Postcardiotomy Shock Research Articles

SCAI Shock Classification to Predict Outcomes of Venoarterial Extracorporeal Membrane Oxygenation

<h3>Purpose</h3> The Society for Cardiovascular Angiography and Interventions (SCAI) recently introduced a staging schema for cardiogenic shock (CS) based on exam findings, lab markers, and hemodynamics. We applied the SCAI schema to CS patients treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) to assess clinical relevance. <h3>Methods</h3> We retrospectively reviewed patients receiving VA-ECMO for CS at our institution from January 2015 to December 2019. Patients with post-cardiotomy shock and non-cardiac shock etiologies were excluded. Patients were classified to a SCAI stage A-E based on device and drug initiation, hemodynamics, CPR use, and levels of lactate and creatinine. Outcomes included in-hospital mortality, myocardial recovery, and adverse events during ECMO course. <h3>Results</h3> A total of 245 patients met the inclusion criteria, with median age of 59 years [IQR: 48-67]. One hundred fifty-nine patients (65%) were male. The number of patients in SCAI stages was 0 (0%) in A, 0 (0%) in B, 34 (14%) in C, 82 (33%) in D, and 129 (53%) in E. Of the E patients, 88 (68%) were undergoing CPR. Underlying CS etiologies of acute decompensated heart failure (C: 53%, D: 43%, E: 17%, p<0.001) and ventricular fibrillation (C: 9%, D: 0%, E: 3%, p<0.001) were greater in C. Median ECMO duration decreased with stage (C: 7 [4-14], D: 6 [3-9], E: 4 [1-8] days, p<0.001). In-hospital mortality increased (C: 35%, D: 56%, E: 71%, p<0.001) and myocardial recovery decreased (C: 68%, D: 37%, E: 30%, p<0.001) with stage. Adverse events varied in terms of acute kidney injury (C: 35%, D: 45%, E: 54%, p=0.045) and infection (C: 35%, D: 28%, E: 16%, p=0.004). Kaplan-Meier analysis revealed E had worse survival than C and D (Figure 1). Outcomes were similar between E,CPR+ and E,CPR- patients (68% vs. 73%, p=0.76). <h3>Conclusion</h3> In patients treated with VA-ECMO for CS, the SCAI classification provided robust risk stratification.

Clinical and Hemodynamic Efficacy of Left Ventricular Unloading during Venoarterial Extracorporeal Membrane Oxygenation

<h3>Purpose</h3> Left ventricular (LV) distention is a feared complication in patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock. LV unloading could be achieved with concomitant intra-aortic balloon pump (IABP) or Impella. We sought to assess the clinical and hemodynamic effects of IABP and Impella on patients supported with VA-ECMO <h3>Methods</h3> We conducted a retrospective review of patients who received VA-ECMO at our institution between January 2015 and June 2020. Patients with post-cardiotomy shock were excluded. Patients were categorized as having received either ECMO alone or ECMO+LV unloading. LV unloading was further characterized as either ECMO+IABP, or ECMO+Impella. We recorded baseline characteristics, post-operative complications, and hemodynamic changes associated with device initiation. <h3>Results</h3> During the study period, 142 patients received ECMO alone, 76 received ECMO+IABP, and 76 received ECMO+Impella. The ECMO+LV unloading group had more male patients compared to ECMO alone (70.4% vs 57.5%, p=0.026). 39.4% of ECMO alone patients survived to discharge, compared to 44.4% of ECMO+LV unloading patients (p=0.12). The ECMO+LV unloading group showed a greater decrease in mean pulmonary diastolic pressures compared to ECMO alone after 24 hours of support (-6.0 ± 8.4 mmHg vs -0.1 ± 10.8 mmHg, p = 0.032). ECMO+Impella patients had a higher incidence of bleeding events compared to ECMO alone or ECMO+IABP (52.6% vs 37.3% vs 20.8%, p = 0.0003). Kaplan Meier analysis revealed that ECMO+IABP had better survival compared to ECMO alone and ECMO+Impella (Figure 1). In a multivariable Cox-hazard analysis, age (HR= 1.02), male sex (HR=0.57), baseline lactate (HR =1.05), baseline creatinine (HR=1.06), need for ECPR (HR=2.21) and presence of IABP (HR=0.48) were independent predictors for mortality. <h3>Conclusion</h3> Concomitant support with IABP may help to reduce morbidity in patients on VA-ECMO for cardiogenic shock.

Levosimendan in veno-arterial extracorporeal membrane oxygenator supported patients: Impact on the success of weaning and survival.

