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Laimoud M, Machado P, Lo MG, Maghirang MJ, Hakami E, Qureshi R. The absolute lactate levels versus clearance for prognostication of post-cardiotomy patients on veno-arterial ECMO. ESC Heart Fail 2024. [PMID: 38979681 DOI: 10.1002/ehf2.14910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 04/17/2024] [Accepted: 04/19/2024] [Indexed: 07/10/2024] Open
Abstract
AIMS Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a life-saving procedure for supporting patients with cardiogenic shock after cardiac surgery. This work aimed to analyse the impact of changes in blood lactate levels on the survival of patients on post-cardiotomy ECMO (PC-ECMO) and whether lactate clearance (LC) performs better than absolute lactate levels. METHODS AND RESULTS We retrospectively analysed the data of adult patients who received PC-ECMO at our centre between 2016 and 2022. The primary outcome was the in-hospital mortality rate. Arterial lactate levels were measured at ECMO initiation, peak and 12 and 24 h after VA-ECMO support. LC was calculated at 12 and 24 h. Out of 2368 patients who received cardiac surgeries, 152 (median age, 48 years; 57.9% of them were men) received PC-ECMO. Of them, 48 (31.6%) survived and were discharged, while 104 (68.4%) died during the index hospitalization. Non-survivors had higher frequencies of atrial fibrillation (41.35% vs. 12.5%, P < 0.001), chronic kidney disease (26.9% vs. 6.3%, P = 0.004), prolonged cardiopulmonary bypass (237 vs. 192 min, P = 0.016) and aortic cross-clamping times (160 vs. 124 min, P = 0.04) than survivors. Non-survivors had a significantly higher median Sequential Organ Failure Assessment (SOFA) score at ECMO initiation (13.5 vs. 9, P < 0.001) and a lower median Survival After Veno-arterial ECMO (SAVE) score (-3 vs. 3, P < 0.001) with higher SAVE classes (P < 0.001) than survivors. After 12 h of VA-ECMO support, the blood lactate level was negatively correlated with LC in survivors (r = -0.755, P < 0.001) and non-survivors (r = -0.601, P < 0.001). After 24 h, the same negative correlation was identified between survivors (r = -0.764, P < 0.001) and non-survivors (r = -0.847, P < 0.001). Blood lactate levels measured at 12 h to determine hospital mortality [>8.2 mmol/L, area under the receiver operating characteristic curve (AUROC): 0.868] and 24 h (>2.6 mmol/L, AUROC: 0.896) had the best performance, followed by LC-T12 (<21.94%, AUROC: 0.807), LC-T24 (<40.3%, AUROC: 0.839) and peak blood lactate (>14.35 mmol/L, AUROC: 0.828). The initial pre-ECMO blood lactate (>6.25 mmol/L, AUROC: 0.731) had an acceptable ability to discriminate mortality but was less than the following measurements and clearance. Kaplan-Meier curves demonstrated that LC of <21.94% at T12 h and <40.3% at T24 h was associated with decreased survival (log-rank P < 0.001). Cox proportional hazards regression analysis for mortality revealed that LC of <21.94% at T12 h had an adjusted hazard ratio (HR) of 2.73 [95% confidence interval (CI): 1.64-5.762, P < 0.001] and LC of <40.3% at T24 h had an adjusted HR of 1.98 (95% CI: 1.46-4.173, P < 0.001). The predictors of hospital mortality after PC-ECMO were the lactate level at 12 h [odds ratio (OR): 1.67, 95% CI: 1.121-2.181, P = 0.001], initial SOFA score (OR: 1.593, 95% CI: 1.15-2.73, P < 0.001), initial blood lactate (OR: 1.21, 95% CI: 1.016-1.721, P = 0.032) and atrial fibrillation (OR: 6.17, 95% CI: 2.37-57.214, P = 0.003). Bivariate models using lactate levels and clearance at the same points revealed that blood lactate levels performed better than the clearance percentage. CONCLUSIONS Serial measurements of arterial blood lactate and LC help in obtaining early prognostic guidance in adult patients supported by VA-ECMO after cardiac surgery. Absolute lactate levels, compared with LC at the same time points, demonstrated better performance in differentiating mortality.
