Predicting mortality in patients undergoing VA-ECMO after coronary artery bypass grafting: the REMEMBER score

Predictors of mortality and transfusion requirements in venoarterial extracorporeal membrane oxygenation patients

OBJECTIVE

The aim of this study was to evaluate the prognostic impact of variables, including thrombocytopenia and the amount of platelet transfusion, for predicting survival in venoarterial extracorporeal membrane oxygenation (ECMO) recipients. Additionally, we aimed to identify the predictors of increased transfusion requirement during venoarterial ECMO support.

METHODS

All patients who received venoarterial ECMO between December 2008 and March 2020 were retrospectively analyzed. Univariate and multivariate Cox regressions were used to evaluate in-hospital mortality according to variables including thrombocytopenia and daily average of platelet concentrate transfusion. Stepwise multiple linear regression analysis was used to identify independent predictors for transfusion requirements.

RESULTS

Analysis of 218 patients demonstrated severe thrombocytopenia as an independent predictor of in-hospital mortality (hazard ratio = 2.840, 95% CI: 1.593-5.063, P < .001), along with age, pre-ECMO cardiac arrest, and pH. In contrast, the amount of platelet transfusion was not associated with in-hospital mortality. Multiple variables, including the type of indication for ECMO were associated with transfusion requirements.

CONCLUSION

Our findings identified severe thrombocytopenia as an independent prognostic factor of in-hospital mortality. However, daily average platelet transfusion was not associated with survival outcomes. Additionally, our study identified predictive variables of increased transfusion requirements.

Predicting the mortality of patients with cardiogenic shock after coronary artery bypass grafting

INTRODUCTION

Cardiogenic shock (CS) is a critical condition and the leading cause of mortality after coronary artery bypass grafting (CABG). To define the risk factors for CS in patients who undergo CABG and create a risk-predictive model is crucial.

METHODS

In this observational study, we retrospectively evaluated consecutive patients who underwent CABG between January 2018 and October 2022 at Beijing Anzhen Hospital. A total of 496 patients were enrolled and categorized into the training (396 cases) and internal test (100 cases) sets. The variables significantly associated with mortality (p < 0.05) were analyzed using logistic regression analyses.

RESULTS

The E/A ratio at admission, postoperative brain natriuretic peptide, postoperative arterial lactate, two or more arrhythmias at the same time after CABG, and carotid artery stenosis at admission were identified as independent prognostic factors for in-hospital mortality after multivariate logistic regression analysis. The CS after CABG score (ACCS) was established and three classes of ACCS, named classes I (ACCS, <20), II (ACCS, 20-30), and III (ACCS, >30), made up the risk model. The ACCS showed better discrimination with an AUROC of 0.937 (95% confidence interval, 0.982-0.892) and calibration with the Hosmer-Lemeshow test (X2 = 5.854 with 8 df; p = 0.664). In addition, tenfold cross-validation demonstrated that the mean misdiagnosis rate was 5.56% and the lowest misdiagnosis rate was 6.38%.

CONCLUSION

The ACCS score represents a risk-predictive model for in-hospital mortality of patients with CS after CABG in acute care settings. Patients identified as class III may have a worse prognosis.

E-cigarette Use and Severe Coronavirus Disease 2019 (COVID-19) Outcomes: A Meta-Analysis

E-cigarettes have been known to cause varied poor health outcomes prior to coronavirus disease 2019 (COVID-19), but after the impact of COVID-19, evidence came out that was, in some instances, not as expected regarding the severity of COVID-19 among e-cigarette users (vapers). A meta-analysis was performed on the available evidence to comprehensively find the effect of COVID-19 on existing or past e-cigarette users (vapers). The Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines were used to perform this meta-analysis. PubMed was searched for observational studies that described outcomes after COVID-19 positivity from December 1, 2019, to December 2023. Medical Subject Headings (MeSH) keywords were used for searching the relevant studies highlighting the relationship between COVID-19 and e-cigarette users. Calculations for pooled prevalence, 95% confidence interval (95% CI), weights for current e-cigarette users and vapers, and outcomes (events) were made. To analyze the data, Review Manager V.5.4 was used. The I² statistic was used to assess statistical heterogeneity. The I² statistic of >50% was considered significant heterogeneity. The "leave-one-out" method was used for sensitivity analysis. Out of 3231 studies, four studies reported data on vaping and non-vaping status and composite outcomes, resulting in a sample size of 653 COVID-19-positive cases. The pooled prevalence of being COVID-19 positive, having symptoms, or visiting an emergency room was 7.78% (653/8392). COVID-19 patients with current vaping status had decreased odds of poor outcomes compared to non-smokers, with a pooled odds ratio (OR) of 0.09 (95% CI 0.00-2.42; p>0.05) with heterogeneity between studies (I²=99%, p=0.15). Because of difficulties related to data collection and other factors, this meta-analysis was unable to conclusively establish the correlation between e-cigarette usage and severe COVID-19 outcomes such as hospitalization, admission to the intensive care unit, and fatality. Additional research using more detailed data is necessary to fully understand this correlation.

Prognostic implication of Vasoactive Inotropic Score in adult patients with cardiogenic shock on veno-arterial extracorporeal membrane oxygenation

Background

Vasopressors and inotropes are crucial in managing cardiogenic shock (CS) as they enhance microcirculation in patients. Numerous studies have demonstrated the adverse outcomes associated with excessive use of vasoactive drugs and the vasoactive drug scoring system has emerged as a valuable prognostic tool, particularly in pediatric patients. This study aimed to examine the prognostic significance of the Vasoactive Inotropic Score (VIS) in adult patients with CS receiving veno-arterial extracorporeal membrane oxygenation (VA-ECMO) treatment.

Methods

This retrospective multi-center study involved 2,453 adult patients who underwent VA-ECMO in China between 2015 and 2021. Among them, 1,742 adult patients with CS following VA-ECMO were finally included. The maximum VIS (VISmax) was determined by considering the highest doses of vasoactive and inotropic drugs administered within the first 6 hours before ECMO initiation. Based on the VISmax, patients were classified into two groups: 0-20 and >20. The primary outcome of this study was in-hospital mortality.

Results

A total of 1,146 patients were included in the high VISmax group, while 596 patients were assigned to the low VISmax group. Overall, 882 (50.6%) patients experienced in-hospital mortality, with significantly higher rates observed among those with higher VISmax scores (41.4% for VIS ≤20 versus 68.3% for VIS >20; P<0.001). Similar trends were observed for 30-day mortality (40.7% for VIS ≤20 versus 64.9% for VIS >20; P<0.001). Multivariable regression analysis demonstrated that a VIS score exceeding 20 independently predicted in-hospital mortality [odds ratio (OR) 2.64; 95% confidence interval (CI): 2.10-3.33; P<0.001]. The receiver operating characteristic (ROC) analysis revealed that VIS had an area under the curve (AUC) of 0.65 (95% CI: 0.63-0.68; P<0.001) as a predictor of in-hospital mortality, with an optimal cutoff value of 20.1. Moreover, the VIS exhibited good predictive ability for in-hospital mortality in patients with acute myocarditis (AUC 0.70; 95% CI: 0.63-0.78; P<0.001).

Conclusions

Firstly, higher maximum level of VIS within the first 6 hours before ECMO initiation independently predicted poorer clinical outcomes in patients supported with ECMO for CS. Secondly, VIS exceeding 20 was significantly associated with increased risks of in-hospital mortality and 30-day mortality. Thirdly, when categorized by the cause of CS, a high VIS exhibited good predictive ability in patients with acute myocardial infarction, heart failure, and acute myocarditis.

Prediction of In-Hospital Mortality for Ischemic Cardiogenic Shock Requiring Venoarterial Extracorporeal Membrane Oxygenation

BACKGROUND

Clinical outcome of ischemic cardiogenic shock (CS) requiring extracorporeal membrane oxygenation is highly variable, necessitating appropriate assessment of prognosis. However, a systemic predictive model estimating the mortality of refractory ischemic CS is lacking. The PRECISE (Prediction of In-Hospital Mortality for Patients With Refractory Ischemic Cardiogenic Shock Requiring Veno-Arterial Extracorporeal Membrane Oxygenation Support) score was developed to predict the prognosis of refractory ischemic CS due to acute myocardial infarction.

METHODS AND RESULTS

Data were obtained from the multicenter CS registry RESCUE (Retrospective and Prospective Observational Study to Investigate Clinical Outcomes and Efficacy of Left Ventricular Assist Device for Korean Patients With Cardiogenic Shock) that consists of 322 patients with acute myocardial infarction complicated by refractory ischemic CS requiring extracorporeal membrane oxygenation support. Fifteen parameters were selected to assess in-hospital mortality. The developed model was validated internally and externally using an independent external cohort (n=138). Among 322 patients, 138 (42.9%) survived postdischarge. Fifteen predictors were included for model development: age, diastolic blood pressure, hypertension, chronic kidney disease, peak lactic acid, serum creatinine, lowest left ventricular ejection fraction, vasoactive inotropic score, shock to extracorporeal membrane oxygenation insertion time, extracorporeal cardiopulmonary resuscitation, use of intra-aortic balloon pump, continuous renal replacement therapy, mechanical ventilator, successful coronary revascularization, and staged percutaneous coronary intervention. The PRECISE score yielded a high area under the receiver-operating characteristic curve (0.894 [95% CI, 0.860-0.927]). External validation and calibration resulted in competent sensitivity (area under the receiver-operating characteristic curve, 0.895 [95% CI, 0.853-0.930]).

