Treatment Of Refractory Cardiogenic Shock Research Articles

Usefulness of bicarbonate-based Impella purge solution in a patient with heparin-induced thrombocytopenia: the first case report of long-term management in Japan.

Percutaneous mechanical circulatory support utilizing micro-axial flow pumps, such as the Impella group of devices, has become a life-saving technique in the treatment of refractory cardiogenic shock, with ever-increasing success rates. A 30-year-old man presented with acute decompensated heart failure and a severely reduced left ventricular ejection fraction (17%). Despite initial treatment with inotropic drugs and intra-aortic balloon pump support, his hemodynamic status remained unstable. Transition to Impella CP mechanical circulatory support was made on day 6 owing to persistently low systolic blood pressure. A significant decline in platelet count prompted suspicion of heparin-induced thrombocytopenia (HIT), later confirmed by positive platelet-activated anti-platelet factor 4/heparin antibody and a 4Ts score of 6 points. Argatroban was initially used as the purge solution, but owing to complications, a switch to Impella 5.0 and a bicarbonate-based purge solution (BBPS) was performed. Despite additional veno-arterial extracorporeal membrane oxygenation support on day 24, the patient, aiming for ventricular assist device treatment and heart transplantation, died from infection and multiple organ failure. Remarkably, the Impella CP continued functioning normally until the patient's demise, indicating stable Impella pump performance using BBPS. This case highlights the usefulness of BBPS as an alternative to conventional Impella heparin purge solution when HIT occurs.

Ventricular fibrillation/ventricular tachycardia within 72h of VA-ECMO: incidence, outcomes, risk factors, and management.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an important technique for the treatment of refractory cardiogenic shock and cardiac arrest; however, the early management of ventricular fibrillation/ventricular tachycardia (VF/VT), within 72h of VA-ECMO, and its effects on patient prognosis remain unclear. We retrospectively analysed patients at the First Affiliated Hospital of Nanjing Medical University who underwent VA-ECMO between January 2017 and March 2022. The patients were divided into two groups, VF/VT and nVF/VT, based on whether or not VF/VT occurred within 72h after the initiation of VA-ECMO. We utilized logistic regression analysis to evaluate the independent risk factors for VF/VT in patients undergoing VA-ECMO and to ascertain whether the onset of VF/VT affected 28day survival rate, length of intensive care unit stay, and/or other clinical prognostic factors. Subgroup analysis was performed for the VF/VT group to determine whether defibrillation affected prognosis. In the present study, 126 patients were included, 65.87% of whom were males (83/126), with a mean age of 46.89±16.23, a 28day survival rate of 57.14% (72/126), an incidence rate of VF/VT within 72h of VA-ECMO initiation of 27.78% (35/126), and 80% of whom (28/35) received extracorporeal cardiopulmonary resuscitation. The incidence of VF/VT resulting from cardiac arrest at an early stage was significantly higher than that of refractory cardiogenic shock (80% vs. 20%; P=0.022). The restricted cubic spline model revealed a U-shaped relationship between VF/VT incidence and initial heart rate (iHR), and multivariate logistic regression analysis showed that an iHR>120b.p.m. [odds ratio (OR) 6.117; 95% confidence interval (CI) 1.672-22.376; P=0.006] and hyperlactataemia (OR 1.125; 95% CI 1.016-1.246; P=0.023) within 1h of VA-ECMO initiation were independent risk factors for the occurrence of VF/VT. VF/VT was not found to be associated with the 28day survival of patients undergoing VA-ECMO support, nor did it affect other secondary endpoints. Defibrillation did not alter the overall prognosis in patients with VF/VT during VA-ECMO. An iHR>120b.p.m. and hyperlactataemia were independent risk factors for the occurrence of VF/VT within 72h of VA-ECMO initiation. The occurrence of VF/VT does not affect, nor does defibrillation in these patients improve the overall patient prognosis. ChiCTR1900026105.

