Membrane Oxygenation For Postcardiotomy Shock Research Articles

Troponin T and Survival following Cardiac Surgery in Patients Supported with Extracorporeal Membrane Oxygenation for Post-Cardiotomy Shock.

While troponin is an established biomarker of cardiac injury, its prognostic significance in post-cardiotomy cardiogenic shock patients supported by venoarterial extracorporeal membrane oxygenation (PCCS-VA-ECMO) remains unclear. This study aimed to assess the correlation between early post-operative troponin T levels and both short-term and long-term mortality outcomes in this cohort. We evaluated 1457 troponin T measurements from 102 PCCS-VA-ECMO patients treated from 2013 to 2018 at a specialized cardio-surgical and transplantation center. Emphasis was placed on troponin concentrations at 24-48 h post-surgery, post-VA-ECMO implantation, and peak troponin levels in relation to VA-ECMO weaning, as well as 90-day and one-year mortality. No significant association was observed between troponin T levels post-VA-ECMO implantation and 90-day mortality (median: 1338 ng/L for overall, 1529 ng/L for survivors vs. 1294 ng/L for non-survivors; p = 0.146) or between peak troponin levels and 90-day mortality (median: 3583 ng/L for overall, 3337 ng/L for survivors vs. 3666 ng/L for non-survivors; p = 0.709). Comprehensive multivariate models showed no correlation between troponin levels and various mortality endpoints. Notably, age, procedure urgency, type, LVEF pre-surgery, Euroscore II, prior cardiac arrest, and VA-ECMO duration were not linked with troponin release. Hemodiafiltration emerged as the strongest mortality risk factor [HR 2.4]. Isolated early Troponin T release and peak troponin T were not associated, while organ complications were linked with VA-ECMO weaning or short- and long-term prognosis. The results underscore the multi-organ implications of PCCS in determining survival.

Extracorporeal Membrane Oxygenation for Postcardiotomy Shock: Time to Look for Action Instead of Selection?

Extracorporeal Membrane Oxygenation for Postcardiotomy Shock: Time to Look for Action Instead of Selection?

A Standardized Approach Improves Outcomes of Extracorporeal Membrane Oxygenation for Postcardiotomy Shock.

Postcardiotomy shock (PCS) has historically been associated with substantial morbidity and mortality. Mortality at discharge is reportedly more than 60%. We investigated the outcomes of our standardized approach to veno-arterial extracorporeal membrane oxygenation (ECMO) management for PCS. We retrospectively reviewed 60 consecutive PCS patients who required ECMO following major cardiac surgery from January 2017 to September 2019. Index surgery included CABG (n = 10), valve (n = 23), valve and CABG (n = 12), root surgery (n = 10), and other (n = 5). Median lactate level, systolic blood pressure, and mean pulmonary artery pressure before ECMO were 4.0 mmol/L, 80 mm Hg, and 29 mm Hg, respectively. Fifty-nine patients (98%) were on two vasopressors, and 54 (90%) were on at least two inotropes. Vasoactive-Inotropic Score was 30 (IQR, 25-49). Eighty percent of patients received peripheral ECMO. Median ECMO flow index was 1.61 (IQR, 1.4-2.0) L/min/m2. Anticoagulation was not given in 12 (20%) patients during ECMO support. Major adverse events included chest re-exploration (15%), stroke (6.7%), renal replacement therapy (22%), and limb ischemia (5%). In-hospital mortality was 33%. This study suggests that a standardized approach with a dedicated ECMO team is feasible and may improve outcomes of PCS.

Impact of Mitral Valve Prosthesis on Stroke after Insertion of Veno-Arterial Membrane Oxygenation for Postcardiotomy Shock