CONCLUSIONS

The PRECISE score demonstrated high predictive performance and directly translates into the expected in-hospital mortality rate. The PRECISE score may be used to support clinical decision-making in ischemic CS (www.theprecisescore.com).

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02985008.

The IMPACT Score: A New Score to Predict the Risk of Early Mortality in Cardiogenic Shock Patients Treated With Venoarterial Extracorporeal Membrane Oxygenation

OBJECTIVES

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) requires considerable human and financial resources. Few studies have focused on early mortality (ie, occurring within 72 hours after VA-ECMO implantation). The objective of this study was to establish a prognosis score-the IMPACT score (prediction of early mortality associated with VA-ECMO using preimplantation characteristics)-by determining the risk factors associated with early mortality.

DESIGN

This was a retrospective and observational study.

SETTING

The study was conducted at a University hospital.

PARTICIPANTS

This single-center retrospective study included 147 patients treated with VA-ECMO for cardiogenic shock between 2014 and 2021.

METHODS

The primary outcome was early mortality (ie, occurring within 72 hours after VA-ECMO implantation). Multivariate logistic regression was performed using a bootstrapping methodology to identify factors independently associated with early mortality. To construct the score, identified variables had points (pts) assigned corresponding to their odds ratio.

RESULTS

A total of 147 patients were included in the study. Early mortality (<72 hours) was 26% (38 patients). Four variables were established: cardiac arrest (2 pts), lactate levels (3 pts), platelet count <100 g/L (4 pts), and renal-replacement therapy (5 pts). The IMPACT score had an area under the receiver operating characteristic curve of 0.78 (95% CI 0.86-0.70) to predict early mortality.

CONCLUSIONS

In the authors' experience, 26% of patients treated with VA-ECMO presented early mortality. The IMPACT score is a reliable predictor of early mortality and may assist with VA-ECMO initiation decision-making.

Temporary mechanical circulatory support & enhancing recovery after cardiac surgery

PURPOSE OF REVIEW

This review highlights the integration of enhanced recovery principles with temporary mechanical circulatory support associated with adult cardiac surgery.

RECENT FINDINGS

Enhanced recovery elements and efforts have been associated with improvements in quality and value. Temporary mechanical circulatory support technologies have been successfully employed, improved, and the value of their proactive use to maintain hemodynamic goals and preserve long-term myocardial function is accruing.

SUMMARY

Temporary mechanical circulatory support devices promise to enhance recovery by mitigating the risk of complications, such as postcardiotomy cardiogenic shock, organ dysfunction, and death, associated with adult cardiac surgery.

Platelet Count During Course of Cardiogenic Shock

The study investigates the prognostic value of the platelet count in patients with cardiogenic shock (CS). Limited data regarding the prognostic value of platelets in patients suffering from CS is available. Consecutive patients with CS from 2019 to 2021 were included at one institution. Firstly, the prognostic value of the baseline platelet count was tested for 30-day all-cause mortality. Thereafter, the prognostic impact of platelet decline during course of intensive care unit (ICU) hospitalization was assessed. A total of 249 CS patients were included with a median platelet count of 224 × 10 6 /ml. No association of the baseline platelet count with the risk of 30-day all-cause mortality was found (log-rank p = 0.563; hazard ratio [HR] = 0.879; 95% confidence interval [CI] 0.557-1.387; p = 0.579). In contrast, a decrease of platelet count by ≥ 25% from day 1 to day 3 was associated with an increased risk of 30-day all-cause mortality (55% vs. 39%; log-rank p = 0.045; HR = 1.585; 95% CI 0.996-2.521; p = 0.052), which was still evident after multivariable adjustment (HR = 1.951; 95% CI 1.116-3.412; p = 0.019). Platelet decrease during the course of ICU hospitalization but not the baseline platelet count was associated with an increased risk of 30-day all-cause mortality in CS patients.

PEAL Score to Predict the Mortality Risk of Cardiogenic Shock in the Emergency Department: An Observational Study

BACKGROUND

The in-hospital mortality of cardiogenic shock (CS) remains high (28% to 45%). As a result, several studies developed prediction models to assess the mortality risk and provide guidance on treatment, including CardShock and IABP-SHOCK II scores, which performed modestly in external validation studies, reflecting the heterogeneity of the CS populations. Few articles established predictive scores of CS based on Asian people with a higher burden of comorbidities than Caucasians. We aimed to describe the clinical characteristics of a contemporary Asian population with CS, identify risk factors, and develop a predictive scoring model.

METHODS

A retrospective observational study was conducted between 2014 and 2019 to collect the patients who presented with all-cause CS in the emergency department of a single medical center in Taiwan. We divided patients into subgroups of CS related to acute myocardial infarction (AMI-CS) or heart failure (HF-CS). The outcome was all-cause 30-day mortality. We built the prediction model based on the hazard ratio of significant variables, and the cutoff point of each predictor was determined using the Youden index. We also assessed the discrimination ability of the risk score using the area under a receiver operating characteristic curve.

RESULTS

We enrolled 225 patients with CS. One hundred and seven patients (47.6%) were due to AMI-CS, and ninety-eight patients among them received reperfusion therapy. Forty-nine patients (21.8%) eventually died within 30 days. Fifty-three patients (23.55%) presented with platelet counts < 155 × 103/μL, which were negatively associated with a 30-day mortality of CS in the restrictive cubic spline plot, even within the normal range of platelet counts. We identified four predictors: platelet counts < 200 × 103/μL (HR 2.574, 95% CI 1.379-4.805, p = 0.003), left ventricular ejection fraction (LVEF) < 40% (HR 2.613, 95% CI 1.020-6.692, p = 0.045), age > 71 years (HR 2.452, 95% CI 1.327-4.531, p = 0.004), and lactate > 2.7 mmol/L (HR 1.967, 95% CI 1.069-3.620, p = 0.030). The risk score ended with a maximum of 5 points and showed an AUC (95% CI) of 0.774 (0.705-0.843) for all patients, 0.781 (0.678-0.883), and 0.759 (0.662-0.855) for AMI-CS and HF-CS sub-groups, respectively, all p < 0.001.

CONCLUSIONS

Based on four parameters, platelet counts, LVEF, age, and lactate (PEAL), this model showed a good predictive performance for all-cause mortality at 30 days in the all patients, AMI-CS, and HF-CS subgroups. The restrictive cubic spline plot showed a significantly negative correlation between initial platelet counts and 30-day mortality risk in the AMI-CS and HF-CS subgroups.

Validated Prognostic Scores to Predict Outcomes in ECLS-Bridged Patients to Lung Transplantation

Selection of patients who may benefit from extracorporeal life support (ECLS) as a bridge to lung transplant (LTx) is crucial. The aim was to assess if validated prognostic scores could help in selecting patients who may benefit from ECLS-bridging predicting their outcomes. Clinical data of patients successfully ECLS-bridged to LTx from 2009 to 2021 were collected from two European centers. For each patient, we calculated Sequential Organ Failure Assessment (SOFA), Simplified Acute Physiology Score III (SAPS III), Acute Physiology and Chronic Health Evaluation II (APACHE II), before placing ECLS support, and then correlated with outcome. Median values of SOFA, SAPS III, and APACHE II were 5 (IQR 3-9), 57 (IQR 47.5-65), and 21 (IQR 15-26). In-hospital, 30 and 90 days mortality were 21%, 14%, and 22%. SOFA, SAPS III, and APACHE II were analyzed as predictors of in-hospital, 30 and 90 days mortality (SOFA C-Index: 0.67, 0.78, 0.72; SAPS III C-index: 0.48, 0.45, 0.51; APACHE II C-Index: 0.49, 0.45, 0.52). For SOFA, the score with the best performance, a value ≥9 was identified to be the optimal cut-off for the prediction of the outcomes of interest. SOFA may be considered an adequate predictor in these patients, helping clinical decision-making. More specific and simplified scores for this population are necessary.

Predictors of in-hospital mortality after successful weaning of venoarterial extracorporeal membrane oxygenation in cardiogenic shock

Limited knowledge exists regarding the predictors of mortality after successful weaning of venoarterial extracorporeal membrane oxygenation (ECMO). We aimed to identify predictors of in-hospital mortality in patients with cardiogenic shock (CS) after successful weaning from ECMO. Data were obtained from a multicenter registry of CS. Successful ECMO weaning was defined as survival with minimal mean arterial pressure (> 65 mmHg) for > 24 h after ECMO removal. The primary outcome was in-hospital mortality after successful ECMO weaning. Among 1247 patients with CS, 485 received ECMO, and 262 were successfully weaned from ECMO. In-hospital mortality occurred in 48 patients (18.3%). Survivors at discharge differed significantly from non-survivors in age, cardiovascular comorbidities, cause of CS, left ventricular ejection fraction, and use of adjunctive therapy. Five independent predictors for in-hospital mortality were identified: use of continuous renal replacement therapy (odds ratio 5.429, 95% confidence interval [CI] 2.468-11.940; p < 0.001), use of intra-aortic balloon pump (3.204, 1.105-9.287; p = 0.032), diabetes mellitus (3.152, 1.414-7.023; p = 0.005), age (1.050, 1.016-1.084; p = 0.003), and left ventricular ejection fraction after ECMO insertion (0.957, 0.927-0.987; p = 0.006). Even after successful weaning of ECMO, patients with irreversible risk factors should be recognized, and careful monitoring should be done for sign of deconditioning.