Long-term prognosis of patients with refractory cardiogenic shock and cardiac arrest treated with venoarterial ECMO in a hospital without on-site cardiac surgery

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Regional hospital Liberec Introduction Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a mechanical circulatory support increasingly used in the treatment of refractory cardiogenic shock or circulatory arrest. The technique of percutaneous implantation currently allows the use of VA-ECMO even in hospitals without on-site cardiac surgery. Method Analysis of data from a single center prospective registry of patients with refractory cardiogenic shock and cardiac arrest treated with VA-ECMO from May 2015 to September 2022. Results In total 42 patients were implanted. Most of the patients (76%) were men, 63.0 +/- 12.5 years old. 64% of patients fulfilled criteria of stage E of SCAI classification, and 36% were SCAI D. 33% of patients were resuscitated prior to implantation. 31% of patients were implanted during continuous CPR. The most common cause of shock was acute coronary syndrome (64%). In all cases, ECMO was implanted in the catheterization laboratory without any major complications. The most frequent complication during treatment was non-fatal bleeding in 60% of patients. Ischemic and thrombotic complications occurred in 19% of patients. One patient had a fatal complication related to vascular access. Weaning from ECMO was achieved in 55% of all patients. 9 patients were transported to another hospital on ECMO without complications. 38% of patients had simultaneously intra-aortic balloon pump. Two patients were bridged to LVAD. 30-day and 1-year mortality for SCAI D cardiogenic shock was 40% and 60%, respectively. For SCAI E 78% and 83%, respectively. 65% of successfully weaned patients died within 1 year - median 22 days (15 - 52 days). Patients who survive 1 year have a good long-term prognosis - median follow-up 1.2 years (0.8 - 5.4 years). Conclusion Treatment of refractory cardiogenic shock or cardiac arrest with VA-ECMO can be safely initiated, managed and terminated in a hospital without on-site cardiac surgery. The long-term prognosis of most of these patients is serious despite treatment. Patients who survive 1 year have a good long-term prognosis.

Cardiogenic shock - novelty and emerging therapeutic concepts

The cardiogenic shock is a state of low cardiac output, primarily due to cardiac dysfunction, which leads to severe organ hypoperfusion with tissue hypoxia and increased lactate levels. It presents a severe complication with a prevalence of around 15% of all forms of shock and 2-5% of the cardiogenic shock is a complications of acute heart failure. Despite the diverse etiology of the cardiogenic shock, up to 80% of the cases are due to acute myocardial infarction. The ischemia, leads to dysfunction of the myocardium cells, which causes a decline in the blood pressure and subsequent tissue hypoperfusion. The most important part is to start the treatment regime as soon as possible in the pre-shock stage. The treatment of refractory cardiogenic shock is complex, as it contains an intravenous therapy with inotropes/vasopressors and mechanical circulatory support (MCS). The MCS devices are supposed to reduce the workload of the heart and the oxygen need of the myocardial cells and in the same time to maintain an adequate coronary and systemic perfusion. There are different MCS devices like IABP, Impella, Tandem Heart, V-A ECMO. The aim of this review article is to present the new trends in the treatment approach to cardiogenic shock and to bring clarity in the treatment regimes, based on the latest studies and guidelines.

Predictors of weaning failure in case of VA ECMO implantation

The use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for the treatment of refractory cardiogenic shock has increased significantly. Nevertheless, early weaning may be advisable to reduce the potential for severe complications. Only a few studies focusing on ECMO weaning predictors are currently available. Our objective was to evaluate factors that may help predict failure during VA ECMO weaning. We included 57 patients on VA ECMO support previously considered suitable for weaning based on specific criteria. Clinical, haemato-chemical and echocardiographic assessment was considered before and after a “weaning test” (ECMO flow < 2 L/min for at least 60 min). ECMO removal was left to the discretion of the medical team blinded to the results. Weaning failure was defined as a patient who died or required a new VA ECMO, heart transplant or LVAD 30 days after ECMO removal. Thirty-six patients (63.2%) were successfully weaned off VA ECMO, of whom 31 (54.4%) after the first weaning test. In case of first test failure, 3 out of 7 patients could be weaned after a 2nd test and 3 out of 4 patients after a 3rd test. Pre-existing ischemic heart disease (OR 9.6 [1.1–83]), pre-test left ventricular ejection fraction (LVEF) ≤ 25% and/or post-test LVEF ≤ 40% (OR 11 [0.98–115]), post-test systolic blood pressure ≤ 120 mmHg (OR 33 [3–385]), or length of ECMO support > 7 days (OR 24 [2–269]) were predictors of weaning failure. The VA ECMO weaning test failed in less than 40% of patients considered suitable for weaning. Clinical and echocardiographic criteria, which are easily accessible by a non-expert intensivist, may help increase the probability of successful weaning.