Weaning failure and mortality rates in veno-arterial extracorporeal membrane oxygenation (VA-ECMO) supported patients are significant. Small studies suggest the possible usefulness of levosimendan in this environment, especially in postcardiotomy shock. We performed a retrospective analysis of VA-ECMO implants in a referral hospital comparing weaning failure and survival of patients treated with levosimendan with a control group. From 2013 to May 2020, 123 VA-ECMO for several indications were implanted. Levosimendan was administered in 23 patients (18.7%) with good tolerance. Levosimendan was used more frequently in cardiogenic shock due to acute coronary syndrome indication, and in patients with lower left ventricular ejection fraction (LVEF) at the implant. No significant differences were found in success of ECMO weaning (60.9% levosimendan group vs. 44% non-levosimendan group, P=.169) despite worse LVEF in levosimendan group. Survival at follow-up (20.6 [58] months) was higher in the group that received levosimendan, although without finding statistically significant differences (47.8% vs. 32.0%, log rank P=.124). Levosimendan can be safely administered during VA-ECMO support. Patients receiving levosimendan were weaned similarly from circulatory support despite worse LVEF. Its use did not influence in short- and medium-term survival. Randomized studies are needed to evaluate the levosimendan impact in this indication.

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.

Acute Brain Injury in Postcardiotomy Shock Treated With Venoarterial Extracorporeal Membrane Oxygenation

Acute brain injury (ABI) is common in venoarterial extracorporeal membrane oxygenation (VA-ECMO). One of the most common indications for use of VA-ECMO is postcardiotomy shock (PCS). The authors aimed to characterize the prevalence of ABI and its association with outcomes in this population. prospective observational. Single-center tertiary care university hospital. Fifty-two consecutive patients treated for PCS with VA-ECMO from November 2017 to March 2020. None. The median age of patients was 64 (interquartile range 44-84), 62% were male. Of 52 PCS patients treated with extracorporeal membrane oxygenation, 38% (n = 20) experienced acute brain injury. Ischemic stroke was the most common (n = 13, 25%). Patients with central versus peripheral cannulation experienced more ischemic and hemorrhagic strokes (8% v 38%, p = 0.04). Patients with intracardiac thrombus experienced more brain injury (n = 4, 8% p = 0.02). The in-hospital mortality in patients with brain injury was 90% (n = 18/20) compared to 78% (n = 25/32) in patients without brain injury. ABI is common in postcardiotomy VA-ECMO and associated with worse outcome. Patients with central recanalization experienced the majority of acute strokes. Intracardiac thrombus was significantly associated with acute brain injury.

Contemporary Use of Venoarterial Extracorporeal Membrane Oxygenation: Insights from the Multicenter RESCUE Registry

BackgroundVenoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as a life-saving therapy for patients with cardiovascular collapse, but identifying patients unlikely to benefit remains a challenge. Methods and ResultsWe created the RESCUE registry, a retrospective, observational registry of adult patients treated with VA-ECMO between January 2007 and June 2017 at 3 high-volume centers (Columbia University, Duke University, and Washington University) to describe short-term patient outcomes. In 723 patients treated with VA-ECMO, the most common indications for deployment were postcardiotomy shock (31%), cardiomyopathy (including acute heart failure) (26%), and myocardial infarction (17%). Patients frequently suffered in-hospital complications, including acute renal dysfunction (45%), major bleeding (41%), and infection (33%). Only 40% of patients (n = 290) survived to discharge, with a minority receiving durable cardiac support (left ventricular assist device [n = 48] or heart transplantation [n = 7]). Multivariable regression analysis identified risk factors for mortality on ECMO as older age (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.12–1.42) and female sex (OR, 1.44; 95% CI, 1.02–2.02) and risk factors for mortality after decannulation as higher body mass index (OR 1.17; 95% CI, 1.01-1.35) and major bleeding while on ECMO support (OR, 1.92; 95% CI, 1.23–2.99). ConclusionsDespite contemporary care at high-volume centers, patients treated with VA-ECMO continue to have significant in-hospital morbidity and mortality. The optimization of outcomes will require refinements in patient selection and improvement of care delivery.

Microbiological Spectrum of Nosocomial ECMO Infections in a Tertiary Care Center.