Predicting Survival for Veno-Arterial ECMO Using Conditional Inference Trees-A Multicenter Study

BACKGROUND

Despite increasing use and understanding of the process, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) therapy is still associated with considerable mortality. Personalized and quick survival predictions using machine learning methods can assist in clinical decision making before ECMO insertion.

METHODS

This is a multicenter study to develop and validate an easy-to-use prognostic model to predict in-hospital mortality of VA-ECMO therapy, using unbiased recursive partitioning with conditional inference trees. We compared two sets with different numbers of variables (small and comprehensive), all of which were available just before ECMO initiation. The area under the curve (AUC), the cross-validated Brier score, and the error rate were applied to assess model performance. Data were collected retrospectively between 2007 and 2019.

RESULTS

837 patients were eligible for this study; 679 patients in the derivation cohort (median (IQR) age 60 (49 to 69) years; 187 (28%) female patients) and a total of 158 patients in two external validation cohorts (median (IQR) age 57 (49 to 65) and 70 (63 to 76) years). For the small data set, the model showed a cross-validated error rate of 35.79% and an AUC of 0.70 (95% confidence interval from 0.66 to 0.74). In the comprehensive data set, the error rate was the same with a value of 35.35%, with an AUC of 0.71 (95% confidence interval from 0.67 to 0.75). The mean Brier scores of the two models were 0.210 (small data set) and 0.211 (comprehensive data set). External validation showed an error rate of 43% and AUC of 0.60 (95% confidence interval from 0.52 to 0.69) using the small tree and an error rate of 35% with an AUC of 0.63 (95% confidence interval from 0.54 to 0.72) using the comprehensive tree. There were large differences between the two validation sets.

CONCLUSIONS

Conditional inference trees are able to augment prognostic clinical decision making for patients undergoing ECMO treatment. They may provide a degree of accuracy in mortality prediction and prognostic stratification using readily available variables.

Extracorporeal life support as a bridge to lung transplantation: a narrative review

Background and Objective

The utilization of extracorporeal life support (ECLS) as a bridge to lung transplantation (LTx) has rapidly expanded over recent years in highly urgent patients even though the reported outcomes in current literature are still divergent. The aim of our narrative review was to provide a comprehensive picture on the peri and post-operative outcomes of patients bridged to LTx with this device from the most updated literature in the field.

Methods

The literature about ECLS bridge to LTx was searched on PubMed using a formal strategy. We focused our research on studies published between 2015 and 2022 and in English language. Abstracts, case reports, conference presentations, editorials, expert opinions and review articles were excluded.

Key Content and Findings

ECLS has emerged as a valid tool to bridge critically ill patients to LTx. Some issues, like the selection of candidates and the post-operative outcomes, are still matter of debate in the current reported series. We analyzed 14 papers published in the last seven years and with at least 20 patients to provide an updated overview on this topic. We found that, in highly experienced centers, ECLS can be used as a good strategy to allow critically ill patients to remain eligible to LTx with satisfying post-operative outcomes.

Conclusions

Specific scores and algorithms should be implemented to improve the selection process of candidates who could benefit more from ECLS as a bridge to LTx. Ambulatory/awake ECLS strategies should be always preferred to enroll patients in active rehabilitation programs awaiting LTx, improving short and long-term outcomes and increasing the success of LTx.

ECMO PAL: using deep neural networks for survival prediction in venoarterial extracorporeal membrane oxygenation

PURPOSE

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a complex and high-risk life support modality used in severe cardiorespiratory failure. ECMO survival scores are used clinically for patient prognostication and outcomes risk adjustment. This study aims to create the first artificial intelligence (AI)-driven ECMO survival score to predict in-hospital mortality based on a large international patient cohort.

METHODS

A deep neural network, ECMO Predictive Algorithm (ECMO PAL) was trained on a retrospective cohort of 18,167 patients from the international Extracorporeal Life Support Organisation (ELSO) registry (2017-2020), and performance was measured using fivefold cross-validation. External validation was performed on all adult registry patients from 2021 (N = 5015) and compared against existing prognostication scores: SAVE, Modified SAVE, and ECMO ACCEPTS for predicting in-hospital mortality.

RESULTS

Mean age was 56.8 ± 15.1 years, with 66.7% of patients being male and 50.2% having a pre-ECMO cardiac arrest. Cross-validation demonstrated an inhospital mortality sensitivity and precision of 82.1 ± 0.2% and 77.6 ± 0.2%, respectively. Validation accuracy was only 2.8% lower than training accuracy, reducing from 75.5% to 72.7% [99% confidence interval (CI) 71.1-74.3%]. ECMO PAL accuracy outperformed the ECMO ACCEPTS (54.7%), SAVE (61.1%), and Modified SAVE (62%) scores.

CONCLUSIONS

ECMO PAL is the first AI-powered ECMO survival score trained and validated on large international patient cohorts. ECMO PAL demonstrated high generalisability across ECMO regions and outperformed existing, widely used scores. Beyond ECMO, this study highlights how large international registry data can be leveraged for AI prognostication for complex critical care therapies.

Sounding the Alarm: What Clinicians Need to Know about Physical, Emotional, and Cognitive Recovery After Venoarterial Extracorporeal Membrane Oxygenation

OBJECTIVE

We summarize the existing data on the occurrence of physical, emotional, and cognitive dysfunction associated with postintensive care syndrome (PICS) in adult survivors of venoarterial extracorporeal membrane oxygenation (VA-ECMO).

DATA SOURCES

MEDLINE, Cochrane Library, EMBASE, Web of Science, and CINAHL databases were searched.

STUDY SELECTION

Peer-reviewed studies of adults receiving VA-ECMO for any reason with at least one measure of health-related quality of life outcomes or PICS at long-term follow-up of at least 6 months were included.

DATA EXTRACTION

The participant demographics and baseline characteristics, in-hospital outcomes, long-term health outcomes, quality of life outcome measures, and prevalence of PICS were extracted.

DATA SYNTHESIS

Twenty-seven studies met inclusion criteria encompassing 3,271 patients who were treated with VA-ECMO. The studies were limited to single- or two-center studies. Outcomes variables and follow-up time points evaluated were widely heterogeneous which limits comprehensive analysis of PICS after VA-ECMO. In general, the longer-term PICS-related outcomes of survivors of VA-ECMO were worse than the general population, and approaching that of patients with chronic disease. Available studies identified high rates of abnormal 6-minute walk distance, depression, anxiety, and posttraumatic stress disorder that persisted for years. Half or fewer survivors return to work years after discharge. Only 2 of 27 studies examined cognitive outcomes and no studies evaluated cognitive dysfunction within the first year of recovery. No studies evaluated the impact of targeted interventions on these outcomes.

CONCLUSIONS

Survivors of VA-ECMO represent a population of critically ill patients at high risk for deficits in physical, emotional, and cognitive function related to PICS. This systematic review highlights the alarming reality that PICS and in particular, neurocognitive outcomes, in survivors of VA-ECMO are understudied, underrecognized, and thus likely undertreated. These results underscore the imperative that we look beyond survival to focus on understanding the burden of survivorship with the goal of optimizing recovery and outcomes after these life-saving interventions. Future prospective, multicenter, longitudinal studies in recovery after VA-ECMO are justified.

Nucleated red blood cells are a predictor of mortality in patients under extracorporeal membrane oxygenation

BACKGROUND

The presence of Nucleated Red Blood Cells (NRBCs) in critically ill patients is associated with higher mortality and poor prognosis. Although patients on extracorporeal support such as veno-venous or veno-arterial extracorporeal membrane oxygenation (VV/VA-ECMO) are severely ill, NRBCs have rarely been investigated regarding their predictive value so far.

METHODS

As part of a retrospective study, we examined all cardiothoracic surgery patients from July 2019 to September 2020 who received ECMO treatment during their inpatient stay. The aim of this study was to investigate the occurrence of NRBCs during ECMO support in terms of their predictive value for mortality.

RESULTS

In total 30 patients (age at admission: 62.7 ± 14.3 year; 26 male; ECMO duration: 8.5 ± 5.1 days; ICU duration: 18.0 ± 14.5 days) were included. 16 patients (53.3%) died during their inpatient stay. There were no significant differences in demographic characteristics between VA- or VV- ECMO patients. NRBCs occurred in all patients while under ECMO support. NRBC value was significant higher in those who died (2299.6 ± 4356.6 µl) compared to the surviving patients (133.6 ± 218.8 µl, p < 0.001). Univariate analysis found that patients with a cutoff value of ≥ 270 NRBCs/µl during ECMO support were 39 times more likely to die (OR 39.0, 95% CI 1.5-997.5, p < 0.001). 12 out of 13 patients (92.3%) with ≥ 270 NRBCs/µl died. The area under the curve (AUC) of the receiver operating characteristic curve was 0.85 (95% CI 0.69-0.96) with a sensitivity of 75.0% and a specificity of 92.9%.

