Complications of extracorporeal membrane oxygenation for treatment of cardiogenic shock and cardiac arrest: a meta-analysis of 1,866 adult patients.

PURPOSE: This study was designed to identify factors associated with in-intensive care unit (ICU) death and develop a practical mortality risk score for venoarterial-extracorporeal membrane oxygenation (VA-ECMO)-treated acute myocardial infarction (AMI) patients. Long-term survivors' health-related quality of life (HRQOL), anxiety, depression, and post-traumatic stress disorder (PTSD) frequencies were also assessed. METHODS: Data from 138 ECMO-treated AMI patients admitted to two French ICUs (2008-2013) were analyzed. ICU survivors contacted \textgreater6 months post-ICU discharge were assessed for HRQOL, psychological and PTSD status. RESULTS: Sixty-five patients (47 %) survived to ICU discharge. On the basis of multivariable logistic regression analyses, the ENCOURAGE score was constructed with seven pre-ECMO parameters: age \textgreater60, female sex, body mass index \textgreater25 kg/m(2), Glasgow coma score \textless6, creatinine \textgreater150 μmol/L, lactate (\textless2, 2-8, or \textgreater8 mmol/L), and prothrombin activity \textless50 %. Six months after ECMO, probabilities of survival were 80, 58, 25, 20, and 7 % for ENCOURAGE score classes 0-12, 13-18, 19-22, 23-27, and ≥28, respectively. The ENCOURAGE score ROC AUC [0.84 (95 % CI 0.77-0.91)] was significantly better than those of the SAVE, SAPS II, and SOFA scores. Survivors' HRQOL evaluated after median follow-up of 32 months revealed satisfactory mental health but persistent physical and emotional-related difficulties, with 34 % (95 % CI 20-49 %) anxiety, 20 % (95 % CI 8-32 %) depression, and 5 % (95 % CI 0-12 %) PTSD symptoms reported. CONCLUSIONS: The ENCOURAGE score might be a useful tool to predict mortality of severe cardiogenic shock AMI patients who received VA-ECMO. However, it now needs prospective validation on other populations of AMI patients

The ENCOURAGE mortality risk score and analysis of long-term outcomes after VA-ECMO for acute myocardial infarction with cardiogenic shock

Despite a high rate of early revascularization and use of intra-aortic balloon pump counterpulsation therapy, the prognosis of patients with cardiogenic shock has remained poor. In the hopes of improving outcomes, clinicians are increasingly turning to percutaneous left and right mechanical circulatory support devices. Until recently, the evidence base for these devices had consisted only of observational data, meta-analyses, and small feasibility trials. In this article, we describe the contemporary outcomes of patients with cardiogenic shock, the hemodynamics of cardiogenic shock, and hemodynamic effects of percutaneous mechanical circulatory support devices. We then use this discussion to provide clinicians with a useful framework for understanding when selecting between or while managing patients with a percutaneous mechanical circulatory support devices. We critically review the recently published data for and against the use of commercially available devices—the intra-aortic balloon pump counterpulsation, the Impella system, the TandemHeart, and venous–arterial extracorporeal membrane oxygenation—and highlight gaps in our understanding. Given such gaps, a consensus multidisciplinary approach that combines expertise from interventional cardiologists, heart failure specialists, cardiac surgeons, and cardiac anesthesiologists may help pair the right patient with the right device at the right time.

Percutaneous Mechanical Circulatory Support Devices in Cardiogenic Shock

Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock and Cardiac Arrest: A Meta-Analysis

Venoarterial extracorporeal membrane oxygenation (VA ECMO) provides mechanical support to the patient with cardiac or cardiopulmonary failure. This paper reviews the physiology of VA ECMO including the determinants of ECMO flow and gas exchange. The efficacy of this therapy may be determined by assessing patient hemodynamics and device flow, overall gas exchange support, markers of adequate oxygen delivery, and pulsatility of the arterial blood pressure waveform.

/pdf/monitoring-of-the-adult-patient-on-venoarterial-tdl5s3sgf2.pdf

Saehwan Yu

Papers

Efficacy of veno-arterial extracorporeal membrane oxygenation in acute myocardial infarction with cardiogenic shock