Introduction:Extracorporeal membrane oxygenation (ECMO) is a life-saving treatment in cardiogenic and respiratory shock. It is prone to various complications, infection being among the most frequent. This study aims to define the prevalence and characteristics of infections in ECMO patients in a tertiary care center for cardiac diseases.Methods:All ECMO patients between 2012 and 2016 in a single cardiac center were retrospectively included. Demographic data, ECMO indications, type, site, duration, and infection-related data were recorded. Data were analyzed among all patients and separately between pediatric and adult patient groups.Results:One hundred and twenty-six patients, 66 (53.4%) pediatric and 60 (47.6%) adult, received ECMO within the study period. Mean age was 3.54±4.27 years in the pediatric group and 54.92±15.57 years in the adult group. The main indication for ECMO was postcardiotomy shock (77.8%). Forty-six (36.5%) of all cases developed a culture-proven nosocomial infection with a rate of 49/1000 ECMO days. Infection was associated with > 5 days of ECMO duration and hemodialysis requirement in all patients and lower age in the pediatric group. The most frequent infection site was the lower respiratory tract (14.3%), while the most common isolated organisms were Klebsiella (8.7%) and Streptococcus (4.8%) species.Conclusion:The respiratory tract is the most common site of infection, however, all sites impose a threat to recovery, with longer treatment durations required for patients with culture-proven infections. A better understanding of the infectious spectrum and its effect on the mortality and morbidity is required for more successful treatment of ECMO patients.

Central Versus Peripheral Arterial Cannulation for Veno-Arterial Extracorporeal Membrane Oxygenation in Post-Cardiotomy Patients.

Different arterial cannulation strategies are feasible for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in postcardiotomy shock. We aimed to analyze potential benefits and safety of different arterial cannulation strategies. We identified 158 patients with postcardiotomy cardiogenic shock requiring VA-ECMO between 01/10 and 01/19. Eighty-eight patients were cannulated via axillary or femoral artery (group P), and 70 centrally via the ascending aorta directly or through an 8 mm vascular graft anastomosed to the ascending aorta (group C). Demographics and operative parameters were similar. Change of cannulation site for Harlequin's syndrome or hyperperfusion of an extremity occurred in 13 patients in group P but never in group C (p = 0.001). Surgical revision of cannulation site was also encountered more often in group P than C. The need for left ventricular (LV) unloading was similar between groups, whereas surgical venting was more often implemented in group C (11.4% vs. 2.3, p = 0.023). Stroke rates, renal failure, and peripheral ischemia were similar. Weaning rate from ECMO (52.9% vs. 52.3%, p = NS) was similar. The 30 day mortality was higher in group P (60% vs. 76.1%, p = 0.029). Central cannulation for VA-ECMO provides antegrade flow without Harlequin's syndrome, changes of arterial cannula site, and better 30 day survival. Complication rates regarding need for reexploration and transfusion requirements were similar.

Veno-Arterial Extracorporeal Life Support in Heart Transplant and Ventricle Assist Device Centres. Meta-analysis.

AimsBecause reported mortality on veno‐arterial (V‐A) extracorporeal life support (ECLS) substantially varies between centres, the aim of the current analysis was to assess the outcomes between units performing heart transplantation and/or implanting ventricular assist device (HTx/VAD) vs. non‐HTx/VAD units in patients undergoing V‐A ECLS for cardiogenic shock.Methods and resultsSystematic search according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses was performed using PubMed/MEDLINE databases until 30 November 2019. Articles reporting in‐hospital/30‐day mortality and centre's HTx/VAD status were included. In‐hospital outcomes and long‐term survival were analysed in subgroup meta‐analysis. A total of 174 studies enrolling n = 13 308 patients were included with 20 series performed in non‐HTx/VAD centres (1016 patients, 7.8%). Majority of patients underwent V‐A ECLS for post‐cardiotomy shock (44.2%) and acute myocardial infarction (20.7%). Estimated overall in‐hospital mortality was 57.2% (54.9–59.4%). Mortality rates were higher in non‐HTx/VAD [65.5% (59.8–70.8%)] as compared with HTx/VAD centres [55.8% (53.3–58.2%)], P < 0.001. Estimated late survival was 61.8% (55.7–67.9%) without differences between non‐HTx/VAD and HTx/VAD centres: 66.5% (30.3–1.02%) vs. 61.7% (55.5–67.8%), respectively (P = 0.797). No differences were seen with respect to ECLS duration, limb complications, and reoperations for bleeding, kidney injury, and sepsis. Yet, weaning rates were higher in HTx/VAD vs. non‐HTx/VAD centres: 58.7% (56.2–61.1%) vs. 48.9% (42.0–55.9%), P = 0.010. Estimated rate of bridge to heart transplant was 6.6% (5.2–8.3%) with numerical, yet not statistically significant, difference between non‐HTx/VAD [2.7% (0.8–8.3%)] as compared with HTx/VAD [6.7% (5.3–8.6%)] (P = 0.131).ConclusionsSurvival after V‐A ECLS differed according to centre's HTx/VAD status. Potentially different risk profiles of patients must be taken account for before definite conclusions are drawn.

