intensive Care Unit, Department of Anesthesia and Critical Care, University Hospital of Toulouse, Toulouse, France; Department of Cardiology, University Hospital of Rangueil, Toulouse, France
| | - Jean-Marie Conil
- Intensive Care Unit, Department of Anesthesia and Critical Care, University Hospital of Toulouse, Toulouse, France
| | - Simon Sztajnic
- Intensive Care Unit, Department of Anesthesia and Critical Care, University Hospital of Toulouse, Toulouse, France
| | - Bernard Georges
- Intensive Care Unit, Department of Anesthesia and Critical Care, University Hospital of Toulouse, Toulouse, France
| | - Caroline Biendel
- Department of Cardiology, University Hospital of Rangueil, Toulouse, France
| | - Camille Dambrin
- Department of Cardiovascular Surgery, University Hospital of Rangueil, Toulouse, France
| | - Michel Galinier
- Department of Cardiology, University Hospital of Rangueil, Toulouse, France
| | - Vincent Minville
- Intensive Care Unit, Department of Anesthesia and Critical Care, University Hospital of Toulouse, Toulouse, France
| | - Olivier Fourcade
- Intensive Care Unit, Department of Anesthesia and Critical Care, University Hospital of Toulouse, Toulouse, France
| | - Stein Silva
- Intensive Care Unit, Department of Anesthesia and Critical Care, University Hospital of Toulouse, Toulouse, France
| | - Bertrand Marcheix
- Department of Cardiovascular Surgery, University Hospital of Rangueil, Toulouse, France
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Chen WC, Huang KY, Yao CW, Wu CF, Liang SJ, Li CH, Tu CY, Chen HJ. The modified SAVE score: predicting survival using urgent veno-arterial extracorporeal membrane oxygenation within 24 hours of arrival at the emergency department. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:336. [PMID: 27769308 PMCID: PMC5075192 DOI: 10.1186/s13054-016-1520-1] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 09/30/2016] [Indexed: 01/21/2023]
Abstract
Background Although many risk models have been tested in patients who undergo extracorporeal membrane oxygenation, few have been assessed for patients who received veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support in the emergency department (ED). This study aimed to successfully predict outcomes of patients with cardiac or noncardiac failure who received VA-ECMO in the ED within 24 hours of arrival at the ED. Method This retrospective, observational cohort study included 154 patients, who were classified as cardiac (n = 127) and noncardiac (n = 27) patients and received VA-ECMO within 24 hours after arrival at the China Medical University Hospital ED in Taiwan between January 2009 and September 2014. We recorded mechanical ventilation settings, arterial blood gases, laboratory parameters including plasma lactate level, requirement of catecholamines, and risk scores at time of ECMO initiation. ECMO and mechanical ventilation support duration, length of stay in the hospital, and 90-day mortality data were also examined. Results The overall mortality rate was 64.9 %. We used “survival after veno-arterial ECMO (SAVE)” scores to assess survival prediction in survival and nonsurvival groups, which was statistically different (–3.2 vs. –8.3, p <0.001). According to multivariate Cox proportional regression of survival, lactate (hazard ratio [HR] = 1.01, 95 % confidence interval [CI], 1.01–1.01, p <0.001) and SAVE score (HR = 0.92, [95 % CI, 0.88–0.96], p = 0.001) were independent predictors of outcome. Excellent discrimination (area under curve (AUC) = 0.843) was observed when lactate and SAVE score were combined, which we referred to as “the modified SAVE score.” Conclusions Modified SAVE scores improved outcome prediction for patients who underwent urgent VA-ECMO in the ED.
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Affiliation(s)
- Wei-Cheng Chen
- Division of Pulmonary and Critical Care, Department of Internal Medicine, China Medical University Hospital, No. 2, Yude Road, North District, Taichung City, 40402, Taiwan
| | - Kuo-Yang Huang
- Division of Chest Medicine, Department of Internal Medicine, Yuanlin Christian Hospital, Changhua, Taiwan
| | - Chih-Wei Yao
- Division of Chest Medicine, Department of Internal Medicine, Everan Hospital, Taichung, Taiwan
| | - Cing-Feng Wu
- Division of Cardiovascular Surgery, Department of Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Shinn-Jye Liang
- Division of Pulmonary and Critical Care, Department of Internal Medicine, China Medical University Hospital, No. 2, Yude Road, North District, Taichung City, 40402, Taiwan
| | - Chia-Hsiang Li
- Division of Pulmonary and Critical Care, Department of Internal Medicine, China Medical University Hospital, No. 2, Yude Road, North District, Taichung City, 40402, Taiwan
| | - Chih-Yeh Tu
- Division of Pulmonary and Critical Care, Department of Internal Medicine, China Medical University Hospital, No. 2, Yude Road, North District, Taichung City, 40402, Taiwan
| | - Hung-Jen Chen
- Division of Pulmonary and Critical Care, Department of Internal Medicine, China Medical University Hospital, No. 2, Yude Road, North District, Taichung City, 40402, Taiwan. .,Department of Respiratory Therapy, China Medical University, Taichung, Taiwan.