CONCLUSION

NRBCs appear to be an accurate biomarker for mortality in patients with ECMO support. They may be helpful in deciding if therapy becomes futile. Trial registration DRKS00023626 (December 20th 2020).

External validation of the REMEMBER score

Background

The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) after coronary artery bypass grafting (CABG) is associated with high in-hospital mortality rates. The pRedicting mortality in patients undergoing venoarterial Extracorporeal MEMBrane oxygenation after coronary artEry bypass gRafting (REMEMBER) score has been created to predict in-hospital mortality in this subgroup of patients. The aim of this study is to externally validate the REMEMBER score.

Methods

All CABG patients who received VA-ECMO during or after the operation at our center between 01/2012 and 12/2021 were included in the analysis. Discrimination was assessed using concordance statistics, visualized by ROC curve analysis. Calibration-in-the-large and Calibration slope were tested separately.

Results

A total of 107 patients (male: n = 78, 72.9%) were included in this study. The in-hospital mortality rate in our cohort was 45.8% compared with 55% in the original study. The REMEMBER score median predicted mortality rate was 52% (76.9-36%). However, the REMEMBER score showed low discriminative ability [AUC: 0.623 (p = 0.0244; 95% CI = 0.524-0.715)] and inaccurate calibration (intercept = 0.25074; p = 0.0195; slope = 0.39504; p = 0.0303), indicating poor performance.

Conclusions

The REMEMBER score did not predict in-hospital mortality and was therefore not applicable in our cohort of patients. Additional external validation studies in a multicenter setting are therefore advisable.

Patient and Management Variables Associated With Survival After Postcardiotomy Extracorporeal Membrane Oxygenation in Adults: The PELS-1 Multicenter Cohort Study

Background Extracorporeal membrane oxygenation (ECMO) has been increasingly used for postcardiotomy cardiogenic shock, but without a concomitant reduction in observed in-hospital mortality. Long-term outcomes are unknown. This study describes patients' characteristics, in-hospital outcome, and 10-year survival after postcardiotomy ECMO. Variables associated with in-hospital and postdischarge mortality are investigated and reported. Methods and Results The retrospective international multicenter observational PELS-1 (Postcardiotomy Extracorporeal Life Support) study includes data on adults requiring ECMO for postcardiotomy cardiogenic shock between 2000 and 2020 from 34 centers. Variables associated with mortality were estimated preoperatively, intraoperatively, during ECMO, and after the occurrence of any complications, and then analyzed at different time points during a patient's clinical course, through mixed Cox proportional hazards models containing fixed and random effects. Follow-up was established by institutional chart review or contacting patients. This analysis included 2058 patients (59% were men; median [interquartile range] age, 65.0 [55.0-72.0] years). In-hospital mortality was 60.5%. Independent variables associated with in-hospital mortality were age (hazard ratio [HR], 1.02 [95% CI, 1.01-1.02]) and preoperative cardiac arrest (HR, 1.41 [95% CI, 1.15-1.73]). In the subgroup of hospital survivors, the overall 1-, 2-, 5-, and 10-year survival rates were 89.5% (95% CI, 87.0%-92.0%), 85.4% (95% CI, 82.5%-88.3%), 76.4% (95% CI, 72.5%-80.5%), and 65.9% (95% CI, 60.3%-72.0%), respectively. Variables associated with postdischarge mortality included older age, atrial fibrillation, emergency surgery, type of surgery, postoperative acute kidney injury, and postoperative septic shock. Conclusions In adults, in-hospital mortality after postcardiotomy ECMO remains high; however, two-thirds of those who are discharged from hospital survive up to 10 years. Patient selection, intraoperative decisions, and ECMO management remain key variables associated with survival in this cohort. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03857217.

Comparison of vasoactive-inotropic score, vasoactive-ventilation-renal score, and modified vasoactive-ventilation-renal score for predicting the poor prognosis after coronary artery bypass grafting

BACKGROUND

Exploring reliable prediction scoring systems is valuable for the poor prognosis of patients after coronary artery bypass grafting (CABG). Herein, we explored and compared the predictive performance of vasoactive-inotropic score (VIS), vasoactive-ventilation-renal (VVR) score, and modified VVR (M-VVR) score in the poor prognosis of patients undergoing CABG.

METHODS

A retrospective cohort study was performed in Affiliated Hospital of Jining Medical University, and data of 537 patients were collected from January 2019 to May 2021. The independent variables were VIS, VVR, and M-VVR. Study endpoint of interest was the poor prognosis. Association between VIS, VVR, M-VVR and poor prognosis was assessed using logistic regression analysis, and odds ratios (OR) and 95% confidence intervals (CIs) were reported. The performance of VIS, VVR, and M-VVR to predict the poor prognosis was assessed by calculating the area under the curve (AUC), and differences of the AUC of the three scoring systems were compared using DeLong test.

RESULTS

After adjusting gender, BMI, hypertension, diabetes, surgery methods, and left ventricular ejection fraction (LVEF), VIS (OR: 1.09, 95%CI: 1.05-1.13) and M-VVR (OR: 1.09, 95%CI: 1.06-1.12) were associated with the increased odds of poor prognosis. The AUC of M-VVR, VVR, and VIS was 0.720 (95%CI: 0.668-0.771), 0.621 (95%CI: 0.566-0.677), and 0.685 (95%CI: 0.631-0.739), respectively. DeLong test displayed that the performance of M-VVR was better than VVR (P = 0.004) and VIS (P = 0.003).

CONCLUSIONS

Our study found the good prediction performance of M-VVR for the poor prognosis of patients undergoing CABG, indicating that M-VVR may be a useful prediction index in the clinic.

Predictive models in extracorporeal membrane oxygenation (ECMO): a systematic review

PURPOSE

Extracorporeal membrane oxygenation (ECMO) has been increasingly used in the last years to provide hemodynamic and respiratory support in critically ill patients. In this scenario, prognostic scores remain essential to choose which patients should initiate ECMO. This systematic review aims to assess the current landscape and inform subsequent efforts in the development of risk prediction tools for ECMO.

METHODS

PubMed, CINAHL, Embase, MEDLINE and Scopus were consulted. Articles between Jan 2011 and Feb 2022, including adults undergoing ECMO reporting a newly developed and validated predictive model for mortality, were included. Studies based on animal models, systematic reviews, case reports and conference abstracts were excluded. Data extraction aimed to capture study characteristics, risk model characteristics and model performance. The risk of bias was evaluated through the prediction model risk-of-bias assessment tool (PROBAST). The protocol has been registered in Open Science Framework ( https://osf.io/fevw5 ).

RESULTS

Twenty-six prognostic scores for in-hospital mortality were identified, with a study size ranging from 60 to 4557 patients. The most common candidate variables were age, lactate concentration, creatinine concentration, bilirubin concentration and days in mechanical ventilation prior to ECMO. Five out of 16 venous-arterial (VA)-ECMO scores and 3 out of 9 veno-venous (VV)-ECMO scores had been validated externally. Additionally, one score was developed for both VA and VV populations. No score was judged at low risk of bias.

CONCLUSION

Most models have not been validated externally and apply after ECMO initiation; thus, some uncertainty whether ECMO should be initiated still remains. It has yet to be determined whether and to what extent a new methodological perspective may enhance the performance of predictive models for ECMO, with the ultimate goal to implement a model that positively influences patient outcomes.

Research status and development trend of extracorporeal membrane oxygenation based on bibliometrics

Background

Using bibliometric method to analyze the research status and development trend of extracorporeal membrane oxygenation (ECMO), we aim to provide clinicians, scientists, and stakeholders with the most up-to-date and comprehensive overview of ECMO research.

Materials and methods

Using Excel and VOSviewer, the literature on ECMO was systematically analyzed regarding publication trends, journal source, foundation, countries, institutions, core authors, research hotspots, and market distribution.

Results

There were five important time nodes in the research process of ECMO, including the success of the first ECMO operation, the establishment of ELSO, and the outbreak of influenza A/H1N1 and COVID-19. The R&amp;D centers of ECMO were the United States, Germany, Japan, and Italy, and the attention to ECMO was gradually increasing in China. The products most used in the literature were from Maquet, Medtronic, and LivaNova. Medicine enterprises attached great importance to the funding of ECMO research. In recent years, the literature has mainly focused on the following aspects: the treatment of ARDS, the prevention of coagulation system-related complications, the application in neonatal and pediatric patients, mechanical circulatory support for cardiogenic shock, and ECPR and ECMO during the COVID-19 pandemic.

Conclusion

The frequent epidemic occurrence of viral pneumonia and the technical advancement of ECMO in recent years have caused an increase in clinical applications. The hot spots of ECMO research are shown in the treatment of ARDS, mechanical circulatory support for cardiogenic shock, and the application during the COVID-19 pandemic.

Short-term effects of levosimendan use for venoarterial extracorporeal membrane oxygenation: A systematic review and meta-analysis

OBJECTIVE

Levosimendan has been demonstrated to reduce the incidence of cardiogenic shock and facilitate weaning from cardiopulmonary bypass. However, the beneficial effects of levosimendan treatment on hospital outcomes in patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) are uncertain. We performed a systematic review and meta-analysis to evaluate the short-term effects of levosimendan use for patients undergoing VA-ECMO.

