Survival After Veno-arterial ECMO Research Articles

Non-invasive assessment of left ventricular contractility by myocardial work index in veno-arterial membrane oxygenation patients: rationale and design of the MIX-ECMO multicentre observational study

Introduction and aimsVeno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an increasingly utilized therapeutic choice in patients with cardiogenic shock, however, high complication rate often counteracts with its beneficial cardiopulmonary effects. The assessment of left ventricular (LV) function in key in the management of this population, however, the most commonly used measures of LV performance are substantially load-dependent. Non-invasive myocardial work is a novel LV functional measure which may overcome this limitation and estimate LV function independent of the significantly altered loading conditions of VA-ECMO therapy. The Usefulness of Myocardial Work IndeX in ExtraCorporeal Membrane Oxygenation Patients (MIX-ECMO) study aims to examine the prognostic role of non-invasive myocardial work in VA-ECMO-supported patients.MethodsThe MIX-ECMO is a multicentric, prospective, observational study. We aim to enroll 110 patients 48–72 h after the initiation of VA-ECMO support. The patients will undergo a detailed echocardiographic examination and a central echocardiography core laboratory will quantify conventional LV functional measures and non-invasive myocardial work parameters. The primary endpoint will be failure to wean at 30 days as a composite of cardiovascular mortality, need for long-term mechanical circulatory support or heart transplantation at 30 days, and besides that other secondary objectives will also be investigated. Detailed clinical data will also be collected to compare LV functional measures to parameters with established prognostic role and also to the Survival After Veno-arterial-ECMO (SAVE) score.ConclusionsThe MIX-ECMO study will be the first to determine if non-invasive myocardial work has added prognostic value in patients receiving VA-ECMO support.

Extracorporeal membrane oxygenation in South Africa: Experience from a single centre in the private sector.

Extracorporeal membrane oxygenation (ECMO) is an advanced, resource-intensive technology used in a limited capacity in South Africa (SA). Minimal data on the use of ECMO in SA are available. To describe the indications, early outcome and comorbidities of patients placed on ECMO in the highest-volume ECMO centre in SA. We performed a single-centre retrospective review of all adult patients supported with any form of ECMO from August 2016 to December 2018. Operative and clinical records were reviewed. The primary objective of this study was to review the outcome of patients placed on ECMO in the form of survival to hospital discharge. The secondary objectives were to identify population-specific comorbidities and indications for ECMO that could be associated with non-survival and to compare outcome with known risk scores in the form of the Respiratory ECMO Survival Prediction (RESP) and Survival After Venoarterial ECMO (SAVE) scores. One hundred and seven patients were identified. The primary indication for ECMO was respiratory support in 78 patients and cardiac support in 29 patients. Forty-seven patients were discharged from hospital, with a 44.0% overall survival rate. Gender (p=0.039), age (p=0.019) and hypertension (p=0.022) were associated with death in univariate logistic regression analysis. However, after adjusting for potential confounding in multivariate logistic regression analysis, the association was no longer significant. In the all respiratory support group, patients in risk class IV had better than predicted survival according to the RESP score, while risk classes I, II and III had worse than predicted survival. In the circulatory support group, all risk classes had worse than predicted survival according to the SAVE score. We report ECMO outcomes in SA for the first time. We identified very high mortality rates for patients transferred on ECMO from other facilities and for patients converted from venovenous ECMO to venoarterial ECMO. Although our outcomes were comparable in some of the risk classes, further external validation of the SAVE and RESP scores will be needed to compare our outcomes with these scores. What the study adds. We report on extracorporeal membrane oxygenation (ECMO) outcomes in South Africa for the first time. We identified a high mortality rate in patients transferred on ECMO from other facilities, and in patients converted from venovenous ECMO to venoarterial ECMO.Implications of the findings. Transferred patients had a high mortality rate. The reason for this should be further investigated and may highlight the need for possible protocols to assist with appropriate timing of patient transfers and possible earlier intervention or transfer.

SHOCK3: Comparing Veno-arterial Extracorpeal Membrane Oxygenation (VA-ECMO) vs. VA-ECMO plus Impella (ECPELLA) on Mortality in Patients with Cardiac Arrest After an Acute Myocardial Infarction (AMI)

