Postcardiotomy Shock Research Articles

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.

A comparison of existing risk prediction models in patients undergoing venoarterial extracorporeal membrane oxygenation

BackgroundPatients undergoing consideration for venoarterial extracorporeal membrane oxygenation (VA-ECMO) require an immediate risk profile assessment in the setting of incomplete information. A number of survival prediction models for critically ill patients and patients undergoing elective cardiac surgery or institution of VA-ECMO support have been designed. We assess the ability of these models to predict outcomes in a cohort of patients undergoing institution of VA-ECMO for cardiogenic shock or cardiac arrest. MethodsFifty-one patients undergoing institution of VA-ECMO support were retrospectively analyzed. APACHE II, SOFA, SAPS II, Encourage, SAVE, and ACEF scores were calculated. Their ability to predict outcomes were assessed. ResultsIndications for ECMO support included postcardiotomy shock (25%), ischemic etiologies (39%), and other etiologies (36%). Pre-ECMO arrest occurred in 73% and 41% of patients underwent cannulation during arrest. Survival to discharge was 39%. Three survival prediction model scores were significantly higher in nonsurvivors to discharge than surivors; the Encourage score (25.4 vs 20; p = .04), the APACHE II score (23.6 vs 19.2; p = .05), and the ACEF score (3.1 vs 1.8; p = .03). In ROC analysis, the ACEF score demonstrated the greatest predictive ability with an AUC of 0.7. ConclusionsA variety of survival prediction model scores designed for critically ill ICU and VA-ECMO patients demonstrated modest discriminatory ability in the current cohort of patients. The ACEF score, while not designed to predict survival in critically ill patients, demonstrated the best discriminatory ability. Furthermore, it is the simplest to calculate, an advantage in the emergent setting.

Contemporary analysis of charges and mortality in the use of extracorporeal membrane oxygenation: A cautionary tale.

ObjectiveThe use of extracorporeal membrane oxygenation (ECMO) has increased exponentially. Costs and outcomes, however, vary considerably by indication. We sought to elucidate and quantify these differences.MethodsAdult patients supported on ECMO between 2008 and 2016 were analyzed using the Nationwide Inpatient Sample. We divided the study period into an early (2008-2013) and late period (2013-2016). The primary outcome was hospital charges, and the secondary outcomes were mortality, length of stay (LOS), and duration of ECMO support. These were stratified by the 5 most common indications: postcardiotomy shock (PCS), cardiogenic shock (CS), severe acute respiratory failure (SARF), heart (HT), and lung transplantation (LT). Both patient and hospital characteristics were assessed. Charges were adjusted for inflation and analyzed using a generalized linear model with gamma distribution. Pairwise comparison with Bonferroni correction was used to evaluate the cost and multivariate logistic regression to assess the risk of mortality.ResultsData pertaining to 15,829 adult patients were evaluated. Mean age of the entire cohort was 52.8 years, 8895 (56%) were white, and 10,278 (65%) were male. PCS was the predominant indication for ECMO (39%), followed by CS (37%). SARF accounted for 15% and HT and LT accounted for 3.9% and 5.4%, respectively. Mean LOS and duration of ECMO support were 23.4 days and 5.3 days respectively. Mean hospital charges per hospitalization for the entire cohort were USD 731,914 per patient. Charges per patient pertaining to hospitalizations in which ECMO was used in transplant patients were the highest: USD 1,448,931 and USD 1,574,378 (P = .99) for HT and LT, respectively. Charges were lower for the other indications: PCS USD 798,909, CS USD 655,099, and SARF USD 824,852. Overall mortality for the entire cohort was 55%. PCS and CS (53% vs 58%, P = .34) had similar survival, whereas SARF was 45%, LT was 39% and HT 32%. There were no differences in survival in these latter indications (SARF, LT and HT). The cumulative charges (proportion × hospital charges) reveal that PCS and CS (39% and 37%) account for both the majority of charges as well as the greatest mortality. Conversely, SARF and transplantation accounted for the smaller proportion of charges and the lower mortality. Patients undergoing HT had the longest LOS (51.7 days) and duration on ECMO (15.9 days), followed by LT (35.4 and 8.8 days respectively), and patients with SARF (28.6 and 6.6 respectively). LOS and duration of ECMO for those with PCS were 18.7 days and 4.8 days, respectively. Those on ECMO for CS were hospitalized for 19.7 days and spent an average of 3.8 days on ECMO. Mortality decreased, whereas charges increased in the late era.ConclusionsThe use of ECMO is associated with high hospital charges and a wide variation in outcomes. Hospitalizations, in which ECMO is used to support patients with cardiogenic shock (PCS and CS), are individually associated with lower LOS and charges. Cumulatively, however, these account for greater charges and greater mortality. Although mortality may be decreasing, overall charges are increasing with time. These variations may influence reimbursement decisions in value-based healthcare.

