A CONTEMPORARY REVIEW OF EXTRACORPOREAL MEMBRANE OXYGENATION FOR CARDIAC ARRESTS IN THE CARDIAC CATHETERIZATION LABORATORY

Abstract

Patients who sustain refractory in-hospital cardiac arrest (IHCA) with severe cardiopulmonary compromise in the cardiac catheterization laboratory have an extremely low survival. Despite early revascularization to infarct-related coronary artery, mortality rates vary between 80-90%. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can be lifesaving and is increasingly used in patients with reversible conditions who sustain refractory cardiac arrest or profound cardiogenic shock. The primary objective was to determine the characteristics and outcomes of patients receiving VA-ECMO in cardiac catheterization laboratory following IHCA or hemodynamic collapse. Secondary objectives included determination of 30-day mortality and identification of univariate predictors of 30-day survival. Between 2010 and 2016, all consecutive adults who received VA-ECMO in the cardiac catheterization laboratory at a single tertiary care center were retrospectively reviewed. Refractory cardiac arrest was defined as those who required ECMO cannulation during active cardiopulmonary resuscitation or those with profound cardiogenic shock post return of spontaneous circulation (ECPR-ROSC). Data collection information included baseline demographics, comorbid cardiovascular risk factors, referral diagnosis, etiology of cardiac arrest, procedural characteristics and in and out of hospital outcomes. A total of 41 ECMO cannulations (57-66, 18 males) occurred in the cardiac catheterization laboratory between July 2010 and April 2016. The baseline cardiovascular risk factors between survivors and non-survivors were relatively similar (Table 1). Overall, the majority of cases were related to cardiogenic shock secondary to an acute coronary syndrome (Table 1). None of the patients who suffered a mechanical complication secondary to an ACS survived. Procedural complications such as aortic dissections, pulmonary artery and atrial rupture accounted for 10% of the ECMO cannulations and had a 75% (n=3) associated mortality. 30-day survival for the entire cohort was 43.9% (Figure 1). There was no difference from time to cannulation between those that survived 30 days and those that did not survive. There was no difference in the complications rate between those that survived and those that did not survive ECMO cannulation. However, ECMO site bleeding was increased in those that did not survive. In the evolving field of mechanical support, VA-ECMO is becoming increasingly available as a temporizing measure for patients with refractory shock or cardiac arrest. Our study shows that patients with ACS or procedural complication in the catheterization lab who develop IHCA or profound cardiogenic shock benefit from VA-ECMO. VA-ECMO cannulation demonstrates an impressive 30-day survival in a patient cohort which has extremely high mortality.View Large Image Figure ViewerDownload Hi-res image Download (PPT)