Early and late outcomes of 517 consecutive adult patients treated with extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock

doi:10.1016/J.JTCVS.2009.10.043

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Early and late outcomes of 517 consecutive adult patients treated with extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock

Journal Article•DOI•

Early and late outcomes of 517 consecutive adult patients treated with extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock

Ardawan Rastan¹, Andreas Dege¹, Matthias Mohr¹, Nicolas Doll¹, Volkmar Falk¹, Thomas Walther¹, Friedrich W. Mohr¹ - Show less +3 more•Institutions (1)

Leipzig University¹

01 Feb 2010-The Journal of Thoracic and Cardiovascular Surgery (Elsevier)-Vol. 139, Iss: 2, pp 302-311

TL;DR: Extracorporeal membrane oxygenation support is an acceptable option for patients with postcardiotomy cardiogenic shock who otherwise would die and is justified by good long-term outcome of hospital survivors.

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About: This article is published in The Journal of Thoracic and Cardiovascular Surgery.The article was published on 2010-02-01 and is currently open access. It has received 514 citations till now. The article focuses on the topics: Extracorporeal membrane oxygenation & Cardiogenic shock.

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Journal Article•DOI•

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

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Richard Cheng¹, Rory Hachamovitch², Michelle M. Kittleson¹, Jignesh Patel¹, Francisco A. Arabia¹, Jaime Moriguchi¹, Fardad Esmailian¹, Babak Azarbal¹ - Show less +4 more•Institutions (2)

Cedars-Sinai Medical Center¹, Cleveland Clinic²

01 Feb 2014-The Annals of Thoracic Surgery

TL;DR: Although ECMO can improve survival of patients with advanced heart disease, there is significant associated morbidity with performance of this intervention.

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651 citations

Cites background from "Early and late outcomes of 517 cons..."

...For the rates of lower extremity ischemia, lower extremity fasciotomy or compartment syndrome, and lower extremity amputation, studies must also report the number of patients who underwent femoral cannulation, as we tend to agree with Rastan and colleagues [4] and Bisdas and associates [18] that lower limb ischemia (and its associated complications) is more unique to femoral arterial cannulation....
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...Two studies defined stroke as cerebral stroke or cerebral stroke and hemorrhage [4, 5], and the remaining study did not define the complication [20]....
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...However, one study of 517 patients reported a decrease in leg ischemia and leg fasciotomy with the use of distal cannulation [4]....
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...The remaining four of nine studies either referred to neurologic complications as “brain damage” or did not define the complication [4, 6, 9, 25]....
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...Four of five studies referred to the complication as fasciotomy attributable to either ischemia or compartment syndrome [1, 4, 9, 20], with the remaining study referring to the complication as compartment syndrome [3]....
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Journal Article•DOI•

Predicting survival after ECMO for refractory cardiogenic shock: the survival after veno-arterial-ECMO (SAVE)-score

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Matthieu Schmidt¹, Aidan Burrell², L. Roberts³, Michael Bailey², Jayne Sheldrake³, Peter Rycus⁴, Carol L. Hodgson², Carlos Scheinkestel³, D. Jamie Cooper², Ravi R. Thiagarajan⁴, Daniel Brodie⁵, Vincent Pellegrino², David Pilcher² - Show less +9 more•Institutions (5)

Pierre-and-Marie-Curie University¹, Monash University², Alfred Hospital³, Extracorporeal Life Support Organization⁴, Columbia University⁵

01 Sep 2015-European Heart Journal

TL;DR: The SAVE-score may be a tool to predict survival for patients receiving ECMO for refractory cardiogenic shock (www.save-score.com) and create the survival after veno-arterial-ECMO (SAVE)-score.

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Abstract: Rationale Extracorporeal membrane oxygenation (ECMO) may provide mechanical pulmonary and circulatory support for patients with cardiogenic shock refractory to conventional medical therapy. Prediction of survival in these patients may assist in management of these patients and comparison of results from different centers. Aims To identify pre-ECMO factors which predict survival from refractory cardiogenic shock requiring ECMO and create the survival after veno-arterial-ECMO (SAVE)-score. Methods and results Patients with refractory cardiogenic shock treated with veno-arterial ECMO between January 2003 and December 2013 were extracted from the international Extracorporeal Life Support Organization registry. Multivariable logistic regression was performed using bootstrapping methodology with internal and external validation to identify factors independently associated with in-hospital survival. Of 3846 patients with cardiogenic shock treated with ECMO, 1601 (42%) patients were alive at hospital discharge. Chronic renal failure, longer duration of ventilation prior to ECMO initiation, pre-ECMO organ failures, pre-ECMO cardiac arrest, congenital heart disease, lower pulse pressure, and lower serum bicarbonate (HCO3) were risk factors associated with mortality. Younger age, lower weight, acute myocarditis, heart transplant, refractory ventricular tachycardia or fibrillation, higher diastolic blood pressure, and lower peak inspiratory pressure were protective. The SAVE-score (area under the receiver operating characteristics [ROC] curve [AUROC] 0.68 [95%CI 0.64-0.71]) was created. External validation of the SAVE-score in an Australian population of 161 patients showed excellent discrimination with AUROC = 0.90 (95%CI 0.85-0.95). Conclusions The SAVE-score may be a tool to predict survival for patients receiving ECMO for refractory cardiogenic shock (www.save-score.com).

