Left Atrial Venoarterial Extracorporeal Membrane Oxygenation Strategy in Postcardiotomy Cardiogenic Shock: A Case Series

Post-cardiotomy cardiogenic shock is an infrequent but important cause of death following cardiac surgery. Extra-corporeal membrane oxygenation offers the opportunity for temporary cardiovascular support and myocardial rest, with a view to recovery. We examine our results with our recently-implemented management algorithm. We report our series of 15 consecutive patients out of 357 patients [4.2%] who required institution of veno-arterial extra-corporeal membrane oxygenation system support as treatment for Post-cardiotomy cardiogenic shock in the current era [January-2017 to January-2020]. The mean age was 64.3 ± 11.6 years (range: 40-82 years); there were 13 males (86.7%). Duration of veno-arterial extra-corporeal membrane oxygenation support was 6.7 ± 1.9 days. Duration of stay on intensive care unit [ICU] was 18.9 ± 17.1 days. Duration of hospital-stay was 28.3 ± 20.8 days. Survival to discharge and at 2.2 ± 0.9 years was 67%. We have shown clearly that veno-arterial extra-corporeal membrane oxygenation is an important rescue option for patients who develop refractory post-cardiotomy cardiogenic shock, with improved survival of 67% at 2.2 ± 0.9 years in those placed on post-cardiotomy veno-arterial extra corporeal membrane oxygenation support, which is superior to that reported hitherto in literature. We have sought to highlight the successes of post cardiotomy veno-arterial extra corporeal membrane oxygenation support, with improved results, based on careful patient selection, as well as diligent management of these critically-ill patients in the postoperative period, prior to establishment of irreversible end-organ dysfunction. Our strategy has also helped us rationalize and optimize the use of this expensive treatment modality.

IntroductionThe authors present their personal experience in qualifying and treating adult patients using veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) in postcardiotomy cardiogenic shock.AimThe aim of this study was to analyze the results of VA ECMO in patients with postcardiotomy cardiogenic shock. An analysis of the risk factors of postoperative mortality was also performed.Material and methodsWe analyzed the perioperative results of survivors and non-survivors of treatment using VA ECMO. We compared the number of days on VA ECMO therapy, types of cardiac surgical procedures, and the frequency of VA ECMO complications such as coagulation disorders, lower limb ischemia, cardiac tamponade, and renal replacement therapy.ResultsThere were 27 patients treated with VA ECMO during the study period. The mean patient age was 45 ±16 years. The hospital mortality rate of patients treated with VA ECMO therapy was 70% (19/27). There were no significant differences between the groups of survivors and non-survivors regarding age, gender, admission type and coexisting diseases. Type of cardiac surgical procedure had no influence on mortality or complications of therapy using VA ECMO.ConclusionsThe VA ECMO can be an effective form of therapy in some patients in postcardiotomy cardiogenic shock.

30-Day Outcomes Post Veno-Arterial Extra Corporeal Membrane Oxygenation (VA-ECMO) After Cardiac Surgery and Predictors of Survival

Assessment of early outcomes in patients with normal preoperative left ventricular ejection fraction (LVEF) in whom venoarterial extracorporeal membrane oxygenation (VA-ECMO) was implanted for postcardiotomy cardiogenic shock (PCCS) during the first postoperative 48 h. Retrospective single-centre analysis in adult patients with normal LVEF, who received VA-ECMO support for PCCS from May 1998 to May 2018. The primary outcome was 30-day perioperative mortality during the index hospitalization. A total of 62125 adult patients underwent cardiac surgery at our institution during the study period. Among them, 173 patients (0.3%) with normal preoperative LVEF required VA-ECMO for PCCS. Among them, 71 (41.1%) patients presented PCCS due to coronary malperfusion and in 102 (58.9%) patients, no evident cause was found for PCCS. Median duration of VA-ECMO support was 5 days (interquartile range 2-8 days). A total of 135 (78.0%) patients presented VA-ECMO-related complications and the overall 30-day perioperative mortality was 57.8%. Independent predictors of mortality were: lactate level just before VA-ECMO implantation [odds ratio (OR) 1.27; P < 0.001], major bleeding during VA-ECMO (OR 3.76; P = 0.001), prolonged cardiopulmonary bypass time (OR 1.01; P < 0.001) and female gender (OR 4.87; P < 0.001). Mortality rates of VA-ECMO in PCCS patients are high, even in those with preoperative normal LVEF. Coronary problems are an important cause of PCCS; however, the aetiology remains unknown in the vast majority of the cases. The implantation of VA-ECMO before development of tissue hypoperfusion and the control of VA-ECMO-associated complications are the most important prognostic factors in PCCS patients. Lactate levels may help guide timing of VA-ECMO implantation and define the extent of therapeutic effort.