VA ECMO AS A SALVAGE THERAPY FOR POST CARDIOTOMY SHOCK

Post-cardiotomy shock (PCS) is characterized by either an inability to wean off of cardiopulmonary bypass, or a cardiogenic shock state in the immediate postoperative period. Venous-Arterial (VA) ECMO is often utilized in these situations as a salvage technique in instances when other MCS such as

The impact of CRRT modality in patients with AKI receiving ECMO: A nationwide registry study in Taiwan

PurposePatients receiving extracorporeal membrane oxygenation (ECMO) commonly develop acute kidney injury (AKI) and frequently require continuous renal replacement therapy (CRRT). The impact of different CRRT modalities on survival in patients receiving ECMO remains unclear. Materials and methodsUsing claims data from Taiwan's National Health Insurance Research Database, a total of 1077 patients who received ECMO and either continuous venovenous hemofiltration (CVVH) or continuous venovenous hemodialysis (CVVHD) for AKI were identified. Inverse probability of treatment weighting was applied using propensity scores to balance the baseline covariates of the two groups. The primary outcome was in-hospital morality. ResultsWe identified 1077 patients (mean age 57.9; 71.8% men). Postcardiotomy shock (49.2%) was the most frequently reported indication for ECMO. The CVVH group had a lower risk of in-hospital mortality (68.4% vs. 76.9%; odds ratio 0.65; 95% confidence interval [CI] 0.50–0.85) compared with the CVVHD group. The CVVH group also had a shorter mean ICU stay compared with the CVVHD group (mean difference −4.59 days, 95% CI −9.15 to −0.03 days). ConclusionOur results suggest that compared with CVVHD, CVVH may be associated with a lower risk of in-hospital mortality in patients with AKI who receive ECMO.

Outcomes of Venoarterial Extracorporeal Membrane Oxygenation Patients Requiring Multiple Episodes of Support

This study describes the largest North American single-institution experience with adult patients requiring multiple extracorporeal membrane oxygenation (ECMO) runs in the same admission and aims to describe outcomes of survival and complication rates in this patient population. A retrospective chart review-based study in a single quaternary care center of venoarterial (VA) ECMO patients cannulated multiple times on ECMO support to assess for outcomes and survival (both of ECMO therapy and survival to discharge). Single quaternary academic center for ECMO. All patients undergoing VA ECMO who were at least 18 years of age from 2011 to 2019, composed of a total of 14 patients requiring multiple cannulations. None, this was a retrospective chart review. Of the 326 patients reviewed, 14 patients (4.3% of all patients in the database) had multiple ECMO therapies. The average patient age was 55.2 ± 10.99 years of age, and 57% were female; 4 of the 14 (28.6%) patients survived to hospital discharge. The top 2 indications for initial VA ECMO therapy were cardiogenic shock after myocardial infarction (35.7%) and after cardiotomy shock (35.7%). For repeated cannulation, the most common cause was hypoxia (64%, 9 patients), with 6 of these patients requiring a right ventricular assist device plus oxygenator. Other causes for repeated cannulation included post-cardiotomy shock (14%), recurrent ventricular tachycardia (14%), and cardiogenic shock (7%). All patients who required continuous venovenous hemofiltration during their first run of ECMO did not survive to discharge. Fourteen of 326 patients in the authors' VA ECMO database required additional ECMO therapy after decannulation; this represents at least 1 to 2 cases per year at higher-volume centers. Despite the small number of patients in this retrospective review, it seems that certain patients are reasonable candidates for additional ECMO therapy should their cardiopulmonary function again decline. The findings of renal replacement therapy and infection being more common during a second ECMO run are logical, but larger cohorts (ideally multicenter or from within the Extracorporeal Life Support Organization registry) are required to validate these preliminary findings.