METHODS

We searched PubMed, Embase, and the Cochrane Library for English articles published from inception to July 15, 2021. Observational studies comparing levosimendan versus non- levosimendan for VA-ECMO were considered eligible for the current study.

RESULTS

Nine observational studies with 1058 patients were included. In-hospital mortality was 46.3% in the levosimendan group as compared with 50.7% in the control group. Levosimendan significantly reduced in-hospital mortality in patients undergoing VA-ECMO compared with the control group (RR, 0.80; 95% CI, 0.67-0.95; p = 0.013). The incidence of weaning from VA-ECMO was 79.3% in the levosimendan group as compared with 63.4% in the control group. Levosimendan significantly increase the incidence of weaning from VA-ECMO in patients as compared with the control group (RR, 1.20; 95% CI, 1.07-1.34; p = 0.002). In the one-way sensitivity analysis for estimating the effect of each study on mortality or weaning from VA-ECMO, omission of each study did not make a significant difference.

CONCLUSIONS

Our study indicates that levosimendan use significantly reduced in-hospital mortality and increase the incidence of weaning in patients undergoing VA-ECMO.

Prognostic models for mortality risk in patients requiring ECMO

PURPOSE

To provide an overview and evaluate the performance of mortality prediction models for patients requiring extracorporeal membrane oxygenation (ECMO) support for refractory cardiocirculatory or respiratory failure.

METHODS

A systematic literature search was undertaken to identify studies developing and/or validating multivariable prediction models for all-cause mortality in adults requiring or receiving veno-arterial (V-A) or veno-venous (V-V) ECMO. Estimates of model performance (observed versus expected (O:E) ratio and c-statistic) were summarized using random effects models and sources of heterogeneity were explored by means of meta-regression. Risk of bias was assessed using the Prediction model Risk Of BiAS Tool (PROBAST).

RESULTS

Among 4905 articles screened, 96 studies described a total of 58 models and 225 external validations. Out of all 58 models which were specifically developed for ECMO patients, 14 (24%) were ever externally validated. Discriminatory ability of frequently validated models developed for ECMO patients (i.e., SAVE and RESP score) was moderate on average (pooled c-statistics between 0.66 and 0.70), and comparable to general intensive care population-based models (pooled c-statistics varying between 0.66 and 0.69 for the Simplified Acute Physiology Score II (SAPS II), Acute Physiology and Chronic Health Evaluation II (APACHE II) score and Sequential Organ Failure Assessment (SOFA) score). Nearly all models tended to underestimate mortality with a pooled O:E > 1. There was a wide variability in reported performance measures of external validations, reflecting a large between-study heterogeneity. Only 1 of the 58 models met the generally accepted Prediction model Risk Of BiAS Tool criteria of good quality. Importantly, all predicted outcomes were conditional on the fact that ECMO support had already been initiated, thereby reducing their applicability for patient selection in clinical practice.

CONCLUSIONS

A large number of mortality prediction models have been developed for ECMO patients, yet only a minority has been externally validated. Furthermore, we observed only moderate predictive performance, large heterogeneity between-study populations and model performance, and poor methodological quality overall. Most importantly, current models are unsuitable to provide decision support for selecting individuals in whom initiation of ECMO would be most beneficial, as all models were developed in ECMO patients only and the decision to start ECMO had, therefore, already been made.

Venoarterial extracorporeal membrane oxygenation with intra-aortic balloon pump for postcardiotomy cardiogenic shock: A systematic review and meta-analysis

OBJECTIVE

Intra-aortic balloon pump (IABP) is currently recommended as a strategy to address the increased afterload in patients who received venoarterial extracorporeal membrane oxygenation (VA-ECMO). The benefit of VA-ECMO with IABP in postcardiotomy cardiogenic shock is inconclusive. A systematic review and meta-analysis was conducted to assess the influence of VA-ECMO with IABP for postcardiotomy cardiogenic shock (PCS).

METHODS

The Cochrane Library, PubMed, and Embase were searched for all articles published from 1 January, 1964 to July 11, 2020. Retrospective cohort studies targeting the comparison of VA-ECMO with IABP and isolated VA-ECMO were included in this study.

RESULTS

We included 2251 patients in the present study (917 patients in the VA-ECMO with IABP group and 1334 patients in the isolated VA-ECMO group). Deaths occurred in 589 of 917 patients (64.2%) in the VA-ECMO with IABP group and occurred in 885 of 1334 patients (66.3%) in isolated VA-ECMO group. Pooling the results of all studies showed that VA-ECMO with IABP was not related to a reduced in-hospital mortality in patients who received VA-ECMO for PCS (RR, 0.95; 95% CI, 0.86-1.04; p = 0.231). In addition, VA-ECMO with IABP was not related to an increased rate of VA-ECMO weaning in patients who received VA-ECMO for PCS (RR, 1.28; 95% CI, 0.99-1.66; p = 0.058).

CONCLUSIONS

This study indicates that VA-ECMO with IABP did not improve either in-hospital survival or weaning for VA-ECMO in postcardiotomy cardiogenic shock patients.

Echocardiographic Prediction of Successful Weaning From Venoarterial Extracorporeal Membrane Oxygenation

BACKGROUND

Weaning from venoarterial extracorporeal membrane oxygenation (VA-ECMO) support fails in 30% to 70% of patients.

OBJECTIVE

To explore the utility of echocardiographic parameters in predicting successful disconnection from VA-ECMO.

METHODS

Patients receiving VA-ECMO in a referral hospital were included. The relationships between echocardiographic parameters during the weaning trial and weaning success (survival > 24 hours after VA-ECMO explant and no death from cardiogenic shock, heart failure, or cardiac arrest during the hospital stay) and survival were evaluated.

RESULTS

Of 85 patients included, 61% had successful weaning. Parameters significantly related to weaning success were higher left ventricular ejection fraction (LVEF; 40% in patients with weaning success vs 30% in patients with weaning failure, P = .01), left ventricular outflow tract velocity time integral (15 cm vs 11 cm, P = .01), aortic valve opening in every cycle (98% vs 91% of patients, P = .01), and normal qualitative right ventricular function (60% vs 42% of patients, P = .02). The LVEF remained as an independent predictor of weaning success (hazard ratio, 0.938; 95% CI, 0.888-0.991; P = .02). An LVEF >33.4% was the optimal cutoff value to discriminate patients with successful weaning (area under the curve, 0.808; sensitivity, 93%; specificity, 72%) and was related to higher survival at discharge (60% vs 20%, P < .001).

CONCLUSION

Among weaning trial echocardiographic parameters, LVEF was the only independent predictor of successful VA-ECMO weaning. An LVEF >33.4% was the optimal cutoff value to discriminate patients with successful weaning and was related to final survival.

Coronavirus disease 2019 and mechanical circulatory support devices: A comprehensive review

Coronavirus disease (COVID-19) can cause circulatory shock refractory to medical therapy. Such patients can be managed with mechanical circulatory support (MCS) devices like IABP, Impella, VA ECMO, and Left Ventricular Assist Devices (LVADs). Moreover, patients on long-term durable LVADs are a special population having increased susceptibility and mortality to COVID-19 infection. In this narrative review, we searched PubMed and Medline for studies on COVID-19 patients on short-term MCS devices. We found 36 papers with 110 patients who met our review criteria, including 89 LVAD patients and 21 COVID-19 patients who needed MCS device therapy. These studies were used to extract patient demographics, clinical presentation, MCS device details, management, and outcomes. Mean age of patients with COVID-19 infection on LVADs was 60, 73% were male, and HeartMate 3 was the most common device (53%). Most patients (77.5%) needed hospitalization, and mortality was 23.6%. Among the 21 reported cases of critically ill COVID-19 patients who required MCS, the mean age was 49.8 years, 52% were women, and the most common MCS device used was VA ECMO (62%) in conjunction with an Impella for LV venting. Comorbidities were not present in 43%, but 71% had abnormal ventricular function on echocardiography. MCS is a viable option for managing severe COVID-19 infection with shock, with many reported cases of favorable outcomes.

Fingolimod does not prevent syndecan-4 shedding from the endothelial glycocalyx in a cultured human umbilical vein endothelial cell model of vascular injury

Background

Shedding of the endothelial glycocalyx (EG) is associated with poor outcomes in a range of conditions including sepsis. Fresh frozen plasma (FFP) restores the damaged EG to baseline thickness, however the mechanism for this effect is unknown, and some components of FFP have adverse effects unrelated to the EG. There is some limited evidence that sphingosine-1-phosphate (S1P) within FFP restores the EG by activating the endothelial cell S1P receptor 1 (S1PR₁). However, there are disadvantages to using S1P clinically as an EG restorative therapy. A potential alternative is the S1PR agonist fingolimod (FTY720). The aim of this study was to assess whether FTY720 prevents EG shedding in injured cultured human umbilical vein endothelial cells.

Methods

Shedding of the EG was induced in cultured human umbilical vein endothelial cells (HUVECs) by exposure to adrenaline, TNF-α and H₂O₂. The cells were then assigned to one of six conditions for 4 h: uninjured and untreated, injured and untreated, injured and treated with FTY720 with and without the S1PR₁ inhibitor W146, and injured and treated with 25% FFP with and without W146. Syndecan-4, a component of the EG, was measured in cell supernatants, and syndecan-4 and thrombomodulin mRNA expression was quantitated in cell lysates.

