Abstract
Background and Objectives: Over the past decade, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has developed into a mainstream treatment for refractory cardiogenic shock (CS) to maximal conservative management. Successful weaning of VA-ECMO may not be possible, and bridging with further mechanical circulatory support (MCS), such as urgent implantation of a left ventricular assist device (LVAD), may represent the only means to sustain the patient haemodynamically. In the recovery phase, many survivors are not suitably prepared physically or psychologically for the novel issues encountered during daily life with an LVAD. Materials and Methods: A retrospective analysis of our institutional database between 2012 and 2019 was performed to identify patients treated with VA-ECMO for CS who underwent urgent LVAD implantation whilst on MCS. Post-cardiotomy cases were excluded. QoL was assessed prospectively during a routine follow-up visit using the EuroQol-5 dimensions-5 level (EQ-5D-5L) and the Patient Health Questionnaire (PHQ-9) surveys. Results: Among 126 in-hospital survivors of VA-ECMO therapy due to cardiogenic shock without prior cardiac surgery, 31 (24.6%) urgent LVAD recipients were identified. In 11 (36.7%) cases, cardiopulmonary resuscitation (CPR) was performed (median 10, range 1–60 min) before initiation of VA-ECMO, and in 5 (16.7%) cases, MCS was established under CPR. Mean age at LVAD implantation was 51.7 (+/−14) years and surgery was performed after a mean 12.1 (+/−8) days of VA-ECMO support. During follow-up of 46.9 (+/−25.5) months, there were 10 deaths after 20.4 (+/−12.1) months of LVAD support. Analysis of QoL questionnaires returned a mean EQ-5D-5L score of 66% (+/−21) of societal valuation for Germany and a mean PHQ-9 score of 5.7 (+/−5) corresponding to mild depression severity. When compared with 49 elective LVAD recipients without prior VA-ECMO therapy, there was no significant difference in QoL results. Conclusions: Patients requiring urgent LVAD implantation under VA-ECMO support due to CS are associated with comparable quality of life without a significant difference from elective LVAD recipients. Close follow-up is required to oversee patient rehabilitation after successful initial treatment.
Highlights
Over the past decade, veno-arterial extracorporeal membrane oxygenation (VAECMO) has developed into a mainstream treatment for refractory cardiogenic shock (CS) to maximal conservative management [1,2]
A total of 133 adult patients underwent a total of 147 left ventricular assist device (LVAD) implantations (Figure 1), including 13 LVAD replacements and one replacement of another implanted cardiac circulatory support device in our centre during the study period
There were 31 (28.4%) cases of urgent LVAD implantation performed as a bridging from VAECMO, and this cohort comprised the ‘veno-arterial extracorporeal membrane oxygenation (VA-ECMO)’ group
Summary
Veno-arterial extracorporeal membrane oxygenation (VAECMO) has developed into a mainstream treatment for refractory cardiogenic shock (CS) to maximal conservative management [1,2]. Since successful weaning off of VA-ECMO may not always be feasible, bridging with further mechanical circulatory support (MCS) Such as an urgent implantation of a left ventricular assist device (LVAD) may remain the only alternative to support the patient haemodynamically [3]. The purpose of our study was to evaluate the long-term effects on QoL in patients undergoing urgent LVAD implantation as part of VA-ECMO therapy for refractory CS, and to determine whether any difference exists when compared with elective LVAD recipients. Successful weaning of VA-ECMO may not be possible, and bridging with further mechanical circulatory support (MCS), such as urgent implantation of a left ventricular assist device (LVAD), may represent the only means to sustain the patient haemodynamically. Conclusions: Patients requiring urgent LVAD implantation under VA-ECMO support due to CS are associated with comparable quality of life without a significant difference from elective LVAD recipients. Close follow-up is required to oversee patient rehabilitation after successful initial treatment
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