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Davies MG, Hart JP. Extracorporal Membrane Oxygenation in Massive Pulmonary Embolism. Ann Vasc Surg 2024; 105:287-306. [PMID: 38588954 DOI: 10.1016/j.avsg.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/09/2024] [Accepted: 02/10/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Massive pulmonary embolism (MPE) carries significant 30-day mortality risk, and a change in societal guidelines has promoted the increasing use of extracorporeal membrane oxygenation (ECMO) in the immediate management of MPE-associated cardiovascular shock. This narrative review examines the current status of ECMO in MPE. METHODS A literature review was performed from 1982 to 2022 searching for the terms "Pulmonary embolism" and "ECMO," and the search was refined by examining those publications that covered MPE. RESULTS In the patient with MPE, veno-arterial ECMO is now recommended as a bridge to interventional therapy. It can reliably decrease right ventricular overload, improve RV function, and allow hemodynamic stability and restoration of tissue oxygenation. The use of ECMO in MPE has been associated with lower mortality in registry reviews, but there has been no significant difference in outcomes between patients treated with and without ECMO in meta-analyses. Applying ECMO is also associated with substantial multisystem morbidity due to systemic inflammatory response, bleeding with coagulopathy, hemorrhagic stroke, renal dysfunction, and acute limb ischemia, which must be factored into the outcomes. CONCLUSIONS The application of ECMO in MPE should be combined with an aggressive interventional pulmonary interventional program and should strictly adhere to the current selection criteria.
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Affiliation(s)
- Mark G Davies
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX; Department of Vascular and Endovascular Surgery, Ascension Health, Waco, TX.
| | - Joseph P Hart
- Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, WI
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2
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Zhang A, Kurlansky P, Ning Y, Wang A, Kaku Y, Fried J, Takeda K. Outcomes following successful decannulation from extracorporeal life support for cardiogenic shock. J Thorac Cardiovasc Surg 2024; 167:1033-1046.e8. [PMID: 36180251 DOI: 10.1016/j.jtcvs.2022.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 07/09/2022] [Accepted: 08/02/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Although extracorporeal life support (ECLS) has increasingly been used for the treatment of patients with cardiogenic shock (CS), the outcomes of those successfully weaned from support remain poorly defined. METHODS Of 510 venoarterial ECLS CS patients at our institution between January 2015 and December 2020, 249 were decannulated and survived for 30 days or until discharge (ie, successfully weaned). Factors associated with survival to discharge were assessed and 1-year survival was described. RESULTS Of 510 eligible CS ECLS patients, 249 (48.8%) were successfully decannulated, 227 (44.5%) died during/following ECLS, and 34 (6.7%) were bridged to heart transplantation or a ventricular assist device. Patients with a primary graft dysfunction etiology of CS had a greater chance of successful decannulation (odds ratio [OR], 3.088; 95% CI, 1.1-8.671; P = .0323), whereas patients with ECLS during cardiopulmonary resuscitation had a reduced chance of successful decannulation (OR, 0.354; 95% CI, 0.17-0.735; P = .0054). Of successfully decannulated patients, 218 (87.6%) survived to hospital discharge and 31 (12.4%) died in the hospital. Acute myocardial infarction etiology (OR, 4.751; 95% CI, 1.623-13.902; P = .0044), preexisting chronic kidney disease (OR, 3.422; 95% CI, 1.374-8.52; P = .0082), and initiation of continuous renal replacement therapies (OR, 3.188; 95% CI, 1.291-7.871; P = .012) were significantly associated with in-hospital mortality despite successful decannulation. One-year survival in successfully decannulated patients surviving to hospital discharge was 95.0% and comparable to 1-year survival in patients who received a heart transplant or ventricular assist device. CONCLUSIONS Successful decannulation can be achieved in a significant proportion of patients treated with ECLS for CS but does not guarantee survival to hospital discharge. However, 1-year survival of hospital survivors remains high and is comparable to patients bridged to transplant or a ventricular assist device.
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Affiliation(s)
- Ashley Zhang
- Division of Cardiothoracic and Vascular Surgery, 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; Department of Surgery, Center for Innovation and Outcomes Research, Columbia University Medical Center, New York, NY
| | - Yuming Ning
- Department of Surgery, Center for Innovation and Outcomes Research, Columbia University Medical Center, New York, NY
| | - Amy Wang
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, NY
| | - Yuji Kaku
- 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
| | - Koji Takeda
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, NY.