Results

The injury resulted in a 2.1-fold increase in syndecan-4 (p < 0.001), consistent with EG shedding. Syndecan-4 and thrombomodulin mRNA expression was increased (p < 0.001) and decreased (p < 0.05), respectively, by the injury. Syndecan-4 shedding was not affected by treatment with FTY720, whereas FFP attenuated syndecan-4 shedding back to baseline levels in the injured cells and this was unaffected by W146. Neither treatment affected syndecan-4 or thrombomodulin mRNA expression.

Conclusions

FTY720 did not prevent syndecan-4 shedding from the EG in the HUVEC model of endothelial injury, suggesting that activation of S1PR does not prevent EG damage. FFP prevented syndecan-4 shedding from the EG via a mechanism that was independent of S1PR₁ and upregulation of SDC-4 production. Further studies to examine whether FTY720 or another S1PR agonist might have EG-protective effects under different conditions are warranted, as are investigations seeking the mechanism of EG protection conferred by FFP in this experimental model.

Oxygen debt repayment in the early phase of veno-arterial extracorporeal membrane oxygenation: a cluster analysis

Introduction

Early oxygen debt repayment is predictive of successful weaning from veno-arterial extracorporeal membrane oxygenation (V-A ECMO). However, studies are limited by the patient cohort’s heterogeneity. This study aimed to understand the early state of oxygen debt repayment and its association with end-organ failure and 30-day survival using cluster analysis.

Methods

A retrospective, single-center study was conducted on 153V-A ECMO patients. Patients were clustered using a two-step cluster analysis based on oxygen debt and its repayment during the first 24 h of ECMO. Primary outcomes were end-organ failure and 30-day survival.

Results

The overall mortality was 69.3%. For cluster analysis, 137 patients were included, due to an incomplete data set. The mortality rate in this subset was 67.9%. Three clusters were generated, representing increasing levels of total oxygen debt from cluster 1 to cluster 3. Thirty-day survival between clusters was significantly different (cluster 1: 46.9%, cluster 2: 23.4%, and cluster 3: 4.8%, p = 0.001). Patients in cluster 3 showed less decrement in liver enzymes, creatinine, and urea blood levels. There were significant differences in the baseline oxygen debt and the need for continuous veno-venous hemofiltration (CVVH) between survivors and non-survivors (p < 0.05). Forty-seven patients (34.3%) migrated between clusters within the first 24 h of support. Among these patients, 43.4% required CVVH. Notably, patients requiring CVVH and who migrated to a cluster with a higher oxygen debt repayment showed better survival rates compared to those who migrated to a cluster with a lower oxygen debt repayment.

Conclusions

Oxygen debt repayment during the first 24 h of V-A ECMO shows to correspond with survival, where the baseline oxygen debt value and the necessity for continuous kidney replacement therapy appear to be influential.

HEROES V-A-HEmoRrhagic cOmplications in veno-arterial Extracorporeal life Support-Development and internal validation of a multivariable prediction model in adult patients

BACKGROUND

Risk factors for bleeding complications during extracorporeal life support (ECLS) indicated for cardiac support remain poorly investigated. The aim is to develop and internally validate a prediction model to calculate the risk for bleeding complications in adult patients receiving veno-arterial (V-A) ECLS.

METHODS

Data of the Extracorporeal Life Support Organization registry of adult patients undergoing V-A ECLS between 2010 and 2020 were analyzed. The primary outcome was bleeding complications recorded during V-A ECLS. Multivariable logistic regression with backward stepwise elimination was used to develop the prediction model. Performance of the model was tested by discriminative ability and calibration with receiver operator characteristic, area under the curve, and visual inspection of the calibration plot. Internal validation was performed to detect overfitting of the model.

RESULTS

In total 28 767 adult patients were included, of which 29.0% developed bleeding complications. Sex, body mass index, surgical cannulation, pre-ECLS respiratory and hemodynamic variables, pre-ECLS support and interventions, and different type of diagnosis were included in the prediction model. This prediction model showed a predictive capability with an AUC of 0.66.

CONCLUSION

The model is based on the largest cohort of V-A ECLS patients and is the best available predictive model for bleeding events given the predictors that are available in V-A ECLS compared to current literature. The model can help in identifying patients at high risk for bleeding complications and will help in developing further research and decision-making in terms of anticoagulation management. External validation is warranted to extrapolate this model in the clinical setting.

Early Blood Pressure Variables Associated With Improved Outcomes in VA-ECLS: The ELSO Registry Analysis

BACKGROUND

As utilization of veno-arterial extracorporeal life support (VA-ECLS) in treatment of cardiogenic shock (CS) continues to expand, clinical variables that guide clinicians in early recognition of myocardial recovery and therefore, improved survival, after VA-ECLS are critical. There remains a paucity of literature on early postinitiation blood pressure measurements that predict improved outcomes.

OBJECTIVES

The objective of this study is to help identify early blood pressure variables associated with improved outcomes in VA-ECLS.

METHODS

The authors queried the ELSO (Extracorporeal Life Support Organization) registry for cardiogenic shock patients treated with VA-ECLS or venovenous arterial ECLS between 2009 and 2020. Their inclusion criteria included treatment with VA-ECLS or venovenous arterial ECLS; absence of pre-existing durable right, left, or biventricular assist devices; no pre-ECLS cardiac arrest; and no surgical or percutaneously placed left ventricular venting devices during their ECLS runs. Their primary outcome of interest was the survival to discharge during index hospitalization.

RESULTS

A total of 2,400 CS patients met the authors' inclusion criteria and had complete documentation of blood pressures. Actual mortality during index hospitalization in their cohort was 49.5% and survivors were younger and more likely to be Caucasian, intubated for >30 hours pre-ECLS initiation, and had a favorable baseline SAVE (Survival After Veno-arterial ECMO) score (P < 0.05 for all). Multivariable regression analyses adjusting for SAVE score, age, ECLS flow at 4 hours, and race showed that every 10-mm Hg increase in baseline systolic blood pressure (HR: 0.92 [95% CI: 0.89-0.95]; P < 0.001), and baseline pulse pressure (HR: 0.88 [95% CI: 0.84-0.91]; P < 0.001) at 24 hours was associated with a statistically significant reduction in mortality.

CONCLUSIONS

Early (within 24 hours) improvements in pulse pressure and systolic blood pressure from baseline are associated with improved survival to discharge among CS patients treated with VA-ECLS.

Factors affecting mortality after coronary bypass surgery: a scoping review

Objectives

Previous research reports numerous factors of post-operative mortality in patients undergoing isolated coronary artery bypass graft surgery. However, this evidence has not been mapped to the conceptual framework of care improvement. Without such mapping, interventions designed to improve care quality remain unfounded.

Methods

We identified reported factors of in-hospital mortality post isolated coronary artery bypass graft surgery in adults over the age of 19, published in English between January 1, 2000 and December 31, 2019, indexed in PubMed, CINAHL, and EMBASE. We grouped factors and their underlying mechanism for association with in-hospital mortality according to the augmented Donabedian framework for quality of care.

Results

We selected 52 factors reported in 83 articles and mapped them by case-mix, structure, process, and intermediary outcomes. The most reported factors were related to case-mix (characteristics of patients, their disease, and their preoperative health status) (37 articles, 27 factors). Factors related to care processes (27 articles, 12 factors) and structures (11 articles, 6 factors) were reported less frequently; most proposed mechanisms for their mortality effects.

Conclusions

Few papers reported on factors of in-hospital mortality related to structures and processes of care, where intervention for care quality improvement is possible. Therefore, there is limited evidence to support quality improvement efforts that will reduce variation in mortality after coronary artery bypass graft surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-01784-z.

Predicting mortality in nonsurgical patients before cannulation for veno-arterial extracorporeal life support: Development and validation of the LACT-8 score

OBJECTIVES

We sought to derive and validate a model to predict inpatient mortality after veno-arterial extracorporeal life support (VA-ECLS) based on readily available, precannulation clinical data.

BACKGROUND

Refractory cardiogenic shock supported by VA-ECLS is associated with high morbidity and mortality.

METHODS

VA-ECLS cases at our institution from January 2014 through July 2019 were retrospectively reviewed. Exclusion criteria were cannulation: (1) at another institution; (2) for primary surgical indication; or (3) for extracorporeal cardiopulmonary resuscitation. Multivariable logistic regression compared those with and without inpatient mortality. Multiple imputation was performed and optimism-adjusted area under the curve (oAUC) values were computed.

RESULTS

VA-ECLS cases from August 2019 through November 2020 were identified as a validation cohort. In the derivation cohort (n = 135), the final model included Lactate (mmol/L), hemoglobin (g/dl; Anemia), Coma (Glasgow Coma Scale [GCS] < 8) and resusciTATEd cardiac arrest (LACTATE score; oAUC = 0.760). In the validation cohort (n = 30, LACTATE showed similar predictability [AUC = 0.710]). A simplified (LACT-8) score was derived by dichotomizing lactate (>8) and hemoglobin (<8) and summing together the number of components for each patient. LACT-8 performed similarly (derivation, oAUC = 0.724; validation, AUC = 0.725). In the derivation cohort, both scores outperformed SAVE (oAUC = 0.568) and SOFA (oAUC = 0.699) scores. A LACT-8 ≥ 3 had a specificity for mortality of 97.9% and 92.9%, in the derivation and validation cohorts, respectively.