Background: More than 800,000 people suffer from an AMI in the United States every year. One of the most feared complications of an AMI is cardiac arrest, and even if return of spontaneous circulation is achieved, profound cardiogenic shock (CS) is a common sequalae. VA-ECMO is utilized to support patients with CS, and now more frequently, used in conjunction with an Impella to off-load the left ventricle, though a paucity of evidence supports this practice. The goal of this study was to determine whether a mortality difference was observed in VA-ECMO alone vs ECPELLA in patients with CS after cardiac arrest secondary to an AMI. Methods: A dual-center, retrospective chart review of 52 patients who suffered cardiac arrest from an AMI and were supported with VA-ECMO or ECPELLA was performed. Univariable comparisons consisting of baseline demographics, cardiac arrest data, catheterization laboratory reports and intensive care unit (ICU) data were compared between the two groups using chi-squared analysis, independent t-test, and Wilcoxon Rank Sum Test to determine statistical significance. Cox proportional hazard models were constructed to test the independent association between treatment groups and mortality, controlling for various acute physiology and post-cardiac arrest prognostic scores. Results: Thirty-four patients received VA-ECMO only, and 16 patients were supported with an ECPELLA strategy. Ninety-day mortality was 67.6% in the VA-ECMO group, and 87.5% in the ECPELLA group. There was no statistically significant difference between the groups within regards to mortality (Hazard Ratio (HR): 1.69, 95% confidence interval 0.86-3.30). This remained true even when adjusting for the following validated prognostic scores: Simplified Acute Physiology Score II (SAPS), Survival after veno-arterial ECMO (SAVE), modified SAVE, Cardshock, and Charlson Comorbidity index. There we no differences in baseline demographic data nor ICU complications between the groups. Patients who experienced a ST elevated myocardial infarction (STEMI) were more likely to be in the VA-ECMO group rather than the ECPELLA group (p=0.044). Conclusion: Our results found no significant differences in mortality in patients with CS after cardiac arrest secondary to an AMI when treated with VA-ECMO vs ECPELLA. It should be highlighted that the study population was only 52 patients, thus the power of the study was significantly limited. Therefore, more experience and broader collaboration/data sharing is needed to identify if ECPELLA is a beneficial acute cardiac support strategy in this patient population.Figure 1. VA-ECMO vs ECPELLA Survival Curve

Effects of varying blood flow rate during peripheral veno-arterial extracorporeal membrane oxygen (V-A ECMO) on left ventricular function measured by two-dimensional strain.

We evaluated the effects of varying blood flow rate during peripheral veno-arterial extracorporeal membrane oxygen (V-A ECMO) on left ventricular function measured by two-dimensional strain. Adult patients who were supported by peripheral V-A ECMO were recruited. Serial hemodynamic and cardiac performance parameters were measured by transthoracic echocardiogram within the first 48 h after implementation of V-A ECMO. Measurements at 100%, 120%, and 50% of target blood flow (TBF) were compared. A total of 54 patients were included and the main indications for V-A ECMO were myocardial infarction [32 (59.3%)] and myocarditis [6 (11.1%)]. With extracorporeal blood flow at 50% compared with 100% TBF, the mean arterial pressure was lower [66 ± 19 vs. 75 ± 18 mmHg, p < 0.001], stroke volume was greater [23 (12-34) vs. 15 (8-26) ml, p < 0.001], and cardiac index was higher [1.2 (0.7-1.7) vs. 0.8 (0.5-1.3) L/min/m2, p < 0.001]. Left ventricular contractile function measured by global longitudinal strain improved at 50% compared with 100% TBF [-2.8 (-7.6- -0.1) vs. -1.2 (-5.2-0) %, p < 0.001]. Similarly, left ventricular ejection fraction increased [24.4 (15.8-35.5) vs. 16.7 (10.0-28.5) %, p < 0.001] and left ventricular outflow tract velocity time integral increased [7.7 (3.8-11.4) vs. 4.8 (2.5-8.5) cm, p < 0.001]. Adding echocardiographic parameters of left ventricular systolic function to the Survival After Veno-arterial ECMO (SAVE) score had better discriminatory value in predicting eventual hospital mortality (AUROC 0.69, 95% CI 0.55-0.84, p = 0.008) and successful weaning from V-A ECMO (AUROC 0.68, 95% CI 0.53-0.83, p = 0.017). In the initial period of V-A ECMO support, measures of left ventricular function including left ventricular ejection fraction and global longitudinal strain were inversely related to ECMO blood flow rate. Understanding the heart-ECMO interaction is vital to interpretation of echocardiographic measures of the left ventricle while on ECMO.

Left-ventricular unloading in extracorporeal cardiopulmonary resuscitation due to acute myocardial infarction – A multicenter study