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Hunt M, Bermudez CA. Commentary: Debate or consensus on the path that leads to successful extracorporeal membrane oxygenation decannulation? J Thorac Cardiovasc Surg 2024; 167:1047-1048. [PMID: 36210208 DOI: 10.1016/j.jtcvs.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 09/10/2022] [Indexed: 10/14/2022]
Affiliation(s)
- Mallory Hunt
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pa
| | - Christian A Bermudez
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pa.
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Dardik G, Ning Y, Kurlansky P, Almodovar Cruz G, Vinogradsky A, Fried J, Topkara VK, Takeda K. Long-term outcomes of patients bridged to recovery with venoarterial extracorporeal life support. Perfusion 2023:2676591231206524. [PMID: 37861303 DOI: 10.1177/02676591231206524] [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: 10/21/2023]
Abstract
OBJECTIVE Our study examines the long-term outcomes of patients discharged from the hospital without heart replacement therapy (HRT) after recovery from cardiogenic shock using venoarterial extracorporeal life support (VA-ECLS). METHODS We retrospectively reviewed 615 cardiogenic shock patients who recovered from VA-ECLS at our institution between January 2015 and July 2021. Of those, 166 patients (27.0%) who recovered from VA-ECLS without HRT were included in this study. Baseline characteristics, discharge labs, vitals, electrocardiograms and echocardiograms were assessed. Patients were contacted to determine vital status. The primary outcome was post-discharge mortality. RESULTS Of 166 patients, 158 patients (95.2%) had post-discharge follow-up, with a median time of follow-up of 2 years (IQR: [1 year, 4 years]). At discharge, the median ejection fraction (EF) was 52.5% (IQR: [32.5, 57.5]). At discharge, 92 patients (56%) were prescribed β-blockers, 28 (17%) were prescribed an ACE inhibitor, ARB or ARNI, and 50 (30%) were prescribed loop diuretics. Kaplan-Meier analysis showed a 1-year survival rate of 85.6% (95% CI: [80.1%, 91.2%]) and a 5-year survival rate of 60.6% (95% CI: [49.9%, 71.3%]). A Cox regression model demonstrated that a history of congestive heart failure (CHF) was strongly predictive of increased mortality hazard (HR = 1.929; p = 0.036), while neither discharge EF nor etiology of VA-ECLS were associated with increased post-discharge mortality. CONCLUSIONS Patients discharged from the hospital after full myocardial recovery from VA-ECLS support without HRT should have close outpatient follow-up due to the risk of recurrent heart failure and increased mortality in these patients.
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Affiliation(s)
- Gabriel Dardik
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Yuming Ning
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Paul Kurlansky
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | | | - Alice Vinogradsky
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Justin Fried
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Veli K Topkara
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Koji Takeda
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
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Higa KC, Mayer K, Quinn C, Jubina L, Suarez-Pierre A, Colborn K, Jolley SE, Enfield K, Zwischenberger J, Sevin CM, Rove JY. Sounding the Alarm: What Clinicians Need to Know about Physical, Emotional, and Cognitive Recovery After Venoarterial Extracorporeal Membrane Oxygenation. Crit Care Med 2023; 51:1234-1245. [PMID: 37163480 PMCID: PMC11210608 DOI: 10.1097/ccm.0000000000005900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
OBJECTIVE We summarize the existing data on the occurrence of physical, emotional, and cognitive dysfunction associated with postintensive care syndrome (PICS) in adult survivors of venoarterial extracorporeal membrane oxygenation (VA-ECMO). DATA SOURCES MEDLINE, Cochrane Library, EMBASE, Web of Science, and CINAHL databases were searched. STUDY SELECTION Peer-reviewed studies of adults receiving VA-ECMO for any reason with at least one measure of health-related quality of life outcomes or PICS at long-term follow-up of at least 6 months were included. DATA EXTRACTION The participant demographics and baseline characteristics, in-hospital outcomes, long-term health outcomes, quality of life outcome measures, and prevalence of PICS were extracted. DATA SYNTHESIS Twenty-seven studies met inclusion criteria encompassing 3,271 patients who were treated with VA-ECMO. The studies were limited to single- or two-center studies. Outcomes variables and follow-up time points evaluated were widely heterogeneous which limits comprehensive analysis of PICS after VA-ECMO. In general, the longer-term PICS-related outcomes of survivors of VA-ECMO were worse than the general population, and approaching that of patients with chronic disease. Available studies identified high rates of abnormal 6-minute walk distance, depression, anxiety, and posttraumatic stress disorder that persisted for years. Half or fewer survivors return to work years after discharge. Only 2 of 27 studies examined cognitive outcomes and no studies evaluated cognitive dysfunction within the first year of recovery. No studies evaluated the impact of targeted interventions on these outcomes. CONCLUSIONS Survivors of VA-ECMO represent a population of critically ill patients at high risk for deficits in physical, emotional, and cognitive function related to PICS. This systematic review highlights the alarming reality that PICS and in particular, neurocognitive outcomes, in survivors of VA-ECMO are understudied, underrecognized, and thus likely undertreated. These results underscore the imperative that we look beyond survival to focus on understanding the burden of survivorship with the goal of optimizing recovery and outcomes after these life-saving interventions. Future prospective, multicenter, longitudinal studies in recovery after VA-ECMO are justified.
