Postcardiotomy Shock Research Articles

Comparison of ECMO, IABP and ECMO + IABP in the Postoperative Period in Patients with Postcardiotomy Shock.

Background: This study aims to assess the outcomes and complications of patients who received veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and intra-aortic balloon pump (IABP) support after cardiac surgery at Ankara University Heart Center between 2000 and 2023. Methods: We have carried out a retrospective analysis that included 255 patients. Among them, 98 received IABP, 103 received VA-ECMO, and 54 received both VA-ECMO and IABP. Preoperative and postoperative assessments were carried out, including evaluations of left ventricular function and serum creatinine levels. Primary outcomes included 30-day survival and successful VA-ECMO weaning. Complications such as bleeding, sepsis, liver failure, wound infection, and peripheral ischemia were also assessed. Results: The weaning rate from VA-ECMO was significantly higher in the combined VA-ECMO and IABP group (81.4%) compared with the other groups (p = 0.004). One-year survival was also higher in the combined group (75.9%) (p = 0.002). Complications or renal function did not differ significantly among the groups. The primary indication for mechanical support was coronary artery bypass grafting. Conclusions: In conclusion, the combined use of VA-ECMO and IABP therapy led to improved weaning and survival rates without increasing the risk of complications. These findings suggest that a combined approach may be beneficial for selected patients with severe cardiac dysfunction post surgery.

The intra-aortic balloon pump as a rescue device: Do we need to shift our strategy for cardiogenic shock rescue after cardiac surgery?

ObjectiveThe intra-aortic balloon pump (IABP) is widely used to rescue patients from complications following cardiac surgery. Given improvements in rescue strategies over the past decade, the appropriateness of IABP must be reexamined. This study assessed the risk factors, outcomes, and predictors of survival of rescue IABP placement. MethodsPatients receiving an isolated rescue IABP during or after cardiac surgery from 2012 to 2020 were studied. All adult patients undergoing cardiac surgery except transplantation and primary mechanical circulatory support (MCS) procedures were included. ResultsOf 10,591 patients, 397 (3.7%) received a perioperative IABP, including 182 (45.8%) with rescue IABP placement. The indications for rescue IABP were postcardiotomy shock (n = 66; 36.3%), failure to wean off cardiopulmonary bypass (n = 58; 31.9%), myocardial ischemia (n = 30; 16.5%), cardiac arrest (n = 25; 13.7%), and ventricular arrhythmia (n = 3; 1.6%). The in-hospital failure to rescue rate was 17.6% (n = 32 of 182) with a 90-day survival of 80.8% and 1-year survival of 76.9%. The most common etiology of mortality was ongoing cardiogenic shock (61.9%; n = 26 of 42). IABP use for >4 days and cardiac arrest as an indication for IABP were risk factors for 1-year mortality (adjusted hazard ratio, 2.68 [95% confidence interval (CI), 1.31-5.50] and 2.69 [95% CI, 1.11-6.54], respectively). ConclusionsRescue IABP following cardiac surgery is associated with increased early and 1-year mortality. Prolonged IABP use beyond 4 days or cardiac arrest as an indication portended a significantly worse prognosis. Rescue IABP may not be the optimal first-line temporary MCS for all patients, as the level of support provided might not match the severity of cardiogenic shock. Alternative MCS strategies should be considered early.

Central versus peripheral VA ECMO for cardiogenic shock: an 8-year experience of a tertiary cardiac surgery center in Greece