Objective: This study aims to compare central and peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) approaches in patients with postcardiotomy cardiogenic shock, evaluating outcomes such as in-hospital mortality, vascular complications, and weaning success rates. Theoretical Framework: Postcardiotomy cardiogenic shock is a critical condition associated with high mortality rates, requiring advanced temporary circulatory support. Central VA-ECMO, characterized by direct cannulation of the aorta and right atrium, provides greater hemodynamic stability and physiological support but is associated with higher risks of hemorrhagic and infectious complications. Peripheral ECMO, implanted through femoral access, allows for faster and less complex deployment but is linked to vascular complications, such as limb ischemia and differential hypoxemia. The choice between techniques depends on clinical factors such as hemodynamic status, comorbidities, and the need for emergent or prolonged support. Method: A systematic review was conducted with a temporal scope from 2014 to 2024, including 14 studies identified in the PubMed, Scopus, and Web of Science databases. Inclusion criteria covered studies comparing central and peripheral VA-ECMO in adult patients with postcardiotomy cardiogenic shock, analyzing outcomes such as in-hospital mortality, vascular complications, and weaning success rates. Results and Discussion: Findings indicate that central ECMO is associated with greater hemodynamic stability and higher weaning success rates but presents higher risks of hemorrhagic complications and reoperations. In contrast, peripheral ECMO, more commonly used in emergencies, demonstrated faster deployment and lower bleeding rates but a higher incidence of vascular complications such as limb ischemia. Hybrid strategies and the use of additional devices, such as intra-aortic balloon pumps and Impella, showed potential to optimize outcomes but are associated with high costs and increased complication rates. Research Implications: This study highlights the need for multicenter and long-term clinical trials to refine selection criteria between central and peripheral ECMO, as well as to explore hybrid strategies to improve outcomes. Future research should also evaluate the impact of these techniques on quality of life and cost-effectiveness. Originality/Value: This systematic review provides a comprehensive analysis of the differences between central and peripheral ECMO in patients with postcardiotomy cardiogenic shock, contributing to informed clinical decision-making and the improvement of management protocols.

Objectives: Post-cardiotomy cardiogenic shock remains a critical and life-threatening complication in cardiac surgery. This study aims to review and analyze our department's experience with the use of extracorporeal membrane oxygenation (ECMO) as a temporary mechanical circulatory support strategy in managing refractory post-cardiotomy cardiogenic shock. Methods: This is a retrospective study of veno-arterial ECMOs (V-A ECMO) implanted between 2013 and 2022 at the Ibn Sina University Hospital, following cardiac surgery. All adult patients who received a V-A ECMO implantation after cardiac surgery were included. The indications for ECMO were failure to wean from extracorporeal circulation or refractory cardiogenic shock occurring within the first or second postoperative day. Intra-aortic balloon pump (IABP) counter pulsation was systematically associated, either preoperatively or postoperatively. Results: Nine veno-arterial ECMOs were implanted for refractory cardiogenic shock following 5,438 cardiac surgeries, with an incidence of 0.16%. The overall survival rate was 55.5%, with a mean patient age of 61.9 ± 10.5 years. ECMO was implemented after valvular surgery (44.4%), coronary artery bypass grafting (44.4%), acute aortic dissection (11.1%), and post-infarction ventricular septal defect (33.3%). A third of the interventions were combined surgeries. The median ECMO support duration was 89 ± 11 hours, with a weaning rate of 44.4%. Survival rates at 1 month, 1 year, and 3 years were 55.5%, 44.4%, and 33.3%, respectively. Poor prognostic factors included age &gt;65 years, EuroSCORE &gt;8, and post-cardiotomy cardiogenic shock due to right or biventricular failure. Under ECMO, all patients had persistent hyperlactatemia (&gt;10 mmol/L), myocardial and muscular lysis, and multivisceral organ failure (hepatic cytolysis, hyperbilirubinemia, renal dysfunction). They required maximal doses of vasopressors and inotropes, with ECMO duration &gt;72 hours, mechanical ventilation &gt;80 hours,