BackgroundGuidelines advocate the use of extracorporeal cardio-pulmonary resuscitation with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in selected patients with cardiac arrest. Effects of concomitant left-ventricular (LV) unloading with Impella® (ECMELLA) remain unclear. This is the first study to investigate whether treatment with ECMELLA was associated with improved outcomes in patients with refractory cardiac arrest caused by acute myocardial infarction (AMI). MethodsThis study was approved by the local ethical committee. Patients treated with ECMELLA at three centers between 2016 and 2021 were propensity score (PS)-matched to patients receiving VA-ECMO based on age, electrocardiogram rhythm, cardiac arrest location and Survival After Veno-Arterial ECMO (SAVE) score. Cox proportional-hazard and Poisson regression models were used to analyse 30-day mortality rate (primary outcome), hospital and intensive care unit (ICU) length of stay (LOS) (secondary outcomes). Sensitivity analyses on patient demographics and cardiac arrest parameters were performed. Results95 adult patients were included in this study, out of whom 34 pairs of patients were PS-matched. ECMELLA treatment was associated with decreased 30-day mortality risk (Hazard Ratio [HR] 0.53 [95% Confidence Interval (CI) 0.31–0.91], P = 0.021), prolonged hospital (Incidence Rate Ratio (IRR) 1.71 [95% CI 1.50–1.95], P < 0.001) and ICU LOS (IRR 1.81 [95% CI 1.57–2.08], P < 0.001). LV ejection fraction significantly improved until ICU discharge in the ECMELLA group. Especially patients with prolonged low-flow time and high initial lactate benefited from additional LV unloading. ConclusionsLV unloading with Impella® concomitant to VA-ECMO therapy in patients with therapy-refractory cardiac arrest due to AMI was associated with improved patient outcomes.

Treatment with Impella and veno-arterial extracorporeal membrane oxygenation during cardiac arrest on survival in a multicenter cohort

Abstract Background International organisations advocate the use of extracorporeal cardio-pulmonary resuscitation (ECPR) with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in selected patients with therapy-refractory cardiac arrest [1–3]. Although VA-ECMO allows for full circulatory support, it is inherent to increased left ventricular (LV) pressure due to retrograde aortic perfusion, which may hamper myocardial recovery and aggravate pulmonary oedema. In order to mitigate these negative sequelae, adjunct LV unloading with an Impella microaxial flow pump may be considered. The effects of concomitant treatment with VA-ECMO and Impella (ECMELLA) in patients with therapy-refractory cardiac arrest due to acute myocardial infarction (AMI) remains unclear. Objectives To the best of our knowledge this is the first study to investigate whether treatment with ECMELLA is associated with improved 30-day mortality rate in patients with therapy-refractory cardiac arrest caused by AMI, compared to treatment with VA-ECMO alone. Methods Patients treated with ECMELLA were propensity score (PS)-matched to patients receiving VA-ECMO based on age, electrocardiogram (ECG) rhythm, cardiac arrest location (out-of-hospital or in-hospital) and Survival After Veno-Arterial ECMO (SAVE) score. Cox proportional-hazard and Poisson regression models were used to analyse 30-day mortality rate (primary outcome), hospital and intensive care unit (ICU) length of stay (LOS) (secondary outcomes). Multiple sensitivity analyses on patient demographics and cardiac arrest parameters were performed. Results 95 adult patients from three tertiary care centers were included, out of whom 34 pairs were PS-matched. ECMELLA treatment was associated with 47% decreased 30-day mortality risk [95% Confidence Interval (CI) 0.31–0.91, P=0.021], 71% prolonged hospital [95% CI 1.50–1.95, P&amp;lt;0.001] and 81% prolonged ICU LOS [95% CI 1.57–2.08, P&amp;lt;0.001]. Kaplan-Meier analyses (Figure 1) and multiple sub-group analyses (age, sex, initial ECG rhythm, Charlson comorbidity index, body mass index, SAVE score, cardiac arrest location, lactate and pH levels) confirmed survival benefits in the ECMELLA group. Especially patients with prolonged low-flow time and high initial lactate benefited from ECMELLA therapy. Moreover, LV ejection fraction strongly improved in the ECMELLA group between ICU admission and ICU discharge from 15% to 40%, compared 15% and 20% in the VA-ECMO group. Conclusion In this multicenter propensity score-matched cohort of patients with ECPR during therapy-refractory cardiac arrest caused by AMI, treatment with ECMELLA was associated with improved survival compared to treatment with VA-ECMO alone. These findings support current guideline recommendations on early evaluation of ECPR in well selected patients with therapy-refractory cardiac arrest. A clinical trial is urgently needed to further evaluate the role of LV unloading in patients with therapy-refractory cardiac arrest. Funding Acknowledgement Type of funding sources: None.

Venoarterial Extracorporeal Membrane Oxygenation in Severe Drug Intoxication: A Retrospective Comparison of Survivors and Nonsurvivors.

