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Harahwa T, Chor CYT, Harky A. The use of extracorporeal membrane oxygenation postcardiotomy—A systematic review. J Card Surg 2020; 35:1941-1953. [DOI: 10.1111/jocs.14694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
| | | | - Amer Harky
- Department of Cardiothoracic Surgery Liverpool Heart and Chest Hospital Liverpool UK
- School of Medicine University of Liverpool Liverpool UK
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Khorsandi M, Dougherty S, Bouamra O, Pai V, Curry P, Tsui S, Clark S, Westaby S, Al-Attar N, Zamvar V. Extra-corporeal membrane oxygenation for refractory cardiogenic shock after adult cardiac surgery: a systematic review and meta-analysis. J Cardiothorac Surg 2017; 12:55. [PMID: 28716039 PMCID: PMC5512816 DOI: 10.1186/s13019-017-0618-0] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 07/10/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Postcardiotomy cardiogenic shock (PCCS) refractory to inotropic support and intra-aortic balloon pump (IABP) occurs rarely but is almost universally fatal without mechanical circulatory support. In this systematic review and meta-analysis we looked at the evidence behind the use of veno-arterial extra-corporeal membrane oxygenation (VA ECMO) in refractory PCCS from a patient survival rate and determinants of outcome viewpoint. METHODS A systematic review was performed in January 2017 using PubMed (with no defined time period) using the keywords "postcardiotomy", "cardiogenic shock", "extracorporeal membrane oxygenation" and "cardiac surgery". We excluded papers pertaining to ECMO following paediatric cardiac surgery, medical causes of cardiogenic shock, as well as case reports, review articles, expert opinions, and letters to the editor. Once the studies were collated, a meta-analysis was performed on the proportion of survivors in those papers that met the inclusion criteria. Meta-regression was performed for the most commonly reported adverse prognostic indicators (API). RESULTS We identified 24 studies and a cumulative pool of 1926 patients from 1992 to 2016. We tabulated the demographic data, including the strengths and weaknesses for each of the studies, outcomes of VA ECMO for refractory PCCS, complications, and APIs. All the studies were retrospective cohort studies. Meta-analysis of the moderately heterogeneous data (95% CI 0.29 to 0.34, p < 0.01, I 2 = 60%) revealed overall survival rate to hospital discharge of 30.8%. Some of the commonly reported APIs were advanced age (>70 years, 95% CI -0.057 to 0.001, P = 0.058), and long ECMO support (95% CI -0.068 to 0.166, P = 0.412). Postoperative renal failure, high EuroSCORE (>20%), diabetes mellitus, obesity, rising lactate whilst on ECMO, gastrointestinal complications had also been reported. CONCLUSION Haemodynamic support with VA ECMO provides a survival benefit with reasonable intermediate and long-term outcomes. Many studies had reported advanced age, renal failure and prolonged VA ECMO support as the most likely APIs for VA ECMO in PCCS. EuroSCORE can be utilized to anticipate the need for prophylactic perioperative VA ECMO in the high-risk category. APIs can be used to aid decision-making regarding both the institution and weaning of ECMO for refractory PCCS.
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Affiliation(s)
- Maziar Khorsandi
- Department of Cardiac Surgery and Transplantation, Golden Jubilee National Hospital, Glasgow, UK.
| | | | - Omar Bouamra
- Medical Statistics, Trauma, Audit & Research Network, University of Manchester, Salford Royal NHS foundation trust, Manchester, UK
| | - Vasudev Pai
- Department of Cardiovascular and Thoracic Surgery, Kasturba Medical College, Manipal University, Manipal, India
| | - Philip Curry
- Department of Cardiac Surgery and Transplantation, Golden Jubilee National Hospital, Glasgow, UK
| | - Steven Tsui
- Department of Cardiac Surgery and Transplantation, Papworth hospital, Cambridge, UK
| | - Stephen Clark
- Department of Cardiac surgery and Transplantation, Freeman hospital, Newcastle, UK
| | - Stephen Westaby
- Department of Cardiac Surgery, Oxford Heart Center, John Radcliffe Hospital, Oxford, UK
| | - Nawwar Al-Attar
- Department of Cardiac Surgery and Transplantation, Golden Jubilee National Hospital, Glasgow, UK
| | - Vipin Zamvar
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
