Systematic review of percutaneous cardiopulmonary bypass for cardiac arrest or cardiogenic shock states

Extracorporal Membrane Oxygenation in Massive Pulmonary Embolism

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.

Prognostic impact of lung computed tomography density in cardiogenic shock patients with veno-arterial extracorporeal membrane oxygenation

BACKGROUND

Pulmonary complications often occur in patients receiving veno-arterial extracorporeal membrane oxygenation (VA ECMO). However, the prognostic impact of lung damage has not been fully elucidated.

METHODS

This single-center retrospective observational study targeted patients with cardiogenic shock who received VA ECMO between 2012 and 2021. This study included 65 patients who underwent chest computed tomography (CT) on VA ECMO, followed by escalation to central mechanical circulatory support (MCS) with left ventricular venting. The average density of lung CT images was measured using region-of-interest methods, and the primary endpoint was 180-day all-cause death after escalation to the central MCS.

RESULTS

Twenty-two patients (34%) developed 180-day all-cause death. According to the Cox regression analysis, age (hazard ratio [HR], 1.08; 95% confidence interval [CI], 1.03-1.14; p = 0.001), ischemic etiology (HR, 5.53; 95% CI, 2.09-14.62; p < 0.001), duration of VA ECMO support (HR, 1.19; 95% CI, 1.00-1.40; p = 0.045), and lung CT density (≥ -481 Hounsfield unit [HU]) (HR, 6.33; 95% CI, 2.26-17.72; p < 0.001) were independently associated with all-cause death. Receiver operating characteristic curve analysis determined that lung CT density ≥ -481 HU is an optimal cutoff value for predicting all-cause death (area under the curve [AUC], 0.72). The 180-day overall survival rate for patients with high lung CT density (≥ -481 HU) was significantly lower than that for those with low lung CT density (< -481 HU) (44.4% vs. 81.6%, respectively, p = 0.002).

CONCLUSIONS

Higher lung CT density could be a useful predictor of death in patients with VA ECMO requiring central MCS escalation.

Thyrotoxicosis-Induced Cardiomyopathy Complicated by Refractory Cardiogenic Shock Rescued by Extracorporeal Membrane Oxygenation

Patient: Male 53-year-old

Final Diagnosis: Thyrotoxicosis-induced cardiomyopathy

Symptoms: Dyspnea

Medication:—

Clinical Procedure: —

Specialty: Cardiology • Critical Care Medicine

Hydrogen gas with extracorporeal cardiopulmonary resuscitation improves survival after prolonged cardiac arrest in rats

BACKGROUND

Despite the benefits of extracorporeal cardiopulmonary resuscitation (ECPR) in cohorts of selected patients with cardiac arrest (CA), extracorporeal membrane oxygenation (ECMO) includes an artificial oxygenation membrane and circuits that contact the circulating blood and induce excessive oxidative stress and inflammatory responses, resulting in coagulopathy and endothelial cell damage. There is currently no pharmacological treatment that has been proven to improve outcomes after CA/ECPR. We aimed to test the hypothesis that administration of hydrogen gas (H₂) combined with ECPR could improve outcomes after CA/ECPR in rats.

METHODS

Rats were subjected to 20 min of asphyxial CA and were resuscitated by ECPR. Mechanical ventilation (MV) was initiated at the beginning of ECPR. Animals were randomly assigned to the placebo or H₂ gas treatment groups. The supplement gas was administered with O₂ through the ECMO membrane and MV. Survival time, electroencephalography (EEG), brain functional status, and brain tissue oxygenation were measured. Changes in the plasma levels of syndecan-1 (a marker of endothelial damage), multiple cytokines, chemokines, and metabolites were also evaluated.

RESULTS

The survival rate at 4 h was 77.8% (7 out of 9) in the H₂ group and 22.2% (2 out of 9) in the placebo group. The Kaplan-Meier analysis showed that H₂ significantly improved the 4 h-survival endpoint (log-rank P = 0.025 vs. placebo). All animals treated with H₂ regained EEG activity, whereas no recovery was observed in animals treated with placebo. H₂ therapy markedly improved intra-resuscitation brain tissue oxygenation and prevented an increase in central venous pressure after ECPR. H₂ attenuated an increase in syndecan-1 levels and enhanced an increase in interleukin-10, vascular endothelial growth factor, and leptin levels after ECPR. Metabolomics analysis identified significant changes at 2 h after CA/ECPR between the two groups, particularly in D-glutamine and D-glutamate metabolism.

CONCLUSIONS

H₂ therapy improved mortality in highly lethal CA rats rescued by ECPR and helped recover brain electrical activity. The underlying mechanism might be linked to protective effects against endothelial damage. Further studies are warranted to elucidate the mechanisms responsible for the beneficial effects of H₂ on ischemia-reperfusion injury in critically ill patients who require ECMO support.

Combined use of venoarterial extracorporeal membrane oxygenation and intra-aortic balloon pump after cardiac arrest

OBJECTIVES

We investigated whether intra-aortic balloon pump (IABP) combined with venoarterial extracorporeal membrane oxygenation (VA-ECMO) was associated with favourable neurological outcomes for patients after the return of spontaneous circulation (ROSC). Moreover, we evaluated the aetiology of cardiac arrest on the effectiveness of this therapy in a sub-study.

BACKGROUND

There is insufficient research on the optimal combination of machines for patients after ROSC is not established.

