Conversion from Venovenous to Venoarterial Extracorporeal Membrane Oxygenation in Adults.

Lars Falk,Alexander Fletcher-Sandersjöö,Lars Mikael Broman,Jan Hultman

doi:10.3390/membranes11030188

Lars Falk, Alexander Fletcher-Sandersjöö + Show 2 more

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https://doi.org/10.3390/membranes11030188

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Journal: Membranes	Publication Date: Mar 9, 2021
Citations: 9	License type: CC BY 4.0

Affiliation: Karolinska University Hospital, Karolinska Institutet

Abstract

No major study has been performed on the conversion from venovenous (VV) to venoarterial (VA) extracorporeal membrane oxygenation (ECMO) in adults. This single-center retrospective cohort study aimed to investigate the incidence, indication, and outcome in patients who converted from VV to VA ECMO. All adult patients (≥18 years) who commenced VV ECMO at our center between 2005 and 2018 were screened. Of 219 VV ECMO patients, 21% (n = 46) were converted to VA ECMO. The indications for conversion were right ventricular failure (RVF) (65%), cardiogenic shock (26%), and other (9%). In the converted patients, there was a significant increase in Sequential Organ Failure Assessment (SOFA) scores between admission 12 (9–13) and conversion 15 (13–17, p < 0.001). Compared to non-converted patients, converted patients also had a higher mortality rate (62% vs. 16%, p < 0.001) and a lower admission Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score (p < 0.001). Outcomes were especially unfavorable in those converted due to RVF. These results indicate that VA ECMO, as opposed to VV ECMO, should be considered as the first mode of choice in patients with respiratory failure and signs of circulatory impairment, especially in those with impaired RV function. For the remaining patients, Pre-admission RESP score, daily echocardiography, and SOFA score trajectories may help in the early identification of those where conversion from VV to VA ECMO is warranted. Multi-centric studies are warranted to validate these findings.

Highlights

Extracorporeal membrane oxygenation (ECMO) has been successfully employed in pediatric and neonatal patients since the 1980s [1] and is being used more widely in adults as well [2,3,4,5]
The subsequent question is which patients should be started on VA instead of VV ECMO? Our results showed that patients who required conversion were identified using routine echocardiography but could be predicted by their lower on-admission Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) scores and temporal deterioration in daily Sequential Organ Failure Assessment (SOFA) scores
We found that patients converted from VV to VA ECMO had a higher mortality rate compared to non-converted patients and compared to our historical VA ECMO cohort

Summary

Introduction

Extracorporeal membrane oxygenation (ECMO) has been successfully employed in pediatric and neonatal patients since the 1980s [1] and is being used more widely in adults as well [2,3,4,5]. The workload of the right ventricle can be alleviated by reducing ventilator pressures, decreasing right ventricular (RV) afterload, removing fluid overload, and appropriate inotropic support. If these measures are insufficient, conversion to VA ECMO must be considered. One reason may be that before the Influenzae H1N1 pandemic in 2009, only a few centers offered ECMO for adults, and most patients were treated at cardiothoracic units dominated by VA ECMO. During and after the pandemic, adult respiratory ECMO has expanded into medical ICUs. Today, VV ECMO has become the dominating modality, and many ‘respiratory ECMO centers’ offer VV but not VA ECMO due to lack of experience and training. Respiratory ECMO patients at risk include those with air-leak syndrome, acute respiratory distress syndrome, sepsis, fluid overload, and other diagnoses where lung rest is applied [9,10]

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