CONCLUSIONS

The LACT-8 score can predict inpatient mortality prior to before cannulation for VA-ECLS. LACT-8 can be implemented utilizing clinical data without the need for an online calculator.

Risk factors associated with in-hospital mortality for patients with ECLS due to post cardiotomy cardiogenic shock after isolated coronary surgery

OBJECTIVES

Extracorporeal membrane oxygenation (ECMO) or extracorporeal life support (ECLS) in patients after cardiac surgery and post cardiotomy cardiogenic shock (PCS) is known to be associated with high mortality. Especially in patients after coronary artery bypass grafting (CABG) and PCS, ECLS is frequently established. Aim of this analysis was to evaluate factors associated with in-hospital mortality in patients treated with ECLS due to PCS after CABG.

METHODS

Between August 2006 and January 2017, 92 consecutive patients with V-A ECLS due to PCS after isolated CABG were identified and included in this retrospective analysis. Patients were divided into survivors (S) and non-survivors (NS) and analysed in regard of risk factors of in-hospital mortality.

RESULTS

In-hospital mortality added up to 61 patients (66 %). Non-survivors were significantly older (60±12 (S) vs. 67±10 (NS); p=0.013). Bilateral internal mammary artery graft was significantly more frequently used in S (23% (S) vs. 2% (NS); p=0.001). After 24 hours of ECLS support, median lactate levels were significantly higher in NS (1.9(1.3;3.5) mmol/L (S) vs. 3.5(2.1;6.3) mmol/L (NS); p=0.001). NS suffered more often acute kidney injury requiring dialysis (42% (S) vs. 74% (NS); p=0.002).

CONCLUSION

Mortality in patients with refractory PCS after CABG and consecutive ECLS support remains high. Failing end-organ recovery under ECLS despite optimized concomitant medical therapy is an indicator of adverse outcomes in this specific patient cohort. Moreover, total-arterial revascularization might be beneficial for cardiac recovery in patients suffering PCS after CABG and following ECLS.

Concomitant Respiratory Failure Can Impair Myocardial Oxygenation in Patients with Acute Cardiogenic Shock Supported by VA-ECMO

Venous-arterial extracorporeal membrane oxygenation (VA-ECMO) treatment for acute cardiogenic shock in patients who also have acute lung injury predisposes development of a serious complication called "north-south syndrome" (NSS) which causes cerebral hypoxia. NSS is poorly characterized and hemodynamic studies have focused on cerebral perfusion ignoring the heart. We hypothesized in NSS the heart would be more likely to receive hypoxemic blood than the brain due to the proximity of the coronary arteries to the aortic annulus. To test this, we conducted a computational fluid dynamics simulation of blood flow in a human supported by VA-ECMO. Simulations quantified the fraction of blood at each aortic branching vessel originating from residual native cardiac output versus VA-ECMO. As residual cardiac function was increased, simulations demonstrated myocardial hypoxia would develop prior to cerebral hypoxia. These results illustrate the conditions where NSS will develop and the relative cardiac function that will lead to organ-specific hypoxia. Illustration of the impact of north-south syndrome on organ-specific oxygen delivery. Patients on VA-ECMO have two sources of blood flow, one from the VA-ECMO circuit and one from the residual cardiac function. When there is no residual cardiac function, all organs are perfused with oxygenated blood. As myocardial recovery progresses, blood supply from the two sources will begin to mix resulting in non-homogeneous mixing and differential oxygenation based upon the anatomical site of branching vessels.

The Relative Early Decrease in Platelet Count Is Associated With Mortality in Post-cardiotomy Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation

Background: The relationship between the magnitude of platelet count decrease and mortality in post-cardiotomy cardiogenic shock (PCS) patients undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO) has not been well-reported. This study was designed to evaluate the association between the relative decrease in platelet count (RelΔplatelet) at day 1 from VA-ECMO initiation and in-hospital mortality in PCS patients.

Methods: Patients (n = 178) who received VA-ECMO for refractory PCS between January 2016 and December 2018 at the Beijing Anzhen Hospital were reviewed retrospectively. Multivariable logistic regression analyses were performed to assess the association between RelΔplatelet and in-hospital mortality.

Results: One hundred and sixteen patients (65%) were weaned from VA-ECMO, and 84 patients (47%) survived to hospital discharge. The median [interquartile range (IQR)] time on VA-ECMO support was 5 (3–6) days. The median (IQR) RelΔ platelet was 41% (26–59%). Patients with a RelΔ platelet ≥ 50% had an increased mortality compared to those with a RelΔ platelet < 50% (57 vs. 37%; p < 0.001). A large RelΔplatelet (≥50%) was independently associated with in-hospital mortality after controlling for potential confounders (OR 8.93; 95% CI 4.22–18.89; p < 0.001). The area under the receiver operating characteristic curve for RelΔ platelet was 0.78 (95% CI, 0.71–0.85), which was better than that of platelet count at day 1 (0.69; 95% CI, 0.61–0.77).

Conclusions: In patients receiving VA-ECMO for post-cardiotomy cardiogenic shock, a large relative decrease in platelet count in the first day after ECMO initiation is independently associated with an increased in-hospital mortality.

Short-term mechanical circulatory support in elderly patients

BACKGROUND

Age over 70 years seems to confer poor prognosis for patients under mechanical circulatory support (MCS). Advanced age is usually a relative contraindication. Our objective was to assess the impact of age on survival of patients with short-term MCS.

METHODS

Retrospective analysis of ≥70-year-old patients supported with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or Impella CP® due to cardiogenic shock and other situations of hemodynamic instability in a referral hospital (elderly group), compared with younger patients (<70 years). We analyze factors associated with survival in elderly group.

RESULTS

Out of 164 short-term MCS implants from 2013 to October 2020, 45 (27.4%) correspond to ≥70-year-old patients (73.3% VA-ECMO; 26.7% Impella CP®), 80% as bridge to recovery and 15.6% for high-risk percutaneous coronary intervention (PCI). We found no significant differences in complications developed between both groups. Survivals at discharge (40% vs. 43.7%, p = 0.403) and at follow-up (median 13.6 [30] months) were similar in elderly and young patients (35.6% vs. 37.8%, log-rank p = 0.061). Predictive factors of mortality in elderly patients were peripheral artery disease (p = 0.037), higher lactate (p = 0.003) and creatinine (p = 0.035) at implant, longer cardiac arrest (p = 0.003), and worse post-implantation left ventricular ejection fraction (p = 0.003). Patients with indication of MCS for high-risk PCI had higher survival compared to other indications (p = 0.013).

CONCLUSION

Short-term MCS with VA-ECMO or Impella CP® in elderly patients may be a reasonable option in hemodynamic compromise situations as bridge to recovery or elective high-risk PCI, without a significant increase in complications or mortality. Age should not be an absolute contraindication, but careful selection of candidate patients is necessary.

SEDAR/SECCE ECMO management consensus document

ECMO is an extracorporeal cardiorespiratory support system whose use has been increased in the last decade. Respiratory failure, postcardiotomy shock, and lung or heart primary graft failure may require the use of cardiorespiratory mechanical assistance. In this scenario perioperative medical and surgical management is crucial. Despite the evolution of technology in the area of extracorporeal support, morbidity and mortality of these patients continues to be high, and therefore the indication as well as the ECMO removal should be established within a multidisciplinary team with expertise in the area. This consensus document aims to unify medical knowledge and provides recommendations based on both the recent bibliography and the main national ECMO implantation centres experience with the goal of improving comprehensive patient care.

A systematic approach to weaning from extracorporeal membrane oxygenation in patients with refractory cardiac failure

BACKGROUND

Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is commonly used to provide haemodynamic support for patients with severe cardiac failure. However, timing ECMO weaning remains challenging. We aimed to examine if an integrative weaning approach based on predefined haemodynamic, respiratory and echocardiographic criteria is associated with successful weaning.

METHODS

All patients weaned from ECMO between April 2017 and April 2019 at Aarhus University Hospital, Denmark, were consecutively enrolled. Predefined haemodynamic, respiratory and echocardiographic criteria were assessed before and during ECMO flow reduction. A weaning attempt was commenced in haemodynamic stable patients and patients remaining stable at minimal flow were weaned from ECMO. Comparisons were made between patients who met the criteria for weaning at first attempt and patients who did not meet these criteria. Patients completing a full weaning attempt with no further need for mechanical support within 24 h were defined as successfully weaned.

RESULTS

A total of 38 patients were included in the study, of whom 26 (68%) patients met the criteria for weaning. Among these patients, 25 (96%) could be successfully weaned. Successfully weaned patients were younger and had less need for inotropic support and ECMO duration was shorter. Fulfilling the weaning criteria was associated with successful weaning and both favourable 30-d survival and survival to discharge.

CONCLUSION

An integrative weaning approach based on haemodynamic, respiratory and echocardiographic criteria may strengthen the clinical decision process in predicting successful weaning in patients receiving ECMO for refractory cardiac failure.