Structured review of post-cardiotomy extracorporeal membrane oxygenation: part 1-Adult patients.

Cardiogenic shock, cardiac arrest, acute respiratory failure, or a combination of such events, are all potential complications after cardiac surgery which lead to high mortality. Use of extracorporeal temporary cardio-circulatory and respiratory support for progressive clinical deterioration can facilitate bridging the patient to recovery or to more durable support. Over the last decade, extracorporeal membrane oxygenation (ECMO) has emerged as the preferred temporary artificial support system in such circumstances. Many factors have contributed to widespread ECMO use, including the relative ease of implantation, effectiveness, versatility, low cost relative to alternative devices, and potential for full, not just partial circulatory support. While there have been numerous publications detailing the short and midterm outcomes of ECMO support, specific reports about post-cardiotomy ECMO (PC-ECMO), are limited, single-center experiences. Etiology of cardiorespiratory failure leading to ECMO implantation, associated ECMO complications, and overall patient outcomes may be unique to the PC-ECMO population. Despite the rise in PC-ECMO use over the past decade, short-term survival has not improved. This report, therefore, aims to present a comprehensive overview of the literature with respect to the prevalence of ECMO use, patient characteristics, ECMO management, and in-hospital and early post-discharge patient outcomes for those treated for post-cardiotomy heart, lung, or heart-lung failure.

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.

A Simple Scoring System to Predict Survival after Venoarterial Extracorporeal Membrane Oxygenation

Patients undergoing consideration for venoarterial extracorporeal membrane oxygenation (VA ECMO) require an immediate risk profile assessment in the setting of incomplete or no information. A retrospective cohort study of 100 patients undergoing VA ECMO placement at three institutions was carried out. Variables strongly associated with survival to discharge were used to calculate a risk stratification score. Indications for VA ECMO support included postcardiotomy shock (24%), ischemic etiologies (33%), nonischemic cardiomyopathy (32%), and other etiologies (11%). Pre–VA ECMO arrest occurred in 69%, and 30% of patients underwent cannulation during arrest. Survival to discharge was 38%. Three variables demonstrated a strong trend toward predicting survival to discharge: lactate >10 mmol/L (p = .054), albumin <3 g/dL (p = .062), and platelet count <180 K/uL (p = .064), and these variables were included in a scoring system. The extremes of age and duration of pre–VA ECMO ventilation were associated with a dismal prognosis and were also included. These five variables were used to construct a mortality prediction score. A score of 0 was associated with 10% expected mortality, whereas a score of 4+ was associated with 100% expected mortality. Mortality increased in a stepwise fashion with increasing scores. The expected mortality closely paralleled the observed mortality. A simple scoring system composed of easily collected variables may help predict mortality. However, it is not intended to replace an experienced clinician’s judgment, but to enhance it.

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.