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Affiliation(s)
- Kelly C Higa
- Department of Cardiothoracic Surgery, Stanford University, Palo Alto, CA
| | - Kirby Mayer
- Department of Physical Therapy, College of Health Sciences, University of Kentucky, Lexington, KY
| | - Christopher Quinn
- Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Lindsey Jubina
- Department of Physical Therapy, College of Health Sciences, University of Kentucky, Lexington, KY
| | | | - Kathryn Colborn
- Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Sarah E Jolley
- Division of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Kyle Enfield
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia, Charlottesville, VA
| | - Joseph Zwischenberger
- Division of Cardiothoracic Surgery, Department of Surgery, College of Medicine, University of Kentucky, Lexington, KY
| | - Carla M Sevin
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University, Nashville, TN
| | - Jessica Y Rove
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO
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Trieu NHK, Phan XT, Tran LT, Pham HM, Huynh DQ, Nguyen TM, Mai AT, Du QQM, Nguyen BX, Pham TTN. Risk factors for cannula-associated arterial thrombosis following extracorporeal membrane oxygenation support: a retrospective study. Acute Crit Care 2023; 38:315-324. [PMID: 37652861 PMCID: PMC10497893 DOI: 10.4266/acc.2023.00500] [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: 03/21/2023] [Revised: 07/13/2023] [Accepted: 07/13/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Hemostatic dysfunction during extracorporeal membrane oxygenation (ECMO) due to blood-circuit interaction and the consequences of shear stress imposed by flow rates lead to rapid coagulation cascade and thrombus formation in the ECMO system and blood vessels. We aimed to identify the incidence and risk factors for cannula-associated arterial thrombosis (CaAT) post-decannulation. METHODS A retrospective study of patients undergoing arterial cannula removal following ECMO was performed. We evaluated the incidence of CaAT and compared the characteristics, ECMO machine parameters, cannula sizes, number of blood products transfused during ECMO, and daily hemostasis parameters in patients with and without CaAT. Multivariate analysis identified the risk factors for CaAT. RESULTS Forty-seven patients requiring venoarterial ECMO (VA-ECMO) or hybrid methods were recruited for thrombosis screening. The median Sequential Organ Failure Assessment score was 11 (interquartile range, 8-13). CaAT occurred in 29 patients (61.7%), with thrombosis in the superficial femoral artery accounting for 51.7% of cases. The rate of limb ischemia complications in the CaAT group was 17.2%. Multivariate analysis determined that the ECMO flow rate-body surface area (BSA) ratio (100 ml/min/m2) was an independent factor for CaAT, with an odds ratio of 0.79 (95% confidence interval, 0.66-0.95; P=0.014). CONCLUSIONS We found that the incidence of CaAT was 61.7% following successful decannulation from VA-ECMO or hybrid modes, and the ECMO flow rate-BSA ratio was an independent risk factor for CaAT. We suggest screening for arterial thrombosis following VA-ECMO, and further research is needed to determine the risks and benefits of such screening.