Purpose Veno-arterial membrane oxygenation (VA-ECMO) is used in profound postcardiotomy shock (PCS). Previous study raised the possibility that use of VA-ECMO after mitral valve replacement (MVR) may pose a risk of valve thrombosis and embolism including stroke likely due to low transvalvular flow. This study focused on stroke after valve surgery requiring VA-ECMO. Methods Of 482 adult patients undergoing VA-ECMO from January 2011 to July 2020, 113 received VA-ECMO for PCS: coronary artery bypass Grafting (CABG): N=44; Mitral valve repair: N=12; Aortic valve replacement (AVR), N=28; MVR, N=29. Precautions taken to limit thromboembolism included: (1) low VA-ECMO flows were maintained between 1.5-2.2 L /min/m2, if possible, to provide hemodynamic support while maximizing trans-valvular flow and prosthesis washing; (2) anticoagulation was initiated within 24 hours postoperatively; (3) A bioprosthesis was used for 98.2% of valve replacements. The incidence of stroke and survival to discharge were primary outcomes. Results Peripheral VA-ECMO cannulation was performed in 87.6% (CABG, 79.5%; MV repair, 100%; AVR, 96.4%; and MVR 86.2%, p=0.483). Of these, 65.7% of peripheral cannulation was axillary VA-ECMO. The overall survival for PCS was 57.5%, with an incidence of stroke of 11.5% (CABG, 6.8%; MV repair, 8.3%; AVR, 10.7%; and MVR 20.7%; CABG or MV repair vs MVR, p=0.066; CABG or MV repair vs. AVR, p=0.889). Median support length of VA-ECMO was 6 days. In 6 patients who had stroke after MVR, 5 patients (83.3%) developed stroke after decannulation with a median interval of 1 day. The incidence of postoperative atrial fibrillation was 15.9%, 25%, 28.6%, and 32.1%, respectively (P=0.405). In univariable logistic regression analysis, MVR was a predisposing factor for postoperative stroke (odds ratio: OR, 3.39: p=0.078), but AVR (OR, 1.56: p=0.579) and central cannulation (OR, 3.03: p=0.178) were not. Conclusion The incidence of stroke after MVR was significant in PCS requiring VA-ECMO which suggests that an intracardiac embolic source may cause stroke with recovery of heart function. An alternative mechanical support or treatment strategy may be considered after MVR given the high rate of stroke during VA-ECMO support.

Bleeding and Thrombotic Events During Extracorporeal Membrane Oxygenation for Postcardiotomy Shock

BackgroundAnticoagulation therapy management during venoarterial extracorporeal membrane oxygenation (ECMO) is particularly difficult in postcardiotomy shock patients given a significant bleeding risk. We sought to determine the effect of anticoagulation treatment on bleeding and thrombosis risk for postcardiotomy shock patients on ECMO. MethodsWe retrospectively reviewed patients who received ECMO for postcardiotomy shock from July 2007 through July 2019. Characteristics of patients who had bleeding and thrombosis were investigated, and risk factors were assessed by multilevel logistic regression. ResultsOf the 152 patients who received ECMO for postcardiotomy shock, 33 (23%) had 40 thrombotic events and 64 (45%) had 86 bleeding events. Predictors of bleeding were intraoperative packed red blood cell transfusion (odds ratio [OR] 1.05; 95% confidence interval [CI], 1.01 to 1.09), platelet transfusion (OR 1.10; 95% CI, 1.05 to 1.16), international normalized ratio (OR 1.18; 95% CI, 1.02 to 1.37), and activated partial thromboplastin time greater than 60 seconds (OR 2.32; 95% CI, 1.14 to 4.73). Predictors of thrombosis were anticoagulant use (OR 0.39; 95% CI, 0.19 to 0.79), surgical venting (OR 3.07; 95% CI, 1.29 to 7.31), hemoglobin (OR 1.38; 95% CI, 1.06 to 1.79), and central cannulation (OR 2.06; 95% CI, 1.03 to 4.11). The daily predicted probability of thrombosis was between 0.075 and 0.038 for patients who did not receive anticoagulation and decreased to between 0.030 and 0.013 for patients who received anticoagulation treatment at activated partial thromboplastin times between 25 and 80 seconds. ConclusionsAnticoagulation therapy can reduce thromboembolic events in postcardiotomy shock patients on ECMO, but bleeding risk may outweigh this benefit at activated partial thromboplastin times greater than 60 seconds.

Peripheral versus central extracorporeal membrane oxygenation for postcardiotomy shock: Multicenter registry, systematic review, and meta-analysis

BackgroundWe hypothesized that cannulation strategy in venoarterial extracorporeal membrane oxygenation (VA-ECMO) could play a crucial role in the perioperative survival of patients affected by postcardiotomy shock. MethodsBetween January 2010 and March 2018, 781 adult patients receiving VA-ECMO for postcardiotomy shock at 19 cardiac surgical centers were retrieved from the Postcardiotomy Veno-arterial Extracorporeal Membrane Oxygenation study registry. A parallel systematic review and meta-analysis (PubMed/MEDLINE, Embase, and Cochrane Library) through December 2018 was also accomplished. ResultsCentral and peripheral VA-ECMO cannulation were performed in 245 (31.4%) and 536 (68.6%) patients, respectively. Main indications for the institution VA-ECMO were failure to wean from cardiopulmonary bypass (38%) and heart failure following cardiopulmonary bypass weaning (48%). The doubly robust analysis after inverse probability treatment weighting by propensity score demonstrated that central VA-ECMO was associated with greater hospital mortality (odds ratio 1.54; 95% confidence interval, 1.09-2.18), reoperation for bleeding/tamponade (odds ratio, 1.96; 95% confidence interval, 1.37-2.81), and transfusion of more than 9 RBC units (odds ratio, 2.42; 95% confidence interval, 1.59-3.67). The systematic review provided a total of 2491 individuals with postcardiotomy shock treated with VA-ECMO. Pooled prevalence of in-hospital/30-day mortality in overall patient population was 66.6% (95% confidence interval, 64.7-68.4%), and pooled unadjusted risk ratio analysis confirmed that patients undergoing peripheral VA-ECMO had a lower in-hospital/30-day mortality than patients undergoing central cannulation (risk ratio, 0.92; 95% confidence interval, 0.87-0.98). Adjustments for important confounders did not alter our results. ConclusionsIn patients with postcardiotomy shock treated with VA-ECMO, central cannulation was associated with greater in-hospital mortality than peripheral cannulation.