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Affiliation(s)
- Mohamed Laimoud
- Department of Cardiovascular Critical Care, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- Department of Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Patricia Machado
- Department of Cardiovascular Nursing, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Michelle Gretchen Lo
- Department of Cardiovascular Nursing, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mary Jane Maghirang
- Department of Cardiovascular Nursing, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Emad Hakami
- Department of Cardiovascular Nursing, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Rehan Qureshi
- Department of Cardiovascular Critical Care, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Biancari F, Demal T, Nappi F, Onorati F, Francica A, Peterss S, Buech J, Fiore A, Folliguet T, Perrotti A, Hervé A, Conradi L, Rukosujew A, Pinto AG, Lega JR, Pol M, Rocek J, Kacer P, Wisniewski K, Mazzaro E, Vendramin I, Piani D, Ferrante L, Rinaldi M, Quintana E, Pruna-Guillen R, Gerelli S, Di Perna D, Acharya M, Mariscalco G, Field M, Kuduvalli M, Pettinari M, Rosato S, D’Errigo P, Jormalainen M, Mustonen C, Mäkikallio T, Dell’Aquila AM, Juvonen T, Gatti G. Baseline risk factors of in-hospital mortality after surgery for acute type A aortic dissection: an ERTAAD study. Front Cardiovasc Med 2024; 10:1307935. [PMID: 38288052 PMCID: PMC10822912 DOI: 10.3389/fcvm.2023.1307935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/31/2023] [Indexed: 01/31/2024] Open
Abstract
Background Surgery for type A aortic dissection (TAAD) is associated with high risk of mortality. Current risk scoring methods have a limited predictive accuracy. Methods Subjects were patients who underwent surgery for acute TAAD at 18 European centers of cardiac surgery from the European Registry of Type A Aortic Dissection (ERTAAD). Results Out of 3,902 patients included in the ERTAAD, 2,477 fulfilled the inclusion criteria. In the validation dataset (2,229 patients), the rate of in-hospital mortality was 18.4%. The rate of composite outcome (in-hospital death, stroke/global ischemia, dialysis, and/or acute heart failure) was 41.2%, and 10-year mortality rate was 47.0%. Logistic regression identified the following patient-related variables associated with an increased risk of in-hospital mortality [area under the curve (AUC), 0.755, 95% confidence interval (CI), 0.729-0.780; Brier score 0.128]: age; estimated glomerular filtration rate; arterial lactate; iatrogenic dissection; left ventricular ejection fraction ≤50%; invasive mechanical ventilation; cardiopulmonary resuscitation immediately before surgery; and cerebral, mesenteric, and peripheral malperfusion. The estimated risk score was associated with an increased risk of composite outcome (AUC, 0.689, 95% CI, 0.667-0.711) and of late mortality [hazard ratio (HR), 1.035, 95% CI, 1.031-1.038; Harrell's C 0.702; Somer's D 0.403]. In the validation dataset (248 patients), the in-hospital mortality rate was 16.1%, the composite outcome rate was 41.5%, and the 10-year mortality rate was 49.1%. The estimated risk score was predictive of in-hospital mortality (AUC, 0.703, 95% CI, 0.613-0.793; Brier score 0.121; slope 0.905) and of composite outcome (AUC, 0.682, 95% CI, 0.614-0.749). The estimated risk score was predictive of late mortality (HR, 1.035, 95% CI, 1.031-1.038; Harrell's C 0.702; Somer's D 0.403), also when hospital deaths were excluded from the analysis (HR, 1.024, 95% CI, 1.018-1.031; Harrell's C 0.630; Somer's D 0.261). Conclusions The present analysis identified several baseline clinical risk factors, along with preoperative estimated glomerular filtration rate and arterial lactate, which are predictive of in-hospital mortality and major postoperative adverse events after surgical repair of acute TAAD. These risk factors may be valuable components for risk adjustment in the evaluation of surgical and anesthesiological strategies aiming to improve the results of surgery for TAAD. Clinical Trial Registration https://clinicaltrials.gov, identifier NCT04831073.