Use of Levosimendan as a Strategy to Wean off Veno-Arterial ECMO in Cardiogenic Shock; A Systematic Review and Metanalysis

Background VA ECMO is commonly used to support patients suffering profound cardiogenic shock. However, the ideal strategy to wean patients of VA ECMO remains unknown. Methods A systematic search including Pubmed, Cochrane Library and EMBASE was performed to evaluate studies comparing Levosimendan vs. other weaning strategies in patients with cardiogenic shock on VA-ECMO. Evaluated end-point was successful discontinuation on VA-ECMO support. Results Four studies met inclusion criteria for a total of 471 patients, . Mean age was 61, 292 (70%) of the patients were male. Hypertension, CAD and Diabetes were present in 282 patients (60%), 216 (46%) and 136 (29%) respectively, with no significant difference in between groups. The majority of patients required ECMO due to acute myocardial infarction or post cardiotomy shock (up to 50%). 262 received Levosimendan and 209 recieved other interventions. Out of the group who received the calcium sensitizer 215 patients (82%) were successfully weaned vs 135 patients (65%) on the control group, OR 1.27 (CI 95% 1.13-1.4) P Conclusions This metanalysis suggests that the use of Levosimendan on patients while on VA ECMO support for cardiogenic shock improves weaning success

VAA ECMO: A Hybrid Cannulation Strategy in a Patient with Severe Peripheral Arterial Disease

Introduction Peripheral arterial disease (PAD) can restrict vascular access options for venoarterial extracorporeal membrane oxygenation (VA ECMO). In emergent situations, a comprehensive vascular assessment is impractical, and when severe PAD is encountered, cannulation approaches may be limited. We report a successful cannulation strategy in a patient with severe PAD using bilateral femoral arterial access. Case A 69-year-old White male with ischemic cardiomyopathy with baseline EF 20-25%, coronary bypass grafting (CABG), and peripheral arterial disease (PAD) was admitted to an outside hospital for an elective redo CABG. He had post-cardiotomy shock requiring inotropes and a balloon pump. In 48 hours, he progressed to refractory cardiogenic shock and multiorgan failure with oliguria, coagulopathy, and mild cognitive impairment. VA-ECMO was emergently initiated as a potential bridge to durable ventricular assist device, pending renal recovery.After cut down, heavy circumferential calcification of the left common femoral artery (CFA) was observed, with no palpable pulse. Seldinger technique with incremental dilation was performed. However, a standard 180 cm wire met resistance and could not be advanced beyond 20 cm. Hoping this was extensive plaque, rather than a complete occlusion, a 19-French arterial cannula was placed, with a 6-French antegrade perfusion cannula in the left superficial femoral artery (SFA). ECMO was initiated and only 1 L of flow at 4000 RPM was achieved, indicating the resistance encountered likely implied a complete or critical stenosis of the left iliac artery. A second 19-French arterial cannulation in the right CFA was performed with no resistance this time. The arterial cannulae were connected in a Y configuration and ECMO resumed with roughly 3.5 L at 4000 RPM. The right common femoral vein was accessed with a 21-French venous cannula.He was extubated in less than 48 hours and did well for about 5 days, with evidence of LV recovery on ramp studies. Unfortunately, he then developed hypoxic respiratory failure, hemoptysis, recurrence of multiorgan failure, and hemodynamic instability, suspicious for septic shock. At this point, his family elected to initiate comfort measures, particularly in light of worsening cognitive status. Summary Atherosclerotic vessels pose access difficulties and risk vascular complications. As such, severe PAD often limits patient selection for VA ECMO. To the best of our knowledge, this is the first reported case utilizing a bilateral femoral arterial approach to augment a low flow state in the setting of severe PAD. Various hybrid cannulation strategies may be considered with respect to individual anatomy and broaden the patient pool eligible for VA ECMO.

Structured review of post-cardiotomy extracorporeal membrane oxygenation: Part 2-pediatric patients.