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Khorsandi M, Dougherty S, Sinclair A, Buchan K, MacLennan F, Bouamra O, Curry P, Zamvar V, Berg G, Al-Attar N. A 20-year multicentre outcome analysis of salvage mechanical circulatory support for refractory cardiogenic shock after cardiac surgery. J Cardiothorac Surg 2016; 11:151. [PMID: 27821152 PMCID: PMC5100311 DOI: 10.1186/s13019-016-0545-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 10/27/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Refractory post-cardiotomy cardiogenic shock (PCCS) is a relatively rare phenomenon that can lead to rapid multi-organ dysfunction syndrome and is almost invariably fatal without advanced mechanical circulatory support (AMCS), namely extra-corporeal membrane oxygenation (ECMO) or ventricular assist devices (VAD). In this multicentre observational study we retrospectively analyzed the outcomes of salvage venoarterial ECMO (VA ECMO) and VAD for refractory PCCS in the 3 adult cardiothoracic surgery centres in Scotland over a 20-year period. METHODS The data was obtained through the Edinburgh, Glasgow and Aberdeen cardiac surgery databases. Our inclusion criteria included any adult patient from April 1995 to April 2015 who had received salvage VA ECMO or VAD for PCCS refractory to intra-aortic balloon pump (IABP) and maximal inotropic support following adult cardiac surgery. RESULTS A total of 27 patients met the inclusion criteria. Age range was 34-83 years (median 51 years). There was a large male predominance (n = 23, 85 %). Overall 23 patients (85 %) received VA ECMO of which 14 (61 %) had central ECMO and 9 (39 %) had peripheral ECMO. Four patients (15 %) were treated with short-term VAD (BiVAD = 1, RVAD = 1 and LVAD = 2). The most common procedure-related complication was major haemorrhage (n = 10). Renal failure requiring renal replacement therapy (n = 7), fatal stroke (n = 5), septic shock (n = 2), and a pseudo-aneurysm at the femoral artery cannulation site (n = 1) were also observed. Overall survival to hospital discharge was 40.7 %. All survivors were NYHA class I-II at 12 months' follow-up. CONCLUSION AMCS for refractory PCCS carries a survival benefit and achieves acceptable functional recovery despite a significant complication rate.
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Affiliation(s)
- Maziar Khorsandi
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent, old Dalkeith road, Edinburgh, EH16 4SA, UK.
| | - Scott Dougherty
- Department of Cardiology, Ninewells University Hospital, Dundee, DD2 1UB, UK
| | - Andrew Sinclair
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Agamemnon street, Clydebank, Glasgow, G81 4DY, UK
| | - Keith Buchan
- Department of Cardiothoracic Surgery, Aberdeen Royal Infirmary, Burnside house, Cornhill road, Aberdeen, AB25 2ZR, UK
| | - Fiona MacLennan
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Agamemnon street, Clydebank, Glasgow, G81 4DY, UK
| | - Omar Bouamra
- Medical Statistics, Trauma Audit & Research Network, Salford Royal NHS foundation trust and the University of Manchester, Manchester, M6 8HD, UK
| | - Philip Curry
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Agamemnon street, Clydebank, Glasgow, G81 4DY, UK
| | - Vipin Zamvar
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent, old Dalkeith road, Edinburgh, EH16 4SA, UK
| | - Geoffrey Berg
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Agamemnon street, Clydebank, Glasgow, G81 4DY, UK
| | - Nawwar Al-Attar
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Agamemnon street, Clydebank, Glasgow, G81 4DY, UK
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Short-Term Ventricular Assist Device as a Bridge to Decision in Cardiogenic Shock: Is It a Justified Strategy? Int J Artif Organs 2016; 39:0. [DOI: 10.5301/ijao.5000488] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2016] [Indexed: 11/20/2022]
Abstract
Purpose Low cardiac output syndrome is associated with significant mortality. In patients with refractory low cardiac output left ventricular assist devices (VAD) are used to re-establish cardiac output and to prevent death. However, long-term LVAD implantation in these is complicated by a high rate of right heart failure and mortality. Therefore, our strategy is to implant a short-term VAD (left or biventricular) as a bridge to decission. Methods We retrospectively analysed data from 66 patients who received a short-term LVAD support prior to implantation of a long-term LVAD or HTx between 2003 and 2014. We performed short-term LVAD (CentriMag; Thoratec) implantation via median sternotomy with percutaneous cannulas. Patients were included regardless of perioperative status and severity of heart failure. Patients suffering postcardiotomy cardiogenic shock, receiving isolated RVAD as well as posttransplant patients were excluded from this study. Results Mean duration of support in the survivor group was 35 ± 25 days versus 25 ± 25 days in the nonsurvivor group (n.s.), range from 1 to 109 days. The overall survival on support was 40 (60%) patients. In the survivor group 12 patients could be successfully weaned from the system, 12 patients received a heart transplant and in 16 a long-term VAD was implanted. In the nonsurvivor group the rate of pre-operative extracorporeal life support, the rate of postoperative renal failure and multiorgan failure was significantly higher. Conclusions Thanks to its capacity for full ventricular support, short-term univentricular or biventricular LevotronixCentriMag VAD currently represents an ideal solution for bridge-to-decision.