BackgroundVenoarterial extracorporeal membrane oxygenation (VA ECMO) has emerged as an effective rescue therapy in patients with cardiogenic shock refractory to standard treatment protocols, and its use has been rising worldwide in the last decade. Although experience and availability are growing, outcomes remain poor. There is need for evidence to improve clinical practice and outcomes. MethodsWe retrospectively reviewed the medical records of all patients who were supported with VA ECMO for cardiogenic shock at our institution between January 2015 and January 2023. The study purpose was to compare outcomes between patients who were supported with central versus peripheral configuration. ResultsECMO was applied in 108 patients, 48 (44%) of whom received central configuration and 60 (56%) peripheral. Patients supported with central VA ECMO were more likely to be supported for post-cardiotomy shock (odds ratio [OR] 4.6 [95% confidence interval (CI) 2.03–10.41]), while patients in the peripheral group were predominantly treated for chronic heart failure decompensation (OR 9.4 [95% CI 1.16–76.3]). Central VA ECMO had lower survival rates during ECMO support (29.2% versus 51.7%, p = 0.018) and at discharge (8% versus 37%, p = 0.001). These patients were at high risk of complications, such as acute kidney injury (AKI) (OR 2.37 [95% CI 1.06–5.3], p = 0.034) and major bleeding (OR 3.08 [95% CI 1.36–6.94], p < 0.001). ConclusionsPatients on central VA ECMO were supported mainly for post-cardiotomy shock, presented with more complications such as major bleeding and AKI, and had worse survival to hospital discharge compared with patients on peripheral VA ECMO. Patient selection, timing of implementation, cannulation strategy, and configuration remain the main determinants of clinical outcome.

Management of Post-cardiotomy Shock.

Patients undergoing cardiac surgery experience significant physiologic derangements that place them at risk for multiple shock phenotypes. Any combination of cardiogenic, obstructive, hemorrhagic, or vasoplegic shock occurs commonly in post-cardiotomy patients. The approach to the diagnosis and management of these shock states has many facets that are distinct compared to non-surgical cardiac intensive care unit patients. Additionally, the approach to and associated outcomes of cardiac arrest in the post-cardiotomy population are uniquely characterized by emergent bedside resternotomy if the circulation is not immediately restored. This review focuses on the unique aspects of the diagnosis and management of post-cardiotomy shock.

Relationship between indexed surgery and postcardiotomy extracorporeal life support outcomes.

Veno-arterial extracorporeal life support (V-A ECLS) is increasingly being utilized for postcardiotomy shock (PCS), though data describing the relationship between type of indexed operation and outcomes are limited. This study compared V-A ECLS outcomes across four major cardiovascular surgical procedures. This was a single-center retrospective study of patients who required V-A ECLS for PCS between 2015 and 2022. Patients were stratified by the type of indexed operation, which included aortic surgery (AoS), coronary artery bypass grafting (CABG), valve surgery (Valve), and combined CABG and valve surgery (CABG + Valve). Factors associated with postoperative outcomes were assessed using logistic regression. Among 149 PCS patients who received V-A ECLS, there were 35 AoS patients (23.5%), 29 (19.5%) CABG patients, 59 (39.6%) Valve patients, and 26 (17.4%) CABG + Valve patients. Cardiopulmonary bypass times were longest in the AoS group (p < 0.01). Regarding causes of PCS, AoS patients had a greater incidence of ventricular failure, while the CABG group had a higher incidence of ventricular arrhythmia (p = 0.04). Left ventricular venting was most frequently utilized in the Valve group (p = 0.07). In-hospital mortality was worst among CABG + Valve patients (p < 0.01), and the incidence of acute kidney injury was highest in the AoS group (p = 0.03). In multivariable logistic regression, CABG + Valve surgery (odds ratio (OR) 4.20, 95% confidence interval 1.30-13.6, p = 0.02) and lactate level at ECLS initiation (OR, 1.17; 95% CI, 1.06-1.29; p < 0.01) were independently associated with mortality. We demonstrate that indications, management, and outcomes of V-A ECLS for PCS vary by type of indexed cardiovascular surgery.

Post-cardiotomy extracorporeal life support: A cohort of cannulation in the general ward.