The role of temporary mechanical circulatory support as a bridge to advanced heart failure therapies or recovery.

Temporary mechanical circulatory support (tMCS) has become central in the treatment of refractory cardiogenic shock and can be used to bridge patients to durable MCS, heart transplant or recovery. This review will discuss contemporary data regarding bridging strategies utilizing tMCS. There has been significant growth in tMCS use recently, driven by increased familiarity with tMCS devices, and increased experience with both implantation and management. Identifying goals of therapy at the time of therapy initiation can facilitate better outcomes. The three primary goals are bridge to recovery, bridge to heart transplantation or bridge to durable left ventricular assist device. Bridging to recovery requires adequate treatment of underlying conditions and optimization of haemodynamics. Bridging to heart transplantation has become more frequent following changes to the heart allocation policy. Despite early concerns, patients bridge with tMCS, including ventricular-arterial extracorporeal membrane oxygenation, do not appear to have worse posttransplant outcomes. When bridging to durable mechanical circulatory support, tMCS can be used to enhance end-organ dysfunction and improve perioperative outcomes. In situations in which none of these goals are attainable, palliative care plays a critical role to identify patient wishes and assist with withdrawal of care when necessary. The use of tMCS, as a bridge to recovery or heart replacement therapy in patients with refractory cardiogenic shock has grown significantly over the past decade. Multiple device choices are available and must be chosen appropriately to address the specific situation and the goals of therapy.

Influence of inflammation and cardiac hypertrophy on mechanical properties of human pericardium

Different devices for mechanical circulatory support (MCS) have been developed for the treatment of refractory cardiogenic shock. However, all of them are associated with direct blood contact, the need for anticoagulation and bleeding complications. To overcome these limitations the pericardial sac got into the focus as a promising implantation site for MCS. For this purpose, further knowledge about the mechanical properties of human pericardium is required. In this prospective, monocentric, experimental pilot study 56 samples of human pericardium were extracted postmortem from 13 critically ill patients. After preparation of test specimens uniaxial tensile tests were performed. The primary end points were load at fracture per sample width and strain at fracture. Acute inflammation was assessed by blood levels of C-reactive protein, white blood count and procalcitonin measured at several times during hospital stay. Inflammatory load was estimated by area under the inflammatory curves. Correlation and regression analysis were used to assess the relationship of primary end points to inflammation, comorbidities and postmortem time to preparation. Human pericardium showed a load at fracture per sample width of 1.95 [1.38-2.94] N/mm (median [inter quartile range]) and a strain at fracture of 89.29 [73.84-135.23] %. Markers of acute inflammation and cardiac hypertrophy did not correlate to load or strain at fracture. However, strain at fracture increased with higher body mass index and an increasing number of postmortem days. In contrast, higher patient age was associated with a lower strain at fracture. Inflammation and cardiac hypertrophy did not influence mechanical properties of human pericardium.

Impact of temporary mechanical circulatory support on mortality in cardiogenic shock: an emulated target trial with a prospective, multicenter, French cohort study