Selecting patients most likely to benefit from venoarterial extracorporeal membrane oxygenation (V-A ECMO) to treat refractory drug-induced cardiovascular shock remains a difficult challenge for physicians. This study reported short-term survival outcomes and factors associated with mortality in V-A ECMO-treated patients for poisoning. Twenty-two patients placed on V-A ECMO after drug intoxication from January 2014 to December 2020 were retrospectively analyzed. The primary endpoint of this study was survival at hospital discharge. Univariate descriptive analysis was performed to compare survivors and nonsurvivors during hospitalization. The overall survival at hospital discharge was 45.4% (n = 10/22). Survival rate tended to be higher in patients treated for refractory shock (n = 7/10) compared with those treated for refractory cardiac arrest (n = 3/12, p = 0.08). Low-flow duration and time from admission to ECMO cannulation were shorter in survivors ( p = 0.02 and p = 0.03, respectively). Baseline characteristics before ECMO, including the class of drugs involved in the poisoning, between survivors and nonsurvivors were not statistically different except pH, bicarbonate, serum lactate, Sequential Organ Failure Assessment, and Survival After Veno-arterial-ECMO (SAVE) score. All patients with SAVE-score risk classes II/III survived whereas 85.7% (n = 12/14) of those with SAVE-score risk classes IV/V died. A lactic acid >9 mmol/L predicts mortality with a sensitivity/specificity ratio of 83.3%/100%. V-A ECMO for severe drug intoxication should be reserved for highly selected poisoned patients who do not respond to conventional therapies. Shortening the timing of V-A ECMO initiation should be a key priority in improving outcomes. Low-flow time >60min, lactic acid >9mmol/L, and SAVE-score may be good indicators of a worse prognosis.

Early Blood Pressure Variables Associated With Improved Outcomes in VA-ECLS: The ELSO Registry Analysis

BackgroundAs utilization of veno-arterial extracorporeal life support (VA-ECLS) in treatment of cardiogenic shock (CS) continues to expand, clinical variables that guide clinicians in early recognition of myocardial recovery and therefore, improved survival, after VA-ECLS are critical. There remains a paucity of literature on early postinitiation blood pressure measurements that predict improved outcomes. ObjectivesThe objective of this study is to help identify early blood pressure variables associated with improved outcomes in VA-ECLS. MethodsThe authors queried the ELSO (Extracorporeal Life Support Organization) registry for cardiogenic shock patients treated with VA-ECLS or venovenous arterial ECLS between 2009 and 2020. Their inclusion criteria included treatment with VA-ECLS or venovenous arterial ECLS; absence of pre-existing durable right, left, or biventricular assist devices; no pre-ECLS cardiac arrest; and no surgical or percutaneously placed left ventricular venting devices during their ECLS runs. Their primary outcome of interest was the survival to discharge during index hospitalization. ResultsA total of 2,400 CS patients met the authors’ inclusion criteria and had complete documentation of blood pressures. Actual mortality during index hospitalization in their cohort was 49.5% and survivors were younger and more likely to be Caucasian, intubated for >30 hours pre-ECLS initiation, and had a favorable baseline SAVE (Survival After Veno-arterial ECMO) score (P < 0.05 for all). Multivariable regression analyses adjusting for SAVE score, age, ECLS flow at 4 hours, and race showed that every 10-mm Hg increase in baseline systolic blood pressure (HR: 0.92 [95% CI: 0.89-0.95]; P < 0.001), and baseline pulse pressure (HR: 0.88 [95% CI: 0.84-0.91]; P < 0.001) at 24 hours was associated with a statistically significant reduction in mortality. ConclusionsEarly (within 24 hours) improvements in pulse pressure and systolic blood pressure from baseline are associated with improved survival to discharge among CS patients treated with VA-ECLS.

Research progress of survival predictive score in veno-arterial extracorporeal membrane oxygenation

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an extracorporeal circulation technique that provides circulatory and oxygenation support, and it is currently used in the treatment of cardiogenic shock (CS), pulmonary embolism, cardiac arrest (CA), and other diseases. However, this technology is still associated with high complications and mortality. The use of predictive scores for risk stratification before VA-ECMO will be helpful to screen the optimal benefiting population, make optimal clinical decisions, and allocate medical resources reasonably. At present, there are few reports about predictive scores for VA-ECMO. This article systematically reviewed the predictive performance of various scoring tools [the survival after venoarterial ECMO (SAVE) score, prediction of cardiogenic shock outcome for acute myocardial infarction (AMI) patients salvaged by VA-ECMO (ENCOURAGE) score, model for end-stage liver disease (MELD-XI) score, post-cardiotomy extracorporeal membrane oxygenation (PC-ECMO) score, the predicting mortality in patients undergoing VA-ECMO after coronary artery bypass grafting (REMEMBER) score, predictors of mortality with VA-ECMO for acute massive pulmonary embolism, extracorporeal cardiopulmonary resuscitation (ECPR) score, the hypothermia outcome prediction after extracorporeal life support (HOPE) score] for patients receiving VA-ECMO to provide reference for clinical treatment.

The value of clinical scores in predicting mortality of adult patients on veno-arterial extracorporeal membrane oxygenation

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used for refractory cardiogenic shock and is still associated with frequent morbidities and high mortality. Many risk scores have been used to stratify the patients for rapid decision making. The recent studies using the risk scores during VA-ECMO support were reviewed and the conflicting results were addressed. The Survival After VA-ECMO (SAVE), modified SAVE, Sequential Organ Failure Assessment (SOFA), Simplified Acute Physiology score II (SAPS II), REMEMBER, ENCOURAGE scores were used in retrospective studies without validation prospective studies. The risk scores used in evaluation of adult patients with VA-ECMO support for refractory cardiogenic shock help in clinical judgment but should not affect decision making for withdrawal of support.