Post-cardiotomy extracorporeal life support (ECLS) cannulation might occur in a general post-operative ward due to emergent conditions. Its characteristics have been poorly reported and investigated This study investigates the characteristics and outcomes of adult patients receiving ECLS cannulation in a general post-operative cardiac ward. The Post-cardiotomy Extracorporeal Life Support (PELS) is a retrospective (2000-2020), multicenter (34 centers), observational study including adult patients who required ECLS for post-cardiotomy shock. This PELS sub-analysis analyzed patients´ characteristics, in-hospital outcomes, and long-term survival in patients cannulated for veno-arterial ECLS in the general ward, and further compared in-hospital survivors and non-survivors. The PELS study included 2058 patients of whom 39 (1.9%) were cannulated in the general ward. Most patients underwent isolated coronary bypass grafting (CABG, n = 15, 38.5%) or isolated non-CABG operations (n = 20, 51.3%). The main indications to initiate ECLS included cardiac arrest (n = 17, 44.7%) and cardiogenic shock (n = 14, 35.9%). ECLS cannulation occurred after a median time of 4 (2-7) days post-operatively. Most patients' courses were complicated by acute kidney injury (n = 23, 59%), arrhythmias (n = 19, 48.7%), and postoperative bleeding (n = 20, 51.3%). In-hospital mortality was 84.6% (n = 33) with persistent heart failure (n = 11, 28.2%) as the most common cause of death. No peculiar differences were observed between in-hospital survivors and nonsurvivors. This study demonstrates that ECLS cannulation due to post-cardiotomy emergent adverse events in the general ward is rare, mainly occurring in preoperative low-risk patients and after a postoperative cardiac arrest. High complication rates and low in-hospital survival require further investigations to identify patients at risk for such a complication, optimize resources, enhance intervention, and improve outcomes.

Mitral bioprosthesis early dysfunction treated with transapical valvuloplasty during V-A ECMO.

We report the case of a 61-year-old male who had complications with a mitral valve (MV) bioprosthesis replacement by post-cardiotomy shock leading to VA ECMO implantation. The patient suffered early bioprosthetic valve failure owing to early thrombosis. The complication was successfully treated with a MV bioprosthesis transapical balloon valvuloplasty that restored normal leaflet mobility.

SCAI SHOCK stage classification: valid for all indications and devices in patients with short-term mechanical circulatory support?

Abstract Funding Acknowledgements None. Background The Society for Cardiovascular Angiography and Intervention (SCAI) SHOCK stage has demonstrated prognostic value in patients with cardiogenic shock (CS), including patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) support. It has also been validated in different scenarios as acute coronary syndrome -ACS- or out-of-hospital cardiac arrest. Purpose Our objective was to study the prognostic value of SCAI SHOCK stage in different indications and etiologies requiring different types of short-term mechanical circulatory support (MCS). Methods Retrospective analysis of consecutive patients supported with VA-ECMO or Impella CP® in a referral center. We studied the SCAI SHOCK stage at MCS implantation according different devices, indication and etiology, and its relationship with in-hospital and follow-up survival. Results 263 patients were included between 2014-March 2023 (Table). The SCAI SHOCK stage was less advanced in complex high risk percutaneous coronary intervention (CHIP-PCI) indication and more advanced in postcardiotomy shock, myocarditis, pulmonary embolism (PE), refractory cardiac arrest or electric storm (Figure A). In-hospital survival was 41.1% and it was significantly lower as SCAI SHOCK stage increased (A 83.9%, B 100%, C 66.7%, D 39.2%, E 24.5%; p=0.000), as well as in follow-up for a median time of 24.5 [47] months (figure B). This association was maintained with both types of devices separately: VA-ECMO (A 80%, B 100%, C 33.3%, D 38.9%, E 24.5%, p=0.001) and Impella (A 84%, B 100%, C 75%, D 42.9%, E 25%, p=0.005). Regarding the indication and etiology for MCS, SCAI SHOCK classification was significantly related with survival in CS indication, as well as in ACS and heart failure (HF) etiology (Figure B). However, no relationship between SCAI and survival was observed in indications as CHIP-PCI (A 83.9%, B 100%, C 50%; p=0.386), electrical storm (C 0%, D 100%, E 70%; p=0.075) and postcardiotomy shock (D 35.6%, E 20%; p=0.470), neither in etiologies as PE (D 0%, E 28.6%; p=1), infective endocarditis (D 28.6%, E 0%; p=1), myocarditis (D 100%, E 0%; p=0.250),and other causes of cardiac arrest (D 0%, E 25%; p=1), nor in patients admitted for elective cardiac surgery. Conclusions SCAI SHOCK stage classification showed prognostic value in patients with short-term MCS indicated by diverse etiologies, including both VA-ECMO and Impella CP devices. The prognostic value was maintained for the indication of CS, and in ACS and HF etiologies, but not in electrical storm, CHIP-PCI, PE, myocarditis or postcardiotomy shock. Studies are needed to validate this classification in other settings.TableFigure