Renal replacement therapy in patients on extracorporeal membrane oxygenation support: Who and how.

Patients undergoing extracorporeal membrane oxygenation (ECMO) support frequently develop renal failure requiring renal replacement therapy (RRT). RRT may be performed via a dialysis catheter based approach or via the ECMO circuit. We describe our experience with both techniques. A total of 68 patients undergoing ECMO support at our institution were retrospectively analyzed. Predictors of renal failure requiring RRT were determined. Patients undergoing RRT via a dialysis catheter were compared with those undergoing RRT via the ECMO circuit. 10 of the 68 patients required RRT support prior to ECMO. Of the remaining 58 patients, 25 (43%) required new RRT support on ECMO. Lower albumin levels and postcardiotomy shock were predictive of new renal failure requiring RRT on ECMO. RRT performed via the ECMO circuit demonstrated similar efficacy as via a dialysis catheter. Outcomes were much worse for patients requiring new RRT on ECMO support, with a doubling of the length of ECMO support and less that one-third the survival rate of patients not requiring RRT on ECMO support. New renal failure requiring RRT occurs in nearly one-half of patients on ECMO support, with poor outcomes. RRT may be performed via the ECMO circuit with similar efficacy as via a dialysis catheter.

Early and long-term outcomes of extracorporeal membrane oxygenation support in refractory cardiogenic shock for non-surgical patients: nine years experience at our Institute

Abstract Purpose Venoarterial extracorporeal membrane oxygenation (VA-ECMO) support is ultimately applied in refractory cardiogenic shock and is associated with high in-hospital mortality. We sought to describe the characteristics and analyze early and long-term outcomes of patients with refractory cardiogenic shock at our institution as well as our approach to patient selection. Methods This single-center retrospective study used the ECMO database from the cardiac surgery department to identify all patients with refractory cardiogenic shock at our Institute. VA-ECMO for patients with postcardiotomy shock, on-going cardiopulmonary resuscitation and venovenous ECMO were excluded. Primary endpoint was in-hospital mortality after VA-ECMO. Secondary outcomes were early complications on VA-ECMO and long-term survival after hospital discharge. Refractory cardiogenic shock was defined by either hypotension or end-organ failure despite adequate inotropic support. Results All patients with refractory cardiogenic shock were admitted to our cardiological ICU and our Heart team was systematically consulted. This team was mainly composed of transplant and LVAD cardiologists and cardiac surgeons specialized in ECMO. After case discussion, the decision for VA-ECMO implantation as a bridge therapy was made if the patient was deemed candidate to advance heart failure treatment. VA-ECMO was rapidly implanted by cardiac surgeons at bedside or in operating room with a median time from decision to implantation of 150 minutes (IQR: 100–233). Fifty-nine patients underwent VA-ECMO for refractory cardiogenic shock between 2010–2019. Patients were 52.1±14.5 years old, 75% were male and more than 90% were not known for any prior cardiac history. The indication for VA-ECMO support was acute myocardial infarction in 34 patients (58%) with reduced LVEF, mitral regurgitation, arrhythmia storm or ventricular septal defect. Myocarditis occurred in 19% of patients. The median LVEF was 13% (IQR: 10–31). Peripheral cannulation was most frequently implanted (92%). During VA-ECMO support, 43 patients survived and 16 patients died. Figure 1 shows weaning strategies for patients who survived VA-ECMO support. Of these, 37 patients survived up to discharge (86%). After a median follow-up of 2.9 years (IQR: 1.8–4.8), 92% were alive. The median time on VA-ECMO support was 4.9 days (IQR 3.5–7.6). Complications were bleeding needing reoperation (41%), pneumonia (41%), renal failure requiring dialysis (39%) and limb ischemia (17%). Conclusion In our experience, venoarterial ECMO is a feasible and acceptable alternative to support patients with refractory cardiogenic shock despite inotropic agents. Interestingly, the survival rate was particularly high as compared to the literature. This could be explained by patient selection and early VA-ECMO implantation. Evolution of patients after ECMO Funding Acknowledgement Type of funding source: None