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Affiliation(s)
- Fausto Biancari
- Department of Medicine, South-Karelia Central Hospital, University of Helsinki, Lappeenranta, Finland
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Till Demal
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Francesco Onorati
- Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Alessandra Francica
- Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Sven Peterss
- LMU University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Joscha Buech
- LMU University Hospital, Ludwig Maximilian University, Munich, Germany
- German Centre for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Antonio Fiore
- Department of Cardiac Surgery, HĂ´pitaux Universitaires Henri Mondor, Assistance Publique-HĂ´pitaux de Paris, Creteil, France
| | - Thierry Folliguet
- Department of Cardiac Surgery, HĂ´pitaux Universitaires Henri Mondor, Assistance Publique-HĂ´pitaux de Paris, Creteil, France
| | - Andrea Perrotti
- Department of Thoracic and Cardiovascular Surgery, University of Franche-Comte, Besancon, France
| | - Amélie Hervé
- Department of Thoracic and Cardiovascular Surgery, University of Franche-Comte, Besancon, France
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Andreas Rukosujew
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - Angel G. Pinto
- Cardiovascular Surgery Department, University Hospital Gregorio Marañón, Madrid, Spain
| | - Javier Rodriguez Lega
- Cardiovascular Surgery Department, University Hospital Gregorio Marañón, Madrid, Spain
| | - Marek Pol
- Department of Cardiac Surgery, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Jan Rocek
- Department of Cardiac Surgery, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Petr Kacer
- Department of Cardiac Surgery, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Konrad Wisniewski
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Enzo Mazzaro
- Division of Cardiac Surgery, Cardio-Thoracic and Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Igor Vendramin
- Cardiothoracic Department, University Hospital, Udine, Italy
| | - Daniela Piani
- Cardiothoracic Department, University Hospital, Udine, Italy
| | - Luisa Ferrante
- Cardiac Surgery, Molinette Hospital, University of Turin, Turin, Italy
| | - Mauro Rinaldi
- Cardiac Surgery, Molinette Hospital, University of Turin, Turin, Italy
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital ClĂnic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Robert Pruna-Guillen
- Department of Cardiovascular Surgery, Hospital ClĂnic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Sebastien Gerelli
- Department of Cardiac Surgery, Centre Hospitalier Annecy Genevois, Annecy, France
| | - Dario Di Perna
- Department of Cardiac Surgery, Centre Hospitalier Annecy Genevois, Annecy, France
| | - Metesh Acharya
- Department of Cardiac Surgery, Glenfield Hospital, Leicester, United Kingdom
| | - Giovanni Mariscalco
- Department of Cardiac Surgery, Glenfield Hospital, Leicester, United Kingdom
| | - Mark Field
- Liverpool Centre for Cardiovascular Sciences, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Manoj Kuduvalli
- Liverpool Centre for Cardiovascular Sciences, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Matteo Pettinari
- Department of Cardiac Surgery, Ziekenhuis Oost Limburg, Genk, Belgium
| | - Stefano Rosato
- National Center for Global Health, Istituto Superiore di Sanitá, Rome, Italy
| | - Paola D’Errigo
- National Center for Global Health, Istituto Superiore di Sanitá, Rome, Italy
| | - Mikko Jormalainen
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Caius Mustonen
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Timo Mäkikallio
- Department of Medicine, South-Karelia Central Hospital, University of Helsinki, Lappeenranta, Finland
| | - Angelo M. Dell’Aquila
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
- Department of Cardiac Surgery, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Tatu Juvonen
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
- Research Unit of Surgery, Anesthesia and Critical Care, University of Oulu, Oulu, Finland
| | - Giuseppe Gatti
- Division of Cardiac Surgery, Cardio-Thoracic and Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
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Biancari F, Mäkikallio T, Loforte A, Kaserer A, Ruggieri VG, Cho SM, Kang JK, Dalén M, Welp H, Jónsson K, Ragnarsson S, Hernández Pérez FJ, Gatti G, Alkhamees K, Fiore A, Lechiancole A, Rosato S, Spadaccio C, Pettinari M, Perrotti A, Sahli SD, L'Acqua C, Arafat AA, Albabtain MA, AlBarak MM, Laimoud M, Djordjevic I, Krasivskyi I, Samalavicius R, Jankuviene A, Alonso-Fernandez-Gatta M, Wilhelm MJ, Juvonen T, Mariscalco G. Inter-institutional analysis of the outcome after postcardiotomy veno-arterial extracorporeal membrane oxygenation. Int J Artif Organs 2024; 47:25-34. [PMID: 38053227 DOI: 10.1177/03913988231214934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