Abstract Background The field of temporary mechanical circulatory support (TMCS) has advanced in last decade justifying that TMCS is increasingly used for treatment of refractory cardiogenic shock (CS). Nevertheless, the efficacy of TMCS (extracorporeal life support (ECLS) and Impella) in CS remains controversial due to the lack of high-quality evidence. The aim of this prospective multicenter observational study simulating a randomized trial was to assess the impact of TMCS on the hospital mortality in patients with CS. Methods This study (ClinicalTrials.gov ID: NCT03528291) was conducted at 3 TMCS centers organized in a cardiac assistance network, one as a level 1 TMCS center (expert center), and 2 as level 2 centers (hub centers). The study was designed and led by the heart team of the expert center with input from the hub centers. All patients admitted to an intensive care unit between July 2017 and May 2020 either directly at the TMCS centers or after transfer from a non-specialized hospital, were screened for TMCS indication provided they were admitted for CS. CS was defined according to the European Society of Cardiology criteria. Were excluded patients younger than 18 years, CS after cardiac surgery, or after cardiac arrest if it was refractory or with a no flow &amp;gt;3 min and/or out-of-hospital cardiac arrest with non-shockable rhythm, or CS in the context of myocardial infarction complications, massive pulmonary embolism, and if TMCS was contraindicated TMCS indication was decided after a multidisciplinary discussion carried out by the “heart team”. Implantation of TMCS resulted from an agreement of the heart team within the first 24 hours after admission mainly based on the initial severity of the CS, or if CS was refractory to the medical treatment. The primary outcome was in-hospital survival. A propensity score-weighted analysis was done for treatment-effect estimation. This method, which weights each patient according to their propensity score, includes all participants in the analysis. Results 246 patients with CS were included in the study: 121 in TMCS group (72% ECLS, 14% Impella, 14% both ECLS and Impella) and 125 in control group. After adjustment by a propensity score, hospital mortality was comparable in the two groups (32% TMCS group vs 27% control group; Odds ratio with TMCS, 1.28; 95% confidence interval, 0.87 to 1.88; p=0.21). Mortality at D180 was also similar in the two group (33% vs 30% respectively; p=0.51). Thromboembolic events were significantly higher in the TCMS group (14% vs 4%; p&amp;lt;0.01) as well as the transfusion rate ((median (IQR); 4.0 (0.0; 9.0) vs 0.0 (0.0; 0.0); p&amp;lt;0.01). Conclusion In our study, the use of TMCS does not seem to improve hospital survival in patients with cardiogenic shock. Thus, TMCS, which are iatrogenic side effects providers, should be reserved for the most severe patient and discussed by a multidisciplinary team. Funding Acknowledgement Type of funding sources: None. Flow chart

Consequences of adding standardized levosimendan infusion in VA-ECMO weaning protocol

Abstract Introduction Employment of VA-ECMO in the treatment of refractory cardiogenic shock is increasing. Weaning rates are highly variable between studies. Methods We designed a retrospective observational single-centre study in order to analyse procedural success rate after including scheduled and standardized levosimendan infusion as part of our weaning protocol. Procedural success rate includes weaning from VA-ECMO, bridging to other mechanical circulatory support (MCS) or transplantation. Results A total of 37 VA-ECMO were managed in our Cardiac Intensive Care Unit (CICU) between January 2019 and March 2021. Most frequent aetiologies are reflected in table 1. Ventricular unloading was accomplished in 62.2% (23). We included four phases in our weaning protocol as described in figure 1. Second phase was used to select patients who could benefit from levosimendan infusion. This group included patients who accomplished the following criteria: appropriate aetiological treatment of shock, tolerance for 50% VA-ECMO flow reduction, noradrenaline dose &amp;lt;0,5 ug/kg/min, inotropic score &amp;lt;10 and correction of blood lactate, kidney and liver function parameters. Levosimendan was administered in 62.2% (23). 5 patients (13.5%) were not considered candidates to benefit from levosimendan (2 of them had early systolic function recovery and 3 patients seemed to have no chance to recover). Average time from VA-ECMO implantation to levosimendan infusion was 3.6 days, with a medium dose of 0,1 ug/kg/min. Norepinephrine medium dose was 0,12 mg/kg/min, with a medium inotropic score of 3 and vasoactive-inotropic score of 16,1. Levosimendan infusion did not cause any major side effects and was well tolerated by entire cohort even though norepinephrine dose had to be slightly increased in some cases. Whole sample procedural success rate reached 64.9% (24) whereas weaning rate from VA-ECMO without further support was 51.4% (19). 5 patients were upgraded to another MCS and 4 of them survived after transplantation. The subgroup which meets inclusion criteria to levosimendan reached a procedural success rate of 82.6% (19) and a weaning rate of 73.9% (19). Differences between patients with and without levosimendan treatment were statistically significant (procedural success rate: 82.6% vs 35.7%, p 0.006, weaning rate: 73.9% vs 14.3%, p&amp;lt;0.001). Meanwhile there were no significant differences regarding in-hospital mortality rate: 47.8% (11) vs 71.4% (10), p 0.160, even though there was a downward trend in levosimendan treated patients. Most frequent causes of death are shown in table 1. Only 3 patients died due to cardiac failure (1 was rejected for cardiac surgery and 2 were not candidates to other advanced therapies). Conclusions Standardized levosimendan infusion as part of VA-ECMO weaning protocol could enhance myocardial recovery and significantly increase procedural success rate. Randomized or propensity score matching studies would be desirable to prove this hypothesis. Funding Acknowledgement Type of funding sources: None. Table 1Weaning protocol

Quality of Life Following Urgent LVAD Implantation for ECMO Therapy in Cardiogenic Shock: A Long-Term Follow-Up.