METHODS

This is a large-scale, multicentre, 30-day cohort study. Among 80,716 patients who delivered to the emergency room, 935 patients treated with VA-ECMO after ROSC were included using the data from the Tokyo Cardiovascular Care Unit Network Registry between 2010 and 2017. The study patients were stratified according to the use of IABP [the ECMO + IABP group (n = 762) vs. the ECMO-alone group (n = 173)]. We also evaluated the cause of cardiac arrest [acute coronary syndrome (ACS) and non-ACS] in the sub-study. To adjust the patients' backgrounds, we used the propensity score matching for additional analyses. The endpoint was 30-day favourable neurological outcome.

RESULTS

The ECMO + IABP group showed significantly better neurological outcomes than the ECMO-alone group (crude; 35% vs. 25%; log-lank P < 0.001). In the ACS subgroup, the ECMO + IABP group showed significantly better neurological outcome (crude; 34% vs. 18%; log-lank P < 0.001), but not in the non-ACS subgroup (crude; 38% vs. 32%; log-lank P = 0.11). These results are similar after adjustments to their backgrounds using propensity matching.

CONCLUSIONS

Compared to VA-ECMO alone, the combined use of VA-ECMO and IABP is associated with better neurological outcomes after ROSC, especially in complicated ACS.

Outcomes of adult patients supported by extracorporeal membrane oxygenation (ECMO) following cardiopulmonary arrest. The Mayo Clinic experience

INTRODUCTION

To describe our experience in use of extracorporeal life support (ECLS) as a rescue strategy in patients following cardiopulmonary resuscitation.

METHODS

A retrospective analysis was performed for patients (n = 101) who received ECLS after cardiorespiratory arrest between May 2001 and December 2014. The primary outcome was survival to hospital discharge.

RESULTS

In this cohort median (IQR) age was 56 (37-67) years, 53 (53%) were male, and 90 (89%) were Caucasian. Ventricular tachycardia or ventricular fibrillations were the initial cardiac rhythm in 49 (48.5%) and asystole/pulseless electrical activity in 37 (36.8%). Median (IQR) time to initiation of extracorporeal support from arrest time was 72 (43-170) min. The median (IQR) duration of support was 100 (47-157) hours. Renal failure (66%) and bleeding (66%) were the two most commonly observed complications during ECLS support. The survival to hospital discharge was seen in 47 (47%) patients, and good neurologic outcome (mRs 0-3) was seen in 29%. Acidosis, lactate and continuous renal replacement therapy were independent predictors of mortality. The median (IQR) intensive care unit stay was 14 (4-28) days and hospital stay was 17 (4-35) days.

CONCLUSION

Our institutional experience with ECLS as a rescue measure following cardiac arrest is associated with improvement in mortality, and favorable neurologic status at hospital discharge.

Precannulation International Normalized Ratio is Independently Associated With Mortality in Veno-Arterial Extracorporeal Membrane Oxygenation

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.

Differential Prognostic Implications of Vasoactive Inotropic Score for Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock According to Use of Mechanical Circulatory Support

OBJECTIVES

To identify whether the prognostic implications of Vasoactive Inotropic Score according to use of mechanical circulatory support differ in the treatment of acute myocardial infarction complicated by cardiogenic shock.

DESIGN

A multicenter retrospective and prospective observational cohort study.

SETTING/PATIENT

The REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy registry includes 1,247 patients with cardiogenic shock from 12 centers in Korea. A total of 836 patients with acute myocardial infarction complicated by cardiogenic shock were finally selected, and the study population was stratified by quartiles of Vasoactive Inotropic Score (< 10, 10-30, 30-90, and > 90) for the present study.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Primary endpoint was in-hospital mortality and secondary endpoint was follow-up mortality. Among the study population, 326 patients (39.0%) received medical treatment alone, 218 (26.1%) received intra-aortic balloon pump, and 292 (34.9%) received extracorporeal membrane oxygenation. In-hospital mortality occurred in 305 patients (36.5%) and was significantly higher in patients with higher Vasoactive Inotropic Score (15.6%, 20.8%, 40.2%, and 67.3%, for < 10, 10-30, 30-90, and > 90; p < 0.001). Vasoactive Inotropic Score showed better ability to predict in-hospital mortality in acute myocardial infarction patients with cardiogenic shock who received medical treatment alone (area under the curve: 0.797; 95% CI, 0.728-0.865) than in those who received intra-aortic balloon pump (area under the curve, 0.704; 95% CI, 0.625-0.783) or extracorporeal membrane oxygenation (area under the curve, 0.644; 95% CI, 0.580-0.709). The best cutoff value of Vasoactive Inotropic Score for the prediction of in-hospital mortality also differed according to the use of mechanical circulatory support (16.5, 40.1, and 84.0 for medical treatment alone, intra-aortic balloon pump, and extracorporeal membrane oxygenation, respectively). There was a significant interaction between Vasoactive Inotropic Score as a continuous value and the use of mechanical circulatory support including intra-aortic balloon pump (interaction-p = 0.006) and extracorporeal membrane oxygenation (interaction-p < 0.001) for all-cause mortality during follow-up.

CONCLUSIONS

High Vasoactive Inotropic Score was associated with significantly higher in-hospital and follow-up mortality in patients with acute myocardial infarction complicated by cardiogenic shock. The predictive value of Vasoactive Inotropic Score for mortality was significantly higher in acute myocardial infarction patients with cardiogenic shock treated by medical treatment alone than in those treated by mechanical circulatory support such as intra-aortic balloon pump or extracorporeal membrane oxygenation.