PROGNOSTIC FACTORS OF VENO-ARTERIAL ECMO PATIENTS: A MULTIPLE LOGISTIC REGRESSION ANALYSIS

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: Several mortality prediction models exist for patients on Veno-arterial (VA) extracorporeal membrane oxygenation (ECMO), including the Survival after VA ECMO (SAVE) Score. Whether additional characteristics, such as body surface area (BSA), race, gender, Hispanic ethnicity, and dialysis history, affect mortality of VA ECMO patients are not as well understood. This study thus assessed such prognostic factors in these patients. METHODS: A retrospective single-institutional study collected all consecutive non-pediatric patients who received VA ECMO between 2016-2020. 410 patients were identified. We excluded 13 patients who were transitioned to or from VA ECMO. Univariate and multivariate analyses were performed. The risk factors affecting survival to hospital discharge were determined by multiple logistic regression analysis. RESULTS: 264 (64.4%) of VA ECMO patients did not survive until hospital discharge. Median age amongst VA ECMO patients was 59 years old, and median BSA was 2.10 m2. 339 (82.7%), 55 (13.4%), and 16 (3.90%) of patients were white, black, and of other race, respectively. 13 (3.17%) were of Hispanic ethnicity and 130 (31.7%) were female. 158 (38.5%) and 31 (7.56%) had undergone a cardiotomy or heart transplant, respectively. A multiple logistic regression model assessing survival to hospital discharge was created, incorporating 11 covariates and with a model Likelihood Ratio chi-square test of 61.8 (p < 0.001). Patient age less than 55 years old was significantly associated with improved odds of survival to hospital discharge (adjusted odds ratio, 3.07; 95% confidence interval, 1.88 to 5.04). Two covariates were significantly associated with decreased odds of survival to hospital discharge: history of dialysis (adjusted odds ratio, 0.31; 95% confidence interval 0.11 to 0.99); and, if patient had a cardiac arrest (adjusted odds ratio, 0.42; 95% confidence interval 0.23 to 0.78). CONCLUSIONS: Age < 55 years old was associated with improved prognosis, while history of dialysis and presence of cardiac arrest were associated with worse prognosis. Race, gender, BSA, and history of cardiotomy or heart transplant were not significantly associated with survival to hospital discharge in this cohort of VA ECMO patients. CLINICAL IMPLICATIONS: Additional factors affecting prognosis of VA ECMO patients were identified. These variables, such as history of dialysis, can be incorporated into an existing or new risk prediction model to better assess a patient’s clinical course. In addition, certain social disparities of health, such as race and gender, were not found to be associated with VA ECMO outcomes, although more research is needed. DISCLOSURES: No relevant relationships by Rohun Bhagat, source=Web Response No relevant relationships by Jay Hwang, source=Web Response No relevant relationships by Andrew Jones, source=Web Response No relevant relationships by Clauden Louis, source=Web Response No relevant relationships by Kevin McGann, source=Web Response

Secondary ARDS Following Acute Pancreatitis: Is Extracorporeal Membrane Oxygenation Feasible or Futile?

Objective: To assess the feasibility of extracorporeal membrane oxygenation (ECMO) or life support (ECLS) as last resort life support therapy in patients with acute pancreatitis and subsequent secondary acute respiratory distress syndrome (ARDS). Methods: Retrospective analysis from January 2013, to April 2020, of ECMO patients with pancreatitis-induced ARDS at a German University Hospital. Demographics, hospital and ICU length of stay, duration of ECMO therapy, days on mechanical ventilation, fluid balance, need for decompressive laparotomy, amount of blood products, prognostic scores (CCI (Charlson Comorbidity Index), SOFA (Sequential Organ Failure Assessment), RESP(Respiratory ECMO Survival Prediction), SAVE (Survival after Veno-Arterial ECMO)), and the total known length of survival were assessed. Results: A total of n = 495 patients underwent ECMO. Eight patients with acute pancreatitis received ECLS (seven veno-venous, one veno-arterial). Five (71%) required decompressive laparotomy as salvage therapy due to abdominal hypertension. Two patients with acute pancreatitis (25%) survived to hospital discharge. The overall median length of survival was 22 days. Survivors required less fluid in the first 72 h of ECMO support and showed lower values for all prognostic scores. Conclusion: ECLS can be performed as a rescue therapy in patients with pancreatitis and secondary ARDS, but nevertheless mortality remains still high. Thus, this last-resort therapy may be best suited for patients with fewer pre-existing comorbidities and no other organ failure.

Comparison of Mortality Risk Models in Patients with Postcardiac Arrest Cardiogenic Shock and Percutaneous Mechanical Circulatory Support.