Outcomes following veno-arterial extracorporeal membrane oxygenation for post-cardiotomy cardiogenic shock in adult cardiac surgical patients with a normal preoperative left ventricular ejection fraction

The ultimate goals of cardiovascular physiology are to ensure adequate end-organ perfusion to satisfy the local metabolic demand, to maintain homeostasis and achieve ‘milieu intérieur’. Cardiogenic shock is a state of pump failure which results in tissue hypoperfusion and its associated complications. There are a wide variety of causes which lead to this deranged physiology, and one such important and common scenario is the post-cardiotomy state which is encountered in cardiac surgical units. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an important modality of managing post-cardiotomy cardiogenic shock with variable outcomes which would otherwise be universally fatal. VA-ECMO is considered as a double-edged sword with the advantages of luxurious perfusion while providing an avenue for the failing heart to recover, but with the problems of anticoagulation, inflammatory and adverse systemic effects. Optimal outcomes after VA-ECMO are heavily reliant on a multitude of factors and require a multi-disciplinary team to handle them. This article aims to provide an insight into the pathophysiology of VA-ECMO, cannulation techniques, commonly encountered problems, monitoring, weaning strategies and ethical considerations along with a literature review of current evidence-based practices.

There are contrasting reports on the effectiveness of a concomitant intra-aortic balloon pump (IABP) in cardiogenic shock patients treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO). This study sought to compare short-term mortality in patients with cardiogenic shock treated with VA-ECMO with and without IABP. We reviewed the published literature from 2000 to 2018 for studies evaluating adult patients requiring VA-ECMO for cardiogenic shock with concomitant IABP. Studies reporting short-term mortality were included. Meta-analysis of the association of IABP with mortality was performed using Mantel-Haenszel models. Subgroup analyses were performed in patients with cardiogenic shock complicating acute myocardial infarction (AMI) and postcardiotomy cardiogenic shock. Twenty-two observational studies with 4653 patients were included. These studies showed high heterogeneity for the total and postcardiotomy cardiogenic shock cohorts and low heterogeneity for the AMI cohort. Short-term mortality was not significantly different in patients with and without IABP 42.1% versus 57.8%; risk ratio, 0.80; 95% CI, 0.52-1.22; P=0.30. However, concomitant IABP with VA-ECMO was associated with lower mortality in patients with AMI (50.8% versus 62.4%; risk ratio, 0.56; 95% CI, 0.46-0.67; P<0.001). There was no difference in mortality in postcardiotomy cardiogenic shock and mixed causes for cardiogenic shock. In cardiogenic shock patients requiring VA-ECMO support, the use of IABP did not influence mortality in the total cohort. In patients with AMI, use of IABP with VA-ECMO was associated with 18.5% lower mortality in comparison to patients on VA-ECMO alone. Further randomized studies are warranted to corroborate these observational data.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an option for mechanical support for patients with postcardiotomy cardiogenic shock (PCS). However, the use of VA-ECMO in patients suffering from aortic disease with PCS has not been greatly reported. This is a retrospective review of adult patients undergoing aortic surgery who received VA-ECMO support to treat refractory PCS from August 2009 to May 2016. A total of 36 patients who underwent aortic surgery with VA-ECMO support for refractory PCS were included. Preoperative, perioperative, and postoperative variables were assessed and analyzed for possible correlation with in-hospital mortality. After a mean duration of 3.6 ± 2.9 days, 24 patients (67%) were weaned off VA-ECMO, and 18 patients (50%) were discharged from the hospital. The overall in-hospital mortality was 50%. The main cause of death was multiple organ dysfunction. The survivors had a lower level of preoperative creatine kinase-MB (CK-MB), a higher rate of antegrade cannulation, and a lower lactate level at 12 h, respectively. Relevant factors for in-hospital mortality were retrograde-flow cannulation (odds ratio [OR], 2.49), peak lactate levels greater than 20 mmol/L (OR, 5.0), and preoperative CK-MB greater than 100 IU/L (OR, 6.40). Antegrade cannulation may provide better perfusion and should be emphasized to improve outcomes. Additionally, levels of peak serum lactate and preoperative CK-MB may be relevant factors for in-hospital mortality in aortic patients with PCS.