Extracorporeal Life Support and Mechanical Circulatory Support in Out-of-Hospital Cardiac Arrest and Refractory Cardiogenic Shock

The prevalence of extracorporeal cardiopulmonary resuscitation is increasing worldwide as more health care centers develop the necessary infrastructure, protocols, and technical expertise required to provide mobile extracorporeal life support with short notice. Strict adherence to patient selection guidelines in the setting of out-of-hospital cardiac arrest, as well as in-hospital cardiac arrest, allows for improved survival with neurologically favorable outcomes in a larger patient population. This review discusses the preferred approaches, cannulation techniques, and available support devices ideal for the various clinical situations encountered during the treatment of cardiac arrest and refractory cardiogenic shock.

Acute Decompensated Heart Failure in Patients with Heart Failure with Reduced Ejection Fraction

Acute decompensated heart failure (ADHF) requires immediate treatments because it impairs perfusion to systemic organs and their function. Half of all patients with ADHF are diagnosed with heart failure with reduced left ventricular ejection fraction (HFrEF). The initial goal of management for ADHF is to stabilize hemodynamic status. Pulmonary edema is treated with vasodilators or diuretics. Inhibitors of the renin-angiotensin-aldosterone system and β-blockers should be started and/or increased to meet the maximum dose, ideally the target dose, that the patient can tolerate as a treatment of HFrEF. Patients with severe circulatory failure need inotropic drugs or mechanical circulatory support.

ECMO in cardiogenic shock and bridge to heart transplant

Purpose

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

Methods and results

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

Conclusion

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

Pulmonary artery pressure may be a predictor of closed aortic valve in patients managed by venoarterial extracorporeal membrane oxygenation

In the management of venoarterial extracorporeal membrane oxygenation, some patients present persistently closed aortic valve. However, little is known about the variables that contribute to persistently closed aortic valve. We investigated the factors that could predict persistently closed aortic valve at the time of venoarterial extracorporeal membrane oxygenation initiation. We investigated 17 patients who presented closed aortic valve immediately after the introduction of venoarterial extracorporeal membrane oxygenation. Patients who presented closed aortic valve 24 h after introduction of venoarterial extracorporeal membrane oxygenation were defined as the Closed-AV group (n = 8), while those whose aortic valve remained opened after 24 h were defined as the Open-AV group (n = 9). All patients were managed by concomitant use of intra-aortic balloon pumping. At baseline, there were no significant differences between mean arterial blood pressure, central venous pressure, and left ventricular ejection fraction. However, Closed-AV group had significantly lower mean pulmonary artery pressure and pulmonary artery pulse pressure compared to those of Open-AV group (mean pulmonary artery pressure: 15 ± 6 mmHg vs 25 ± 8 mmHg, p = 0.01; pulmonary artery pulse pressure: 3 ± 2 mmHg vs 8 ± 3 mmHg, p < 0.01). Logistic regression analyses revealed that the lower mean pulmonary artery pressure and pulmonary artery pulse pressure had the predictive value of closed aortic valve within 24 h after venoarterial extracorporeal membrane oxygenation initiation (mean pulmonary artery pressure: odds ratio = 0.78, 95% confidence interval = 0.58-0.95, p < 0.01; pulmonary artery pulse pressure: odds ratio = 0.18, 95% confidence interval = 0.01-0.61, p < 0.01). Lower mean pulmonary artery pressure and pulmonary artery pulse pressure values could predict persistent closed aortic valve 24 h after venoarterial extracorporeal membrane oxygenation initiation. Left ventricular preload derived from right heart function may have a major impact on aortic valve status.

Fingolimod Plays Role in Attenuation of Myocardial Injury Related to Experimental Model of Cardiac Arrest and Extracorporeal Life Support Resuscitation

Background: Sudden cardiac arrest is a major global health concern, and survival of patients with ischemia–reperfusion injury is a leading cause of myocardial dysfunction. The mechanism of this phenomenon is not well understood because of the complex pathophysiological nature of the disease. Aim of the study was to investigate the cardioprotective role of fingolimod in an in vivo model of cardiac arrest and resuscitation. Methods: In this study, an in vivo rat model of cardiac arrest using extracorporeal membrane oxygenation resuscitation monitored by invasive hemodynamic measurement was developed. At the beginning of extracorporeal life support (ECLS), animals were randomly treated with fingolimod (Group A, n = 30) or saline (Group B, n = 30). Half of the animals in each group (Group A1 and B1, n = 15 each) were sacrificed after 1 h, and the remaining animals (Group A2 and B2) after 24 h of reperfusion. Blood and myocardial tissues were collected for analysis of cardiac features, inflammatory biomarkers, and cell signaling pathways. Results: Treatment with fingolimod resulted in activation of survival pathways resulting into reduced inflammation, myocardial oxidative stress and apoptosis of cardiomyocytes. This led to significant improvement in systolic and diastolic functions of the left ventricle and improved contractility index. Conclusions: Sphingosine1phosphate receptor activation with fingolimod improved cardiac function after cardiac arrest supported with ECLS. Present study findings strongly support a cardioprotective role of fingolimod through sphingosine-1-phosphate receptor activation during reperfusion after circulatory arrest.

Tissue-Specific Metabolic Profiles After Prolonged Cardiac Arrest Reveal Brain Metabolome Dysfunction Predominantly After Resuscitation

Background

Cardiac arrest (CA) has been a leading cause of death for many decades. Despite years of research, we still do not understand how each organ responds to the reintroduction of blood flow after prolonged CA. Following changes in metabolites of individual organs after CA and resuscitation gives context to the efficiency and limitations of current resuscitation protocols.

