An extracorporeal membrane oxygenation-based approach to cardiogenic shock in an older population

Age-Related Quality of Life in Cardiac Surgical Patients with Extracorporeal Life Support

BACKGROUND

 The rationale of the study was to analyze the impact of age on quality of life (QoL) in patients who had undergone cardiac surgery with consecutive extracorporeal life support (ECLS) treatment.

METHODS

 The study population consisted of 200 patients, operated upon between August 2006 and December 2018. The patient cohort was divided into two groups following an arbitrary cutoff age of 70 years. Comparative outcome analysis was calculated utilizing the European Quality of Life-5-Dimensions-5-Level Version (EQ-5D-5L).

RESULTS

 A total of 113 patients were 70 years or less old (group young), whereas 87 patients were older than 70 years (group old). In 45.7% of cases, the ECLS system was established during cardiogenic shock and external cardiac massage. The overall survival-to-discharge was 31.5% (n = 63), with a significantly better survival in the younger patient group (young = 38.9%; old = 21.8%, p = 0.01). Forty-two patients (66%) responded to the QoL survey after a median follow-up of 4.3 years. Older patients reported more problems with mobility (y = 52%; o = 88%, p = 0.02) and self-care (y = 24%; o = 76%, p = 0.01). However, the patients' self-rated health status utilizing the Visual Analogue Scale revealed no differences (y = 70% [50-80%]; o = 70% [60-80%], p = 0.38). Likewise, the comparison with an age-adjusted German reference population revealed similar QoL indices. There were no statistically significant differences in the EQ-5D-5L index values related to sex, number of comorbidities, and emergency procedures.

CONCLUSION

 Despite the limited sample size due to the high mortality rate especially in elderly, the present study suggests that QoL of elderly patients surviving ECLS treatment is almost comparable to younger patients.

Haemodynamic support with percutaneous devices in patients with cardiogenic shock: the current evidence of mechanical circulatory support

INTRODUCTION

Cardiogenic shock (CS) is a complex life-threatening condition that results from primary cardiac dysfunction, leading to persistent hypotension and systemic hypoperfusion. Among the therapeutic options for CS are various percutaneous mechanical circulatory support (MCS) devices that have emerged as an increasingly effective hemodynamic support option. Percutaneous therapies can act as short-term mechanical circulatory assistance and can be split into intra-aortic balloon pump (IABP) and non-IABP percutaneous mechanical devices.

AREAS COVERED

This review will evaluate the MCS value while considering the mortality rate improvements. We also aim to outline the function of pharmacotherapies and percutaneous hemodynamic MCS devices in managing CS patients to avoid the onset of end-organ dysfunction and improve both early and late outcomes.

EXPERT OPINION

Given the complexity, acuity and high mortality associated with CS, and despite the availability and efficacy of pharmacological management, MCS is required to achieve hemodynamic stability and improve survival. Various percutaneous MCS devices are available with varying indications and clinical outcomes. The rates of early mortality and complications were found to be comparable between the four devices, yet, IABP seemed to show the most optimal clinical profile whilst ECMO demonstrated its more long-term efficacy.

Effect of veno-arterial extracorporeal membrane oxygenation lower-extremity cannulation on intra-arterial flow characteristics, oxygen content, and thrombosis risk

PURPOSE

This study aimed to investigate the effects of lower-extremity cannulation on the intra-arterial hemodynamic environment, oxygen content, blood damage, and thrombosis risk under different levels of veno-arterial (V-A) ECMO support.

METHODS

Computational fluid dynamics methods were used to investigate the effects of different levels of ECMO support (ECMO flow ratios supplying oxygen-rich blood 100-40 %). Flow rates and oxygen content in each arterial branch were used to determine organ perfusion. A new thrombosis model considering platelet activation and deposition was proposed to determine the platelet activation and thrombosis risk at different levels of ECMO support. A red blood cell damage model was used to explore the risk of hemolysis.

RESULTS

Our study found that partial recovery of cardiac function improved the intra-arterial hemodynamic environment, with reduced impingement of the intra-arterial flow field by high-velocity blood flow from the cannula, a flow rate per unit time into each arterial branch closer to physiological levels, and improved perfusion in the lower extremities. Partial recovery of cardiac function helps reduce intra-arterial high shear stress and residence time, thereby reducing blood damage. The overall level of hemolysis and platelet activation in the aorta decreased with the gradual recovery of cardiac contraction function. The areas at high risk of thrombosis under V-A ECMO femoral cannulation support were the aortic root and the area distal to the cannula, which moved to the descending aorta when cardiac function recovered to 40-60 %. However, with the recovery of cardiac contraction function, hypoxic blood pumped by the heart is insufficient in supplying oxygen to the front of the aortic arch, which may result in upper extremity hypoxia.

CONCLUSION

We developed a thrombosis risk prediction model applicable to ECMO cannulation and validated the model accuracy using clinical data. Partial recovery of cardiac function contributed to an improvement in the aortic hemodynamic environment and a reduction in the risk of blood damage; however, there is a potential risk of insufficient perfusion of oxygen-rich blood to organs.

Contemporary approach to cardiogenic shock care: a state-of-the-art review

Cardiogenic shock (CS) is a time-sensitive and hemodynamically complex syndrome with a broad spectrum of etiologies and clinical presentations. Despite contemporary therapies, CS continues to maintain high morbidity and mortality ranging from 35 to 50%. More recently, burgeoning observational research in this field aimed at enhancing the early recognition and characterization of the shock state through standardized team-based protocols, comprehensive hemodynamic profiling, and tailored and selective utilization of temporary mechanical circulatory support devices has been associated with improved outcomes. In this narrative review, we discuss the pathophysiology of CS, novel phenotypes, evolving definitions and staging systems, currently available pharmacologic and device-based therapies, standardized, team-based management protocols, and regionalized systems-of-care aimed at improving shock outcomes. We also explore opportunities for fertile investigation through randomized and non-randomized studies to address the prevailing knowledge gaps that will be critical to improving long-term outcomes.

Review of anticoagulation considerations in extracorporeal membrane oxygenation support

Since its first success in 1975, extracorporeal membrane oxygenation (ECMO) has been used with increasing frequency for pulmonary and cardiopulmonary bypass. Use in adults has increased exponentially since the early 2000s, but despite thousands of international cannulations using both veno-arterial (VA) and veno-venous (VV) ECMO, there are still significant hemocompatibility-related adverse events. Current management of anticoagulation has been based on the Extracorporeal Life Support Organization guidance published in 2014 with recent updates published in 2022. Despite this guidance, there is still limited international consensus on how to manage anticoagulation in ECMO. For this review, we completed a comprehensive search of multiple electronic databases to identify studies pertaining to anticoagulation of adult patients on VV or VA-ECMO. The highest priority was given to sources that were prospective, randomized, controlled studies, but in the absence of such resources, observational studies, retrospective uncontrolled studies, and case series/reports were considered for inclusion. This document serves to provide a comprehensive review of the current understanding of management pertaining to anticoagulation relating to ECMO.

The Early Introduction of Extracorporeal Membrane Oxygenation for Postcardiotomy Cardiogenic Shock Does Not Improve 30-Day Mortality Rates in Low-Volume Centers

Background and objective

Postcardiotomy cardiogenic shock (PCS) is one of the most critical conditions observed in cardiac surgery. Recently, the early initiation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been recommended for PCS patients to ensure end-organ perfusion, especially in high-volume centers. In this study, we investigated the effectiveness of earlier initiation of VA-ECMO for PCS in low-volume centers.

Methods

We retrospectively assessed patients admitted in two of our related facilities from April 2014 to March 2019. The patients who underwent VA-ECMO during peri- or post-cardiac surgery (within 48 hours) were included. We divided the patients into two groups according to the timing of VA-ECMO initiation. In the early initiation of VA-ECMO group, the “early ECMO group,” VA-ECMO was initiated when patients needed high-dose inotropic support with high-dose catecholamines, such as epinephrine, without waiting for PCS recovery. In the late initiation of VA-ECMO group, the “late ECMO group,” VA-ECMO was delayed until PCS was not controlled with high-dose catecholamines, with the intent of avoiding severe bleeding complications.

Results

A total of 30 patients were included in the analysis (early ECMO group/late ECMO group: 19/11 patients). Thirty-day mortality in the entire cohort was 60% (n=18), and there was no significant difference between the two groups (early ECMO group/late ECMO group: 64%/55%, p=0.712). Thirteen and six patients died without being weaned off in the early ECMO (43%) and late ECMO groups (55%), respectively; there was no significant difference between the two groups (p=0.696). The median duration of ECMO support was five days (IQR: 1.5-6.5).