Contemporary Use of Veno-arterial Extracorporeal Membrane Oxygenation: Insights from the Multicenter Rescue Registry

Background Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly utilized as life-saving therapy for patients with cardiovascular collapse, but identifying patients unlikely to benefit remains a challenge. Methods and Results We created the RESCUE registry, a retrospective, observational registry of adult patients treated with VA-ECMO between January 2007 and June 2017 at three high-volume centers (Columbia University, Duke University, and Washington University) to describe short-term patient outcomes. In 723 patients treated with VA-ECMO, the most common indications for deployment were post-cardiotomy shock (31%), cardiomyopathy (including acute heart failure) (26%), and myocardial infarction (17%). Patients frequently suffered in-hospital complications, including acute renal dysfunction (45%), major bleeding (41%), and infection (33%). Only 40% (n=290) survived to discharge, with a minority receiving durable cardiac support (LVAD [n=48] or heart transplant [n=7]). Multivariable regression analysis identified risk factors for mortality on ECMO as older age (OR 1.26 [1.12-1.42]) and female sex (OR 1.44 [1.02-2.02]) and risk factors for mortality after decannulation as higher BMI (OR 1.17 [1.01-1.35]) and major bleeding while on ECMO support (OR 1.92 [1.23-2.99]). Conclusions Despite contemporary care at high-volume centers, patients treated with VA-ECMO continue to have significant in-hospital morbidity and mortality. Optimization of outcomes will require refinements in patient selection and improvement of care delivery. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly utilized as life-saving therapy for patients with cardiovascular collapse, but identifying patients unlikely to benefit remains a challenge. We created the RESCUE registry, a retrospective, observational registry of adult patients treated with VA-ECMO between January 2007 and June 2017 at three high-volume centers (Columbia University, Duke University, and Washington University) to describe short-term patient outcomes. In 723 patients treated with VA-ECMO, the most common indications for deployment were post-cardiotomy shock (31%), cardiomyopathy (including acute heart failure) (26%), and myocardial infarction (17%). Patients frequently suffered in-hospital complications, including acute renal dysfunction (45%), major bleeding (41%), and infection (33%). Only 40% (n=290) survived to discharge, with a minority receiving durable cardiac support (LVAD [n=48] or heart transplant [n=7]). Multivariable regression analysis identified risk factors for mortality on ECMO as older age (OR 1.26 [1.12-1.42]) and female sex (OR 1.44 [1.02-2.02]) and risk factors for mortality after decannulation as higher BMI (OR 1.17 [1.01-1.35]) and major bleeding while on ECMO support (OR 1.92 [1.23-2.99]). Despite contemporary care at high-volume centers, patients treated with VA-ECMO continue to have significant in-hospital morbidity and mortality. Optimization of outcomes will require refinements in patient selection and improvement of care delivery.

Early venoarterial extracorporeal membrane oxygenation improves outcomes in post-cardiotomy shock.

Post-cardiotomy shock (PCS) is associated with substantial morbidity and mortality. We reviewed our 12-year experience of venoarterial extracorporeal membrane oxygenation (VA-ECMO) therapy for PCS. Between July 2007 and June 2018, 156 consecutive patients underwent VA-ECMO for PCS. We retrospectively investigated patient characteristics, indications, and management to determine factors affecting outcomes. Secondary analysis was performed by dividing the cohort into Era 1 (2007-2012, n = 52) and Era 2 (2013-2018, n = 104) for comparison. After a median of 4.70days (interquartile range [IQR] 2.76-8.53) of ECMO support, 72 patients (46.1%) survived to discharge. In-hospital mortality decreased in Era 2 from 75 to 43.3% (P < 0.001). Survivors were cannulated at lower serum lactate (5.3 [IQR 2.8-8.2] versus 7.5 [4.7-10.7], P = 0.003) and vasoactive-inotropic score (22.7 [IQR 11.3-35.5] versus 28.1 [IQR 20.8-42.5], P = 0.017). Patients in Era 2 were more frequently cannulated intraoperatively (63.5% versus 34.6%, P = 0.002), earlier in their hospital course, and at lower levels of serum lactate and vasoactive-inotropic score than in Era 1. Independent risk factors for mortality included increased age (odds ratio [OR] 1.06, P = 0.002), serum lactate at cannulation (OR 1.17, P = 0.009), and vasoactive-inotropic score (OR 1.04, P = 0.009). Bleeding and limb ischemia were less common in Era 2. Overall, outcomes of ECMO for PCS improved over the study period. The survival benefit appears to be associated with earlier ECMO initiation before prolonged hypoperfusion occurs.

