Short-term continuous-flow ventricular assist devices

Adult cardiac veno-arterial extracorporeal life support (VA-ECMO): prevention and management of acute complications

Background

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been shown to be a viable and effective treatment for patients suffering from refractory cardiogenic shock (rCS), which is associated with high mortality rates. Although ECMO therapy used as short-term mechanical circulatory support (MCS) has shown tremendous growth in its application over the past decade, the complication and mortality rates remain high. This retrospective study analyzes complications associated with VA-ECMO support, evaluates the use of defined protocols at a single center, and examines factors that may contribute to patient complication and mortality.

Methods

This retrospective analysis included 184 patients who were supported with ECMO from September 2014 through March 2018 at Integris Baptist Medical Center (IBMC). Descriptive statistics were generated to analyze baseline characteristics, demographics, complications, and outcomes.

Results

Acute myocardial infarct (AMI) was the primary etiology of this cohort (N=40; 22%). The mean age was 55±15 (median 56, range 15-84) years. All patients were inotrope and/or vasopressor dependent prior to ECMO initiation. Mean time on ECMO support was 7.8±7.9 days with median time of 6 days. Total patient days on support were 1,430. Most ECMO cannulations, 97 (52%) were performed within Integris Baptist Medical Center, with 48% done outside the hospital; 38% were performed outside of the hospital by the IBMC ECMO team, and 10.5% were performed by an outside team. Bleeding was noted to be the most common VA ECMO complication [N=41; 22.3%; 0.028 events per patient day (EPPD)].

Conclusions

A dedicated 24/7 ECMO service using a multidisciplinary team (MDT) and defined protocols in a single center is able to effectively reduce complications due to VA-ECMO support in the sickest of the sick VA-ECMO patients.

Temporary Circulatory Support and Extracorporeal Membrane Oxygenation

Cardiogenic shock (CS) refractory to conventional therapies continues to be a challenging medical syndrome, with poor prognosis and high complication and mortality rates. The application and use of temporary mechanical circulatory support (MCS) is a component in the treatment of CS patients and should be applied early in the presentation. Crucial to the success of their application, temporary MCS devices should be chosen based on degree of patient acuity and etiology of CS. Not all temporary MCS devices deliver the same degree of hemodynamic support and range from minimal support to systemic support via veno-arterial extracorporeal membrane oxygenation.