Conclusions

The early initiation of ECMO did not contribute to patients’ 30-day outcomes in low-volume centers. To improve outcomes of ECMO therapy in patients with PCS, centralization of low-volume centers may be required.

Nosocomial Infections During Extracorporeal Membrane Oxygenation in Pediatric Patients: A Multicenter Retrospective Study

OBJECTIVE

Extracorporeal membrane oxygenation (ECMO) is increasingly used in critically ill patients with respiratory and/or cardiac failure. This study aimed to investigate the epidemiology and risk factors of nosocomial infection (NI) in pediatric patients who underwent ECMO for respiratory and/or circulatory failure.

METHODS

Medical records for patients that were administered underwent ECMO support at Xiangya Second Hospital of Central South University, The Sixth Medical Center of PLA General Hospital, and Children's Hospital Affiliation of Zhengzhou University, from September 2012 to December 2019 were retrospectively reviewed. Clinical data of the patients who developed NI were collected and analyzed. Univariate and multivariate logistic regressions were performed to identify the independent predictive factors of NI during ECMO.

RESULTS

A total of 54 first episodes of NI were identified in the 190 patients on ECMO, including 32 cases of respiratory tract infections, 20 cases of bloodstream infections, and 2 cases of surgical site wound infections. Gram-negative pathogens were the dominant pathogens isolated, accounting for 92.6% of the NI. The incidence of ECMO-related NI was 47.6 cases per 1,000 ECMO days. In the univariate logistic regression, ECMO mode, ECMO duration, ICU duration, and peritoneal dialysis were associated with the development of NI in patients with ECMO support. However, in the multivariate analysis, only ECMO duration (OR = 2.46, 95%CI: 1.10, 5.51; P = 0.029), ICU duration (OR = 1.35, 95%CI: 1.05, 1.59; P = 0.017) and peritoneal dialysis (OR = 2.69, 95%CI: 1.08, 5.73; P = 0.031) were the independent predictive factors for NI during ECMO support.

CONCLUSION

This study identified the significant correlation between ECMO-related NI and ECMO duration, ICU duration, and peritoneal dialysis. Appropriate preventive measures are needed for hospitals to reduce the incidence of ECMO in pediatric patients.

Extracorporeal membrane oxygenation in the forensic setting: A series of 19 forensic cases

Extracorporeal membrane oxygenation (ECMO) employs vascular cannulation and a gas exchange circuit to provide support to patients with severely compromised cardiopulmonary function. ECMO is often the last intervention taken before death and thus presents a unique challenge to medical examiners. This study describes the characteristics of decedents on ECMO at the time of death, including clinical indications, types of circuit configurations, causes and manners of death, gross findings at autopsy, and therapeutic complications. Files of a regional medical examiner office within an academic medical center were searched for the period between 2013 and 2019. Nineteen cases were identified with a median age of 36 years. The circumstances surrounding the initial presentation included: sudden death, trauma, substance abuse, homicide, therapeutic complication, work-related injury, drowning, and hypothermia. The underlying causes of death included injury-related, as well as respiratory and cardiac-related natural diseases. The time spent on ECMO varied from less than 1 h to 10 months. Complications encountered due to ECMO included cannulation site bleeding, pneumohemopericardium, retroperitoneal hematoma, limb ischemia, clotting, and cannula dislodgement. The patient population likely to receive ECMO has significant overlap with death circumstances likely to be reported to the medical examiner. As ECMO therapy has become increasingly available, it is of importance for medical examiners and death investigators to be familiar with the procedure as well as its limitations. Familiarity with ECMO and its sequelae allows for the proper documentation of postmortem findings and fosters an informed determination of the cause and manner of death.

Impact of age on the outcomes of extracorporeal cardiopulmonary resuscitation: analysis using inverse probability of treatment weighting

OBJECTIVES

Patient selection is crucial to improving the outcomes of extracorporeal cardiopulmonary resuscitation (ECPR). However, ECPR's efficacy with older patients remains unknown.

METHODS

We reviewed patients who underwent extracorporeal membrane oxygenation (ECMO) for refractory cardiac arrest from January 2006 to December 2018. Exclusion criteria were age <18 years, cannulation failure and ECMO applied at another hospital. We divided patients into 2 groups with an age cut-off of 66 years, using the Contal and O'Quigley method for overall survival. We performed inverse probability of treatment weighting (IPTW) between the 2 groups and set the primary outcome as overall survival.

RESULTS

We included 318 patients in our study (≤66 years, n = 199; >66 years, n = 119). Before IPTW, we observed that the older group had a higher frequency of diabetes, hypertension, and myocardial infarction. In the young group, more patients had out-of-hospital cardiac arrest as compared with the older group. The hospital mortality rate was 55% (48.7% in the young group, 65.5% in the older group; P = 0.004). In the multivariable analysis after IPTW, the older group showed worse outcomes in overall survival [hazard ratio (HR) = 2.02; 95% confidence interval (CI), 1.50-2.70; P < 0.001] and neurological outcomes at discharge (odds ratio = 2.95; 95% CI, 1.69-5.14; P = <0.001). ECMO insertion during catheterization (HR = 0.57; 95% CI, 0.36-0.90; P = 0.015) and recovery of spontaneous circulation before pump-on (HR = 0.67; 95% CI, 0.50-0.89; P = 0.007) were positive predictors, but initial asystole rhythm, non-cardiac cause (HR = 2.39; 95% CI, 1.59-3.61; P < 0.001), out-of-hospital cardiac arrest (HR = 1.86; 95% CI, 1.24-2.79; P = 0.003) and prolonged cardiopulmonary resuscitation to pump-on time (HR = 1.01; 95% CI, 1.01-1.02; P < 0.001) were negative predictors for overall survival.

CONCLUSIONS

Older patients who had ECPR had significantly worse survival and neurological outcomes. For patients older than age 66 years, more careful patient selection is critically important for improving the efficacy of ECPR.

Characteristics of Pediatric Extracorporeal Membrane Oxygenation Programs in the United States and Canada

The aim of this study was to evaluate the current infrastructure and practice characteristics of pediatric extracorporeal membrane oxygenation (ECMO) programs. A 40-question survey of center-specific demographics, practice structure, program experience, and support network utilized to cannulate and maintain a pediatric patient on ECMO was designed via a web-based survey tool. The survey was distributed to pediatric ECMO programs in the United States and Canada. Of the 101 centers that were identified to participate, 41 completed the survey. The majority of responding centers are university affiliated (73%) and have an intensive care unit (ICU) with 15-25 beds (58%). Extracorporeal membrane oxygenation has been offered for >10 years in 85% of the centers. The median number of total cannulations per center in 2017 was 15 (interquartile range [IQR] = 5-30), with the majority occurring in the cardiovascular intensive care unit (median = 13, IQR = 5-25). Fifty-seven percent of responding centers offer ECPR, with a median number of four cases per year (IQR = 2-7). Most centers cannulate in an operating room or ICU; 11 centers can cannulate in the pediatric ED. Sixty-three percent of centers have standardized protocols for postcannulation management. The majority of protocols guide anticoagulation, sedation, or ventilator management; left ventricle decompression and reperfusion catheter placement are the least standardized procedures. The majority of pediatric ECMO centers have adopted the infrastructure recommendations from the Extracorporeal Life Support Organization. However, there remains broad variability of practice characteristics and organizational infrastructure for pediatric ECMO centers across the United States and Canada.

Venoarterial Extracorporeal Membrane Oxygenation for Postcardiotomy Shock-Analysis of the Extracorporeal Life Support Organization Registry

OBJECTIVES

Refractory postcardiotomy cardiogenic shock complicating cardiac surgery yields nearly 100% mortality when untreated. Use of venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock has increased worldwide recently. The aim of the current analysis was to outline the trends in use, changing patient profiles, and in-hospital outcomes including complications in patients undergoing venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock.

DESIGN

Analysis of extracorporeal life support organization registry from January 2010 to December 2018.

SETTING

Multicenter worldwide registry.

PATIENTS

Seven-thousand one-hundred eighty-five patients supported with venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock.

INTERVENTIONS

Venoarterial extracorporeal membrane oxygenation.