Prosthetic valve thrombosis during extracorporeal life support for postcardiotomy shock.

Postcardiotomy shock is a complication after open-heart surgery that may be alleviated with extracorporeal life support (ECLS). Postcardiotomy shock patients on ECLS with prosthetic valves are at a high risk of valve thrombosis. We retrospectively reviewed patients supported with ECLS after the development of postcardiotomy shock at our centre, 90 of which had prosthetic valves. Nine patients developed prosthetic valve thrombosis, an incidence of 10%. Patients who developed prosthetic valve thrombosis were more often supported via central cannulation (78% vs 38%, P = 0.034) and had a higher median initial flow (4.4 vs 3.2 l/min, P = 0.018). Central cannulation was associated with valve thrombosis by multivariable logistic regression (odds ratio 7.56; 95% confidence interval 1.12-149.87). Central cannulation with high flow is thought to reduce intracardiac blood flow, thereby increasing the risk of stasis and thrombus formation. Patients with prosthetic valve thrombosis were treated with anticoagulation or surgical intervention and 4 patients (44%) survived to discharge.

Outcome of CentriMag\u2122 extracorporeal mechanical circulatory support use in critical cardiogenic shock (INTERMACS 1) patients

PurposePrognosis of patients presenting with INTERMACS 1 critical cardiogenic shock is generally poor. The aim of our study was to investigate the results of CentriMag™ extracorporeal short-term mechanical circulatory support as a bridge to decision in patients presenting with critical cardiogenic shock in our unit.MethodsWe retrospectively analysed 63 consecutive patients from January 2005 to June 2017, who were treated with a CentriMag™ device at our institution as a bridge to decision. Patients requiring extracorporeal support for post-cardiotomy shock and for primary graft dysfunction after heart transplantation were excluded.ResultsPatients’ median age was 44 years (IQR 31–52, range 15.4–62.0) and 42 (67%) were male. Primary diagnosis at presentation was ischaemic cardiomyopathy (n = 24; 38.1%), viral myocarditis (n = 19; 30.2%), idiopathic dilated cardiomyopathy (n = 8; 12.7%), and others (n = 12; 19%). The median duration of support was 25 (IQR 9.5–56) days. A total of 7 (11%) patients were supported with peripheral veno-arterial (VA) extra corporeal membrane oxygenation (ECMO), 6 (9%) with central VA ECMO, 8 (13%) with left ventricular assist device (LVAD), 17 (27%) with biventricular assist device (BiVAD), and 25 (40%) with ECMO and then converted to BiVAD. Overall, 22 (34.9%) patients died while on CentriMag™ mechanical circulatory support. Complications included bleeding requiring reoperation/intervention in 24 (38%), renal failure requiring dialysis in 29 (46%), bacterial infections in 23 (37%), fungal infections in 15 (24%), critical limb ischaemia in 6 (10%), and stroke in 8 (13%). The overall survival to successful explant from CentriMag™ was 65.1% (n = 41) and survival to hospital discharge was 58.7% (n = 37). Of these, 10 (16%) had cardiac recovery and were successfully explanted, 20 (32%) were bridged to heart transplantation, 11 (17%) were bridged to long-term left ventricular assist device, 3 (4.7%) were later on transplanted, and 1 (1.6%) recovered to decommissioning. The 1-, 5-, and 10-year survival rates were 55%, 46%, and 23% respectively.ConclusionOur results demonstrate an excellent outcome with the use of the CentriMag™ device in this seriously ill population. Despite requiring multiple procedures, over 58% of patients were discharged from hospital with 5-year survival of 46%.

The Effect of Different Types of Mechanical Circulatory Support on Mortality of Patients after Adult Cardiac Surgery: A Systematic Review and Meta-Analysis.