Veno-arterial extracorporeal membrane oxygenation (ECMO) is established therapy for short-term circulatory support for children with life-treating cardiorespiratory dysfunction. In children with congenital heart disease (CHD), ECMO is commonly used to support patients with post-cardiotomy shock or complications including intractable arrhythmias, cardiac arrest, and acute respiratory failure. Cannulation configurations include central, when the right atrium and aorta are utilized in patients with recent sternotomy, or peripheral, when cannulation of the neck or femoral vessels are used in non-operative patients. ECMO can be used to support any form of cardiac disease, including univentricular palliated circulation. Although veno-arterial ECMO is commonly used to support children with CHD, veno-venous ECMO has been used in selected patients with hypoxemia or ventilatory failure in the presence of good cardiac function. ECMO use and outcomes in the CHD population are mainly informed by single-center studies and reports from collated registry data. Significant knowledge gaps remain, including optimal patient selection, timing of ECMO deployment, duration of support, anti-coagulation, complications, and the impact of these factors on short- and long-term outcomes. This report, therefore, aims to present a comprehensive overview of the available literature informing patient selection, ECMO management, and in-hospital and early post-discharge outcomes in pediatric patients treated with ECMO for post-cardiotomy cardiorespiratory failure.

Nutritional Support in Postcardiotomy Shock Extracorporeal Membrane Oxygenation Patients: A Prospective, Observational Study

BackgroundDespite the 6000 patients treated with extracorporeal membrane oxygenation (ECMO) annually, there is a paucity of data regarding the nutritional management of these patients. Materials and methodsWe performed a prospective, observational study of nutrition in postcardiotomy shock patients at our institution. Over a 3.5-year study period, we identified 50 ECMO patients and 225 non-ECMO patients. We identified type, amount, duration, and disruption of nutritional delivery by cohort. The primary outcome was percent of caloric goal met, and secondary outcome was gastrointestinal complications. ResultsECMO patients met less of their caloric (29% versus 40%, P = 0.017) and protein goals (34% versus 55%, P < 0.001) compared with non-ECMO patients. Tube feeds were administered more slowly (26 versus 37 mL/h, P < 0.001) and held for longer (8.3 versus 4.5 h/d, P < 0.001) in ECMO patients because of procedures (60%) and high-dose pressors (20% versus 7%, P < 0.001). Multivariate analysis demonstrated that ECMO decreased caloric intake by 14%, with no detected increased risk of gastrointestinal complications. Conclusions–ECMO patients received significantly less nutrition support compared with a non-ECMO population. Tube feed hold deficits could potentially be avoided by utilizing postpyloric tubes to feed through procedures, by eliminating holds for vasopressors/inotropes in hemodynamically stable patients, or by establishing volume-based feeding protocols. Further clinical studies are needed to establish efficacy of these interventions and to understand the impact of nutrition on outcomes in ECMO patients.

Neutrophil-to-lymphocyte ratio for early renal failure under extracorporeal membrane oxygenation support for postcardiotomy shock.

This study aims to investigate the relationship between the neutrophil-to-lymphocyte ratio and renal injury in patients under extracorporeal membrane oxygenation support for postcardiotomy shock. Between January 2007 and July 2018, a total of 119 patients (38 males, 81 females; mean age 54.4±13.0 years; range, 24 to 74 years) who received extracorporeal membrane oxygenation support for postcardiotomy shock and survived at least 48 hours in our center were retrospectively analyzed. Pre- and postoperative neutrophil-to-lymphocyte ratios, demographic characteristics, renal function parameters, and extracorporeal membrane oxygenationrelated data of the patients were recorded. Occurrence and stages of renal injury was determined using the revised Acute Kidney Injury Network and Kidney Disease Improving Global Outcomes criteria. No significant relationship was found between preoperative neutrophil-to-lymphocyte ratio and renal injury (p>0.05). Postoperative neutrophil-to-lymphocyte ratio was higher in patients who developed renal injury, compared to patients without renal injury (8.68 [0.84-42.00] vs. 4.02 [1.04-21.21], respectively, p=0.004). When patients were grouped for renal injury stage according to the revised Acute Kidney Injury Network (p=0.015) and Kidney Disease Improving Global Outcomes (p=0.006) criteria, the patients with more severe renal injury had higher neutrophil-to-lymphocyte ratio. The receiver operating characteristics analysis revealed a cut-off value of 6.71 for the neutrophil-to-lymphocyte ratio for the detection of renal injury. Patients with a value above 6.71 had an odds ratio of 5.941 for occurrence of renal injury. Postoperative, but not preoperative neutrophil-tolymphocyte ratio is associated with presence and severity of renal injury in patients under extracorporeal membrane oxygenation support for postcardiotomy shock. Neutrophil-to-lymphocyte ratio is a simple and inexpensive marker of inflammation in this patient population.