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616 citations

Journal Article•DOI•

2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care: Endorsed by the American Heart Assocation, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; Affirmation of Value by the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d’intervention

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Charanjit S. Rihal¹, Srihari S. Naidu², Michael M. Givertz³, Wilson Y. Szeto⁴, James A. Burke⁵, Navin K. Kapur⁶, Morton J. Kern⁷, Kirk N. Garratt⁸, James A. Goldstein, Vasiliki V Dimas⁹, Thomas M. Tu - Show less +7 more•Institutions (9)

Mayo Clinic¹, Winthrop-University Hospital², Harvard University³, University of Pennsylvania⁴, Lehigh University⁵, Tufts University⁶, University of California, Irvine⁷, Lenox Hill Hospital⁸, University of Texas Southwestern Medical Center⁹

19 May 2015-Journal of the American College of Cardiology

TL;DR: The physiologic impact on the circulation of these devices and their use in specific clinical situations are reviewed and the clinical utility of mechanical circulatory support devices is reviewed, as are the American College of Cardiology/American Heart Association clinical practice guidelines.

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523 citations

Cites methods from "Early and late outcomes of 517 cons..."

...Percutaneous hemodynamic support has historically been limited to the intra-aortic balloon pump (IABP) or extracorporeal bypass with membrane oxygenator (ECMO) [1–3]....
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Journal Article•DOI•

Association of hospital-level volume of extracorporeal membrane oxygenation cases and mortality: Analysis of the extracorporeal life support organization registry

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Ryan P. Barbaro, Folafoluwa O. Odetola, Kelley M. Kidwell¹, Matthew L. Paden², Robert H. Bartlett¹, Matthew M. Davis, Gail M. Annich³ - Show less +3 more•Institutions (3)

University of Michigan¹, Emory University², University of Toronto³

15 Apr 2015-American Journal of Respiratory and Critical Care Medicine

TL;DR: In this international, case-mix-adjusted analysis, higher annual hospital ECMO volume was associated with lower mortality in 1989-2013 for neonates and adults; the association among adults persisted in 2008-2013.

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Abstract: Rationale: Recent pediatric studies suggest a survival benefit exists for higher-volume extracorporeal membrane oxygenation (ECMO) centers.Objectives: To determine if higher annual ECMO patient volume is associated with lower case-mix–adjusted hospital mortality rate.Methods: We retrospectively analyzed an international registry of ECMO support from 1989 to 2013. Patients were separated into three age groups: neonatal (0–28 d), pediatric (29 d to <18 yr), and adult (≥18 yr). The measure of hospital ECMO volume was age group–specific and adjusted for patient-level case-mix and hospital-level variance using multivariable hierarchical logistic regression modeling. The primary outcome was death before hospital discharge. A subgroup analysis was conducted for 2008–2013.Measurements and Main Results: From 1989 to 2013, a total of 290 centers provided ECMO support to 56,222 patients (30,909 neonates, 14,725 children, and 10,588 adults). Annual ECMO mortality rates varied widely across ECMO centers: the interquar...

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515 citations

Journal Article•

A meta-analysis of complications and mortality of extracorporeal membrane oxygenation

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Alberto Zangrillo, Giovanni Landoni¹, Giuseppe Biondi-Zoccai, Massimiliano Greco¹, Teresa Greco¹, Giacomo Frati, Nicolò Patroniti², Massimo Antonelli³, Antonio Pesenti², Federico Pappalardo¹ - Show less +6 more•Institutions (3)

Vita-Salute San Raffaele University¹, University of Milan², Catholic University of the Sacred Heart³

01 Sep 2013-Critical Care and Resuscitation

TL;DR: Even with conditions usually associated with a high chance of death, almost 50% of patients receiving ECMO survive up to discharge, and the most common complications associated with ECMO were renal failure, pneumonia or sepsis, and bleeding.