Sample size may limit the ability of individual studies to detect differences in clinical outcomes between extracorporeal membrane oxygenation (ECMO) alone and ECMO plus intra-aortic balloon pump (IABP) after adult cardiac surgery. Therefore, we undertook a meta-analysis of the best evidence available on the comparison of clinical outcomes of ECMO alone and ECMO plus IABP after adult cardiac surgery. PubMed, EMBASE, Web of Science, and Cochrane Center Registry of Controlled Trials were searched for studies comparing the use of ECMO alone and ECMO plus IABP after adult cardiac surgery. A meta-analysis and a sensitivity analysis were conducted. Among the 472 screened articles, 24 studies (1302 cases of ECMO plus IABP and 1603 cases of ECMO) were included. A significant relationship between patient risk profile and benefits from IABP plus ECMO was found in terms of the 30-day mortality (odds ratio [OR] 0.75; 95% confidence interval [CI] 0.62 to 0.91; P = .004) with postcardiotomy shock (PCS). However, ECMO alone was associated with lower in-hospital mortality (OR 1.75; 95% CI 1.06 to 3.01; Z = 2.19; P = .03) compared with ECMO plus IABP without PCS. Pooled data show that patients receiving IABP plus ECMO with PCS have lower 30-day mortality than those receiving ECMO also, which in turn show higher 30-day mortality in patients with IABP plus ECMO without PCS. Further randomized studies are warranted to corroborate these observational data.

Acute mesenteric ischaemia in refractory shock on veno-arterial extracorporeal membrane oxygenation.

Acute mesenteric ischaemia is a severe complication in critically ill patients, but has never been evaluated in patients on veno-arterial extracorporeal membrane oxygenation (V-A ECMO). This study was designed to determine the prevalence of mesenteric ischaemia in patients supported by V-A ECMO and to evaluate its risk factors, as well as to appreciate therapeutic modalities and outcome. In a retrospective single centre study (January 2013 to January 2017), all consecutive adult patients who underwent V-A ECMO were included, with exclusion of those dying in the first 24 hours. Diagnosis of mesenteric ischaemia was performed using digestive endoscopy, computed tomography scan or first-line laparotomy. One hundred and fifty V-A ECMOs were implanted (65 for post-cardiotomy shock, 85 for acute cardiogenic shock, including 39 patients after refractory cardiac arrest). Overall, median age was 58 (48-69) years and mortality 56%. Acute mesenteric ischaemia was suspected in 38 patients, with a delay of four (2-7) days after ECMO implantation, and confirmed in 14 patients, that is, a prevalence of 9%. Exploratory laparotomy was performed in six out of 14 patients, the others being too unstable to undergo surgery. All patients with mesenteric ischaemia died. Independent risk factors for developing mesenteric ischaemia were renal replacement therapy (odds ratio (OR) 4.5, 95% confidence interval (CI) 1.3-15.7, p=0.02) and onset of a second shock within the first five days (OR 7.8, 95% CI 1.5-41.3, p=0.02). Conversely, early initiation of enteral nutrition was negatively associated with mesenteric ischaemia (OR 0.15, 95% CI 0.03-0.69, p=0.02). Acute mesenteric ischaemia is a relatively frequent but dramatic complication among patients on V-A ECMO.

Probability of Uneventful Recovery After Elective Aortic Root Replacement for Aortic Aneurysm

Little is known about the chance of patients not experiencing complications (uneventful recovery) after aortic root replacement for aortic aneurysm. The aim of this study was to investigate the probability of uneventful recovery, identify its predictors, and address the association between the uneventful recovery and long-term survival. Patients with aortic aneurysm who underwent elective aortic root replacement between 2005 and 2018 were retrospectively reviewed (N= 676). Uneventful recovery was defined as avoidance of all of the following complications during the index hospital stay (selected based on Cox proportional hazards regression for long-term survival): mortality, any stroke, reexploration for bleeding, respiratory failure, acute renal failure, deep sternal infection, and postcardiotomy shock. Permanent pacemaker implantation was included because of its clinical perspectives. Patients were divided into 4 different age groups (group <60 years of age, n= 299; group 60-69 years of age, n= 209; group 70-79 years of age, n= 125; group ≥80 years of age, n= 43), according to a restricted cubic spline analysis on in-hospital mortality and postoperative stroke. Uneventful recovery was 78.1%. The probability of uneventful recovery decreased in a linear fashion as the age increases (82.6% in the group <60 years of age, 79.0% in the group 60-69 years of age, 70.4% in the group 70-79 years of age, 65.1% in the group ≥80 years of age; P= .007). A multivariable logistic regression showed age, left ventricular ejection fraction, previous cardiac surgery, and peripheral artery disease were independent predictors of uneventful recovery. Uneventful recovery resulted in significantly better 5-year survival (log-rank P= .039). This study provides novel information regarding the probability of uneventful recovery while confirming low in-hospital mortality and stroke rates after elective aortic root replacement for aortic aneurysm. Importantly, uneventful recovery ensures excellent long-term survival.