Methods and Results

Adult male Sprague–Dawley rats were arbitrarily assigned into 3 groups: control, 20 minutes of CA, or 20 minutes of CA followed by 30 minutes of cardiopulmonary bypass resuscitation. The rats were euthanized by decapitation to harvest brain, heart, kidney, and liver tissues. The obtained tissue samples were analyzed by ultra‐high‐performance liquid chromatography–high‐accuracy mass spectrometry for comprehensive metabolomics evaluation. After resuscitation, the brain showed decreased glycolysis metabolites and fatty acids and increased amino acids compared with control. Similarly, the heart displayed alterations mostly in amino acids. The kidney showed decreased amino acid and fatty acid pools with severely increased tricarboxylic acid cycle metabolites following resuscitation, while the liver showed minimal alterations with slight changes in the lipid pool. Each tissue has a distinct pattern of metabolite changes after ischemia/reperfusion. Furthermore, resuscitation worsens the metabolic dysregulation in the brain and kidney, while it normalizes metabolism in the heart.

Conclusions

Developing metabolic profiles using a global metabolome analysis identifies the variable nature of metabolites in individual organs after CA and reperfusion, establishing a stark contrast between the normalized heart and liver and the exacerbated brain and kidney, only after the reestablishment of blood circulation.

Utilization of Percutaneous Mechanical Circulatory Support Devices in Cardiogenic Shock Complicating Acute Myocardial Infarction and High-Risk Percutaneous Coronary Interventions

Given the tremendous progress in interventional cardiology over the last decade, a growing number of older patients, who have more comorbidities and more complex coronary artery disease, are being considered for technically challenging and high-risk percutaneous coronary interventions (PCI). The success of performing such complex PCI is increasingly dependent on the availability and improvement of mechanical circulatory support (MCS) devices, which aim to provide hemodynamic support and left ventricular (LV) unloading to enable safe and successful coronary revascularization. MCS as an adjunct to high-risk PCI may, therefore, be an important component for improvement in clinical outcomes. MCS devices in this setting can be used for two main clinical conditions: patients who present with cardiogenic shock complicating acute myocardial infarction (AMI) and those undergoing technically complex and high-risk PCI without having overt cardiogenic shock. The current article reviews the advancement in the use of various devices in both AMI complicated by cardiogenic shock and complex high-risk PCI, highlights the available hemodynamic and clinical data associated with the use of MCS devices, and presents suggestive management strategies focusing on appropriate patient selection and optimal timing and support to potentially increase the clinical benefit from utilizing these devices during PCI in this high-risk group of patients.

Effect of Mean Blood Pressure During Extracorporeal Life Support on Outcome After Out-of-Hospital Cardiac Arrest

Objective

Extracorporeal Life Support (ECLS) can help to improve the outcome of refractory cardiac arrest (CA). ECLS allows to maintain blood pressure and tissue perfusion until the cause of CA is treated. The aim of the present study was to describe the mean blood pressure (MBP) during the first 24 h of ECLS for out-of-hospital CA (OHCA).

Methods

We performed a retrospective analysis of consecutive refractory OHCA requiring ECLS admitted to the intensive care unit. MBP was examined after starting ECLS (H0) and every 6 h during the first 24 h (H6, H12, H18 and H24).

Results

Forty patients were analysed. MBP significantly differs between survivors and non-survivors since 6 h: 77 vs 44 mm Hg (p=0.002), 51 vs 87 mm Hg at H12 (p=0.008), 57 vs 75 mm Hg at H18 (p=0.015) and 79 vs 53 mm Hg at H24 (p=0.004), whereas no difference was observed at H0: 69 vs 55 mm Hg (p=0.06). An MBP lower than 65 mm Hg since 6 h is associated with a poor outcome (sensitivity and specificity of death of 87% and 66% at H6, 80% and 75% at H12, 100% and 75% at H18 and 70% and 80% at H24, respectively).

Conclusion

Despite high levels of catecholamine, the inability to maintain MBP higher than 60 mm Hg after starting ECLS for OHCA is associated with a poor outcome.

Experience of extracorporeal cardiopulmonary resuscitation in a refractory cardiac arrest patient at the emergency department

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) is a method to improve survival outcomes in refractory cardiac arrest.

HYPOTHESIS

This study aimed to determine the associated factors related to outcome and to analyze the post-ECPR management in patients who received ECPR due to nonresponse to advanced cardiac life support (ACLS).

METHODS

This was a retrospective analysis based on a prospective cohort. Cardiac arrest patients who received ECPR in our emergency department from May 2006 to December 2017 were selected from the prospective cohort. Patients who received ECPR for rearrest were excluded. The primary outcome was survival to discharge.

RESULTS

ECPR was attempted in 100 patients who did not respond to ACLS. Fourteen patients survived to discharge, and 12 (85.7%) patients showed good neurologic outcomes. The rate of survival to discharge decreased according to increasing age and ACLS duration. Age, presence of any return of spontaneous circulation (ROSC) during ACLS, and prolongation of ACLS were associated factors for survival discharge in ECPR patients. Fourteen patients required distal perfusion catheters, and 35 patients received continuous renal replacement therapy (CRRT). The proportion of death was the highest within 24 hours after ECPR as 57.0%.

CONCLUSIONS

The early transition from ACLS to ECPR may improve the ECPR outcomes. In addition, good outcomes are expected for ECPR performed after refractory arrest if the patient is young and experiences an ROSC event during ACLS. In post ECPR management, the majority of mortality events were occurred in the early period, and distal perfusion catheter and CRRT were frequently required.