Minimally Invasive Direct Aortic Implantation of Impella 5.5 As Bridge to Transplant: A Case Report

The use of temporary mechanical circulatory support (t-MCS) in cardiogenic shock (CS) is increasing.The Impella (Abiomed) is a percutaneous, microaxial ventricular assist device approved for short-term use in CS that can be implanted peripherally. Direct aortic placement is an alternative commonly performed when the sternum is open, for example, in post-cardiotomy shock, or when the peripheral vasculature is of insufficient size or quality for implantation. Herein we describe direct aortic implantation of the Impella 5.5 via right mini-thoracotomy for a patient in CS secondary to decompensated heart failure as a bridge to candidacy, and ultimately, transplantation.

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.

Impact of a multidisciplinary team "ECMO Team" on the prognosis of patients undergoing veno-arterial extracorporeal membrane oxygenation for refractory cardiogenic shock and cardiac arrest

Veno-arterial Extracorporeal membrane oxygenation (VA ECMO) is a salvage intervention in patients with cardiogenic shock (CS), and cardiac arrest (CA) refractory to standard therapies. The design of ECMO Teams has achieved the standardization of processes, although its impact on survival and prognosis is unknown. We aimed to analyze whether the creation of an ECMO Team has modified the prognosis of patients undergoing VA ECMO for refractory CS or CA. . We conducted a single-center retrospective cohort study. Patients with refractory CS or CA who underwent VA ECMO were divided in two consecutive periods: from 2014 to April 2019 (pre-ECMO T) and from May 2019 to December 2022 (Post ECMO T). The main outcomes were survival on ECMO, in-hospital survival, complications, and annual ECMO volume. Eighty-three patients were included (36 pre-ECMO T and 47 post-ECMO T). The mean age was 53 +/-13 years. The most common reason for device indication was different: postcardiotomy shock (47.2%) pre-ECMO T and refractory cardiogenic shock (29.7%) post-ECMO T. The rate of extracorporeal cardiopulmonary resuscitation was 14.5%. The median duration of VA ECMO was longer after ECMO team implementation: 8 days (IQR 5-12.5) vs. five days (IQR 2-9, p=0.04). Global in-hospital survival was 45.8% (38.9% pre-ECMO T vs. 51.1% post-ECMO T; p=0.37), and the survival rate from VA ECMO was 60.2% (55.6% pre-ECMO T vs 63.8% post-ECMO T; p= 0.50). The volume of VA ECMO implantation was significantly higher in the post-ECMO team period (13.2 +/3.5 per year vs. 6.5 +/-3.5 per year, p: 0.02). The rate of complications was similar in both groups. After the implementation of an ECMO team, there was no statistical difference in the survival rate of patients treated with VA ECMO. However, a significant increase in the number of patients supported per year was observed after the implementation of this multidisciplinary team. Post-ECMO T, the most common reason for device indication was cardiogenic shock, with longer run times and a higher rate of extracorporeal cardiopulmonary resuscitation.