The Effect of Anticoagulation on Bleeding and Thrombotic Events during Extracorporeal Membrane Oxygenation Support for Postcardiotomy Shock

Postcardiotomy shock patients supported with venoarterial extracorporeal membrane oxygenation (VA ECMO) are at high-risk for thrombotic and bleeding complications. No standardized anticoagulation guideline exists for these complex patients. We investigated the incidence of bleeding and thrombotic complications and their relation to anticoagulation therapy during VA ECMO in postcardiotomy shock patients. Between December 2007 and June 2018, VA ECMO was used to support 150 patients with postcardiotomy shock at our hospital. We conducted a retrospective review of this cohort. Bleeding events were defined as bleeding requiring transfusion or re-intervention occurring during VA ECMO support. Thrombotic events included circuit thrombosis, venous or arterial system thrombosis, intracardiac thrombus, and vascular catheter thrombosis. Logistic regression was performed to determine predictors of bleeding and thrombotic events. The median patient age was 65 years (interquartile range [IQR] 55-73). The median duration of VA ECMO support was 4.65 days (IQR 2.75-8.00). 116 patients (77%) were anticoagulated with heparin. The median length from initiation of VA ECMO to anticoagulation was 27 hours (IQR 10-59). The median activated partial thromboplastin time (aPTT) for the duration of support was 43 seconds (IQR 37-50). Bleeding occurred in 42 patients (28%), of which 32 received heparin. Thrombosis occurred in 32 patients (21%), of which 30 received heparin. Both bleeding and thrombosis occurred in 10 patients (6%). The average aPTT in those with bleeding did not differ from those without bleeding (50 vs. 51s, p = 0.719). The average aPTT in those with thrombosis was less than in those without thrombosis (45 vs. 52s, p = 0.047). Multivariable logistic regression demonstrated that bleeding complications were associated with increased length of support (p = 0.005) and female sex (p = 0.004), while thrombotic events were associated with male sex (p = 0.03), history of atrial fibrillation (p = 0.05), and history of hypertension (p = 0.01). Bleeding and thrombotic events are common complications during VA ECMO support for postcarditomy shock. aPTT values during VA ECMO may not adequately reflect the risk of bleeding but may better reflect the risk of thrombosis.

The Role of Palliative Care Consultation in Withdrawal of Veno-Arterial Extracorporeal Membrane Oxygenation Support for Cardiogenic Shock

To evaluate the clinical characteristics of patients withdrawn from veno-arterial extracorporeal membrane oxygenation support (VA-ECMO), as well as the role of palliative care (PC) consultation in the decision to withdraw VA-ECMO. We retrospectively reviewed the electronic medical records of adult patients with cardiogenic shock treated with VA-ECMO at our institution between March 1, 2007 and May 31, 2019 to determine those who died after VA-ECMO was withdrawn. Patients were excluded if they survived less than 2 hours on VA-ECMO, died more than 72 hours after withdrawal, or were diagnosed with brain death prior to withdrawal. Of 643 Patients who received VA-ECMO, 127 patients (19.8%) were included. The etiology for VA-ECMO initiation included acute decompensated heart failure (11.8%), acute myocardial infarction (22.0%), extracorporeal cardiopulmonary resuscitation (4.7%), post-cardiotomy shock (34.6%), and others (26.8%). Mean time on VA-ECMO was 6.1 days, and most patients had other forms of life support, including renal replacement therapy (64.6%), mechanical ventilation (97.6%), intra-aortic balloon pump or Impella (47.2%), and AICD or pacemaker (16.5%). After 2013, 43 patients (44.8%) had a PC consult with a mean of 6.4 days from initial consultation to withdrawal. Only 1 patient had capacity to request withdrawal, and 1 patient had no surrogate requiring a legal guardian to be designated. At the time of withdrawal, 31 (24.4%) had clinical or radiologic evidence of anoxic brain injury, and this was associated with number of life support measures, length of time on VA-ECMO, and number of PC visits (Wilks lambda 0.5549, DF 4,71, p = 0.006). The length of time on VA-ECMO correlated with increased number of PC visits (r=0.525, p=0.001). Presence of anoxic brain injury was associated with decreased number of PC visits (t=3.02, p=0.003). Most patients withdrawn from VA-ECMO did not have capacity to determine their end of life care. Number of PC visits may be a surrogate marker of the complexity of the decision to withdraw. The longer the time on VA-ECMO, the greater the number of PC visits patients received. Further, the presence of anoxic brain injury was associated with fewer PC visits, which may indicate a less controversial decision to withdraw in patients with poor neurological prognosis.