KSHF Guidelines for the Management of Acute Heart Failure: Part II. Treatment of Acute Heart Failure

The prevalence of heart failure (HF) is on the rise due to the aging of society. Furthermore, the continuous progress and widespread adoption of screening and diagnostic strategies have led to an increase in the detection rate of HF, effectively increasing the number of patients requiring monitoring and treatment. Because HF is associated with substantial rates of mortality and morbidity, as well as high socioeconomic burden, there is an increasing need for developing specific guidelines for HF management. The Korean guidelines for the diagnosis and management of chronic HF were introduced in March 2016. However, chronic and acute HF represent distinct disease entities. Here, we introduce the Korean guidelines for the management of acute HF with reduced or preserved ejection fraction. Part II of this guideline covers the treatment of acute HF.

Mechanical Circulatory Support in High-Risk Percutaneous Coronary Intervention

Due to advancing age and increasing comorbidities, the current population has a higher incidence of complex coronary artery disease, often without surgical options for revascularization. In this setting, hemodynamic support devices are an important adjunct in the interventionist's toolbox as they allow for a safer, more effective procedure. The following paper reviews the indications of various available mechanical support devices, highlights their clinical data and technical parameters, and offers a practical approach towards appropriate patient and device selection.

ECMO and Short-term Support for Cardiogenic Shock in Heart Failure

PURPOSE OF REVIEW

This review aims to discuss the role of ECMO in the treatment of cardiogenic shock in heart failure.

RECENT FINDINGS

Trials done previously have shown that IABP does not improve survival in cardiogenic shock compared to medical treatment, and that neither Impella 2.5 nor TandemHeart improves survival compared to IABP. The "IMPRESS in severe shock" trial compared Impella CP with IABP and found no difference in survival. A meta-analysis of cohort studies comparing ECMO with IABP showed 33% improved 30-day survival with ECMO (risk difference 33%; 95% CI 14-52%; p = 0.0008; NNT 3). ECMO is indicated in medically refractory cardiogenic shock. ECMO can be considered in cardiogenic shock patients with estimated mortality of more than 50%. ECMO is probably the MCS of choice in cardiogenic shock with; biventricular failure, respiratory failure, life-threatening arrhythmias and cardiac arrest.

Risk Prediction Model of In-hospital Mortality in Patients With Myocardial Infarction Treated With Venoarterial Extracorporeal Membrane Oxygenation

INTRODUCTION AND OBJECTIVES

There are limited data to develop a risk prediction model of in-hospital mortality for acute myocardial infarction (AMI) patients treated with venoarterial (VA)-extracorporeal membrane oxygenation (ECMO). We aimed to develop a risk prediction model for in-hospital mortality in patients with AMI who were treated with VA-ECMO.

METHODS

A total of 145 patients with AMI who underwent VA-ECMO between May 2004 and April 2016 were included from the Samsung Medical Center ECMO registry. The primary outcome was in-hospital mortality. To develop a new predictive scoring system, named the AMI-ECMO score, backward stepwise elimination and β coefficient-based scoring were used based on logistic regression analyses. The leave-one-out cross-validation method was performed for internal validation.

RESULTS

In-hospital mortality occurred in 69 patients (47.6%). On multivariable logistic regression analysis, the AMI-ECMO score comprised 6 pre-ECMO or angiographic parameters: age> 65 years, body mass index> 25 kg/m², Glasgow coma score <6, lactic acid> 8 mmol/L, anterior wall infarction, and no or failed revascularization. The C-statistic value of AMI-ECMO score for predicting in-hospital mortality was 0.880 (95%CI, 0.820-0.940). The incidence of in-hospital mortality after VA-ECMO insertion was 6.2%, 28.1%, 51.6%, and 93.8% for AMI-ECMO score quartiles (0 to 16, 17 to 19, 20 to 26, and> 26), respectively (P <.001 for trend). The AMI-ECMO scores were also significantly associated with the estimated rate of all-cause mortality during follow-up (per 1 increase, HR, 1.11; 95%CI, 1.08-1.14; P <.001).

CONCLUSIONS

The AMI-ECMO score can help predict early prognosis in AMI patients who undergo VA-ECMO.

The future of cardiac transplantation

The first human-to-human heart transplant was performed 50 years ago in 1967. Heart transplantation has now entered an era of tremendous growth and innovation. The future of heart transplantation is bright with the advent of newer immunosuppressive medications and strategies that may even result in tolerance. Much of this progress in heart transplant medicine is predicated on a better understanding of acute and chronic rejection pathways through basic science studies. The future will also include personalized medicine where genomics and molecular science will dictate customized treatment for optimal outcomes. The introduction of mechanical circulatory support (MCS) devices has changed the landscape for patients with severe heart failure to stabilize the most ill patient and make them better candidates for heart transplant. As ex vivo preservation takes hold, we may witness an expansion of the donor pool through the use of donation after cardiac death (DCD) donors. In addition, further geographical donor heart sharing through ex vivo preservation may further decrease waitlist mortality by enabling longer distance donor hearts to be allocated for the sickest waitlist patient. It is no doubt an exciting time to be involved in the field of heart transplantation. In this perspective, we will summarize the present state of heart transplantation and discuss various innovations that are being pursued.

Extubation in Patients Undergoing Extracorporeal Life Support

Purpose

Extracorporeal life support (ECLS) is a cardiopulmonary support system used for the treatment of severe cardiac and/or respiratory failure. Mortality is high partly because of the severity of the condition that requires support. The use of ECLS is generally associated with heavy sedation. The aim of this study was to demonstrate the feasibility of stopping sedation, allowing extubation of patients supported by ECLS.