MEASUREMENTS AND MAIN RESULTS

Hospital death, weaning from extracorporeal membrane oxygenation, hospital complications. Mortality predictors were assessed by multivariable logistic regression. Propensity score matching was performed for comparison of peripheral and central cannulation for extracorporeal membrane oxygenation. A significant trend toward more extracorporeal membrane oxygenation use in recent years (coefficient, 0.009; p < 0.001) was found. Mean age was 56.3 ± 14.9 years and significantly increased over time (coefficient, 0.513; p < 0.001). Most commonly, venoarterial extracorporeal membrane oxygenation was instituted after coronary artery bypass surgery (26.8%) and valvular surgery (25.6%), followed by heart transplantation (20.7%). Overall, successful extracorporeal membrane oxygenation weaning was possible in 4,520 cases (56.4%), and survival to hospital discharge was achieved in 41.7% of cases. In-hospital mortality rates remained constant over time (coefficient, -8.775; p = 0.682), whereas complication rates were significantly reduced (coefficient, -0.009; p = 0.003). Higher mortality was observed after coronary artery bypass surgery (65.4%), combined coronary artery bypass surgery with valve (68.4%), and aortic (69.6%) procedures than other indications. Lower mortality rates were observed in heart transplantation recipients (46.0%). Age (p < 0.001), central cannulation (p < 0.001), and occurrence of complications while on extracorporeal membrane oxygenation were independently associated with poorer prognosis.

CONCLUSIONS

The analysis confirmed increased use of venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock. Mortality rates remained relatively constant over time despite a decrease in complications, in the setting of supporting older patients.

Novel strategy for improved outcomes of extra-corporeal membrane oxygenation as a treatment for refractory post cardiotomy cardiogenic shock in the current era: a refreshing new perspective

OBJECTIVES

Post-cardiotomy cardiogenic shock is an infrequent but important cause of death following cardiac surgery. Extra-corporeal membrane oxygenation offers the opportunity for temporary cardiovascular support and myocardial rest, with a view to recovery. We examine our results with our recently-implemented management algorithm.

METHODS

We report our series of 15 consecutive patients out of 357 patients [4.2%] who required institution of veno-arterial extra-corporeal membrane oxygenation system support as treatment for Post-cardiotomy cardiogenic shock in the current era [January-2017 to January-2020].

RESULTS

The mean age was 64.3 ± 11.6 years (range: 40-82 years); there were 13 males (86.7%). Duration of veno-arterial extra-corporeal membrane oxygenation support was 6.7 ± 1.9 days. Duration of stay on intensive care unit [ICU] was 18.9 ± 17.1 days. Duration of hospital-stay was 28.3 ± 20.8 days. Survival to discharge and at 2.2 ± 0.9 years was 67%.

CONCLUSIONS

We have shown clearly that veno-arterial extra-corporeal membrane oxygenation is an important rescue option for patients who develop refractory post-cardiotomy cardiogenic shock, with improved survival of 67% at 2.2 ± 0.9 years in those placed on post-cardiotomy veno-arterial extra corporeal membrane oxygenation support, which is superior to that reported hitherto in literature. We have sought to highlight the successes of post cardiotomy veno-arterial extra corporeal membrane oxygenation support, with improved results, based on careful patient selection, as well as diligent management of these critically-ill patients in the postoperative period, prior to establishment of irreversible end-organ dysfunction. Our strategy has also helped us rationalize and optimize the use of this expensive treatment modality.

Understanding the "extracorporeal membrane oxygenation gap" in veno-arterial configuration for adult patients: Timing and causes of death

Timing and causes of hospital mortality in adult patients undergoing veno‐arterial extracorporeal membrane oxygenation (V‐A ECMO) have been poorly described. Aim of the current review was to investigate the timing and causes of death of adult patients supported with V‐A ECMO and subsequently define the “V‐A ECMO gap,” which represents the patients who are successfully weaned of ECMO but eventually die during hospital stay. A systematic search was performed using electronic MEDLINE and EMBASE databases through PubMed. Studies reporting on adult V‐A ECMO patients from January 1993 to December 2020 were screened. The studies included in this review were studies that reported more than 10 adult, human patients, and no mechanical circulatory support other than V‐A ECMO. Information extracted from each study included mainly mortality and causes of death on ECMO and after weaning. Complications and discharge rates were also extracted. Sixty studies with 9181 patients were included for analysis in this systematic review. Overall mortality was 38.0% (95% confidence intervals [CIs] 34.2%‐41.9%) during V‐A ECMO support (reported by 60 studies) and 15.3% (95% CI 11.1%‐19.5%, reported by 57 studies) after weaning. Finally, 44.0% of patients (95% CI 39.8‐52.2) were discharged from hospital (reported by 60 studies). Most common causes of death on ECMO were multiple organ failure, followed by cardiac failure and neurological causes. More than one‐third of V‐A ECMO patients die during ECMO support. Additionally, many of successfully weaned patients still decease during hospital stay, defining the “V‐A ECMO gap.” Underreporting and lack of uniformity in reporting of important parameters remains problematic in ECMO research. Future studies should uniformly define timing and causes of death in V‐A ECMO patients to better understand the effectiveness and complications of this support.

Vascular Complications of Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Regression Analysis

OBJECTIVES

Perform a systematic review and meta-analysis of vascular complications associated with extracorporeal membrane oxygenation and identify prognostic and predictive factors.

DATA SOURCES

Systematic search for publications reporting vascular complications on extracorporeal membrane oxygenation, published from 1972 to January 31, 2020, was conducted via PubMed, Scopus, and Embase.

STUDY SELECTION

Of 4,076 references screened, 47 studies with 6,583 patients were included in final analyses. Studies with fewer than 10 patients were excluded.

DATA EXTRACTION

Relevant data, including demographics, comorbidities, extracorporeal membrane oxygenation and cannulation characteristics, occurrence rates of early and late vascular complications, patient outcomes, and use of distal perfusion cannula, were extracted from selected articles into an excel sheet specifically designed for this review.

DATA SYNTHESIS

Random-effects meta-analyses and meta-regression analyses were undertaken. Overall pooled estimate of vascular complications in our meta-analysis was 29.5% (95% CI, 23.6-35.9%). Two-thousand three-hundred forty-seven vascular complications in 6,124 venoarterial extracorporeal membrane oxygenation patients compared with 95 in 459 venovenous extracorporeal membrane oxygenation patients (odds ratio, 2.35; 95% CI, 1.87-2.96; p < 0.0001) were analyzed. Successful weaning off extracorporeal membrane oxygenation occurred in 60.6% of pooled patients; 46.2% were eventually discharged. Pooled prevalences of vascular complications like significant bleeding, limb ischemia, and cannula site bleeding were 15.4% (95% CI, 8.6-23.7%), 12.6% (95% CI, 10.0-15.5%), and 12.6% (95% CI, 9.6-18.5%), respectively. Meta-analysis showed that the use of distal perfusion cannula was associated with lower odds of limb ischemia (odds ratio, 1.93; 95% CI, 1.17-2.47; p = 0.03) Meta-regression showed that male sex, smoking, advanced age, and comorbidities contributed to higher in-hospital mortality, while distal perfusion cannula was protective.

CONCLUSIONS

Nearly a third of patients on extracorporeal membrane oxygenation develop vascular complications; elderly males with comorbidities appear vulnerable. The use of distal perfusion cannulas caused significant reduction in limb ischemia and mortality.

30-Day perioperative mortality following venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock in patients with normal preoperative ejection fraction

OBJECTIVES

Assessment of early outcomes in patients with normal preoperative left ventricular ejection fraction (LVEF) in whom venoarterial extracorporeal membrane oxygenation (VA-ECMO) was implanted for postcardiotomy cardiogenic shock (PCCS) during the first postoperative 48 h.

METHODS

Retrospective single-centre analysis in adult patients with normal LVEF, who received VA-ECMO support for PCCS from May 1998 to May 2018. The primary outcome was 30-day perioperative mortality during the index hospitalization.

RESULTS

A total of 62 125 adult patients underwent cardiac surgery at our institution during the study period. Among them, 173 patients (0.3%) with normal preoperative LVEF required VA-ECMO for PCCS. Among them, 71 (41.1%) patients presented PCCS due to coronary malperfusion and in 102 (58.9%) patients, no evident cause was found for PCCS. Median duration of VA-ECMO support was 5 days (interquartile range 2-8 days). A total of 135 (78.0%) patients presented VA-ECMO-related complications and the overall 30-day perioperative mortality was 57.8%. Independent predictors of mortality were: lactate level just before VA-ECMO implantation [odds ratio (OR) 1.27; P < 0.001], major bleeding during VA-ECMO (OR 3.76; P = 0.001), prolonged cardiopulmonary bypass time (OR 1.01; P < 0.001) and female gender (OR 4.87; P < 0.001).