Background and Objectives: Over the past decade, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has developed into a mainstream treatment for refractory cardiogenic shock (CS) to maximal conservative management. Successful weaning of VA-ECMO may not be possible, and bridging with further mechanical circulatory support (MCS), such as urgent implantation of a left ventricular assist device (LVAD), may represent the only means to sustain the patient haemodynamically. In the recovery phase, many survivors are not suitably prepared physically or psychologically for the novel issues encountered during daily life with an LVAD. Materials and Methods: A retrospective analysis of our institutional database between 2012 and 2019 was performed to identify patients treated with VA-ECMO for CS who underwent urgent LVAD implantation whilst on MCS. Post-cardiotomy cases were excluded. QoL was assessed prospectively during a routine follow-up visit using the EuroQol-5 dimensions-5 level (EQ-5D-5L) and the Patient Health Questionnaire (PHQ-9) surveys. Results: Among 126 in-hospital survivors of VA-ECMO therapy due to cardiogenic shock without prior cardiac surgery, 31 (24.6%) urgent LVAD recipients were identified. In 11 (36.7%) cases, cardiopulmonary resuscitation (CPR) was performed (median 10, range 1–60 min) before initiation of VA-ECMO, and in 5 (16.7%) cases, MCS was established under CPR. Mean age at LVAD implantation was 51.7 (+/−14) years and surgery was performed after a mean 12.1 (+/−8) days of VA-ECMO support. During follow-up of 46.9 (+/−25.5) months, there were 10 deaths after 20.4 (+/−12.1) months of LVAD support. Analysis of QoL questionnaires returned a mean EQ-5D-5L score of 66% (+/−21) of societal valuation for Germany and a mean PHQ-9 score of 5.7 (+/−5) corresponding to mild depression severity. When compared with 49 elective LVAD recipients without prior VA-ECMO therapy, there was no significant difference in QoL results. Conclusions: Patients requiring urgent LVAD implantation under VA-ECMO support due to CS are associated with comparable quality of life without a significant difference from elective LVAD recipients. Close follow-up is required to oversee patient rehabilitation after successful initial treatment.

Impact of Venoarterial Extracorporeal Membrane Oxygenation Flow on Outcomes in Cardiogenic Shock.

Venoarterial extracorporeal membrane oxygenation (VA ECMO) is used to provide cardiopulmonary support in cardiogenic shock; however, high extracorporeal flow may increase left ventricular (LV) afterload leading to LV distention and intracardiac stasis. It is unclear how ECMO flow affects patient outcomes and complications related to ECMO. Retrospective review of patients at a single institution placed on VA ECMO from 2007 to 2018 was performed. Patients were divided into full flow (flow index > 2.2 L/min/m2) and partial flow (flow index < 2.2 L/min/m2) groups. In-hospital mortality and markers of end-organ perfusion were compared between groups balanced for risk factors using propensity score inverse probability of treatment weighting. ECMO-related complications such as LV distention, limb ischemia, and bleeding were recorded. There were 488 patients included, 405 (83%) in the partial flow group, and 83 (17%) in the full flow group. No major differences in age, gender, or comorbidities were found. There was no difference in in-hospital mortality between groups (51% vs. 55%, p = 0.59). At 72 hours post-ECMO initiation, there was no difference in the change in renal, hepatic function, or lactate from baseline nor in the rates of continuous venoveno hemofiltration initiation (p = 0.41). There was a trend towards the decreased incidence of LV distention requiring LV vent placement in the partial flow group (12% vs. 7%, p = 0.16). Compared with full flow VA ECMO, partial flow VA ECMO in carefully selected patients results in similar in-hospital mortality and provides similar end-organ perfusion for the treatment of refractory cardiogenic shock.