Methods

196 patients supported by ECLS for a period of 4 years were included. Sedation was stopped as soon as possible to allow extubation. The 44 extubated patients were compared with non-extubated patients. Finally, 24% of patients were not extubated without a determined cause and were compared with extubated patients.

Results

The extubated patients had a lower incidence of ventilator-associated pneumonia. In a multivariate analysis, the independent risk factors for death were the duration of ECLS, age and lack of extubation. Stopping sedation and extubation are feasible in selected patients under ECLS.

Conclusions

This strategy could be a survival factor.

Advanced Age as a Predictor of Survival and Weaning in Venoarterial Extracorporeal Oxygenation: A Retrospective Observational Study

Background. In most reports on ECMO treatment, advanced age is classified as a contraindication to VA ECMO. We attempted to investigate whether advanced age would be a main risk factor deciding VA ECMO application and performing VA ECMO support. We determined whether advanced age should be regarded as an absolute or relative contraindication to VA ECMO and could affect weaning and survival rates of VA ECMO patients. Methods. VA ECMO was performed on 135 adult patients with primary cardiogenic shock between January 2010 and December 2014. Successful weaning was defined as weaning from ECMO followed by survival for more than 48 hours. Results. Among the 135 patients, 35 survived and were discharged uneventfully, and the remaining 100 did not survive. There were significant differences in survival between age groups, and older age showed a lower survival rate with statistical significance (P = .01). By multivariate logistic regression analysis, age was not significantly associated with in-hospital mortality (P = .83) and was not significantly associated with VA ECMO weaning (P = .11). Conclusions. Advanced age is an undeniable risk factor for VA ECMO; however, patients of advanced age should not be excluded from the chance of recovery after VA ECMO treatment.

[Coronary artery disease : Interventional and operative therapeutic options after cardiac arrest]

Coronary artery disease (CAD) represents a common structural cause for developing cardiac arrest in older patients, whereas in young adults cardiac arrest is more often caused by cardiomyopathies and cardiac channelopathies. A structural heart disease is known in almost 50% of patients prior to cardiac arrest. The present review outlines current interventional and operative therapeutic options for patients surviving cardiac arrest. The focus is on associations between epidemiological data on the incidence of malignant arrhythmias causing cardiac arrest depending on the presence or absence of CAD. Furthermore, the potential benefits of an early coronary revascularization as well as of a prompt complete coronary revascularization compared to the individual treatment of the so-called culprit lesion only are described. Finally, the advantages of invasive therapies for patients surviving cardiac arrest, such as targeted temperature management and mechanical cardiac assist devices, are elucidated. Cardiac assist devices comprise the use of the intra-aortic balloon pump (IABP) and devices for extracorporeal life support (ECLS) for peripheral and central support of the right and left heart chambers.

DHA-supplemented diet increases the survival of rats following asphyxia-induced cardiac arrest and cardiopulmonary bypass resuscitation

Accumulating evidence illustrates the beneficial effects of dietary docosahexaenoic acid (DHA) on cardiovascular diseases. However, its effects on cardiac arrest (CA) remain controversial in epidemiological studies and have not been reported in controlled animal studies. Here, we examined whether dietary DHA can improve survival, the most important endpoint in CA. Male Sprague-Dawley rats were randomized into two groups and received either a control diet or a DHA-supplemented diet for 7–8 weeks. Rats were then subjected to 20 min asphyxia-induced cardiac arrest followed by 30 min cardiopulmonary bypass resuscitation. Rat survival was monitored for additional 3.5 h following resuscitation. In the control group, 1 of 9 rats survived for 4 h, whereas 6 of 9 rats survived in the DHA-treated group. Surviving rats in the DHA-treated group displayed moderately improved hemodynamics compared to rats in the control group 1 h after the start of resuscitation. Rats in the control group showed no sign of brain function whereas rats in the DHA-treated group had recurrent seizures and spontaneous respiration, suggesting dietary DHA also protects the brain. Overall, our study shows that dietary DHA significantly improves rat survival following 20 min of severe CA.

Current and Future Status of Extracorporeal Cardiopulmonary Resuscitation for In-Hospital Cardiac Arrest

Numerous series, propensity-matched trials, and meta-analyses suggest that appropriate use of extracorporeal cardiopulmonary resuscitation (E-CPR) for in-hospital cardiac arrest (IHCA) can be lifesaving. Even with an antecedent cardiopulmonary resuscitation (CPR) duration in excess of 45 minutes, 30-day survival with favourable neurologic outcome using E-CPR is approximately 35%-45%. Survival may be related to age, duration of CPR, or etiology. Associated complications include sepsis, renal failure, limb and neurologic complications, hemorrhage, and thrombosis. However, methodological biases-including small sample size, selection bias, publication bias, and inability to control for confounders-in these series prevent definitive conclusions. As such, the 2015 American Heart Association Advanced Cardiac Life Support guidelines update recommended E-CPR as a Level of Evidence IIb recommendation in appropriate cases. The absence of high-quality evidence presents an opportunity for clinician/scientists to generate practice-defining data through collaborative investigation and prospective trials. A multidisciplinary dialogue is required to standardize the field and promote multicentre investigation of E-CPR with data sharing and the development of a foundation for high-quality trials. The objectives of this review are to (1) provide an overview of the strengths and limitations of currently available studies investigating the use of E-CPR in patients with IHCA and highlight knowledge gaps; (2) create a framework for the standardization of terminology, clinical practice, data collection, and investigation of E-CPR for patients with IHCA that will help ensure congruence in future work in this area; and (3) propose suggestions to guide future research by the cardiovascular community to advance this important field.