Analysis of the 2020 EACTS/ELSO/STS/AATS Expert Guidelines on the Management of Adult Postcardiotomy Extracorporeal Life Support

Extracorporeal life support (ECLS), also known as extracorporeal membrane oxygenation (ECMO), increasingly is used in postcardiotomy (PC) shock to facilitate a bridge to sustained recovery, long-term mechanical support, or heart transplantation. Given increasing prevalence and complexity of PC-ECLS, a joint expert consensus guideline was created in 2020 for management of adult PC-ECLS by the European Association for Cardio-Thoracic Surgery (EACTS), the Extracorporeal Life Support Organization (ELSO), the Society of Thoracic Surgeons (STS), and the American Association of Thoracic Surgery (AATS). The aim of this analysis was to comprehensively review the expert consensus guidelines, with particular emphasis on PC-ECLS candidacy, timing, cannula configuration, left ventricular distention, anticoagulation, ECLS weaning, and intensive care unit complications. This analysis finds the expert consensus guideline to be timely, pertinent, and clinically valuable, although there remains the need for larger clinical trials to codify best practices.

Early Positive Fluid Balance is Associated with Mortality in Patients Treated with Veno-Arterial Extra Corporeal Membrane Oxygenation For Cardiogenic Shock: a Retrospective Cohort Study

PURPOSE

Veno-arterial Extracoporeal Membrane Oxygenation (VA-ECMO) provides circulatory assistance for patients in cardiogenic shock. Large quantities of fluids are often required, especially during the early stages, but can result in a potentially harmful fluid-overload. The objective was to determine the association of early fluid-balance and mortality.

METHODS

Retrospective single-center study in 101 VA-ECMO patients between 2013 and 2016. Daily fluid-balance and weight changes over the 5 first days were observed. Analyses between survivors and non-survivors were conducted using Mann-Whitney tests and logistic regression multivariable and Cox hazard-proportional analyses to determine any association with 28-days mortality.

RESULTS

Mortality was 47.5%. The fluid-balance was higher in non-survivors at day-1 (47.3[18.1-71.9] vs. 19.3[1.5-36.2] mL/kg, P < 0.0001) and day-2 (30.6[14.8-71.0] vs. 10.1[-9.8 to 34.7] mL/kg, P = 0.025), as was the cumulative fluid-balance over the first 5 days (107.3[40.5-146.2] vs. 53.0[7.5-74.3] mL/kg, P = 0.04). The administration of unintentional fluids (used for preparation and infusion of drugs) represented an important part of the administrated fluids (15 mL/kg/d-23 mL/kg/d). A significant but moderate correlation was observed between fluid-balance and weight variations over the 5 days (r values ranging from 0.36 to 0.54). Among other parameters, day-1 fluid-balance was independently associated with mortality (OR = 14.34 [1.58-129.79], P = 0.02) and day-1 and day-2 with time to death (HR = 8.26 [1.12-60.98], P = 0.04 and 2.89 [1.26-6.65], P = 0.01). A threshold of 38.8 mL/kg predicted mortality with a sensitivity of 60% and specificity of 83% (area under the curve: 0.749).

CONCLUSION

Early positive fluid-balance is associated with mortality in VA-ECMO patients.

Mortality Predictors in Elderly Patients With Cardiogenic Shock on Venoarterial Extracorporeal Life Support. Analysis From the Extracorporeal Life Support Organization Registry

OBJECTIVES

Because significantly higher mortality is observed in elderly patients undergoing venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock, decision-making in this setting is challenging. We aimed to elucidate predictors of unfavorable outcomes in these elderly (≥ 70 yr) patients.

DESIGN

Analysis of international worldwide extracorporeal life support organization registry.

SETTING

Refractory cardiogenic shock due to various etiologies (cardiac arrest excluded).

PATIENTS

Elderly patients (≥ 70 yr).

INTERVENTIONS

Venoarterial extracorporeal membrane oxygenation.

MEASUREMENTS AND MAIN RESULTS

Three age groups (70-74, 75-79, ≥80 yr) were in-depth analyzed. Uni- and multivariable analysis were performed. From January 1997 to December 2018, 2,644 patients greater than or equal to 70 years (1,395 [52.8%] 70-74 yr old, 858 [32.5%] 75-79 yr, and 391 [14.8%] ≥ 80 yr old) were submitted to venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock with marked increase in the most recent years. Peripheral access was applied in majority of patients. Median extracorporeal membrane oxygenation support duration was 3.5 days (interquartile range: 1.6-6.1 d), (3.9 d [3.7-4.6 d] in patients ≥ 80 yr) (p < 0.001). Weaning from extracorporeal membrane oxygenation was possible in 1,236 patients (46.7%). Overall in-hospital mortality was estimated at 68.3% with highest crude mortality rates observed in 75-79 years old subgroup (70.1%). Complications were mostly cardiovascular and bleeding, without apparent differences between subgroups. Airway pressures, 24-hour pH after extracorporeal membrane oxygenation start, extracorporeal membrane oxygenation duration, and renal replacement therapy were predictive of higher mortality. In-hospital mortality was lower in heart transplantation recipients, posttranscatheter aortic valve replacement, and pulmonary embolism; conversely, higher mortality followed extracorporeal membrane oxygenation institution after coronary artery bypass + valve and in decompensated chronic heart failure, and nearly 100% mortality followed in extracorporeal membrane oxygenation for sepsis.

CONCLUSIONS

This study confirmed the remarkable increase of venoarterial extracorporeal membrane oxygenation use in elderly affected by refractory cardiogenic shock. Despite in-hospital mortality remains high, venoarterial extracorporeal membrane oxygenation should still be considered in such setting even in elderly patients, since increasing age itself was not linked to increased mortality, whereas several predictors may guide indication and management.

Venoarterial extracorporeal membrane oxygenation for cardiogenic shock after coronary endarterectomy

BACKGROUND

Clinical outcomes of cardiogenic shock patients who were supported with venoarterial extracorporeal membrane oxygenation (VA-ECMO) after coronary endarterectomy (CE) have not yet been reported. We conducted a retrospective observational study to evaluate the short-term outcomes of patients supported with VA-ECMO after CE.

METHODS

Patients (n = 32) who received VA-ECMO refractory cardiogenic shock after CE between January 2011 and December 2020 at the Beijing Anzhen Hospital were reviewed retrospectively. Multivariable logistic regression analysis was used to identify factors independently associated with in-hospital mortality.

RESULTS

Twenty patients (63%) could be weaned from VA-ECMO, and 12 patients (38%) survived to hospital discharge. The median (interquartile range [IQR]) time on VA-ECMO support was 4 (3-6) days. The median (IQR) length of ICU stay and hospital stay were 9 (5-13) and 20 (15-27) days, respectively. Neurological complications were observed in 4 (13%) of the patients. ECMO-related complications occurred in 9 (28%) of the patients. SAVE score was identified as an independent protective factor for in-hospital mortality (OR, 0.70; 95% CI, 0.54-0.91; p = 0.009). The area under the receiver operating characteristic curve for SAVE score was 0.83 (95% CI, 0.67-0.98). SOFA score (0.78; 95% CI, 0.62-0.94) and EuroSCORE (0.79; 95% CI, 0.62-0.97) also exhibited good performances.

CONCLUSIONS

VA-ECMO is an acceptable technique for the treatment of cardiogenic shock in patients undergoing CE. SAVE score might be a useful tool to predict survival for these patients. Prospective studies are needed to assess long-term outcomes of hospital survivors.

Nomogram to predict survival outcome of patients with veno-arterial extracorporeal membrane oxygenation after refractory cardiogenic shock

Objective: This study aims to develop a nomogram model to predict the survival of refractory cardiogenic shock (RCS) patients that received veno-arterial extracorporeal membrane oxygenation (VA-ECMO).Methods: A total of 235 and 209 RCS patients were supported with VA-ECMO from January 2018 to December 2019 in Guangdong Provincial People's Hospital, and from January 2020 to December 2020 in four third-grade and class-A hospitals were a development cohort (DC) and validation cohort (VC), respectively. Finally, 137 and 98 patients were included in the DC and VC. Multivariate logistic regression analysis was used to identify variables, and only these independent risk factors were used to establish the nomogram model. The receiver operating characteristic curve (ROC), calibration plot, decision curve, and clinical impact curves were used to evaluate the nomogram's discriminative ability, predictive accuracy, and clinical application value.Results: Pre-ECMO cardiogenic arrest (pre-ECA), lactate (Lac), inotropic score (IS), and modified nutrition risk in the critically ill score (mNUTRIC score) were incorporated into the nomogram. This showed good discrimination in the DC, with an area under ROC (AUROC) and a 95% confidence interval (CI) of 0.959 (0.911-0.986). The AUROC (95% CI) of the VC was 0.928 (0.858-0.971). The calibration plots of the DC and VC presented good calibration results. The decision curve and clinical impact curve of the nomogram provided improved benefits for RCS patients.Conclusions: This study established a prediction nomogram composed of pre-ECA, Lac, IS, and mNUTRIC scores that could help clinicians to predict the survival probability at hospital discharge precisely and rapidly for RCS patients that received VA-ECMO.