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Affiliation(s)
- Ngan Hoang Kim Trieu
- Department of Emergency and Critical Care Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
- Intensive Care Unit, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Xuan Thi Phan
- Intensive Care Unit, Tam Anh Hospital, Ho Chi Minh City, Vietnam
| | - Linh Thanh Tran
- Intensive Care Unit, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Huy Minh Pham
- Intensive Care Unit, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Dai Quang Huynh
- Department of Emergency and Critical Care Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
- Intensive Care Unit, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Tuan Manh Nguyen
- Intensive Care Unit, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Anh Tuan Mai
- Department of Emergency and Critical Care Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
- Intensive Care Unit, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | | | - Bach Xuan Nguyen
- Department of Emergency and Critical Care Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
- Intensive Care Unit, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Thao Thi Ngoc Pham
- Department of Emergency and Critical Care Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
- Intensive Care Unit, Cho Ray Hospital, Ho Chi Minh City, Vietnam
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Lau FM, Chan WK, Mok YT, Lai PCK, Ma SKT, Ngai CW, Sin WC, Kwok WLP, Yu KY, Chan WM, Fraser JF, Ng PY. Feasibility of pump-controlled retrograde trial off in weaning from veno-arterial ECMO in adults-A single-center case series. Artif Organs 2023. [PMID: 37012220 DOI: 10.1111/aor.14527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 12/28/2022] [Accepted: 03/20/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Various strategies of weaning V-A ECMO have been described. PCRTO is a weaning technique which involves serial decremental pump revolutions until a retrograde flow from the arterial to venous ECMO cannula is achieved. It has been reported as a feasible weaning strategy in the pediatric population, but its application in adults has not been widely reported. METHODS This was a case series including all adult patients who underwent PCRTO during weaning from V-A ECMO at a tertiary ECMO center between January 2019 and July 2021. The primary end point was the successful weaning from V-A ECMO support. RESULTS A total of 57 runs of PCRTO in 36 patients were analyzed-45 (78.9%) of the trials were concluded successfully. The median retrograde blood flow rate during PCRTO was 0.6 ± 0.2 L/min, and the median duration of each PCRTO was 180 (120-240) min. Of the 35 patients who had at least one session of successful PCRTO, 31 (88.6%) were ultimately weaned from ECMO. There were no major complications from PCRTO including systemic or circuit thrombosis. CONCLUSIONS PCRTO is a feasible strategy for assessing readiness for weaning from V-A ECMO with a low risk of adverse events and high rate of predicting eventual successful ECMO decannulation. Further investigation including comparison with alternative weaning strategies in prospective studies is required to confirm the approach.
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Affiliation(s)
- Fung Ming Lau
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, Hong Kong SAR
| | - Wai Kit Chan
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, Hong Kong SAR
| | - Yuen Tin Mok
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, Hong Kong SAR
| | - Peter Chi Keung Lai
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, Hong Kong SAR
| | - Sin Kwan Tammy Ma
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, Hong Kong SAR
| | - Chun Wai Ngai
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, Hong Kong SAR
| | - Wai Ching Sin
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, Hong Kong SAR
- Critical Care Medicine Unit, The University of Hong Kong, Hong Kong, Hong Kong SAR
| | | | - Kin Yip Yu
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, Hong Kong SAR
| | - Wai Ming Chan
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, Hong Kong SAR
| | - John F Fraser
- University of Queensland, Brisbane, Queensland, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Pauline Yeung Ng
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, Hong Kong SAR
- Critical Care Medicine Unit, The University of Hong Kong, Hong Kong, Hong Kong SAR
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Oren D, Zilinyi R, Lotan D, Uriel M, Uriel N, Sayer G. The role of temporary mechanical circulatory support as a bridge to advanced heart failure therapies or recovery. Curr Opin Cardiol 2022; 37:394-402. [PMID: 35766587 DOI: 10.1097/hco.0000000000000976] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Temporary mechanical circulatory support (tMCS) has become central in the treatment of refractory cardiogenic shock and can be used to bridge patients to durable MCS, heart transplant or recovery. This review will discuss contemporary data regarding bridging strategies utilizing tMCS. RECENT FINDINGS There has been significant growth in tMCS use recently, driven by increased familiarity with tMCS devices, and increased experience with both implantation and management. Identifying goals of therapy at the time of therapy initiation can facilitate better outcomes. The three primary goals are bridge to recovery, bridge to heart transplantation or bridge to durable left ventricular assist device. Bridging to recovery requires adequate treatment of underlying conditions and optimization of haemodynamics. Bridging to heart transplantation has become more frequent following changes to the heart allocation policy. Despite early concerns, patients bridge with tMCS, including ventricular-arterial extracorporeal membrane oxygenation, do not appear to have worse posttransplant outcomes. When bridging to durable mechanical circulatory support, tMCS can be used to enhance end-organ dysfunction and improve perioperative outcomes. In situations in which none of these goals are attainable, palliative care plays a critical role to identify patient wishes and assist with withdrawal of care when necessary. SUMMARY The use of tMCS, as a bridge to recovery or heart replacement therapy in patients with refractory cardiogenic shock has grown significantly over the past decade. Multiple device choices are available and must be chosen appropriately to address the specific situation and the goals of therapy.