Cardiac Troponin T level is not a predictor of mortality in patients with post-cardiotomy shock supported with venoarterial extracorporeal membrane oxygenation

Abstract Background The prognostic significance of a dominant biomarker of cardiac injury, troponin, is unexplored in patients with post-cardiotomy cardiogenic shock supported with venoarterial extracorporeal membrane oxygenation (PCCS–VA-ECMO). Aims We sought to investigate the association of early postoperative troponin T with short- and long-term mortality in patients supported with VA-ECMO in the postoperative period. Methods We analyzed 1457 troponin measurements of 102 patients with PCCS–VA-ECMO treated between 2013–2018 in a cardiosurgical and transplantation centre. We focused on the relation of troponin concentration 24–48 hours after surgery and 24–48 hours after VA-ECMO implantation and peak troponin value with VA-ECMO weaning, 90-day and one-year mortality. Results The median troponin T 24–48 hours following VA-ECMO implantation was 1338 ng/L [Q1–Q3: 526–2727, 90-day survivors 1529 ng/L (Q1–Q3: 836–5791) vs. non-survivors 1294 ng/L (Q1–Q3: 316–2657); P = 0.146]. The median peak troponin was 3583 ng/L [Q1–Q3: 1710–9238, 90-day survivors 3337 ng/L (Q1–Q3: 1863–12305) vs. non-survivors 3666 ng/L (Q1-Q3: 1462–9238); P = 0.709]. Multivariate models of troponin analysis: for VA-ECMO explanation, in-hospital, 90-day and 1-year mortality showed no relation between troponin and mortality. Age, urgency, type and number of procedures, left ventricle ejection fraction before surgery, Euroscore II result, cardiac arrest prior to VA-ECMO implantation or duration of VA-ECMO did not correlate with the extent of troponin release. The strongest risk factor for short- and long-term mortality was the need for hemodiafiltration [HR 2.4]. Conclusions 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 multiorgan implications of PCCS in determining survival.

National Trends for Temporary Mechanical Circulatory Support Utilization in Patients With Cardiogenic Shock From Decompensated Chronic Heart Failure: Incidence, Predictors, Outcomes, and Cost

BackgroundTrends in temporary mechanical circulatory support (tMCS) use with associated outcomes and cost in cardiogenic shock secondary to decompensated chronic heart failure (HF-CS) remains poorly understood. We describe trends in tMCS use, associated outcomes, and cost in HF-CS. MethodsWe included adults enrolled in a national insurance claims dataset with HF-CS who received intra-aortic balloon pump (IABP), Impella, or extracorporeal membrane oxygenation (ECMO) without acute coronary syndrome, or postcardiotomy shock. We identified predictors of device use, associated outcomes, and inflation-adjusted costs. ResultsWe studied 2722 HF-CS patients receiving tMCS: 1799 (66%) male, 1771 (65%) White, and 1836 (67%) with ischemic cardiomyopathy. Rate of tMCS use increased from 2010-2019. Impella use showed the largest increase (Δ+344%), followed by ECMO (Δ+112%). Patients receiving ECMO had a higher comorbidity burden, and patients receiving IABP were more likely to have valvular heart disease. Compared with IABP, 30-day mortality rate was no different for Impella (adjusted odds ratio, 1.24; 95% CI, 0.93-1.66) but was higher with ECMO (adjusted odds ratio, 3.08; 95% CI, 2.22-4.27). Adjusted hospitalization cost was highest for ECMO (median, $191,079 [IQR, $165,760-$239,373]), followed by Impella (median, $142,518 [IQR, $126,845-$179,938]), and IABP (median, $132,060 [IQR, $113,794-$160,244]). We observed a linear association between price standardized cost-quartile and complications, but not for 30-day mortality. ConclusionsThe use of Impella and ECMO is increasing with an associated cost increase. The use of ECMO coincided with higher 30-day mortality compared with IABP in HF-CS. These findings likely reflect increasing disease severity and evolving practice patterns rather than causation.