Role of Scoring Systems Calculation in Predicting Extracorporeal Life Support Patients’ Outcomes: A Single Centre Experience

Purpose To investigate the predictive value of Acute Physiology, Age and Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology (SAPS) II and Sequential Organ Failure Assessment (SOFA) scores for patient selection and timing to Extracorporeal Life Support (ECLS) as treatment of refractory cardiogenic shock. Methods Retrospective analysis of a prospectively-maintained operative dataset. Results Our study population included 185 patients receiving ECLS at our department between 2006 and 2018. Patient median age was 50.6 years; 62% were male. The most frequent reason for ECLS need, in our subset of patients, was post-cardiotomy syndrome (52.4%) followed by acute decompensation of chronic heart failure (17.5%), isolated right ventricular dysfunction (16.2%), acute myocardial infarction (10.2%) and myocarditis (3.7%). Median duration of ECLS was 8.9 days. Forty-one patients (22.2%) received heart transplantation. In-hospital mortality was 34.6% on ECLS running and 25.9% after ECLS removal. Multivariate regression analysis showed patient age, ECLS duration and bridge to transplantation (BTT) category as indipendent predictors of death (p Conclusion This study confirms the poor prognosis of critically ill patients receiving ECLS support. The APACHE II and SOFA scores, mainly, proved to be a reproducible evaluation tool with high prognostic abilities. In our population, age >65 years, ECLS duration >10 days and BTT ECLS intention appear to impact negatively.

R14 Concomitant Use of Intra-Aortic Balloon Pump and Extra-Corporeal Membrane Oxygenation – A Benchtop Trial

VA-ECMO is the mainstay of treatment for refractory cardiogenic shock. However, it has been associated with increased LV loading. The Intra-Aortic Balloon Pump (IABP) has been utilised to assist in weaning of VA-ECMO patients, as some studies have shown an improvement in survival. Yet the evidence on its improvement in LV venting, afterload reduction, coronary and cerebral flow are conflicting, and the procedural risks may outweigh any potential benefit. Our aim was to determine the impact of the addition of an IABP to ECMO in various simulations of cardiac failure.

Incidence, Characteristics and Outcomes of Cardiac Tamponade in Patients on Extracorporeal Membrane Oxygenation for the Treatment of Refractory Cardiogenic Shock

Background Extracorporeal membrane oxygenation(ECMO) for the treatment of refractory cardiogenic shock has gained popularity over the last decade. Cardiac tamponade(CT), a life threatening condition, has been reported to occur in patients after the initiation of ECMO therapy. However, there is a scarcity of data pertaining to the incidence, characteristics and outcomes of pericardial tamponade in non-cardiac surgery patients undergoing ECMO for the treatment of refractory cardiogenic shock. Methodology This is a single center retrospective review of all patients developing CT post ECMO for refractory cardiogenic shock presenting between January 1999-January 2020. Patients were excluded if they were on ECMO post cardiac surgery, aged less than 18 years or had a moderate to large pericardial effusion prior to ECMO initiation. Results Out of 220 patients presenting with cardiogenic shock, 8(3.6%) patients developed CT after being treated with ECMO. Patients were mostly male (7,78%) and 66±12.8 years old. 7(77.5%) patients were on VA ECMO, 1(12.5%) patient on VAV ECMO, all of which were accessed peripherally . 5(62.5%) patients were on additional mechanical support devices: Impella(2,25%), IABP(2,25%) and tandem heart with impella(1,12.5%). 6(75%) patients were supratherapeutic whilst on systemic anticoagulation preceding CT. Initial ECMO pump flow rates were 4±0.68ml/min, mean sheath size of 22±3.1 F. 5(62.5%) patients developed CT 24 hours after ECMO initiation, 3(37.5%) patients before 24 hours. Average size of pericardial effusion was 2.1±0.1cm. None of the patients had any evidence of myocardial/great vessel perforation. 4(50%) patients were treated with pericardiocentesis, 2(25%) patients required pericardial window, and 2(25%) required both. Fluid analysis in 6(87.5%) patients revealed hemorrhagic pericardial fluid, 1(12.5%) with serosanguinous fluid and 1(12.5%) with serous fluid .6(75%) of patients died during hospitalization, but not directly from CT. Conclusion 3.6% of patients on ECMO for refractory cardiogenic shock develop CT, with most cases occurring after 24 hours of therapy initiation. Most patients who develop this are coagulopathic and are on additional mechanical support devices. CT can occur in patients without evidence of cardiac/great vessel perforation. CT should be considered in all patients on ECMO with unexplained reductions in flow rates, and this should immediately be addressed to optimize cardio-pulmonary support. Although treatable, CT in this subset of patients is reflective of an overall grave prognosis.