INTRODUCTION Patients requiring postcardiotomy veno-arterial extracorporeal membrane oxygenation (V-A-ECMO) have a high risk of early mortality. In this analysis, we evaluated whether any interinstitutional difference exists in the results of postcardiotomy V-A-ECMO. METHODS Studies on postcardiotomy V-A-ECMO were identified through a systematic review for individual patient data (IPD) meta-analysis. Analysis of interinstitutional results was performed using direct standardization, estimation of observed/expected in-hospital mortality ratio and propensity score matching. RESULTS Systematic review of the literature yielded 31 studies. Data from 10 studies on 1269 patients treated at 25 hospitals were available for the present analysis. In-hospital mortality was 66.7%. The relative risk of in-hospital mortality was significantly higher in six hospitals. Observed versus expected in-hospital mortality ratio showed that four hospitals were outliers with significantly increased mortality rates, and one hospital had significantly lower in-hospital mortality rate. Participating hospitals were classified as underperforming and overperforming hospitals if their observed/expected in-hospital mortality was higher or lower than 1.0, respectively. Among 395 propensity score matched pairs, the overperforming hospitals had significantly lower in-hospital mortality (60.3% vs 71.4%, p = 0.001) than underperforming hospitals. Low annual volume of postcardiotomy V-A-ECMO tended to be predictive of poor outcome only when adjusted for patients' risk profile. CONCLUSIONS In-hospital mortality after postcardiotomy V-A-ECMO differed significantly between participating hospitals. These findings suggest that in many centers there is room for improvement of the results of postcardiotomy V-A-ECMO.
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Affiliation(s)
- Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
- Department of Medicine, South-Karelia Central Hospital, University of Helsinki, Helsinki, Finland
| | - Timo Mäkikallio
- Department of Medicine, South-Karelia Central Hospital, University of Helsinki, Helsinki, Finland
| | - Antonio Loforte
- Department of Cardiothoracic, Transplantation and Vascular Surgery, S. Orsola Hospital, University of Bologna, Bologna, and Department of Surgical Science, University of Turin, Turin, Italy
| | - Alexander Kaserer
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Vito G Ruggieri
- Division of Cardiothoracic and Vascular Surgery, Robert Debré University Hospital, Reims, France
| | - Sung-Min Cho
- Division of Neurosciences, Critical Care and Cardiac Surgery, Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jin Kook Kang
- Division of Neurosciences, Critical Care and Cardiac Surgery, Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Henryk Welp
- Department of Cardiothoracic Surgery, MĂĽnster University Hospital, MĂĽnster, Germany
| | - Kristján Jónsson
- Department of Cardiac Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | | | - Giuseppe Gatti
- Division of Cardiac Surgery, Cardio-Thoracic and Vascular Department, University Hospital of Trieste, Trieste, Italy
| | | | - Antonio Fiore
- Department of Cardiac Surgery, HĂ´pitaux Universitaires Henri Mondor, Creteil, France
| | | | - Stefano Rosato
- Center for Global Health, Italian National Institute, Rome, Italy
| | | | - Matteo Pettinari
- Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Andrea Perrotti
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Sebastian D Sahli
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Camilla L'Acqua
- Anesthesia and Intensive Care Unit, Centro Cardiologico Monzino, Milan, Italy
- Anesthesia and Intensive Care Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Amr A Arafat
- Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
- Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt
| | - Monirah A Albabtain
- Cardiology Clinical Pharmacy, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Mohammed M AlBarak
- Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Mohamed Laimoud
- Cardiac Surgical Intensive Care Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- Critical Care Medicine Department, Cairo University, Cairo, Egypt
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Ihor Krasivskyi
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Robertas Samalavicius
- II Department of Anesthesia, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
- Clinic of Emergency Medicine, Medical Faculty, Vilnius University, Vilnius, Lithuania
| | - Agne Jankuviene
- II Department of Anesthesia, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Marta Alonso-Fernandez-Gatta
- Cardiology Department, University Hospital of Salamanca, Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain
- CIBER-CV Instituto de Salud Carlos III, Madrid, Spain
| | - Markus J Wilhelm
- Clinic for Cardiac Surgery, University Heart Center, University and University Hospital Zurich, Zurich, Switzerland
| | - Tatu Juvonen
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
- Research Unit of Surgery, Anesthesia and Intensive Care, University of Oulu, Oulu, Finland
| | - Giovanni Mariscalco
- Department of Intensive Care Medicine and Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester, Leicester, UK
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