CONCLUSIONS

Mortality rates of VA-ECMO in PCCS patients are high, even in those with preoperative normal LVEF. Coronary problems are an important cause of PCCS; however, the aetiology remains unknown in the vast majority of the cases. The implantation of VA-ECMO before development of tissue hypoperfusion and the control of VA-ECMO-associated complications are the most important prognostic factors in PCCS patients. Lactate levels may help guide timing of VA-ECMO implantation and define the extent of therapeutic effort.

A Systematic Literature Review of Packed Red Cell Transfusion Usage in Adult Extracorporeal Membrane Oxygenation

Background: Blood product administration plays a major role in the management of patients treated with extracorporeal membrane oxygenation (ECMO) and may be a contributor to morbidity and mortality. Methods: We performed a systematic review of the published literature to determine the current usage of packed red cell transfusions. Predefined search criteria were used to identify journal articles reporting transfusion practice in ECMO by interrogating EMBASE and Medline databases and following the PRISMA statement. Results: Out of 1579 abstracts screened, articles reporting ECMO usage in a minimum of 10 adult patients were included. Full texts of 331 articles were obtained, and 54 were included in the final analysis. All studies were observational (2 were designed prospectively, and two were multicentre). A total of 3808 patients were reported (range 10–517). Mean exposure to ECMO was 8.2 days (95% confidence interval (CI) 7.0–9.4). A median of 5.6% was not transfused (interquartile range (IQR) 0–11.3%, 19 studies). The mean red cell transfusion per ECMO run was 17.7 units (CI 14.2–21.2, from 52 studies) or 2.60 units per day (CI 1.93–3.27, from 49 studies). The median survival to discharge was 50.8% (IQR 40.0–64.9%). Conclusion: Current evidence on transfusion practice in ECMO is mainly drawn from single-centre observational trials and varies widely. The need for transfusions is highly variable. Confounding factors influencing transfusion practice need to be identified in prospective multicentre studies to mitigate potential harmful effects and generate hypotheses for interventional trials.

Do-(Not-)Mechanical-Circulatory-Support Orders: Should We Ask All Cardiac Surgery Patients for Informed Consent for Post-Cardiotomy Extracorporeal Life Circulatory Support?

Post-cardiotomy extracorporeal life support (PC-ECLS) has seen a substantial increase in use over the past 10 years. PC-ECLS can be a life-saving procedure and is mostly applied in the presence of unexpected, severe cardio-respiratory complication. Despite PC-ECLS being critical in allowing for organ recovery, it is unfortunately closely connected with an unpredictable outcomes, high morbidity, and, even in the case of cardiac function improvement, potential sustained disabilities that have a life-changing impact for the patient and his or her family. Since the decision to start PC-ECLS is made in an acute setting, there is often only limited or no time for self-determined choices. Due to the major impact of the intervention, it would be highly desirable to obtain informed consent before starting PC-ECLS, since the autonomy of the patient and shared-decision making are two of the most important ethical values in modern medicine. Recent developments regarding awareness of the impacts of a prolonged intensive care stay make this a particularly relevant topic. Therefore, it would be desirable to develop a structural strategy that takes into account the likelihood of such an intervention and the wishes and preferences of the patient, and thus the related autonomy of the patient. This article proposes key points for such a strategy in the form of a PC-ECLS informed consent, a do-(not-)mechanical-circulatory-support order (D(N)MCS), and specific guidelines to determine the extent of the shared decision making. The concept presented in this article could be a starting point for improved and ethical PC-ECLS treatment and application.

Postcardiotomy mechanical support in patients with mitral valve prostheses is associated with poor survival

AIMS

To elaborate on early survival in patients with mitral valve replacement requiring temporary extracorporeal life support system (ECLS).

METHODS

We analyzed survival, significant bleeding, wound infection, and ECLS duration in 421 from 14,400 patients with postoperative need for ECLS from January 2008 to December 2017 at our institution. Finally, patients were stratified according to the type of surgery performed: the mitral group (mitral valve replacement) n = 63 and the control group (any cardiac surgery excluding the mitral valve) n = 358. In order to adjust for preoperative patient characteristics, a propensity matching analysis was performed. Differences in in-hospital mortality were analyzed accordingly.

RESULTS

In-hospital mortality was significantly higher in the mitral group as compared to the control group before and after adjustment (p < 0.001). Median duration of ECLS was 4 days in both groups. Perioperative bleeding (p < 0.001) and wound infection (p < 0.001) also showed significant worse outcome parameters in the mitral group. The main causes of death in the mitral group were multiorgan failure, n = 48 (76%), stroke, n = 7 (12%), and intracardiac thrombus formation, n = 5 (10%).

CONCLUSIONS

ECLS is associated with a high in-hospital mortality rate in patients after mitral valve replacement.

Risk Factors for Developing Severe Acute Kidney Injury in Adult Patients With Refractory Postcardiotomy Cardiogenic Shock Receiving Venoarterial Extracorporeal Membrane Oxygenation

OBJECTIVES

Postcardiotomy cardiogenic shock occurs in 2-6% of patients undergoing cardiac surgery, and 1% of cardiac surgery patients will require mechanical circulatory support using venoarterial extracorporeal membrane oxygenation. Acute kidney injury is a frequent complication in this population and negatively impacts the survival. We aimed to determine whether the timing of extracorporeal membrane oxygenation implantation influences the renal prognosis of these patients.

DESIGN

Retrospective observational cohort study between January 2013 and December 2016.

SETTING

An 18-bed surgical ICU in a university hospital.

PATIENTS

A total of 4,796 consecutive adult patients who underwent cardiac surgery were included in the study, and 347 (7.2%) were assisted with venoarterial extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock. The patients who died during the first 48 hours after venoarterial extracorporeal membrane oxygenation implantation were excluded. The complete-case analysis included 257 patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the occurrence, within 10 days following the venoarterial extracorporeal membrane oxygenation implantation, of a stage 3 acute kidney injury defined by the Kidney Disease: Improving Global Outcomes group. One hundred sixty-nine patients (65.7%) presented with a Kidney Disease: Improving Global Outcomes stage 3 acute kidney injury; 14 patients (5.4%) died before the end of the follow-up period, without developing the primary outcome. Ninety-two percent of patients with Kidney Disease: Improving Global Outcomes 3 acute kidney injury received renal replacement therapy, for a median duration of 7 days (3-16 d). Late implantation of venoarterial extracorporeal membrane oxygenation was independently associated with an increased risk of Kidney Disease: Improving Global Outcomes stage 3 acute kidney injury (odds ratio, 2.81 [95% CI, 1.31-6.07]; p = 0.008). The other factors associated with Kidney Disease: Improving Global Outcomes stage 3 acute kidney injury were preoperative left ventricular ejection fraction (odds ratio, 1.03 [95% CI, 1.01-1.05]; p = 0.007), intraoperative plasma transfusion (odds ratio, 1.13 [95% CI, 1.02-1.26]; p = 0.022), increased bilirubinemia level (odds ratio, 1.013 [95% CI, 1.001-1.026]; p = 0.032), and increased creatinine levels (odds ratio, 1.012 [95% CI, 1.006-1.018]; p < 0.001) on the day of implantation.

CONCLUSIONS

Significant kidney dysfunction is particularly frequent in patients with refractory postcardiotomy cardiogenic shock assisted with venoarterial extracorporeal membrane oxygenation. Early implantation of extracorporeal membrane oxygenation may help prevent acute kidney injury.

Postcardiotomy extracorporeal membrane oxygenator: No longer a bridge to no where?

BACKGROUND

Postcardiotomy extracorporeal membrane oxygenation (PC-ECMO) represents a unique subset of critically ill patients, with a paucity of data regarding long-term survival and correlated characteristics. We present a retrospective cohort of PC-ECMO patients, with outcomes at 1 and 3 years.

METHODS

Data were collected retrospectively for all patients requiring ECMO within 72 hours of an index cardiac operation (excluding assist devices and transplants). Primary outcomes were the ability to wean from ECMO, hospital survival, and long-term survival.