Surgically implanted endovascular, microaxial left ventricular assist device: A single institution study

ObjectiveThe Impella 5.5 (Abiomed, Inc), a surgically implanted endovascular microaxial left ventricular assist device, is increasingly used worldwide and there have been more than 10,000 implants. The purpose of this study is to describe a large-volume, single-center experience with the use of the Impella 5.5. MethodsData were obtained retrospectively from patients supported with the Impella 5.5 implanted at our institution from May 1, 2020, to December 31, 2022. Demographic, operative, and postoperative outcomes for each group are described. Results are reported in median (interquartile range) or n (%). The entire cohort was divided into 5 main groups based on the intention to treat at the time of the Impella 5.5 implantation: (1) patients who had a planned Impella 5.5 implanted at the time of high-risk cardiac surgery; (2) patients with cardiogenic shock; (3) patients bridged to a durable left ventricular assist device; (4) patients bridged to transplant; and (5) patients with postcardiotomy shock who received an unplanned Impella 5.5 implant. ResultsA total of 126 patients were supported with the Impella 5.5. Overall survival to device explant was 76.2%, with 67.5% surviving to discharge. Midterm survival was assessed with a median follow-up time of 318 days and demonstrated an overall survival of 60.3% and a median of 650 days (549-752). ConclusionsOutcomes after using the Impella 5.5 are variable depending on the indication of use. Patient selection may be of utmost importance and requires further experience with this device to determine who will benefit from insertion.

Coronary artery bypass grafting in left ventricular dysfunction: when and how.

The surgical management of patients undergoing coronary artery bypass grafting (CABG) with low ejection fraction presents unique challenges that require meticulous attention to details and good surgical technique and judgement. This review details the latest evidence and best practices in the care of such patients. CABG in patients with low ejection fraction carries a significant risk of perioperative mortality and morbidity related to the development of postcardiotomy shock. Preoperative optimization with pharmacological or mechanical support is required, especially in patients with cardiogenic shock. Rapid and complete revascularization is what CABG surgeons aim to achieve. Multiple arterial revascularization should be reserved to selected patients. Off-pump CABG, on-pump breathing heart CABG, and new cardioplegic solutions remain of uncertain benefit compared with traditional CABG. Tremendous advancements in CABG allowed surgeons to offer revascularization to patients with severe left ventricular dysfunction and multivessel disease with acceptable risk. Despite that, there is a lack of comprehensive and robust studies particularly on long-term outcomes. Individualized patient assessment and a heart team approach should be used to determine the optimal surgical strategy for each patient.

The importance of timing in postcardiotomy venoarterial extracorporeal membrane oxygenation: A descriptive multicenter observational study

ObjectivesPostcardiotomy extracorporeal membrane oxygenation (ECMO) can be initiated intraoperatively or postoperatively based on indications, settings, patient profile, and conditions. The topic of implantation timing only recently gained attention from the clinical community. We compare patient characteristics as well as in-hospital and long-term survival between intraoperative and postoperative ECMO. MethodsThe retrospective, multicenter, observational Postcardiotomy Extracorporeal Life Support (PELS-1) study includes adults who required ECMO due to postcardiotomy shock between 2000 and 2020. We compared patients who received ECMO in the operating theater (intraoperative) with those in the intensive care unit (postoperative) on in-hospital and postdischarge outcomes. ResultsWe studied 2003 patients (women: 41.1%; median age: 65 years; interquartile range [IQR], 55.0-72.0). Intraoperative ECMO patients (n = 1287) compared with postoperative ECMO patients (n = 716) had worse preoperative risk profiles. Cardiogenic shock (45.3%), right ventricular failure (15.9%), and cardiac arrest (14.3%) were the main indications for postoperative ECMO initiation, with cannulation occurring after (median) 1 day (IQR, 1-3 days). Compared with intraoperative application, patients who received postoperative ECMO showed more complications, cardiac reoperations (intraoperative: 19.7%; postoperative: 24.8%, P = .011), percutaneous coronary interventions (intraoperative: 1.8%; postoperative: 3.6%, P = .026), and had greater in-hospital mortality (intraoperative: 57.5%; postoperative: 64.5%, P = .002). Among hospital survivors, ECMO duration was shorter after intraoperative ECMO (median, 104; IQR, 67.8-164.2 hours) compared with postoperative ECMO (median, 139.7; IQR, 95.8-192 hours, P < .001), whereas postdischarge long-term survival was similar between the 2 groups (P = .86). ConclusionsIntraoperative and postoperative ECMO implantations are associated with different patient characteristics and outcomes, with greater complications and in-hospital mortality after postoperative ECMO. Strategies to identify the optimal location and timing of postcardiotomy ECMO in relation to specific patient characteristics are warranted to optimize in-hospital outcomes.

