Abstract
BackgroundPostcardiotomy cardiogenic shock (PCS) that is refractory to inotropic support remains a major concern in cardiac surgery and is almost universally fatal unless treated with mechanical support. While reported mortality rates on ECMO vary from center to center, aim of the current report is assess if the outcomes differ between centres according to volume and heart transplantation status.MethodsA systematic search was performed according to PRISMA statement using PubMed/Medline databases between 2010 and 2018. Relevant articles were scrutinized and included in the meta-analysis only if reporting in-hospital/30-day mortality and heart transplantation status of the centre. Paediatric and congenital heart surgery-related studies along with those conducted in the setting of veno-venous ECMO for respiratory distress syndrome were excluded. Differences were assessed by means of subgroup meta-analysis and meta-regression.ResultsFifty-four studies enrolling N = 4421 ECMO patients were included. Of those, 6 series were performed in non-HTx centres (204 pts.;4.6%). Overall 30-day survival (95% Confidence Intervals) was 35.3% (32.5–38.2%) and did not statistically differ between non-HTx: 33.3% (26.8–40.4%) and HTx centres: 35.7% (32.7–38.8%); Pinteraction = 0.531. There was no impact of centre volume on survival as well: ßcoef = 0.0006; P = 0.833. No statistical differences were seen between HTx and non-HTx with respect to ECMO duration, limb complications, reoperations for bleeding, kidney injury and sepsis. There were however significantly less neurological complications in the HTx as compared to non-HTx centres: 11.9% vs 19.5% respectively; P = 0.009; an inverse relationship was seen for neurologic complications in centres performing more ECMOs annually ßcoef = − 0.0066; P = 0.031. Weaning rates and bridging to HTx and/or VADs were higher in HTx facilities.ConclusionsThere was no apparent difference in survival after ECMO implantation for refractory PCS according to centre’s ECMO volume and transplantation status. Potentially different risk profiles of patients in these centres must be taken account for before definite conclusions are drawn.
Highlights
Postcardiotomy cardiogenic shock (PCS) that is refractory to inotropic support remains a major concern in cardiac surgery and is almost universally fatal unless treated with mechanical support
In some patients, prolonged mechanical circulatory support (MCS) does not lead to improved cardiac function or organ integrity; clinicians are forced to bridge the patient; since bridge to recovery is no longer an option, more advanced treatments, such as heart transplantation (HTx) or long-lasting ventricular assist devices (VADs) remain
Included studies were divided into Heart transplantation (HTx) vs non-HTx centres subgroups: 48 studies including 4217 (95.4%) patients were conducted in HTx- whereas 6 studies (N = 204) in nonHTx centres
Summary
Postcardiotomy cardiogenic shock (PCS) that is refractory to inotropic support remains a major concern in cardiac surgery and is almost universally fatal unless treated with mechanical support. Unlike STEMIs, cardiac surgical patients are usually characterized by substantial pre-ECMO comorbidities and more advanced age [9]. All these factors, individually or in association, may inhibit the potential of myocardium to recover after the surgery and/or hamper favorable body response to prolonged MCS. In some patients, prolonged MCS does not lead to improved cardiac function or organ integrity; clinicians are forced to bridge the patient; since bridge to recovery is no longer an option, more advanced treatments, such as heart transplantation (HTx) or long-lasting ventricular assist devices (VADs) remain. Not all heart surgery centres perform HTx, and not all of them perform VADs
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