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Affiliation(s)
- Daniel Oren
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
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Abruzzo A, Gorantla V, Thomas SE. Venous thromboembolic events in the setting of extracorporeal membrane oxygenation support in adults: A systematic review. Thromb Res 2022; 212:58-71. [DOI: 10.1016/j.thromres.2022.02.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/01/2022] [Accepted: 02/18/2022] [Indexed: 01/04/2023]
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10
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 61:1178-1185. [DOI: 10.1093/ejcts/ezac035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 12/07/2021] [Accepted: 01/15/2022] [Indexed: 11/14/2022] Open
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Sertic F, Diagne D, Chavez L, Richards T, Berg A, Acker M, Giri JS, Szeto WY, Khandhar S, Gutsche J, Pugliese S, Fiorilli P, Rame E, Bermudez C. Mid-term outcomes with the use of extracorporeal membrane oxygenation for cardiopulmonary failure secondary to massive pulmonary embolism. Eur J Cardiothorac Surg 2020; 58:923-931. [PMID: 32725134 DOI: 10.1093/ejcts/ezaa189] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/28/2020] [Accepted: 05/04/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES There has been increasing interest in using extracorporeal membrane oxygenation (ECMO) to rescue patients with pulmonary embolism (PE) in the advanced stages of respiratory or haemodynamic decompensation. We examined mid-term outcomes and risk factors for in-hospital mortality. METHODS We conducted a retrospective study of 36 patients who required ECMO placement (32 veno-arterial ECMO, 4 veno-venous) following acute PE. Survival curves were estimated using the Kaplan-Meier method. Risk factors for in-hospital mortality were assessed by logistic regression analysis. Functional status and quality of life were assessed by phone questionnaire. RESULTS Overall survival to hospital discharge was 44.4% (16/36). Two-year survival conditional to discharge was 94% (15/16). Two-year survival after veno-arterial ECMO was 39% (13/32). In patients supported with veno-venous ECMO, survival to discharge was 50%, and both patients were alive at follow-up. In univariable analysis, a history of recent surgery (P = 0.064), low left ventricular ejection fraction (P = 0.029), right ventricular dysfunction ≥ moderate at weaning (P = 0.083), on-going cardiopulmonary resuscitation at ECMO placement (P = 0.053) and elevated lactate at weaning (P = 0.002) were risk factors for in-hospital mortality. In multivariable analysis, recent surgery (P = 0.018) and low left ventricular ejection fraction at weaning (P = 0.013) were independent factors associated with in-hospital mortality. At a median follow-up of 23 months, 10 patients responded to our phone survey; all had acceptable functional status and quality of life. CONCLUSIONS Massive acute PE requiring ECMO support is associated with high early mortality, but patients surviving to hospital discharge have excellent mid-term outcomes with acceptable functional status and quality of life. ECMO can provide a stable platform to administer other intervention with the potential to improve outcomes. Risk factors for in-hospital mortality after PE and veno-arterial ECMO support were identified.
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Affiliation(s)
- Federico Sertic
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dieynaba Diagne
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lexy Chavez
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas Richards
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ashley Berg
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael Acker
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jay S Giri
- Department of Medicine, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Wilson Y Szeto
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sameer Khandhar
- Department of Medicine, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jacob Gutsche
- Department of Intensive Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven Pugliese
- Department of Medicine, Division of Pulmonology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul Fiorilli
- Department of Medicine, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Eduardo Rame
- Department of Medicine, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Christian Bermudez
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Sertic F, Bermudez C, Rame JE. Venoarterial Extracorporeal Membrane Oxygenation as a Bridge to Recovery or Bridge to Heart Replacement Therapy in Refractory Cardiogenic Shock. Curr Heart Fail Rep 2020; 17:341-349. [DOI: 10.1007/s11897-020-00495-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 01/16/2023]
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13
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Yeo HJ, Kim YS, Kim D, Cho WH. Risk factors for complete recovery of adults after weaning from veno-venous extracorporeal membrane oxygenation for severe acute respiratory failure: an analysis from adult patients in the Extracorporeal Life Support Organization registry. J Intensive Care 2020; 8:64. [PMID: 32839669 PMCID: PMC7439234 DOI: 10.1186/s40560-020-00480-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 08/10/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND As extracorporeal membrane oxygenation (ECMO) has been widely used, the patient quality of life following ECMO termination has become an important issue as same as the patient's survival. To date, the factors affecting complete recovery of adult survivors from ECMO have not been investigated. METHODS Data from adult patients in the Extracorporeal Life Support