Hemodynamic Support Devices for Complex Percutaneous Coronary Intervention

High-risk percutaneous coronary intervention (PCI) encompasses a growing portion of total PCIs performed and typically includes patients with high-risk clinical and anatomic characteristics. Such patients may represent not only a high-risk group for complications but also a group who may derive the most benefit from complete revascularization. Several hemodynamic support devices are available. Trial data, consensus documents, and guidelines currently recommend high-risk PCI aided by hemodynamic support devices, and this article discusses the patient populations who would benefit from such an approach, the available devices and strategies, and expected outcomes.

Upscaling cardiac assist devices in decompensated heart failure: Choice of device and its timing

Advanced heart failure is a heterogeneous condition unified by a very high mortality unless right treatment is instituted at the right time. The first step is understanding the mechanism leading to instability: hemodynamic or ischemic. Right kind of therapy; drugs (ionotropic) or IABP or other cardiac assist devices should be chosen according to mechanism of insult as well as degree of insult. Drugs such as ionotropes are effective only in very early course but if the decompensation has progressed beyond a certain point device such as IABP may be effective but again only early in the course when CPO? 0.6. Beyond a certain point, even IABP may not be effective: here only Impella (2.5, CP or 5) or Tandem Heart may be effective. However, beyond a certain point CPO<0.53, even these devices may not be effective. Thus crux of the matter is choice of a right device/drug and timing of its institution.

2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care (Endorsed by the American Heart Association, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; Affirmation of Value by the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d'intervention)

Although historically the intra-aortic balloon pump has been the only mechanical circulatory support device available to clinicians, a number of new devices have become commercially available and have entered clinical practice. These include axial flow pumps, such as Impella(®); left atrial to femoral artery bypass pumps, specifically the TandemHeart; and new devices for institution of extracorporeal membrane oxygenation. These devices differ significantly in their hemodynamic effects, insertion, monitoring, and clinical applicability. This document reviews the physiologic impact on the circulation of these devices and their use in specific clinical situations. These situations include patients undergoing high-risk percutaneous coronary intervention, those presenting with cardiogenic shock, and acute decompensated heart failure. Specialized uses for right-sided support and in pediatric populations are discussed and the clinical utility of mechanical circulatory support devices is reviewed, as are the American College of Cardiology/American Heart Association clinical practice guidelines.

Consciousness, unconsciousness and death in the context of slaughter. Part II. Evaluation methods

This second review describes indicators of consciousness and unconsciousness that can be used in the abattoir. These indicators evaluate different aspects of cerebral functioning, but only indirectly. It is therefore necessary to monitor several indicators. Animals are considered unconscious if signs of consciousness are absent, and signs of unconsciousness are present. Given that the unconscious state may be reversible it is further necessary to monitor these indicators until the end of bleeding. The techniques used to diagnose brain death in humans cannot be used in the slaughterhouse. Under field conditions, at the end of bleeding, the absence of breathing and of brainstem reflexes and the adequacy of the exsanguination are verified. If these three aspects are confirmed, in the context of the slaughterhouse and at this stage of the slaughter process the loss of vital functions is irreversible and the animal can be considered dead.

The pre-ECMO simplified acute physiology score II as a predictor for mortality in patients with initiation ECMO support at the emergency department for acute circulatory and/or respiratory failure: a retrospective study

Background

In the emergency department (ED), extracorporeal membrane oxygenation (ECMO) can be used as a rescue treatment modality for patients with refractory circulatory and/or respiratory failure. Serious consideration must be given to the indication, and the PRESERVE and RESP scores for mortality have been investigated. However these scores were validated to predict survival in patients who received mainly veno-venous (VV) ECMO in the intensive care unit. The aim of the present study was to investigate the factors that predicted the outcomes for patients who received mixed mode (veno-arterial [VA] and VV) ECMO support in the ED.

Methods

This single center retrospective study included 65 patients who received ECMO support at the ED for circulatory or respiratory failure between January 2009 and December 2013. Pre-ECMO SAPS II and other variables were evaluated and compared for predicting mortality.

Results

Fifty-four percent of patients received ECMO-cardiopulmonary resuscitation (E-CPR), 31 % received VA and V-AV ECMO, and 15 % received VV ECMO. The 28-day and 60-month mortality rates were 52 % and 63 %. In the multivariate analysis, only the pre-ECMO Simplified Acute Physiology Score II (SAPS II) (odd ratio: 1.189, 95 % confidence interval: 1.032–1.370, p = 0.016) could predict the 28-day mortality. The area under the receiver operating characteristic curve and the optimal cutoff value for pre-ECMO SAPS II in predicting 28-day mortality was 0.852 (95 % CI: 0.753–0.951, p < 0.001) and 80 (sensitivity of 97.1 % and specificity of 71.0 %), respectively. Validation of the 80 cutoff value revealed a statistically significant difference for the 28-day and 60-month mortality rates in the overall, E-CPR, and VA groups (28-day: p < 0.001, p = 0.004, p = 0.005; 60-month: p < 0.001, p = 0.004, p = 0.020). In the Kaplan-Meier analysis, the 28-day and 60-month survival rates were lower among the patients with a pre-ECMO SAPS II of ≤80, compared to those with a score of >80 (both, p < 0.001).