Impact of preoperative extracorporeal life support on left ventricular assist device outcomes: A comparative study.

To investigate whether preoperative short-term extracorporeal life support therapy in patients undergoing continuous-flow left ventricular assist device implantation has an impact on the outcome regarding survival and adverse events. Between January 2011 and May 2018, 100 consecutive patients received HeartMate II, HeartWare, or HeartMate III for end-stage heart failure. Mean age was 64.2 ± 10.3 years. Three patient groups were identified: without preoperative extracorporeal life support (non-extracorporeal life support group, n = 80), with preoperative extracorporeal life support due to postcardiotomy shock after conventional cardiac surgery (postcardiotomy shock group, n = 9), and with preoperative extracorporeal life support without previous surgery (non-postcardiotomy shock group, n = 11). The primary endpoint was overall survival after device implantation. Secondary endpoints were adverse events during the follow-up period. Survival was significantly different between the groups (p < 0.05): 30-day, 6-month, and 1-year survival rates were 85%, 68%, and 61% for non-extracorporeal life support group; 44%, 22%, and 22% for postcardiotomy shock group; and 45%, 27%, and 24% for non-postcardiotomy shock group, respectively. Furthermore, in both extracorporeal life support groups (postcardiotomy shock and non-postcardiotomy shock), there were a higher incidence (p < 0.05) of postoperative right heart failure (30% vs 66.7% vs 54.5%), acute renal failure requiring dialysis (20% vs 77.8% vs 54.5%), and respiratory failure (31.3% vs 88.9% vs 81.8%). Continuous-flow left ventricular assist device implantation with prior extracorporeal life support appears to have a worse outcome regarding survival, right heart failure, renal and respiratory dysfunction (p < 0.05). Future studies have to be done to evaluate the outcome after extracorporeal life support bridge pre-left ventricular assist device, especially as ultima ratio in postcardiotomy shock patients.

Mid Term Survival after VA ECMO Weaning

Purpose The aimed of this study was to evaluate the outcome of the patients successfully weaned from ECMO after cardiac recovery. Methods From January 2008 to January 2018, 384 patients were supported with VA ECMO for cardiogenic shock in our institution. 47.1% patients (n=181) died during support. 40.9% patients were weaned from VA-ECMO (n=157), 5.7% (n=22 were supported with a LVAD or a TAH and 6.3%patients (n=4) received a heart transplant. We prospectively followed the patients weaned from ECMO by periodic visit at our center. We analyzed survival, causes of early and late deaths and predictors for death for this population. Results 157 patients, median age 52 years (1st and 3rd quart. 39-62), were successfully weaned from VA ECMO after a median time of 7 days of support (1st and 3rd quart. 4-10 days). Main etiologies of shock were post cardiotomy (n=57, 36.3%), acute myocardial infarction (n=39, 24.8%), pulmonary embolism (n=11, 7.0%), myocarditis (n=6, 3.8%), and acute end stage heart failure (n=6, 3.8%). During a mean follow up of 1.9 years (max 10 years), 137 patients were discharged home. Early deaths ( 2 years from ECMO weaning) were due to septic shock (n=4), heart graft failure (n=1), unknown (n=1). Three patients underwent HTx, 2 others patients are still waiting for a HTx,. Overall one-month, 6- month and 3-years survival were respectively of 93.4 (IC: 87.7-96.5); 83.4% (IC: 75.3- 89.0) and 76.5% (IC: 65.1-84.6). By multivariate Cox analysis, ECMO duration (HR= 1.15, p=0.0002), stroke during ECMO course (HR =3.85, p=0.0015), age (HR=1.06, p=0.0008), and post cardiotomy shock (HR =3.62, p=0.0124) were independent risk factor for death. Conclusion In our ten-year experience, patients could be successfully weaned from ECMO after a refractory shock. Most of them had a satisfactory outcome and could be discharged home. Older age, a longer duration of support, stroke and post cardiotomy shock were associated with poor outcome. Further studies are needed to evaluate the risk of recurrence of heart failure and a close follow up of those patients is mandatory.