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?

The Utility of Risk Scores in Postcardiotomy Extracorporeal Membrane Oxygenation.

The use of a venoarterial extracorporeal membrane oxygenation (ECMO) in the postcardiotomy shock setting (PC-ECMO) can be life-saving. Risk stratification for patients under PC-ECMO is currently challenging. The aim of this study was to assess the discriminatory ability of the different available risk scores for mortality in PC-ECMO patients. Patients aged >18years undergoing coronary artery bypass, valve surgery, or a combination of these procedures and implanted an ECMO for postcardiotomy shock between January 2017 and June 2022 in a single ELSO registered center were retrospectively included. The STS, Euroscore II, SAVE, modified SAVE, APACHE II, and VIS scores were compared for their discriminatory ability concerning weaning and 30-day survival. During the study period, 7342 patients underwent coronary bypass or valve surgery, of whom 109 patients with PC-ECMO were included in the analysis. The Euroscore II and STS scores were not associated significantly with 30-day mortality, whereas the SAVE, the modified SAVE, APACHE II, and VIS scores significantly predicted 30-day mortality. The SAVE and the modified SAVE scores showed moderate discrimination ability with AUCs of 0.672 and 0.695, while the APACHE and VIS scores had a satisfactory discriminatory ability with AUCs of 0.727 and 0.844, respectively. Currently used risk scores for PC-ECMO patients do not provide satisfactory predictions for weaning and survival. VIS at the 24th hour can be a valuable parameter for risk analysis and prospective studies can investigate novel PC-ECMO risk scoring systems.

Extracorporeal Life Support for Cardiogenic Shock in Octogenarians: Single Center Experience.

The age limit for the use of extracorporeal membrane oxygenation (ECMO) support for post-cardiotomy cardiac failure is not defined. The aim of the study was to evaluate the outcomes of octogenarians supported with ECMO due to cardiogenic shock. A retrospective review of consecutive elderly patients supported with ECMO during a 13-year period in a tertiary care center. Patient's demographic variables, comorbidities, perioperative data and outcomes were collected from patient medical records. Data of octogenarian patients were compared with the septuagenarian group. The main outcomes of the study was in hospital mortality, 6-month survival and 1-year survival after hospital discharge and discharge options. Multivariate logistic regression analysis was performed to identify the factors associated with hospital survival. Eleven patients (18.3%) in the elderly group were octogenarians (aged 80 years or above), and forty-nine (81.7%) were septuagenarians (aged 70-79 years). There were no differences except age in demographic and preoperative variables between groups. Pre ECMO SAVE, SOFA, SAPS-II and inotropic scores were significantly higher in septuagenarians than octogenarians. There was no statistically significant difference in hospital mortality, 6-month survival, 1 year survival or discharge options between groups. ECMO could be successfully used in selected octogenarian patients undergoing cardiac surgery to support a failing heart. An early decision to initiate ECMO therapy in elderly post-cardiotomy shock patients is associated with favorable outcomes.

Management of Post-Myocardial Infarction Right Ventricular Failure.

Right ventricular failure (RVF) due to an acute myocardial infarction (MI) has been associated with high morbidity and mortality. Initial treatment is guided by early recognition and prompt revascularization. Current management of post-MI RVF is built upon expert consensus and is also informed by RVF from other etiologies, including massive pulmonary embolism, left ventricular assist device-associated right ventricular dysfunction, postcardiotomy shock, etc.; this speaks to the limited data available on the specific management of RVF in acute MI. The goal of this review is to discuss the current literature on the pathophysiology, general management considerations, interventional management, hemodynamic monitoring, medical management, and mechanical circulatory support of MI-induced RVF.