Conclusion

The pre-ECMO SAPS II could be helpful for identifying patients with refractory acute circulatory and/or respiratory failure who will respond to ECMO support in the ED.

Non-intubated recovery from refractory cardiogenic shock on percutaneous VA-extracorporeal membrane oxygenation

We report on the use of percutaneous femoral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in a fully awake, non-intubated and spontaneously breathing patient suffering from acute, severe and refractory cardiogenic shock due to a (sub)acute anterior myocardial infarction. Intensified heart failure therapy was closely monitored with a pulmonary artery catheter and allowed gradual weaning off the ECMO support without additional invasive measures, notably without mechanical ventilation. Neurological assessment was possible at all times and complete physical mobilisation was straightforward directly after weaning from ECMO. This limited invasive approach may encourage a more widespread use of percutaneous VA-ECMO.

Current Approaches to Cardiopulmonary Resuscitation

Real progress has been made in improving long-term outcome after out-of-hospital cardiac arrest in the past 10 years. Many communities have doubled their survival-to-hospital-discharge rate during this period. Common features of such successful programs include the following: (1) 911 dispatcher-assisted cardiopulmonary resuscitation (CPR) instruction, (2) bystander chest compression-only CPR program, (3) public access defibrillation, including targeted automated external defibrillator programs, (4) renewed emphasis on minimally interrupted chest compressions by emergency medical services responders, and (5) aggressive postresuscitation care, including targeted temperature management and early coronary angiography and intervention. An important lesson from these successful community efforts is that multiple, simultaneous changes to the local cardiac arrest response system are necessary to improve survival. The next exciting step in this quest appears to be the treatment of refractory cardiac arrest with the combination of mechanical CPR, intra-arrest hypothermia, extracorporeal CPR with mechanical circulatory support devices, and early coronary intervention.

Extracorporeal membrane oxygenation for critically ill adults

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is a form of life support that targets the heart and lungs. Extracorporeal membrane oxygenation for severe respiratory failure accesses and returns blood from the venous system and provides non-pulmonary gas exchange. Extracorporeal membrane oxygenation for severe cardiac failure or for refractory cardiac arrest (extracorporeal cardiopulmonary resuscitation (ECPR)) provides gas exchange and systemic circulation. The configuration of ECMO is variable, and several pump-driven and pump-free systems are in use. Use of ECMO is associated with several risks. Patient-related adverse events include haemorrhage or extremity ischaemia; circuit-related adverse effects may include pump failure, oxygenator failure and thrombus formation. Use of ECMO in newborns and infants is well established, yet its clinical effectiveness in adults remains uncertain.

OBJECTIVES

The primary objective of this systematic review was to determine whether use of veno-venous (VV) or venous-arterial (VA) ECMO in adults is more effective in improving survival compared with conventional respiratory and cardiac support.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid) and EMBASE (Ovid) on 18 August 2014. We searched conference proceedings, meeting abstracts, reference lists of retrieved articles and databases of ongoing trials and contacted experts in the field. We imposed no restrictions on language or location of publications.

SELECTION CRITERIA

We included randomized controlled trials (RCTs), quasi-RCTs and cluster-RCTs that compared adult ECMO versus conventional support.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts of all retrieved citations against the inclusion criteria. We independently reviewed full-text copies of studies that met the inclusion criteria. We entered all data extracted from the included studies into Review Manager. Two review authors independently performed risk of bias assessment. All included studies were appraised with respect to random sequence generation, concealment of allocation, blinding of outcome assessment, incomplete outcome data, selective reporting and other bias.

MAIN RESULTS

We included four RCTs that randomly assigned 389 participants with acute respiratory failure. Risk of bias was low in three RCTs and high in one RCT. We found no statistically significant differences in all-cause mortality at six months (two RCTs) or before six months (during 30 days of randomization in one trial and during hospital stay in another RCT). The quality of the evidence was low to moderate, and further research is very likely to impact our confidence in the estimate of effects because significant changes have been noted in ECMO applications and treatment modalities over study periods to the present.Two RCTs supplied data on disability. In one RCT survival was low in both groups but none of the survivors had limitations in their daily activities six months after discharge. The other RCT reported improved survival without severe disability in the intervention group (transfer to an ECMO centre ± ECMO) six months after study randomization but no statistically significant differences in health-related quality of life.In three RCTs, participants in the ECMO group received greater numbers of blood transfusions. One RCT recorded significantly more non-brain haemorrhage in the ECMO group. Another RCT reported two serious adverse events in the ECMO group, and another reported three adverse events in the ECMO group.Clinical heterogeneity between studies prevented meta-analyses across outcomes. We found no completed RCT that had investigated ECMO in the context of cardiac failure or arrest. We found one ongoing RCT that examined patients with acute respiratory failure and two ongoing RCTs that included patients with acute cardiac failure (arrest).

AUTHORS' CONCLUSIONS

Extracorporeal membrane oxygenation remains a rescue therapy. Since the year 2000, patient treatment and practice with ECMO have considerably changed as the result of research findings and technological advancements over time. Over the past four decades, only four RCTs have been published that compared the intervention versus conventional treatment at the time of the study. Clinical heterogeneity across these published studies prevented pooling of data for a meta-analysis.We recommend combining results of ongoing RCTs with results of trials conducted after the year 2000 if no significant shifts in technology or treatment occur. Until these new results become available, data on use of ECMO in patients with acute respiratory failure remain inconclusive. For patients with acute cardiac failure or arrest, outcomes of ongoing RCTs will assist clinicians in determining what role ECMO and ECPR can play in patient care.