Organization registry who received veno-venous ECMO between 2012 and 2017 were analyzed. Multivariate logistic regression analyses were conducted. RESULTS In total, 6536 patients with 242,183 days of veno-venous ECMO were reviewed. The overall survival to discharge rate after weaning from ECMO was 89.7% (n = 5861), and 10.3% (n = 675) of the patients died during hospitalization. The discharge location varied as follows: 33.7% (n = 1976) returned home, 23.4% (n = 1369) were transferred to a referral hospital, 41.8% (n = 2447) required hospital services, and 0.6% (n = 36) were discharged to other places. The patients were divided into two groups according to the discharge location: a complete recovery group (n = 1976) and a partial recovery group (n = 3885). In the multivariate analyses, age (≥ 65 years) (odds ratio (OR) 0.72, 95% confidence interval (CI) 0.59-0.87, p = 0.001), cardiac arrest before ECMO (OR 0.76, 95% CI 0.60-0.96, p = 0.021), vasopressor use (OR 0.73, 95% CI 0.64-0.83, p < 0.001), renal replacement therapy (OR 0.40, 95% CI 0.28-0.57, p < 0.001), ECMO-related complications (OR 0.76, 95% CI 0.67-0.85, p < 0.001), and long-term ECMO support (≥ 2 weeks) (OR 0.42, 95% CI 0.37-0.48, p < 0.001) were significantly associated with complete recovery. CONCLUSION Complete recovery after veno-venous ECMO support is associated with the patient's baseline condition, ECMO duration, and ECMO-related complications. Respiratory ECMO should aim to increase both the survival and the quality of life after weaning from ECMO.
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Affiliation(s)
- Hye Ju Yeo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Geumo-ro 20, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do 626-770 Republic of Korea
| | - Yun Seong Kim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Geumo-ro 20, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do 626-770 Republic of Korea
| | - Dohyung Kim
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | | | - Woo Hyun Cho
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Geumo-ro 20, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do 626-770 Republic of Korea
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Lüsebrink E, Stremmel C, Stark K, Joskowiak D, Czermak T, Born F, Kupka D, Scherer C, Orban M, Petzold T, von Samson-Himmelstjerna P, Kääb S, Hagl C, Massberg S, Peterss S, Orban M. Update on Weaning from Veno-Arterial Extracorporeal Membrane Oxygenation. J Clin Med 2020; 9:E992. [PMID: 32252267 PMCID: PMC7230450 DOI: 10.3390/jcm9040992] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/18/2020] [Accepted: 03/27/2020] [Indexed: 01/14/2023] Open
Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary cardiac and respiratory support and has emerged as an established salvage intervention for patients with hemodynamic compromise or shock. It is thereby used as a bridge to recovery, bridge to permanent ventricular assist devices, bridge to transplantation, or bridge to decision. However, weaning from VA-ECMO differs between centers, and information about standardized weaning protocols are rare. Given the high mortality of patients undergoing VA-ECMO treatment, it is all the more important to answer the many questions still remaining unresolved in this field Standardized algorithms are recommended to optimize the weaning process and determine whether the VA-ECMO can be safely removed. Successful weaning as a multifactorial process requires sufficient recovery of myocardial and end-organ function. The patient should be considered hemodynamically stable, although left ventricular function often remains impaired during and after weaning. Echocardiographic and invasive hemodynamic monitoring seem to be indispensable when evaluating biventricular recovery and in determining whether the VA-ECMO can be weaned successfully or not, whereas cardiac biomarkers may not be useful in stratifying those who will recover. This review summarizes the strategies of weaning of VA-ECMO and discusses predictors of successful and poor weaning outcome.
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Affiliation(s)
- Enzo Lüsebrink
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Christopher Stremmel
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Konstantin Stark
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Dominik Joskowiak
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Thomas Czermak
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Frank Born
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Danny Kupka
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Clemens Scherer
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Mathias Orban
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Tobias Petzold
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Patrick von Samson-Himmelstjerna
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Stefan Kääb
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Steffen Massberg
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Sven Peterss
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Martin Orban
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
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15
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Carrier M. Commentary: Survival following extracorporeal membrane oxygenation support, a sobering view. J Thorac Cardiovasc Surg 2020; 161:679-680. [PMID: 31926692 DOI: 10.1016/j.jtcvs.2019.11.115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 11/27/2019] [Accepted: 11/29/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Michel Carrier
- Division of Cardiac Surgery, Department of Surgery, University of Montreal and Montreal Heart Institute, Montréal, Québec, Canada.
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