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Zalawadiya S, Fudim M, Bhat G, Cotts W, Lindenfeld J. Extracorporeal membrane oxygenation support and post-heart transplant outcomes among United States adults. J Heart Lung Transplant 2016; 36:77-81. [PMID: 27866925 DOI: 10.1016/j.healun.2016.10.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 09/20/2016] [Accepted: 10/12/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Patients supported with extracorporeal membrane oxygenation (ECMO) are given priority listing status for heart transplant (HT). Data on post-HT outcomes for adults with ECMO support at the time of HT are limited. METHODS We analyzed data from the United Network for Organ Registry (UNOS) registry for 157 ECMO-supported adults (age ≥ 18 years) undergoing HT after January 1, 2000. Data at the time of HT were examined for their association with post-transplant mortality using multivariable Cox proportional hazard analyses. RESULTS Patients (69.4% males; mean age, 46.0 ± 15.6 years; 15.9% African Americans) were monitored for median of 0.55 years (interquartile range, 0.04-4.5). Seventy patients (44.6%) died during follow-up (survival at 1 year was 57.8%), of which 43 (61.4%) died within 30 days post-HT. For patients surviving the first 30 days after transplant, long-term survival was acceptable (82.3% at 1 year and 76.2% at 5 years). Prevalence of immediate post-HT complications, such as stroke and need for dialysis, were 10.1% and 28.1%, respectively. Post-HT survival did not differ between those who received an allograft before and after January 1, 2009 (univariate hazard ratio, 0.84; 95% confidence interval, 0.51-1.38; p = 0.48). Among the predictors identified for 30-day and long-term mortality were recipient history of renal insufficiency (RI; defined as estimated glomerular filtration rate < 45 ml/min/1.73 m2 or dialysis) and mechanical ventilation (MV; interaction p < 0.05); those with both MV and RI had significantly poorer post-transplant survival (29.4% and 12.5% for 30-day and 1-year survival, respectively) compared with those without (78.7% and 71.4% for 30-day and 1-year survival, respectively). CONCLUSIONS Post-HT mortality did not change for ECMO-supported adults in the contemporary era, and those with RI and MV had significantly poorer post-transplant survival. A critical review of priority listing status for ECMO-supported patients is warranted for optimal allocation and outcomes of cardiac allografts.
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Affiliation(s)
- Sandip Zalawadiya
- Division of Advanced Heart Failure, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Marat Fudim
- Division of Cardiology, Department of Internal Medicine, Duke University Hospital, Durham, North Carolina
| | - Geetha Bhat
- Division of Advanced Heart Failure, Advocate Christ Medical Center, Chicago, Illinois
| | - William Cotts
- Division of Advanced Heart Failure, Advocate Christ Medical Center, Chicago, Illinois
| | - JoAnn Lindenfeld
- Division of Advanced Heart Failure, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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Choi MJ, Ha SO, Kim HS, Park S, Han SJ, Lee SH. The Simplified Acute Physiology Score II as a Predictor of Mortality in Patients Who Underwent Extracorporeal Membrane Oxygenation for Septic Shock. Ann Thorac Surg 2016; 103:1246-1253. [PMID: 27743640 DOI: 10.1016/j.athoracsur.2016.07.069] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 07/25/2016] [Accepted: 07/28/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND The use of extracorporeal membrane oxygenation (ECMO) for patients with septic shock is controversial. The outcomes are favorable in children but heterogeneous in adults. The present study aimed to analyze the outcomes of adult patients who underwent ECMO for septic shock, and to determine the factors associated with prognosis. METHODS We respectively reviewed the medical records of patients who underwent ECMO for septic shock between January 2007 and December 2013. Patients were divided into survivor and nonsurvivor groups based on survival to hospital discharge. The patient characteristics before and during ECMO were compared between the groups. Independent risk factors for mortality were evaluated using multivariate logistic regression, receiver-operating characteristic curves, and Kaplan-Meier analysis. RESULTS Twenty-eight patients were treated with venoarterial (n = 21), venovenous (n = 4), or venoarteriovenous (n = 3) mode ECMO. The overall survival rate to hospital discharge was 35.7%. The Simplified Acute Physiology Score II (SAPS II) and prealbumin were predictors of survival to hospital discharge. The optimal cutoff value for SAPS II was 80 (area under the curve 0.80, p = 0.010). Kaplan-Meier survival curves showed that the cumulative survival rate at hospital discharge and at 54-month follow-up was significantly higher among patients with SAPS II of 80 or less compared with patients with SAPS II greater than 80 (66.7% versus 12.5% and 58.3% versus 12.5%, respectively; p = 0.001). CONCLUSIONS It is still difficult to conclude whether ECMO should be recommended as therapy for adult patients with septic shock. However, a SAPS II score of 80 or less may be an indicator of favorable outcomes with the use of ECMO.