RESULTS

Thirty-one patients required PC-ECMO, representing a total of 172 days of ECMO support. Overall survival data were the ability to wean 58%, hospital survival 52%, 1-month survival 42%. The estimated 12- and 36-month survival for all PC-ECMO patients was 35% and 29%, respectively. Twelve and 36-month survival for all hospital survivors was 62% and 56%. Operative times, the Society of Thoracic Surgeons risk scores, type of operation, open chest status, hemorrhage, and cannulation location, and timing were all compared. Centrally cannulated patients were more likely to wean from ECMO (83% vs 44%; P = .03), and survive hospitalization (75% vs 36%; P = .04) and trended toward long-term survival benefit (67% vs 33%; P = .06). Otherwise, no statistically significant relationships were observed.

CONCLUSIONS

Central cannulation may provide benefits in the postcardiotomy patient, compared to peripheral strategies. Twelve and 36-month survival for all PC-ECMO patients was 35% and 29%. For hospital survivors, 12 and 36-month survival 62% 56% at 36. These data support PC-ECMO as a reasonable salvage strategy, with midterm survival comparable to other surgically treated diseases.

30-Day Outcomes Post Veno-Arterial Extra Corporeal Membrane Oxygenation (VA-ECMO) After Cardiac Surgery and Predictors of Survival

BACKGROUND

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is sometimes needed for post-cardiotomy cardiogenic shock (PCCS). There is little data regarding outcomes in the Australian context, particularly in a non-cardiac transplant centre. Our aim was to report on 30-day outcomes after patients with PCCS treated with VA-ECMO in an Australian non-cardiac transplant tertiary centre, and to determine risk factors for non-survival in this population.

METHODS

A retrospective analysis was performed on all adults treated with VA-ECMO for PCCS between August 2001 and September 2016 at our centre. Univariate analysis with adjustment for multiplicity identified risk factors for non-survival. Area under the receiver operating characteristics (AUROC) method was used to assess their predictive value.

RESULTS

We identified 64 patients out of 5,502 open-heart surgery cases of which three patients did not meet inclusion criteria. Mean (SD) age was 63 (14) years. Survival to hospital discharge or 30 days post VA-ECMO occurred in 27/61 (44%) patients. VA-ECMO was able to be weaned in 44/61 patients (72%); 54/61 patients (89%) had at least one major complication. Prior to VA-ECMO initiation, no statistically significant differences between survivors and non-survivors could be determined. After VA-ECMO initiation, only 24-hour nadir lactate and 48-hour nadir lactate levels were significantly different between survivors and non-survivors (1.50 mmol/L vs 3.20 mmol/L p=0.001; and 1.20 mmol/L vs. 1.90 mmol/L p=0.001 respectively). For mortality prediction, 24- and 48-hour nadir lactate levels had AUROCs of 0.775 and 0.782, respectively.

CONCLUSIONS

VA-ECMO is associated with acceptable survival rates but significant morbidity. Nadir lactate levels in the first 24 and 48 hours after VA-ECMO initiation may be useful in predicting early survival.

Risk factors of in-hospital mortality in adult postcardiotomy cardiogenic shock patients successfully weaned from venoarterial extracorporeal membrane oxygenation

OBJECTIVE

Mortality of adult postcardiotomy cardiogenic shock patients after successfully weaned from venoarterial extracorporeal membrane oxygenation remains high. The objective of this study is to identify the risk factors associated with mortality after successfully weaning from venoarterial extracorporeal membrane oxygenation in adult postcardiotomy cardiogenic shock patients.

METHODS

All consecutive patients who were successfully weaned from venoarterial extracorporeal membrane oxygenation between January 2011 and December 2016 at the Beijing Anzhen Hospital were analyzed retrospectively. Multivariate logistic regression was performed to identify risk factors associated with in-hospital mortality after successfully weaning from venoarterial extracorporeal membrane oxygenation.

RESULTS

In total, 212 (58.4%) of 363 postcardiotomy cardiogenic shock patients were successfully weaned from venoarterial extracorporeal membrane oxygenation. The non-survivors had a longer duration of extracorporeal membrane oxygenation than the survivors (120.0 (98.0, 160.50) vs. 100.0 (77.0, 126.0), p = 0.000). Variables associated with mortality of patients successfully weaned from extracorporeal membrane oxygenation by univariable analysis were age, diabetes, vasoactive inotropic score pre-extracorporeal membrane oxygenation, vasoactive inotropic score at weaning, left ventricular ejection fraction at weaning, central venous pressure at weaning, sequential organ failure assessment score pre-extracorporeal membrane oxygenation, sequential organ failure assessment at weaning, survival after venoarterial ECMO pre-extracorporeal membrane oxygenation, and survival after venoarterial ECMO at weaning. In the multivariate analysis, sequential organ failure assessment score at weaning (odds ratio = 1.889, 95% confidence interval = 1.460-2.455, p < 0.001) was an independent risk factor for in-hospital mortality of patients successfully weaned from venoarterial extracorporeal membrane oxygenation. The cumulative 30-day survival rate in patients with a sequential organ failure assessment score < 7 was significantly (p < 0.001) higher than in patients with a sequential organ failure assessment score ⩾ 7 (87% vs. 56.7%, p < 0.001).

CONCLUSION

Vasoactive inotropic score, left ventricular ejection fraction, central venous pressure, and sequential organ failure assessment score at weaning were associated with in-hospital mortality for postcardiotomy cardiogenic shock patients successfully weaned from venoarterial extracorporeal membrane oxygenation. Sequential organ failure assessment score might help clinicians to predict in-hospital mortality for patients successfully weaned from venoarterial extracorporeal membrane oxygenation.

Structured review of post-cardiotomy extracorporeal membrane oxygenation: part 1-Adult patients

Cardiogenic shock, cardiac arrest, acute respiratory failure, or a combination of such events, are all potential complications after cardiac surgery which lead to high mortality. Use of extracorporeal temporary cardio-circulatory and respiratory support for progressive clinical deterioration can facilitate bridging the patient to recovery or to more durable support. Over the last decade, extracorporeal membrane oxygenation (ECMO) has emerged as the preferred temporary artificial support system in such circumstances. Many factors have contributed to widespread ECMO use, including the relative ease of implantation, effectiveness, versatility, low cost relative to alternative devices, and potential for full, not just partial circulatory support. While there have been numerous publications detailing the short and midterm outcomes of ECMO support, specific reports about post-cardiotomy ECMO (PC-ECMO), are limited, single-center experiences. Etiology of cardiorespiratory failure leading to ECMO implantation, associated ECMO complications, and overall patient outcomes may be unique to the PC-ECMO population. Despite the rise in PC-ECMO use over the past decade, short-term survival has not improved. This report, therefore, aims to present a comprehensive overview of the literature with respect to the prevalence of ECMO use, patient characteristics, ECMO management, and in-hospital and early post-discharge patient outcomes for those treated for post-cardiotomy heart, lung, or heart-lung failure.

Limb ischemia in peripheral veno-arterial extracorporeal membrane oxygenation: a narrative review of incidence, prevention, monitoring, and treatment

Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is an increasingly adopted life-saving mechanical circulatory support for a number of potentially reversible or treatable cardiac diseases. It is also started as a bridge-to-transplantation/ventricular assist device in the case of unrecoverable cardiac or cardio-respiratory illness. In recent years, principally for non-post-cardiotomy shock, peripheral cannulation using the femoral vessels has been the approach of choice because it does not need the chest opening, can be quickly established, can be applied percutaneously, and is less likely to cause bleeding and infections than central cannulation. Peripheral ECMO, however, is characterized by a higher rate of vascular complications. The mechanisms of such adverse events are often multifactorial, including suboptimal arterial perfusion and hemodynamic instability due to the underlying disease, peripheral vascular disease, and placement of cannulas that nearly occlude the vessel. The effect of femoral artery damage and/or significant reduced limb perfusion can be devastating because limb ischemia can lead to compartment syndrome, requiring fasciotomy and, occasionally, even limb amputation, thereby negatively impacting hospital stay, long-term functional outcomes, and survival. Data on this topic are highly fragmentary, and there are no clear-cut recommendations. Accordingly, the strategies adopted to cope with this complication vary a great deal, ranging from preventive placement of antegrade distal perfusion cannulas to rescue interventions and vascular surgery after the complication has manifested.This review aims to provide a comprehensive overview of limb ischemia during femoral cannulation for VA-ECMO in adults, focusing on incidence, tools for early diagnosis, risk factors, and preventive and treating strategies.

Outcomes of early versus delayed initiation of extracorporeal life support in cardiac surgery

Background

Extracorporeal membrane oxygenation offers temporary hemodynamic support for patients with refractory cardiogenic shock after cardiovascular surgery. However, the initiation time for such patients is controversial. Changing the initiation time might improve the outcomes. This study aimed to investigate whether early extracorporeal membrane oxygenation could improve postoperative outcomes in patients at a high risk of cardiogenic shock.