Background Although scoring systems are widely used to predict outcomes in postcardiac arrest cardiogenic shock (CS) after out-of-hospital cardiac arrest (OHCA) complicating acute myocardial infarction (AMI), data concerning the accuracy of these scores to predict mortality of patients treated with Impella in this setting are lacking. Thus, we aimed to evaluate as well as to compare the prognostic accuracy of acute physiology and chronic health II (APACHE II), simplified acute physiology score II (SAPS II), sepsis-related organ failure assessment (SOFA), the intra-aortic balloon pump (IABP), CardShock, the prediction of cardiogenic shock outcome for AMI patients salvaged by VA-ECMO (ENCOURAGE), and the survival after venoarterial extracorporeal membrane oxygenation (SAVE) score in patients with OHCA refractory CS due to an AMI treated with Impella 2.5 or CP. Methods Retrospective study of 65 consecutive Impella 2.5 and 32 CP patients treated in our cardiac arrest center from September 2015 until June 2020. Results Overall survival to discharge was 44.3%. The expected mortality according to scores was SOFA 70%, SAPS II 90%, IABP shock 55%, CardShock 80%, APACHE II 85%, ENCOURAGE 50%, and SAVE score 70% in the 2.5 group; SOFA 70%, SAPS II 85%, IABP shock 55%, CardShock 80%, APACHE II 85%, ENCOURAGE 75%, and SAVE score 70% in the CP group. The ENCOURAGE score was the most effective predictive model of mortality outcome presenting a moderate area under the curve (AUC) of 0.79, followed by the CardShock, APACHE II, IABP, and SAPS score. These derived an AUC between 0.71 and 0.78. The SOFA and the SAVE scores failed to predict the outcome in this particular setting of refractory CS after OHCA due to an AMI. Conclusion The available intensive care and newly developed CS scores offered only a moderate prognostic accuracy for outcomes in OHCA patients with refractory CS due to an AMI treated with Impella. A new score is needed in order to guide the therapy in these patients.

Low volume ECMO results study

Objectives: To report extracorporeal membrane oxygenation (ECMO) experience at Princess Alexandra and Gold Coast University hospitals and compare mortality with benchmarks. Design: Case series of patients treated with ECMO. Setting: Two adult tertiary Australian intensive care units with low ECMO case volumes. Participants: Patients treated with ECMO, aged > 18 years. Main outcome measures: Patients were categorised into respiratory, cardiac, and extracorporeal cardiopulmonary resuscitation (eCPR) groups. Observed mortality was compared with mortality predicted using individual risk of death predictions from the Survival after Veno-arterial ECMO (SAVE) and Respiratory ECMO Survival Prediction (RESP) scores; mortality predicted when mortality predictions of the SAVE score were modified to be consistent with the validation cohort in the SAVE study (Alfred Hospital); and with mortality predicted when eCPR patients were all assigned a risk of death equal to Extracorporeal Life Support Organization (ELSO) Registry eCPR mortality. Results: Over 10 years, 86 patients were treated with ECMO. Eight deaths were observed in 49 patients with respiratory failure, below the 95% CI (13-24) for the deaths predicted by the RESP score (P < 0.001). Nine deaths were observed in 27 patients with cardiac failure, below the 95% CI (14-23) for the deaths predicted by the SAVE score (P < 0.001), but within the 95% CI (9-17) for the deaths predicted by the SAVE score modified to be consistent with the Alfred Hospital cohort (P > 0.05). Seven deaths were observed in the ten eCPR patients, within the 95% CI (4-10) predicted using the risk of death derived from the ELSO Registry. Conclusions: Mortality in two low volume ECMO centres was not inferior to benchmarks.

Abstract 13800: Using Different Scoring Systems to Differentiate In-hospital Mortality in Patients With Extracorporeal Membrane Oxygenation

Introduction: The objective of this study was to evaluate the performance of different scoring systems in discriminating in-hospital mortality among patients receiving extracorporeal membrane oxygenation (ECMO). Methods: This observation registry involved adult patients who received ECMO from 2006 to 2016 in a medical center in Taiwan. Clinical variables collected when ECMO was instituted were used to generate the following scores: Charlson Comorbidity Index (CCI), Acute Physiology and Chronic Health Evaluation (APACHE), sequential organ failure assessment (SOFA) score, the logistic organ dysfunction score (LODS), the multiple organ dysfunction score (MODS), The Simplified Acute Physiology Score III (SAPS3), and the survival after venoarterial ECMO (SAVE) score. A logistic regression model incorporating statistically significant variables was applied to find the predicted probability of in-hospital death, which was then used as a new model-based estimator. Receiver-operating characteristic (ROC) curves were drawn and area under curves (AUC) was used as the marker for discriminatory power. Results: A total of 1342 patients (71.5% men) were included with mean age of 53.5 (15.7) years and in-hospital mortality rate 62.3%. Based on the valid observations, the AUCs were 0.590 (95% CI: 0.553~0.627, n = 929) for CCI, 0.672 (95% CI: 0.638~0.706, n = 998) for APACHE, 0.691 (95% CI: 0.655~0.727, n = 841) for SOFA, 0.696 (95% CI: 0.660~0.732, n = 820) for LODS, 0.657 (95% CI: 0.619~0.695, n = 974) for MODS, 0.660 (95% CI: 0.623~0.696, n = 840) for SAPS3, 0.649 (95% CI: 0.596~0.701, n = 429) for SAVE (all p &lt; 0.001), and 0.766 for the model-based estimator (95% CI: 0.740~0.791, n = 1342). When the cases were restricted to the 247 patients in whom all scores could be successfully calculated, the model-based estimator still resulted in the highest discriminatory power (AUC 0.747, 95% CI: 0.686~0.807), with other systems ranging from 0.590 (CCI) to 0.684 (SAPS3). Conclusions: The model-based algorithm incorporated mathematically optimized coefficients to produce a new estimator that outperformed different types of clinical risk scores, and could be used for future clinical prediction.