Evaluation of risk factors for adverse outcome in extracorporeal membrane oxygenation-supported elderly postcardiotomy patients.

Recently extracorporeal membrane oxygenation is becoming the commonly used mechanical assist device for the treatment of severe cardiogenic shock in postcardiotomy patients. Evaluation of risk factors of negative outcome would be beneficial in decision-making in the elderly patient population. This was a retrospective single-centre analysis of elderly patients who underwent extracorporeal membrane oxygenation treatment for refractory cardiogenic shock in a tertiary care centre. Demographic data, comorbidities and perioperative parameters were collected to evaluate their impact on the outcome of extracorporeal membrane oxygenation treatment in this patient group. Logistic regression analysis of the variables was performed to identify factors predicting an adverse outcome. Forty consecutive elderly patients underwent extracorporeal membrane oxygenation treatment during the study period. The mean age was 76.7 ± 3.8 years, 27 (68%) were male. The mean Survival after Veno-Arterial extracorporeal membrane oxygenation score before initiating extracorporeal membrane oxygenation support was - 11 ± 6. Intra-aortic counterpulsation was used as the first-line mechanical support in 31 (77%) patients. The mean duration of extracorporeal membrane oxygenation support was 172 ± 128 hours. Twenty-four patients (56%) were successfully weaned from extracorporeal membrane oxygenation, and 8 (20%) survived to hospital discharge. Lactate level before extracorporeal membrane oxygenation initiation was the only predictor of unfavourable outcome in multivariate analysis (p < 0.05). High lactate level before initiation of extracorporeal membrane oxygenation was the most important prognostic values of an unfavourable outcome.

TO CANNULATE OR NOT TO CANNULATE, A VA-ECMO SUCCESS STORY

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is an increasingly utilized treatment for refractory cardiogenic shock. Despite advances in ECMO technology, however, complication rates and mortality remain high. Risk scores have been developed in an attempt to improve outcomes. It remains

Upgrading of ECLS (ECMO versus STCF-VAD): Is It a Matter of Time?

Purpose ECMO for the treatment of refractory cardiogenic shock (RCS) has demonstrated dubious results after 9 days of support. Short-term continuous-flow ventricular assist devices (STCF-VADs) could represent a more physiological choice. We therefore evaluate the outcome of patients that needed prolonged support and underwent STCF-VAD implantation compared to conventional ECMO. Methods Between January 2009 and December 2017, 196 extracorporeal life support (ECLS) were implanted in our centre for primary RCS; we selected the 106 patients that exceed the 9 days of ECLS. 45 cases (42%) were treated exclusively with ECMO implantation (Group 1), while 61 cases (58%) underwent left ventricular or biventricular continuous-flow ventricular assist device STCF-VAD implantation (Group 2). Among these last patients, in 44 cases the STCF-VAD was intended as upgrade of ECMO support. Results The duration of ECLS was 17±9 days in the Group 1 and 14±9 days in the Group 2 (p=0.07), while the mean rates of the maximal theoretic flow were 62±15% and 81±21% (p Conclusion In the purview of prolonged ECLS and full hemodynamic support, STCF-VAD has proved to enhance the early survival respect single-stage ECMO in patients with primary RCS.

Left ventricular decompression in veno-arterial extracorporeal membrane oxygenation.