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Affiliation(s)
- Myung Jin Choi
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Chuncheon-si, Korea
| | - Sang Ook Ha
- Department of Emergency Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang-si, Gyeonggi-do, Korea
| | - Hyoung Soo Kim
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang-si, Gyeonggi-do, Korea.
| | - Sunghoon Park
- Division of Pulmonary, Allergy, and Critical Care Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang-si, Gyeonggi-do, Korea
| | - Sang Jin Han
- Division of Cardiology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang-si, Gyeonggi-do, Korea
| | - Sun Hee Lee
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang-si, Gyeonggi-do, Korea
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Extracorporeal Membrane Oxygenation for Pediatric Respiratory Failure: Risk Factors Associated With Center Volume and Mortality. Pediatr Crit Care Med 2016; 17:779-88. [PMID: 27187531 DOI: 10.1097/pcc.0000000000000775] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Recent analyses show higher mortality at low-volume centers providing extracorporeal membrane oxygenation. We sought to identify factors associated with center volume and mortality to explain survival differences and identify areas for improvement. DESIGN Retrospective cohort study. SETTING Patients admitted to children's hospitals in the Pediatric Health Information System database and supported with extracorporeal membrane oxygenation for respiratory failure from 2003 to 2014. PATIENTS A total of 5,303 patients aged 0-18 years old met inclusion criteria: 3,349 neonates and 1,954 children. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Low center volume was defined as less than 20, medium 20-49, and large greater than or equal to 50 cases per year. Center volume was also assessed as a continuous integer. Among neonates, clinical factors including intraventricular hemorrhage (relative risk, 1.4; 95% CI, 1.24-1.56) and acute renal failure (relative risk, 1.38; 95% CI, 1.20-1.60) were more common at low-volume compared to larger centers and were associated with in-hospital death. After adjustment for differences in demographic factors and primary pulmonary conditions, mild prematurity, acute renal failure, intraventricular hemorrhage, and receipt of dialysis remained independently associated with mortality, as did center volume measured as a continuous number. Among children, the risk of acute renal failure was almost 20% greater (relative risk, 1.18; 95% CI, 1.02-1.38) in small compared to large centers, but dialysis and bronchoscopy were used significantly less but were associated with mortality. After adjustment for differences in demographic factors and primary pulmonary conditions, acute renal failure, acute liver necrosis, acute pancreatitis, and receipt of bronchoscopy remained independently associated with mortality. Center volume measurement was not associated with mortality given these factors. CONCLUSIONS Among neonates, investigation for intraventricular hemorrhage prior to extracorporeal membrane oxygenation and preservation of renal function are important factors for improvement. Earlier initiation of extracorporeal membrane oxygenation and careful attention to preservation of organ function are important to improve survival for children.
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Gibbons of the world, dream on. J Thorac Cardiovasc Surg 2015; 151:13-4. [PMID: 26434703 DOI: 10.1016/j.jtcvs.2015.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 09/02/2015] [Indexed: 11/23/2022]
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47
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Haft JW. Cardiac extracorporeal membrane oxygenation: how to predict the unpredictable. J Surg Res 2015; 199:294-5. [PMID: 26049287 DOI: 10.1016/j.jss.2015.04.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 04/13/2015] [Accepted: 04/21/2015] [Indexed: 01/19/2023]
Affiliation(s)
- Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
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