Predicting Survival After VA-ECMO for Refractory Cardiogenic Shock: Validating the SAVE Score

BackgroundVeno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used increasingly to support patients who are in cardiogenic shock. Due to the risk of complications, prediction models may aid in identifying patients who would benefit most from VA-ECMO. One such model is the Survival After Veno-Arterial Extracorporeal Membrane Oxygenation (SAVE) score. Therefore, we wanted to validate the utility of the SAVE score in a contemporary cohort of adult patients. MethodsRetrospective data were extracted from electronic health records of 120 patients with cardiogenic shock supported with VA-ECMO between 2011 and 2018. The SAVE score was calculated for each patient to predict survival to hospital discharge. We assessed the SAVE score calibration by comparing predicted vs observed survival at discharge. We assessed discrimination with the area under the receiver operating curve using logistic regression. ResultsA total of 45% of patients survived to hospital discharge. Survivors had a significantly higher mean SAVE score (–9.3 ± 4.1 in survivors vs –13.1 ± 4.4, respectively; P = 0.001). SAVE score discrimination was adequate (c = 0.77; 95% confidence interval 0.69-0.86; P < 0.001). SAVE score calibration was limited, as observed survival rates for risk classes II-V were higher in our cohort (II: 67% vs 58%; III: 78% vs 42%; IV: 61% vs 30%; and V: 29% vs 18%). ConclusionsThe SAVE score underestimates survival in a contemporary North American cohort of adult patients with cardiogenic shock. Its inaccurate performance could lead to denying ECMO support to patients deemed to be too high risk. Further studies are needed to validate additional predictive models for patients requiring VA-ECMO.

Application and Comparison of Different Prognostic Scoring Systems in Patients Who Underwent Cardiologist-Managed Percutaneous Cardiopulmonary Support.

Temporary mechanical support, including percutaneous cardiopulmonary support (PCPS), is crucial for reversing patients' compromised hemodynamic function. Knowledge about whether cardiologists can directly manage patients receiving PCPS and about the predictive values of different prognostic scores is insufficient. We examined the data and in-hospital mortality of 45 eligible patients receiving cardiologist-managed PCPS from July 2012 to January 2019 in our institute. We compared different prognostic scores [namely Survival After Veno-arterial ECMO (SAVE), modified SAVE, prEdictioN of Cardiogenic shock OUtcome foR acute myocardial infarction patients salvaGed by VA-ECMO (ENCOURAGE), and Sequential Organ Failure Assessment (SOFA) scores] through area under the receiver operating characteristic curve (AUC) analysis. The patients' mean age was 64.3 ± 11.3 years, and 71.1% were men. The overall in-hospital survival rate was 35.6%. Compared to survivors, nonsurvivors were more likely to have an ischemic etiology, cardiopulmonary resuscitation, and higher lactate levels. Survivors had higher SAVE (-5.9 vs. -11.4) and modified SAVE (4.2 vs. -7.1) scores than nonsurvivors (both p = 0.001), but SOFA (9.7 vs. 10.3) and ENCOURAGE (24.8 vs. 26.8) scores were similar (both p > 0.1). In multivariate models, only modified SAVE score remained statistically significant (hazard ratio: 0.96, 95% confidence interval: 0.93-1.00; p = 0.047). Modified SAVE score showed the best risk discrimination (AUC = 0.78). Establishing regular and continual training protocols can enable cardiologists to perform emergency PCPS (without on-site surgery) and daily care for patients with refractory cardiogenic shock. The modified SAVE score facilitates risk stratification and future decision-making processes.