Despite the survival benefit of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for treatment of refractory cardiogenic shock, it can also have potentially deleterious effects of left ventricular overload and pulmonary edema. The objective of this review was to investigate the current evidence on the incidence, diagnosis, risk factors, prevention, and interventions for left ventricular overload in adult and pediatric VA-ECMO patients. Five electronic databases, including MEDLINE, EMBASE, PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews, were searched for original published studies from their dates of inception to January 2018. All types of adult and pediatric studies that investigated LV overload in VA-ECMO and were published in the English language were reviewed. Exclusion criteria included abstracts and conference presentations. The reported incidence and sequelae of LV overload in VA-ECMO are highly variable, with presentations ranging from pulmonary arterial diastolic pressures of greater than 25 mmHg and LV distention on echocardiography, to severe pulmonary edema, LV thrombosis, and refractory ventricular arrhythmias. Currently, there are no standardized diagnostic criteria or guidelines for the type and timing of intervention for LV overload. Techniques for LV decompression have included direct surgical LV venting with catheter insertion via sternotomy or a minimally invasive incision; percutaneous catheterization via a transaortic, transseptal, or transpulmonary approach; ventricular assist devices; and intra-aortic balloon pumps. Left ventricular volume distention is a significant problem in VA-ECMO patients, with sequelae including myocardial ischemia, severe pulmonary edema, and intracardiac thrombosis. Further research is required on its incidence, diagnostic criteria, and risk factors, as well as the optimal timing and method for LV decompression, given the diversity of surgical and percutaneous techniques that are available.

Long-term survival and major outcomes in post-cardiotomy extracorporeal membrane oxygenation for adult patients in cardiogenic shock

Extracorporeal membrane oxygenation (ECMO) in the veno-arterial (VA) configuration is an established method for the treatment of refractory cardiogenic shock. Such a condition characterizes the postoperative course of approximatively 1% of cardiac surgery patients. Although some studies have reported ECMO-related short-term results, little is known about the long-term outcomes of VA-ECMO therapy in the post-cardiotomy setting. Therefore, an extensive literature search was conducted regarding articles published after 1990 reporting postoperative ECMO use. PubMed, EMBASE and Web of Science were searched for sources. In-hospital mortality was high in post-cardiotomy VA-ECMO patients, ranging from 24.8% to 52%. Long-term results were poorly reported. However, based on the limited information available, hospital survivors showed a favorable outcome, with improvement in overall clinical condition, quality of life and limited hospital readmission for cardiac-related events. To conclude, in-hospital outcome in post-cardiotomy ECMO is often unfavorable, post-discharge results show satisfactory condition, with stable improvement of overall patient clinical status and low rate of hospital readmission and cardiac-related adverse events. Data reporting is, however, scarce and hence new and detailed studies are still warranted to investigate such aspects.

OC22 ECLS IN PRIMARY REFRACTORY CARDIOGENIC SHOCK: IMPACT OF SHORT-TERM EXTRACORPOREAL MECHANICAL CIRCULATORY SUPPORT ON SURVIVAL

Abstract Background/Aim: Previous studies have demonstrated dubious results of ECMO for the treatment of refractory cardiogenic shock (RCS) after 9 days of support. The use of short-term extracorporeal mechanical circulatory support (ST-MCS) has emerged in the last years. We therefore evaluate the outcome of patients that needed prolonged support and underwent ST-MCS implantation compared to conventional ECMO implantation. Methods: Between January 2009 and October 2017, 183 patients were treated with extracorporeal life support (ECLS) in our centre for primary RCS; we selected the 101 patients that exceed the 9 days of ECLS. 44 cases (44%) were treated exclusively with ECMO implantation (Group 1), while 57 cases (56%) underwent left ventricular or biventricular extracorporeal ST-MCS implantation (Group 2). Among these last patients, in 42 cases the ST-MCS was intended as upgrade of ECMO support. Results: Average duration of the support was 17 ± 9 days in the Group 1 and 13 ± 9 days in the Group 2 (p = 0.08), while mean rates support of the maximal theoretic flow were 62 ± 15% and 79 ± 20% (p &lt; 0.01), respectively. 12 patients of first group and 9 patients of second one died during ECLS support (p = 0.12); 30-days survivals were 61% and 70% (p = 0.24) and rates of hospital discharge were 43% and 61% (p = 0.04), respectively. Kaplan-Meier analysis (Fig.1) demonstrates a better survival in Group 2 rather than in Group 1 (p = 0.04) at median follow-up of 16 ± 24 months. Conclusions: ST-MCS has proved to increase the survival respect single-stage ECMO in patients with primary RCS who need prolonged ECLS and full hemodynamic support.