Postcardiotomy cardiogenic shock describes the syndrome of refractory cardiac performance following cardiac surgery. The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for the management of postcardiotomy cardiogenic shock is controversial, and there are at least three scenarios where it may be necessary: first, pre-emptive postoperative VA-ECMO, where the decision for postoperative mechanical support is made prior to surgery, for example, in the context of poor pre-operative cardiac function; second, early yet unplanned post-cardiopulmonary bypass VA-ECMO following a long duration of cardiopulmonary bypass due to, for example, unexpected surgical complications; third, late rescue VA-ECMO following several attempts at weaning, either immediately following cardiopulmonary bypass or following transfer to the intensive care unit. The use of mechanical circulatory support for postcardiotomy cardiogenic shock is further complicated by the wide range of available devices, the availability of VA-ECMO in different centres, variations in experience and expertise as a function of local VA-ECMO workload, and regional variations in the diagnosis and management of postcardiotomy cardiogenic shock. Furthermore, survival appears to be low for such patients and it is not yet possible to predict who will survive. Many questions remain, however, such as those in relation to practices around patient selection, how best to study long-term outcomes, the ethics and efficacy of ECMO in such patients, and on all aspects of clinical decision-making. This review sets these clinical challenges in the context of the available evidence, including that from our centre.

Background: Post-cardiotomy cardiogenic shock (PCCS), which is defined as severe low cardiac output syndrome after cardiac surgery, has a mortality rate of up to 90%. No study has yet been performed to compare patients with PCCS treated by conservative means to patients receiving additional mechanical circulatory support with veno-arterial extracorporeal membrane oxygenation (ECMO). Methods: A single-center retrospective analysis from January 2018 to June 2022 was performed. Results: Out of 7028 patients who underwent cardiac surgery during this time period, 220 patients (3%) developed PCCS. The patients were stratified according to their severity of shock based on the Stage Classification Expert Consensus (SCAI) group. Known risk factors for shock-related mortality, including the vasoactive–inotropic score (VIS) and plasma lactate levels, were assessed at structured intervals. In patients treated additionally with ECMO (n = 73), the in-hospital mortality rate was 60%, compared to an in-hospital mortality rate of 85% in patients treated by conservative means (non-ECMO; n = 52). In 18/73 (25%) ECMO patients, the plasma lactate level normalized within 48 h, compared to 2/52 (4%) in non-ECMO patients. The morbidity of non-ECMO patients compared to ECMO patients included a need for dialysis (42% vs. 60%), myocardial infarction (19% vs. 27%), and cerebrovascular accident (17% vs. 12%). Conclusions: In conclusion, the additional use of ECMO in PCCS holds promise for enhancing outcomes in these critically ill patients, more rapid improvement of end-organ perfusion, and the normalization of plasma lactate levels.

Extracorporeal membrane oxygenation support for adult postcardiotomy cardiogenic shock

Postcardiotomy cardiogenic shock (PCCS) is associated with considerably high rates of mortality. In PCCS, veno-arterial extracorporeal membrane oxygenation has been used despite the high rates of complications and poor outcome. Since the introduction of Impella CP (Abiomed, Danvers, MA, USA), effective left-ventricular unloading and systemic perfusion could be maintained even in patients with severe PCCS. Herein, we describe the successful treatment of PCCS following combined heart surgery in a patient by Impella CP insertion.

Post-cardiotomy cardiogenic shock (PCCS) results in substantial morbidity and mortality, whereas refractory cases require mechanical circulatory support. The aim of this study was to evaluate factors influencing survival during short-term ventricular assist support in PCCS. In total, 154 CentriMag(®) (Thoratec; CA, USA) devices were implanted for cardiogenic shock between 2004 and 2011 out of which 31 were for PCCS. A retrospective review was performed in 31 PCCS patients who required the CentriMag short-term VAD as a bridge to decision. Survivors and non-survivors were compared with respect to pre- and intra-operative characteristics as well as duration of short-term VAD support. Mean duration of support was 11.7±15.4days (range 1-65days). Seventeen (54.83%) patients died on support, 14 (45.16%) were weaned off or upgraded to long-term device, while 11 (35.5%) were discharged home. The overall survival to myocardial recovery and device explantation, or upgrade to a long-term VAD, was 41.9% (n=13) at the study cutoff. EuroSCORE II was significantly higher in non-survivors as compared to survivors (p=0.047). The duration of short-term VAD support was significantly longer in survivors (p<0.001). The CentriMag is a versatile, safe and effective short-term circulatory support for patients with PCCS as a bridge to decision which enables longer support and better recovery of both heart and end-organ function and thus may improve the survival of PCCS patients. Lower EuroSCORE may be essential for myocardial recovery in PCCS.