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Khorsandi M, Shaikhrezai K, Prasad S, Pessotto R, Walker W, Berg G, Zamvar V. Advanced mechanical circulatory support for post-cardiotomy cardiogenic shock: a 20-year outcome analysis in a non-transplant unit. J Cardiothorac Surg 2016; 11:29. [PMID: 26892226 PMCID: PMC4758144 DOI: 10.1186/s13019-016-0430-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 02/15/2016] [Indexed: 11/24/2022] Open
Abstract
Background Post-cardiotomy cardiogenic shock (PCCS) has an incidence of 2–6 % after routine adult cardiac surgery. 0.5–1.5 % are refractory to inotropic and intra-aortic balloon pump (IABP) support. Advanced mechanical circulatory support (AMCS) can be used to salvage carefully selected number of such patients. High costs and major complication rates have lead to centralization and limited funding for such devices in the UK. We have looked the outcomes of such devices in a non-transplant, intermediate-size adult cardiothoracic surgery unit. Methods Inclusion criteria included any adult patient who had received salvage veno-arterial extra-corporeal membrane oxygenation (V-A ECMO) or a ventricular assist device (VAD) for PCCS refractory to IABP and inotropic support following cardiac surgery from April 1995-April 2015. Results Sixteen patients met the inclusion criteria. Age range was 34–83 years (median 71). There was a male predominance of 12 (75 %). Overall, 15 (94 %) had received ECMO of which, 10 (67 %) had received central ECMO and 5 (33 %) had received peripheral ECMO. One patient (6 %) had a VAD. The most common complication was haemorrhage. Stroke, femoral artery pseudo-aneurysm, sepsis and renal failure also occurred. Thirty-day survival was 37.5 %. Survival rate to hospital discharge was 31.2 %. All survivors had NYHA class I-II at 24 months follow-up. Conclusions Our survival rate is similar to that reported in several previous studies. However, the use of AMCS for refractory PCCS is associated with serious complications. The survivors in our cohort appear to maintain an acceptable quality of life.
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Affiliation(s)
- Maziar Khorsandi
- Department of Cardio-Thoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK.
| | - Kasra Shaikhrezai
- Department of Cardio-Thoracic Surgery, Golden Jubilee National Hospital, Glasgow, UK
| | - Sai Prasad
- Department of Cardio-Thoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Renzo Pessotto
- Department of Cardio-Thoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - William Walker
- Department of Cardio-Thoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Geoffrey Berg
- Department of Cardio-Thoracic Surgery, Golden Jubilee National Hospital, Glasgow, UK
| | - Vipin Zamvar
- Department of Cardio-Thoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
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Westaby S, Baig K, De Silva R, Unsworth-White J, Pepper J. Recruitment to UK cardiothoracic surgery in the era of public outcome reporting. Eur J Cardiothorac Surg 2015; 47:679-83. [PMID: 25646396 DOI: 10.1093/ejcts/ezu509] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Since 1999 important widely publicized issues have affected morale in UK cardiothoracic (CT) surgery. Because more surgeons are needed, we sought to investigate whether these events have affected recruitment and demographic change in the specialty between 1999 and 2014. METHODS We collected information on UK consultant CT surgeons using the SCTS public portal, the GMC Specialist Register and the NHS Annual Workforce Census via the Health & Social Care Information Centre. We analysed the demographics of UK CT surgeons with regard to country of primary medical qualification and ethnicity between 1999 and 2014. We compared the changes with other surgical specialties, cardiology and respiratory medicine. RESULTS There has been a worrying decline in UK medical graduates entering the specialty and a 4-fold increase (282%) in consultant appointments from Europe. Whilst consultant numbers expanded by 83% overall, 59% of congenital heart surgeons, 46% of thoracic surgeons and 36% of adult cardiac surgeons are overseas graduates. It is found that 5% are female. Currently, only 32% of trainee surgeons are UK graduates. Of those receiving UK Certificate of Completion of Training in 2013, only 18% were UK graduates compared with 68% in 2000. Comparison with other specialties shows fewer UK graduates in CT surgery with the exception of Obstetrics and Gynaecology (52%). In cardiology, 77% are UK graduates with only 8% from Europe. CONCLUSIONS Repeated negative messages have had a detrimental influence on recruitment. Because 55% of UK medical graduates, but less than 5% of CT surgeons are female, recruitment problems may worsen. Action is needed to restore interest in the specialty.
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Punjabi PP. Surgeon-specific mortality data: bury your head in the sand. Eur J Cardiothorac Surg 2014; 47:346-7. [PMID: 25378362 DOI: 10.1093/ejcts/ezu424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Prakash P Punjabi
- Department of Cardiothoracic Surgery, National Heart and Lung Institute, Imperial College London, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
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Noble DW, Bloomfield R. Problem Solving in Intensive Care — The Role of Extracorporeal Technologies. J Intensive Care Soc 2014. [DOI: 10.1177/175114371401500102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- David W Noble
- Consultant in Intensive Care, Aberdeen Royal Infirmary
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