Methods

In this retrospective study, 173 patients with cardiovascular diseases at a high risk of refractory cardiogenic shock which assessed via empirical risk evaluation from 2010 to 2017 were included. After propensity matching, 36 patients, who were matched to patients initiated with extracorporeal membrane oxygenation after cardiovascular operation (delayed extracorporeal membrane oxygenation group, n = 36), were also initiated with such early in the operating room (early extracorporeal membrane oxygenation group, n = 36). The primary outcome was death. The secondary outcomes included receiving continuous renal replacement therapy, ventricular arrhythmia, and pulmonary infection.

Results

The demographic and baseline variables were similar between the matched groups. The early extracorporeal membrane oxygenation group showed lower mortality (69.44% vs 41.67%, P = 0.03), pulmonary infection morbidity (86.11% vs 55.56%, P < 0.01), and continuous renal replacement therapy rate(88.89% vs 66.67%, P = 0.04). Moreover, they showed improved cardiac index (P = 0.01) and lactate clearance (P < 0.01).

Conclusions

Extracorporeal membrane oxygenation provides effective support for cardiogenic failure refractory to medical management; early initiation improves cardiac output and promotes lactate clearance, thus increasing survival in patients with cardiogenic shock after cardiovascular surgery.

Trial registration

This is a retrospective study. It was not registered.

Concurrent initiation of intra-aortic balloon pumping with extracorporeal membrane oxygenation reduced in-hospital mortality in postcardiotomy cardiogenic shock

Background

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is widely used in postcardiotomy cardiac shock (PCS). The factors that affect mortality in patients who receive ECMO for PCS remain unclear. In this study, we analyzed the outcomes, predictive factors and complications of ECMO use for PCS.

Methods

A total of 152 adult subjects who received VA-ECMO for PCS in Fuwai Hospital were consecutively included. We retrospectively collected the baseline characteristics, outcomes and complications. Baseline characteristics were compared between survivors with non-survivors, and logistic regression was performed to identify predictive factors for in-hospital mortality.

Results

The mean age of the subjects was 49.5 ± 14.1 years, with a male dominancy of 73.7%. The main surgical procedures were heart transplantation (32.2%), coronary artery bypass graft (17%) and valvular surgery (11.8%). Intra-aortic balloon pumping (IABP) was initiated concurrently with ECMO in 32.2% subjects and sequentially in 18.4% subjects. The ECMO weaning rate was 56.6%, and the in-hospital mortality was 52.0%. When compared with non-survivors, survivors had less hypertension (15.1% vs. 35.4%, p = 0.004), secondary thoracotomy before ECMO initiation (19.2% vs. 39.2%, p = 0.007), pre-ECMO cardiac arrest/ventricular fibrillation (11.0% vs. 34.2%, p = 0.001), bedside implantation of ECMO (11.0% vs. 41.8%, p < 0.001), and more transplant procedure (45.2% vs. 20.3%, p = 0.001), concurrent IABP initiation with ECMO (41.1% vs. 24.1%, p = 0.025). Multivariate logistic regression indicated concurrent IABP initiation with ECMO was the only independent protective factor for in-hospital mortality (OR = 0.375, p = 0.041, 95% CI 0.146–0.963). Concurrent IABP initiation with ECMO had less need for continuous renal replacement therapy (30.6% vs. 49.3%, p = 0.039) and less neurological complications (8.2% vs. 22.7%, p = 0.035), but more thrombosis complications (18.4% vs. 2.7%, p = 0.007).

Conclusion

Concurrent initiation of IABP with ECMO provides better short-term survival for PCS, with reduced peripheral perfusion complications.

Concurrent Implantation of Intra-Aortic Balloon Pump and Extracorporeal Membrane Oxygenation Improved Survival of Patients With Postcardiotomy Cardiogenic Shock

The aim of this study is to report the combined application of extracorporeal membrane oxygenation (ECMO) with intra‐aortic balloon pumping (IABP) in postcardiotomy cardiac shock (PCS). A total of 60 consecutive patients who received both ECMO and IABP (concomitantly 24 hours) for PCS from February 2006 to March 2017 at Fuwai Hospital were included in our study. Clinical characteristics of the patients were collected retrospectively and compared between survivors and non‐survivors. Logistic regression analysis was used as predictors for survival to discharge. The study cohort had a mean age of 51.4±12.7 years with 75% males. ECMO was implanted intra‐operatively in 38 (63%) patients and post‐operatively in 22 (37%) patients. ECMO was implanted concurrently with IABP in 38 (63%) patients. Heart transplantation (38%) and coronary artery bypass graft (33%) were the main surgical procedures. ECMO was weaned successfully in 48% patients, and the rate of survival to discharge was 43%. Survivors showed less bedside ECMO implantation (12% vs. 41%, P=0.012) and more concurrent implantation of ECMO with IABP (81% vs. 50%, P=0.014). Concurrent implantation of IABP with ECMO (OR=0.177, P=0.015, 95% CI: 0.044‐0.718) was an independent predictor of survival to discharge. As for complications, the rate of renal failure (59% vs. 15%, P=0.001) and multiple organ dysfunction syndrome (29% vs. 0, P=0.003) was higher in patients who failed to survive to discharge. Patients who had heart transplantation had a better long‐term survival than others (P=0.0358). In summary, concurrent implantation of ECMO with IABP provides better short‐term outcome for PCS and combined application of ECMO with IABP for PCS after heart transplantation had a favorable long‐term outcome.

Percutaneous Bridge to Heart Transplantation by Venoarterial ECMO and Transaortic Left Ventricular Venting

We report a case in which life support for cardiogenic shock was achieved by a nonpulsatile venoarterial bypass, and left ventricular decompression was obtained by a catheter placed percutaneously through the aortic valve into the left ventricle. The blood drained from the left ventricle was pumped into the femoral artery. The normalization of left heart filling pressures allowed the resolution of pulmonary edema, and the patient underwent a successful heart transplantation following 7 days of mechanical cardiocirculatory support.

Extracorporeal membrane oxygenation in adult patients with acute fulminant myocarditis : Clinical outcomes and risk factor analysis

BACKGROUND

Our study aimed to summarize the clinical outcomes of extracorporeal membrane oxygenation (ECMO) in adult patients with acute fulminant myocarditis and to investigate the risk factors associated with its application.

PATIENTS AND METHODS

We retrospectively examined patients with cardiogenic shock and acute fulminant myocarditis. The following data were collected: patients' preoperative general condition, related clinical factors during ECMO, complications, and outcomes of ECMO. The patients were divided into a survivor group and a nonsurvivor group.

RESULTS

From a total of 33 patients, seven died in hospital. The survival rate was 78.7%. The following complications were observed during ECMO: 16 cases of acute renal failure (48.4%), seven cases of sepsis (21.2%), six cases of pulmonary infection (18.1%), six cases of multiple organ failure (MOF; 18.1%), three cases of cerebral hemorrhage (9%), and four cases of limb ischemia (12.1%). Pre-ECMO cardiopulmonary resuscitation, high levels of lactic acid, high amounts of blood transfusion during ECMO, renal failure, encephalorrhagia, gastrointestinal complications, lower-limb ischemia, high bilirubin levels, and MOF during ECMO were associated with unfavorable patient outcomes.

CONCLUSION

ECMO is an effective auxiliary tool for treating acute fulminant myocarditis. Acute renal failure is the most common complication during ECMO. Improving tissue perfusion, reducing blood transfusions, and preventing acute kidney failure may improve patient outcomes.

Impact of Right Ventricular Performance in Patients Undergoing Extracorporeal Membrane Oxygenation Following Cardiac Surgery

BACKGROUND

Extracorporeal membrane oxygenation following cardiac surgery safeguards end-organ oxygenation but unfavorably alters cardiac hemodynamics. Along with the detrimental effects of cardiac surgery to the right heart, this might impact outcome, particularly in patients with preexisting right ventricular (RV) dysfunction. We sought to determine the prognostic impact of RV function and to improve established risk-prediction models in this vulnerable patient cohort.