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Abstract: Objective: To comprehensively assess published peerreviewed studies related to extracorporeal membrane oxygenation (ECMO), focusing on outcomes and complications of ECMO in adult patients. Design: Systematic review and meta-analysis. Data sources: MEDLINE/PubMed was searched for articles on complications and mortality occurring during or after ECMO. Data extraction: Included studies had more than 100 patients receiving ECMO and reported in detail fatal or nonfatal complications occurring during or after ECMO. Primary outcome was mortality at the longest follow-up available; secondary outcomes were fatal and non-fatal complications. Data synthesis: Twelve studies were included (1763 patients), mostly reporting on venoarterial ECMO. Criteria for applying ECMO were variable, but usually comprised acute respiratory failure, cardiogenic shock or both. After a median follow-up of 30 days (1st-3rd quartile, 30-68 days), overall mortality was 54% (95% CI, 47%-61%), with 45% (95% CI, 42%-48%) of fatal events occurring during ECMO and 13% (95% CI, 11%-15%) after it. The most common complications associated with ECMO were: renal failure requiring continuous venovenous haemofiltration (occurring in 52%), bacterial pneumonia (33%), any bleeding (33%), oxygenator dysfunction requiring replacement (29%), sepsis (26%), haemolysis (18%), liver dysfunction (16%), leg ischaemia (10%), venous thrombosis (10%), central nervous system complications (8%), gastrointestinal bleeding (7%), aspiration pneumonia (5%), and disseminated intravascular coagulation (5%). Conclusions: Even with conditions usually associated with a high chance of death, almost 50% of patients receiving ECMO survive up to discharge. Complications are frequent and most often comprise renal failure, pneumonia or sepsis, and Crit Care Resusc 2013; 15: 172-178 bleeding.

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404 citations

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References

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Journal Article•DOI•

Outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation for refractory cardiogenic shock*

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Alain Combes¹, Pascal Leprince, Charles-Edouard Luyt, Nicolas Bonnet, Jean-Louis Trouillet, Philippe Léger, Alain Pavie, Jean Chastre - Show less +4 more•Institutions (1)

Pierre-and-Marie-Curie University¹

01 May 2008-Critical Care Medicine

TL;DR: ECMO support can rescue 40% of otherwise fatal cardiogenic shock patients but its initiation under cardiac massage or after renal or hepatic failure carried higher risks of intensive care unit death, while fulminant myocarditis had a better prognosis.

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Abstract: Objective:To assess the outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation (ECMO) for refractory cardiogenic shock.Design, Setting, and Patients:Refractory cardiogenic shock is almost always lethal without emergency circulatory support, e.g., ECMO. EC

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557 citations

"Early and late outcomes of 517 cons..." refers background in this paper

...So we think that closing the chest is not the primary goal for every patient undergoing ECMO....
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...Golding and coworkers15 reported a mean transfusion rate of 53.2 packed red blood cell units/patient and a rethoracotomy rate of 87.3% among 91 patients undergoing ECMO....
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...Dr Rastan and colleagues have reported on a large cohort of patients with PCS supported by ECMO....
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...Further personal management depended on the efforts that had to be made for the individual patient with ECMO....
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...These data are comparable to the Cleveland Clinic experience with an unselected ECMO population, in which patients surviving 30 days had a 63% chance of being alive after 5 years.1 Smith and colleagues18 from Melbourne also found an excellent long-term survival and satisfactory quality of life in an older population of hospital survivors after ECMO....
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Journal Article•DOI•

Clinical experience with 202 adults receiving extracorporeal membrane oxygenation for cardiac failure: Survival at five years

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Nicholas G. Smedira¹, Nader Moazami¹, Camille M. Golding¹, Patrick M. McCarthy¹, Carolyn Apperson-Hansen¹, Eugene H. Blackstone¹, Delos M. Cosgrove¹ - Show less +3 more•Institutions (1)

Cleveland Clinic¹

01 Jul 2001-The Journal of Thoracic and Cardiovascular Surgery

TL;DR: Extracorporeal membrane oxygenation is versatile and salvages some patients who would otherwise die, but improvement in intermediate-term outcome will require a multidisciplinary approach to protect organ function and limit organ injury before and during this support.

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312 citations

"Early and late outcomes of 517 cons..." refers background or result in this paper

...These data are comparable to the Cleveland Clinic experience with an unselected ECMO population, in which patients surviving 30 days had a 63% chance of being alive after 5 years.(1) Smith and colleagues(18) from Melbourne also found an excellent long-term survival and satisfactory quality of life in an older population of hospital survivors after ECMO....
[...]
...This is comparable with limb ischemia rates reported by others.(1,4) We found that the use of a distal leg perfusion cannula reduced leg ischemia and fasciotomy to less than 40%, and we therefore recommend this whenever the femoral artery is used for ECMO implantation....
[...]
...5% but depends highly on the surgical case mix.(1,2) For these patients, the implantation of an extracorporeal membrane oxygenation (ECMO) device is an easily...
[...]