Baseline surgical status and short-term mortality after extracorporeal membrane oxygenation for post-cardiotomy shock: a meta-analysis.

While reported mortality rates on post-cardiotomy extracorporeal membrane oxygenation vary from center to center, impact of baseline surgical status (elective/urgent/emergency/salvage) on mortality is still unknown. A systematic search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement using PubMed/Medline databases until March 2018 using the keywords "postcardiotomy," "cardiogenic shock," "extracorporeal membrane oxygenation," and "extracorporeal life support." Relevant articles were scrutinized and included in the meta-analysis only if reporting in-hospital/30-day mortality and baseline surgical status. The correlations between mortality and percentage of elective/urgent/emergency cases were investigated. Inference analysis of baseline status and extracorporeal membrane oxygenation complications was conducted as well. Twenty-two studies (conducted between 1993 and 2017) enrolling N = 2,235 post-cardiotomy extracorporeal membrane oxygenation patients were found. Patients were mostly of non-emergency status (65.2%). Overall in-hospital/30-day mortality event rate (95% confidence intervals) was 66.7% (63.3-69.9%). There were no differences in in-hospital/30-day mortality with respect to baseline surgical status in the subgroup analysis (test for subgroup differences; p = 0.406). Similarly, no differences between mortality in studies enrolling <50 versus ⩾50% of emergency/salvage cases was found: respective event rates were 66.9% (63.1-70.4%) versus 64.4% (57.3-70.8%); p = 0.525. Yet, there was a significant positive association between increasing percentage of emergency/salvage cases and rates of neurological complications (p < 0.001), limb complications (p < 0.001), and bleeding (p = 0.051). Incidence of brain death (p = 0.099) and sepsis (p = 0.134) was increased as well. Other factors than baseline surgical status may, to a higher degree, influence the mortality in patients treated with extracorporeal membrane oxygenation for post-cardiotomy cardiogenic shock. Baseline status, however, strongly influences the complication occurrence while on extracorporeal membrane oxygenation.

Venoarterial extracorporeal membrane oxygenation for postcardiotomy shock: Risk factors for mortality

ObjectivesRefractory postcardiotomy cardiogenic shock is associated with a high mortality, and venoarterial extracorporeal membrane oxygenation can offer acute cardiopulmonary life support. The aim of this study was to identify pre–venoarterial extracorporeal membrane oxygenation risk factors of 90-day mortality. MethodsWe retrospectively analyzed 105 consecutive patients supported with venoarterial extracorporeal membrane oxygenation due to refractory postcardiotomy cardiogenic shock. The association between preimplant variables and all-cause mortality at 90 days was analyzed with univariable and multivariable logistic regression. ResultsMain surgical subgroups were single noncoronary artery bypass grafting (29%), isolated coronary artery bypass grafting (20%), and 2 and 3 concomitant surgical procedures (31% and 20%, respectively). The median age of patients was 62 years (interquartile range, 52-68 years), and 76% were men. Cardiopulmonary resuscitation was performed in 30% of patients before venoarterial extracorporeal membrane oxygenation initiation. The median duration of venoarterial extracorporeal membrane oxygenation was 7 days (interquartile range, 3-14). The 90-day overall mortality was 57%, and in-hospital mortality was 56%. Forty-seven percent of patients died on venoarterial extracorporeal membrane oxygenation, 51% of patients were successfully weaned, 1% of patients were bridged to heart transplantation, and 1% of patients were bridged to left ventricular assist device. Multivariable logistic regression analysis identified arterial lactate (odds ratio per unit, 1.22; 95% confidence interval, 1.07-14.0; P = .004) and ischemic heart disease (odds ratio, 7.87; 95% confidence interval, 2.55-24.3; P < .001) as independent risk factors of 90-day mortality. ConclusionsIn patients with postcardiotomy cardiogenic shock, ischemic heart disease and level of arterial lactate before venoarterial extracorporeal membrane oxygenation initiation were identified as independent pre–venoarterial extracorporeal membrane oxygenation risk factors of 90-day mortality. These risk factors are easily available for pre–venoarterial extracorporeal membrane oxygenation risk prediction and may improve patient selection for this resource-intensive therapy.