METHODS AND RESULTS

Of 240 patients undergoing extracorporeal membrane oxygenation support following cardiac surgery, 111 had echocardiographic examinations at our institution before implantation of extracorporeal membrane oxygenation and were thus included. Median age was 67 years (interquartile range 60-74), and 74 patients were male. During a median follow-up of 27 months (interquartile range 16-63), 75 patients died. Fifty-one patients died within 30 days, 75 during long-term follow-up (median follow-up 27 months, minimum 5 months, maximum 125 months). Metrics of RV function were the strongest predictors of outcome, even stronger than left ventricular function (P<0.001 for receiver operating characteristics comparisons). Specifically, RV free-wall strain was a powerful predictor univariately and after adjustment for clinical variables, Simplified Acute Physiology Score-3, tricuspid regurgitation, surgery type and duration with adjusted hazard ratios of 0.41 (95%CI 0.24-0.68; P=0.001) for 30-day mortality and 0.48 (95%CI 0.33-0.71; P<0.001) for long-term mortality for a 1-SD (SD=-6%) change in RV free-wall strain. Combined assessment of the additive EuroSCORE and RV free-wall strain improved risk classification by a net reclassification improvement of 57% for 30-day mortality (P=0.01) and 56% for long-term mortality (P=0.02) compared with the additive EuroSCORE alone.

CONCLUSIONS

RV function is strongly linked to mortality, even after adjustment for baseline variables and clinical risk scores. RV performance improves established risk prediction models for short- and long-term mortality.

Anticoagulation practices and the prevalence of major bleeding, thromboembolic events, and mortality in venoarterial extracorporeal membrane oxygenation: A systematic review and meta-analysis

PURPOSE

The purpose was to evaluate the safety of anticoagulation in venoarterial extracorporeal membrane oxygenation (VA-ECMO).

DESIGN

We performed a systematic review and meta-analysis using multiple electronic databases. Studies were from 1977 to September 27, 2016. We evaluated the effect of anticoagulation in VA-ECMO on outcomes including major bleeding, thromboembolic events, and in-hospital mortality using a random effects model meta-analysis.

RESULTS

Twenty-six studies (1496 patients) were included. Ten studies only had patients with postcardiotomy shock, 4 studies only included extracorporeal cardiopulmonary resuscitation patients, and 10 studies had a mixture of patients. Most studies (n=17) were low quality with a Newcastle-Ottawa Scale score ≤5. The summary prevalence of major bleeding was 27% (95% confidence interval [CI], 18%-35%), with considerable between-study heterogeneity (I²=91%). Major bleeding requiring reoperation was the most common bleeding event. The summary prevalence of thromboembolic events was 8% (95% CI, 4%-13%; I²=83%). Limb ischemia, circuit-related clotting, and stroke were the most commonly reported events. The summary prevalence for in-hospital mortality was 59% (95% CI, 52%-67%; I²=78%).

CONCLUSIONS

The optimal targets and strategies for anticoagulation in VA-ECMO are unclear. Evaluation of major bleeding and thromboembolic events is limited by study quality and between-study heterogeneity. Clinical trials are needed to investigate the optimal anticoagulation strategy.

Venoarterial Extracorporeal Membrane Oxygenation for Refractory Cardiogenic Shock in Elderly Patients: Trends in Application and Outcome From the Extracorporeal Life Support Organization (ELSO) Registry

BACKGROUND

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock (RCS) is increasingly used in adult patients, but age represents a controversial factor in this setting.

METHODS

Data from the Extracorporeal Life Support Organization registry was analyzed to assess in-hospital survival of elderly patients (≥70 years of age) undergoing VA-ECMO for RCS from 1992 to 2015. In-hospital survival and complications for elderly patients were compared with data in younger adults (≥18 to <70 years of age) supported with VA-ECMO during the same time period for similar indications.

RESULTS

The mean age of the patient cohort (n = 5,408) was 53.0 ± 15.7 years (range, 18 to 91 years). The elderly group included 735 patients (13.6%), with a mean age of 75.2 ± 4.4 years. In the elderly group, pre-ECMO cardiac procedures were performed in 134 cases (18.9%), and 2.2% received VA-ECMO for postcardiotomy support compared with 0.7% in the younger cohort. The mean duration of VA-ECMO in the elderly group was 101 ± 91 h compared with 138 ± 146 h in the younger group (p < 0.001). Overall, survival to hospital discharge for the entire adult cohort was 41.4% (2,240 of 5,408), with 30.5% (224 of 735) in the elderly patient group and 43.1% (2,016 of 4,673) in the younger patient group (p < 0.001). Elderly patients had a higher rate of multiorgan failure. At multivariable analysis age represented an independent negative predictor of in-hospital survival.

CONCLUSIONS

Based on the acceptable survival to hospital discharge in our study, older age alone should not represent an absolute contraindication when considering VA-ECMO support for RCS.

Examining Noncardiac Surgical Procedures in Patients on Extracorporeal Membrane Oxygenation

As extracorporeal membrane oxygenation (ECMO) is increasingly used for patients with cardiac and/or pulmonary failure, the need for noncardiac surgical procedures (NCSPs) in these patients will continue to increase. This study examined the NCSP required in patients supported with ECMO and determined which variables affect outcomes. The National Inpatient Sample Database was examined for patients supported with ECMO from 2007 to 2010. There were 563 patients requiring ECMO during the study period. Of these, 269 (47.8%) required 380 NCSPs. There were 149 (39.2%) general surgical procedures, with abdominal exploration/bowel resection (18.2%) being most common. Vascular (29.5%) and thoracic procedures (23.4%) were also common. Patients requiring NCSP had longer median length of stay (15.5 vs. 9.2 days, p = 0.001), more wound infections (7.4% vs. 3.7%, p = 0.02), and more bleeding complications (27.9% vs. 17.3%, p = 0.01). The incidences of other complications and inpatient mortality (54.3% vs. 58.2%, p = 0.54) were similar. On logistic regression, the requirement of NCSPs was not associated with mortality (odds ratio [OR]: 0.91, 95% confidence interval [CI]: 0.68-1.23, p = 0.17). However, requirement of blood transfusion was associated with mortality (OR: 1.70, 95% CI: 1.06-2.74, p = 0.03). Although NCSPs in patients supported with ECMO does not increase mortality, it results in increased morbidity and longer hospital stay.

Postcardiotomy ECMO Support after High-risk Operations in Adult Congenital Heart Disease

BACKGROUND

Cardiac operations in high-risk adult congenital heart disease (ACHD) patients may require mechanical circulatory support (MCS), such as extracorporeal membrane oxygenation (ECMO) or intraaortic balloon pump (IABP), to allow the cardiopulmonary system to recover.

METHODS

We reviewed records for all ACHD patients who required MCS following cardiotomy at our institution from 1/2001 to 12/2013.

RESULTS

During the study period, 2264 (mean age 39.1 years, females ∼54.1%) operations were performed in ACHD patients of whom 24 (1.1%) required postoperative MCS (14 males; median age 41 years, range 22-75). Preoperatively the 24 patients had a mean systemic ventricular ejection fraction of 47% (range 10-66%); 72% of these patients were in NYHA class III/IV heart failure. The common underlying diagnoses included pulmonary atresia with intact ventricular septum (20%), tetralogy of Fallot (16%), Ebstein anomaly (12%), cc-TGA (12%), septal defects (12%), and others (28%). Operations performed were valvular operations with/without maze (58.2%), Fontan conversion (21%), coronary bypass grafting with valvular operations (12.5%), and heart transplant (8.3%). Indications for MCS were left-sided (systemic) heart failure (32%), right-sided (subpulmonary) heart failure (24%), biventricular heart failure (36%), persistent arrhythmia (4%), and hypoxemia (4%). Forty-two percent were placed on ECMO only; in the second group, IABP was attempted and subsequently followed by ECMO initiation. The mean duration of MCS was 8.4 days (range 0.8-35.4). Common morbidities included coagulopathy (60%), renal failure (56%), and arrhythmia (48%). Overall, 46% of patients survived to hospital discharge. Deaths were due to either multi organ failure or the underlying cardiac disease; sepsis was the primary cause of death in one patient. Median follow-up for survivors was 41 months (maximum 106 months). NYHA functional class was I/II in all 8 late survivors.

CONCLUSIONS

Following complex operations in high-risk ACHD patients, MCS may be required. Despite significant morbidity, nearly half of patients survive to hospital discharge.

Temporary Venoarterial Extracorporeal Membrane Oxygenation: Ten-Year Experience at a Cardiac Transplant Center

Objective:

Advances in extracorporeal membrane oxygenation (ECMO) have enabled rapid deployment in a wide range of clinical settings. We report our experience with venoarterial (VA) ECMO in adult patients over 10 years and aim to identify predictors of mortality.