Journal Article•DOI•

Five-year results of 219 consecutive patients treated with extracorporeal membrane oxygenation for refractory postoperative cardiogenic shock.

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Nicolas Doll¹, Bob Kiaii¹, Michael A. Borger¹, Jan Bucerius¹, Klaus Krämer¹, Dierk V. Schmitt¹, Thomas Walther¹, Friedrich W. Mohr¹ - Show less +4 more•Institutions (1)

Leipzig University¹

01 Jan 2004-The Annals of Thoracic Surgery

TL;DR: Extracorporeal membrane oxygenation is an acceptable technique for short-term treatment of refractory postoperative low cardiac output and can save the lives of a group of very high risk patients.

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306 citations

"Early and late outcomes of 517 cons..." refers background or methods in this paper

...The institutional ECMO cannulation techniques and management strategies have been previously described.(2,12) In brief, the ECMO circuit consisted of a centrifugal pump console (in most cases, Biopump PB-80; Medtronic Bio-Medicus, Minneapolis, Minn) in conjunction with an in-...
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...5% but depends highly on the surgical case mix.(1,2) For these patients, the implantation of an extracorporeal membrane oxygenation (ECMO) device is an easily...
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...Successful ECMO weaning rate ranges from 31% to 60% and corresponds with an in-hospital mortality of 59% to 84%.(2-11) By indication, acute myocardial failure is the major cause of mortality, although a significant number of other primary causes of death have also been reported....
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Journal Article•DOI•

Extracorporeal membrane oxygenation support for adult postcardiotomy cardiogenic shock

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Wen-Je Ko¹, Ching Yuang Lin, Robert J. Chen¹, Shoei-Shen Wang¹, Fang Yue Lin¹, Yih-Sharng Chen¹ - Show less +2 more•Institutions (1)

National Taiwan University¹

01 Feb 2002-The Annals of Thoracic Surgery

TL;DR: The ECMO provided a satisfactory partial cardiopulmonary support to patients with postcardiotomy cardiogenic shock, and allowed time for clinicians to assess the patients and make appropriate decisions.

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239 citations

"Early and late outcomes of 517 cons..." refers background or result in this paper

...Successful ECMO weaning rate ranges from 31% to 60% and corresponds with an in-hospital mortality of 59% to 84%.(2-11) By indication, acute myocardial failure is the major cause of mortality, although a significant number of other primary causes of death have also been reported....
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...ECMO Predictors for In-Hospital Death Like others, we found several significant predictors for inhospital mortality during ECMO support, including acute liver and renal failure.(4) Findings of persistent anaerobic metabolism after 24 and 48 hours of ECMO support, as...
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...Hospital survival thus was limited to 25%, which is comparable to results of smaller series of patients with PCS undergoing ECMO for which early survivals between 16% and 41% have been reported.(3-11) These data demonstrate that high mortality has continued to plague temporary circulatory ECMO support....
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...This is comparable with limb ischemia rates reported by others.(1,4) We found that the use of a distal leg perfusion cannula reduced leg ischemia and fasciotomy to less than 40%, and we therefore recommend this whenever the femoral artery is used for ECMO implantation....
[...]
...The Journal of Thoracic and Cardiovascular Surg applicable and widely accepted option for temporary mechanical circulatory support allowing cardiac and pulmonary recovery or bridging until further therapeutic alternatives can be carefully considered.(3-5) During the last 20 years however, ECMO results in these patients have not been satisfactory....
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Journal Article•DOI•

Venoarterial extracorporeal membrane oxygenation for treatment of cardiogenic shock: Clinical experiences in 45 adult patients

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Farhad Bakhtiary¹, Harald Keller¹, Selami Dogan¹, Omer Dzemali¹, Feyzan Oezaslan¹, Dirk Meininger¹, Hanns Ackermann¹, Bernhard Zwissler¹, Peter Kleine¹, Anton Moritz¹ - Show less +6 more•Institutions (1)

Goethe University Frankfurt¹

01 Feb 2008-The Journal of Thoracic and Cardiovascular Surgery

TL;DR: Early indication, alternative peripheral cannulation techniques, and reduced anticoagulation to avoid perioperative bleeding could improve the results with increasing experience, as well as predictors of survival.

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189 citations