Incidence and Outcomes of Prosthetic Valve Thrombosis during Extracorporeal Membrane Oxygenation Support for Postcardiotomy Shock

Purpose In postcardiotomy shock patients with prosthetic valves , the use of venoarterial extracorporeal membrane oxygenation (VA ECMO) may induce prosthetic valve thrombosis due to blood stasis in cardiac chambers. Incidence and outcomes of prosthetic valve thrombosis during VA ECMO has not been previously described. Methods Between January 2007 and June 2018, a total of 171 patients underwent VA ECMO therapy after major cardiovascular surgery at our center. Of these patients, 89 had a prosthetic valve in place, and we conducted a retrospective review of this cohort. Results Of the 89 patients with prosthetic valves placed on VA ECMO, 37 (41.5%) had central VA ECMO cannulation , and the remaining 52 patients (58.5%) underwent peripheral VA ECMO cannulation. Median age was 66 years (interquartile range [IQR], 55-74) and 53 (59.6%) were men. Average duration of ECMO support was 5.1 days (IQR 3.0, 8.5). The majority of patients (76.4%, n = 68) were on therapeutic anticoagulation within 24 hours post-cardiotomy, and inotropes were used in all patients. A total of 8 patients (9%) developed prosthetic valve thrombosis: 5 involved the aortic valve (including one mechanical aortic valve prosthesis), 2 involved bioprosthetic mitral valves , and 1 involved a bioprosthetic pulmonary valve (Table). Overall cohort survival to discharge was 41.2% (n = 35), but was reduced to 9% (n = 1) amongst those patients that developed valve thrombosis. Conclusion Prosthetic valve thrombosis is relatively common complication while patients with prosthetic valves are placed on VA-ECMO, and it is almost uniformly fatal when it does develop.

Incidence and Outcome of Neurological Complications in Veno-Arterial Extracorporeal Membrane Oxygenation Support for Cardiogenic Shock

Purpose Neurological complications (NC) are potentially devastating for cardiogenic shock patients receiving veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. The purpose of this study was to investigate the overall incidence and pattern of NC and their impact on outcome. Methods We retrospectively reviewed 498 consecutive patients who received VA-ECMO support for cardiogenic shock between March 2007 and May 2018. Information on NC type, including stroke, altered mental status, seizure, encephalopathy, and transient ischemic attack and other neurological events was collected. Survival to discharge was compared between patients with and without neurological complications. Results Median age of the entire cohort was 60 years (IQR 49-68), and 69% were male. Etiology of cardiogenic shock included post-cardiotomy shock (n=154, 33%), acute myocardial infarction (n=124, 27%), post-transplant graft failure (n=60, 13%), acute decompensated heart failure (n=65, 14%), and others (n=57, 12%). Eighty-seven patients were cannulated via the ascending aorta (18%), 37 via the axillary artery (7%), and 374 (75%) via the femoral artery. In total, 125 patients (25%) were diagnosed with NC: altered mental status was most common n=62 (12%), stroke n=29 (6%), encephalopathy n=16 (3%), seizure n=15 (3%), transient ischemic attack/others n=16 (3%). NC diagnosis was significantly associated with higher in-hospital mortality rates (74%, n=93) vs. non-NC diagnosis (61%, n=229), (p=0.008). Among NC subtypes, encephalopathy had the highest in-hospital mortality rate (94%, n=15), followed by stroke (72%, n=21) and AMS (71%, n=44). Conclusion Neurological disorders are common in cardiogenic shock patients who receive VA-ECMO and significantly impact in-hospital mortality rates.