Design:

This is a retrospective analysis of all adult patients undergoing VA ECMO at a tertiary care center from January 1, 2004, to December 31, 2013.

Results:

A total of 224 consecutive cases were reviewed. Eighty (35.7%) patients survived to discharge and 144 (64.3%) patients died. Patients requiring ECMO for heart transplant graft failure had lower mortality (51.6%) compared to all other etiologies (69.1%; P = .02). Forty-two percent (94 of the 224) of the patients required cardiopulmonary resuscitation (CPR) preceding ECMO and had higher rate of in-hospital mortality (74.5%) compared with patients without cardiac arrest (56.9%; P = .01). Patients with less than 30 minutes of CPR had a mortality rate of 40.0% compared to 91.4% for CPR > 30 minutes ( P = .001). In all, 24.1% of patients (54 of the 224) experienced ECMO-associated complications without significant increase in mortality, and 22.3% (50 of the 224) of the patients were transitioned to ventricular assist devices (VADs) or transplant. Patients bridged to a VAD including left ventricular assist devices and biventricular assist devices had a mortality rate of 56.1% versus 22.2% when bridged directly to transplant ( P = .01). Paradoxically, patients with an ejection fraction (EF) > 35% had a higher mortality compared to patients with an EF < 35% (75.3% vs 49.4%, respectively, P = .001).

Conclusion:

Extracorporeal membrane oxygenation in patients with heart transplant graft failure had the best outcome. In patients who had cardiac arrest, prolonged CPR > 30 minutes was associated with very high mortality. Paradoxically, patients with EF > 35% had a higher mortality than patients with EF < 35%, likely reflecting patients with diastolic heart failure or noncardiac causes necessitating ECMO. For transplant candidates, direct bridge from ECMO to transplant could achieve a very good outcome.

Extracorporeal cardiopulmonary resuscitation for adult patients who underwent post-cardiac surgery

Background

Refractory cardiac arrest (CA) occasionally develops in patients after cardiac surgery.

Objective

To examine the clinical outcomes of extracorporeal cardiopulmonary resuscitation (ECPR) in adult patients with post-cardiotomy CA.

Methods

This was a retrospective study of the 9-year experience (from January 2004 to May 2012) of the Beijing Anzhen Hospital with ECPR in adult patients with post-cardiotomy CA. At this hospital, a dedicated ECPR team is available 24/7 for emergency cases requiring ECPR. Demographic data, biochemical data, survival, morbidity, and complications were examined before, during, and after ECPR. Outcomes were compared between survivors and non-survivors.

Results

Twenty-four adult patients (19 men and 5 women; mean age: 59.3 ± 11.9 years) received ECPR support for post-cardiotomy CA. The cardiac surgery procedures included coronary artery bypass grafting (n = 20, 83.3 %), valvular surgery alone (n = 2, 8.3 %), and correction of congenital heart defects (n = 2, 8.3 %). The mean extracorporeal membrane oxygenation (ECMO) duration was 115.23 ± 70.17 h. Twenty-one patients received ECPR after intra-aortic balloon pump, and three patients received ECPR directly. The main cause of mortality was multiple system organ failure (n = 12, 50.0 %). Approximately one-half of non-survivors had severe neurologic impairments. Among 16 patients who were weaned off ECMO support, eight patients survived to hospital discharge.

Conclusions

ECPR can be effective for partial cardiopulmonary support to resuscitate adult patients suffering from refractory CA after cardiac surgery. Improvement in outcomes of patients who received ECPR requires a multidisciplinary approach to protect organ function and limit organ injury before and during cardiac support.

Short-term and longer-term survival after veno-arterial extracorporeal membrane oxygenation in an adult patient population: does older age matter?

Background:

Veno-arterial (V-A) extracorporeal membrane oxygenation (ECMO) is increasingly being used for patients with refractory cardiopulmonary failure. This study evaluates the short-term (to discharge) and longer-term (1 year) survival among older (⩾65 years) versus younger (<65 years) adults, adjusted for comorbidities, in a diverse cohort of V-A ECMO patients.

Methods:

This was a retrospective cohort analysis of 131 adult patients (28% ⩾65 years old) who received V-A ECMO at an academic medical center from 2004-2013. Demographics, comorbidities and surgical characteristics were abstracted from the medical records and verified. Mortality status at discharge and at one year post-ECMO were determined by the hospital clinical information system, updated monthly with Social Security Death Index data. Cox proportional hazard analyses were conducted to evaluate associations between age strata and mortality at discharge and at one year post ECMO initiation, adjusted for covariates.

Results:

The survival rate following V-A ECMO was 48% (n=68/131) to discharge and 44% (n=58/131) to one year. Age ⩾65 versus <65 was significantly associated with increased mortality during hospitalization (HR:2.03; 95%CI=1.23-3.33) and at one year (HR:1.81; 95% CI=1.12-2.93); these associations were attenuated and did not retain statistical significance after adjustment for comorbidities (HR:1.61; 95%CI=0.90-2.88 and HR:1.42; 95% CI=0.81-2.50, respectively). Statistically significant predictors of mortality at discharge and one year included history of coronary artery bypass graft, peripheral vascular disease and renal failure/dialysis (p<0.05).

Conclusions:

Older age was not independently associated with short-term or longer-term survival among V-A ECMO patients, but may reflect greater comorbidity, suggesting that age alone may not disqualify patients from V-A ECMO therapy.

Long-term outcomes among older patients with non-ST-segment elevation myocardial infarction complicated by cardiogenic shock

BACKGROUND

Cardiogenic shock complicating acute myocardial infarction (MI) in older patients is associated with a high risk of inhospital mortality; however, the long-term prognosis among these patients who survive the index hospitalization is uncertain.

METHODS

We evaluated 42,656 patients 65 years or older with non-ST-segment elevation MI from the CRUSADE Registry treated at 448 hospitals in the United States from 2003 to 2006 and linked to Medicare longitudinal claims data. Among patients who survived to hospital discharge, Cox proportional hazards modeling was used to compare survival between patients with and without inhospital shock. The secondary outcome of "percent days alive and out of hospital" (%DAOH) was also compared between the 2 groups.

RESULTS

Overall, 2,001 (4.7%) patients had shock on presentation and/or developed shock during the index hospitalization. Inhospital mortality rates among those with and without shock were 39.1% versus 4.5% (P < .001). Among the 40,036 index hospital survivors, postdischarge survival curves diverged early with lower survival (48.1% [95% CI 45.0-51.2] vs 56.5% [95% CI 56.0-57.1], P < .001) and lower %DAOH (65.5% ± 40.6% and 73.4% ± 36.8 %, P < .001) among patients with shock through 4 years. Based on the observation of parallel survival curves starting 6 months postdischarge, we performed landmark analyses and found no difference in mortality (hazard ratio 1.02, 95% CI 0.91-1.14) or %DAOH (79.7% ± 32.0% vs 81.3% ± 31.0%, P = .17) beyond 6 months between those with and without shock.

CONCLUSIONS

Our results highlight the time-dependent hazard of risk during the early postdischarge period for older patients with non-ST-segment elevation MI and cardiogenic shock that appears to be mitigated after 6 months, thereby lending support for the examination of new therapies designed to ameliorate this early risk.

Extracorporeal membrane oxygenation in adults: experience from the Middle East

BACKGROUND

The literature reports conflicting results for survival after extracorporeal membrane oxygenator support, and survival differs in pediatric and adult patients. We present our institutional experience of adult extracorporeal membrane oxygenator support.

METHODS

From January 2007 to December 2009, 19 adult patients required extracorporeal membrane oxygenator support after cardiac surgery or catheter interventions. It was provided on an emergency basis to 11 patients, urgently to 5, and electively to 3. Indications included post-cardiotomy cardiogenic shock, post-cardiotomy acute respiratory failure, emergency cardiac resuscitation, and post-percutaneous coronary intervention cardiogenic shock. The mean duration of support was 4 days (range, 1-11 days).

RESULTS

Seven (36.84%) patients could be weaned off extracorporeal membrane oxygenator support; one (14.28%) of them survived to hospital discharge and the other 6 (85.71%) died in hospital. Twelve (63.15%) patients could not be weaned off and died while still on extracorporeal membrane oxygenator support. Overall 30-day hospital mortality was 94.73%, and survival to discharge was 5.26%.

CONCLUSION

Our institutional experience of extracorporeal membrane oxygenator support for cardiac indications in adult patients indicates poor survival. It significantly increased costs by delaying imminent death and prolonging stay in the intensive care unit.