Predicting Survival After Extracorporeal Membrane Oxygenation by Using Machine Learning

Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) undoubtedly saves many lives, but it is associated with a high degree of patient morbidity, mortality, and resource use. This study aimed to develop a machine learning algorithm to augment clinical decision making related to VA-ECMO. Patients supported by VA-ECMO at a single institution from May 2011 to October 2018 were retrospectively reviewed. Laboratory values from only the initial 48 hours of VA-ECMO support were used. Data were split into 70% for training, 15% for validation, and 15% withheld for testing. Feature importance was estimated, and dimensionality reduction techniques were used. A deep neural network was trained to predict survival to discharge, and the final model was assessed using the independent testing cohort. Model performance was compared with that of the SAVE (Survival After Veno-arterial ECMO) score by using a receiver operator characteristic curve. Of the 282 eligible adult patients who were undergoing VA-ECMO, 117 (41%) survived to discharge. A total of 1.96 million laboratory values were extracted from the electronic medical record, from which 270 different summary variables were derived for each patient. The most important variables in predicting the primary outcome included lactate, age, total bilirubin, and creatinine. For the testing cohort, the final model achieved 82% overall accuracy and a greater area under the curve than the SAVE score (0.92 vs 0.65; P= .01) in predicting survival to discharge. This proof of concept study demonstrates the potential for machine learning models to augment clinical decision making for patients undergoing VA-ECMO. Further development with multi-institutional data is warranted.

Predicting Survival with Mobile ECMO: A Single-Center Evaluation

Extracorporeal membrane oxygenation (ECMO) treats acute reversible severe heart/lung failure in adults at high mortality risk. While often initiated in-hospital, ECMO's portability allows for experienced centers to implant it off site. We examined the impact mobile ECMO on survival in patients with severe cardiopulmonary failure. This is a retrospective review of patients with in-hospital or mobile ECMO from January 2013 to October 2019. Participants were included if they were ≥ 18 years old and received ECMO performed at Hartford Hospital or through the mobile, "ECMO on the Go" unit. The Survival After Veno-Arterial ECMO (SAVE) and Respiratory ECMO Survival Prediction (RESP) scores were calculated. The primary endpoints were 48-hour and hospital discharge survival. We included 201 patients with a median (25th, 75th percentile) age 54.0 (39.5, 64.0) years and median ECMO time of 5.0 (3.0, 8.0) days. VA (median SAVE score -6.5 [-9.0, -3.0]) and VV ECMO (median RESP score 2.0 [-1.0, 5.0]) were initiated in 51.7% and 48.3% of patients, respectively. Mobile ECMO was initiated in 61 (30.3%) patients. 48-hour survival was higher in the mobile (65.6%) vs hospital ECMO patients (55.7%, p=0.192). Survival to hospital discharge was also higher with mobile (59.0%) vs hospital ECMO patients (41.4%, p=0.097). Baseline SAVE and RESP scores were higher in patients surviving to 48-hr and hospital discharge (p<0.006 for all)(Figure). We showed that mobile ECMO is effective for treatment of severe cardiopulmonary failure refractory to standard modalities. Mobile ECMO trended towards improved survival compared with in-hospital initiation. SAVE and RESP scores may be predictive of survival using mobile ECMO applications.

Optimizing Save Score for Intraoperative Complications

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is an effective support therapy for refractory cardiogenic shock and can be used as a bridge to more definitive therapy. However, VA ECMO has high rates of complications and requires considerable financial and human resources. Selecting patients most likely to benefit from ECMO is controversial. The Survival After Veno-arterial ECMO (SAVE) Score is a tool developed by Schmidt et al. to predict survival for patients receiving ECMO therapy for cardiogenic shock. We conducted a single-center, retrospective study to validate the relationship between SAVE scores and survival rates, and to identify additional factors that can predict prognosis. We retrospectively reviewed all cardiogenic shock patients who received VA-ECMO therapy at our institution between 2016 - 2019. We collected patient variables/outcomes, ECMO data, and calculated SAVE scores. We identified 66 cardiogenic shock patients treated with VA-ECMO and stratified them by SAVE score risk categories and measured survival to discharge with the following results: 33.33% (4/12) in category V (SAVE score ≤-10; 18% predicted survival); 29.63% (8/27) in category IV (SAVE score -9 to -5; 30% predicted survival); 36.84% (7/19) in category III (SAVE score -4 to 0; 42% predicted survival); 57.14% (4/7) in category II (SAVE score 1 to 5; 58% predicted survival); 0% (0/1) in category I (SAVE score >5; 75% predicted survival). Overall survival was 34.85% (23/66). When patients with an intraoperative complication causing hemodynamic compromise as the etiology of their cardiogenic shock were isolated (18 total) and a -2 SAVE score modifier applied, the following changes to overall survival patterns were seen: 28.57% (4/14) in category V patients, and 41.18% (7/17) in category III patients. Overall, the survival rates predicted by SAVE score risk categories matched well when applied to the patient population at our institution. Of note, risk category I was not considered in analysis due to limited sample size (n = 1). Applying a negative score modifier to intraoperative complication patients brought measured survival rates closer to predicted, suggesting this etiology of cardiogenic shock portends worse survival than reflected in original SAVE score. Further study to identify patterns of complications and survival may aid in more accurate risk stratification.