Venoarterial Extracorporeal Membrane Oxygenation For Refractory Cardiogenic Shock Research Articles

Outcomes comparison between percutaneous decannulation with perclose ProGlide and surgical decannulation of veno-arterial extracorporeal membrane oxygenation.

Our study aimed to compare the decannulation-related outcomes of two different decannulation methods in patients who underwent veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support, namely percutaneous decannulation with Perclose ProGlide device and conventional surgical repair. Surgical vascular repair is a standard strategy when ECMO is to be terminated and sometimes associated with severe complications. Percutaneous decannulation using Perclose ProGlide has been reported to be feasible and safe in selected patients, but there is a paucity of literature to make systematic comparisons between the two decannulation methods. 41 patients who were supported with VA-ECMO for refractory cardiogenic shock, cardiac arrest, or escort of complex interventions from December 2018 to December 2021 were enrolled. Of these, 30 underwent percutaneous Perclose ProGlide decannulation and 11 underwent surgical repair. The clinical characteristics and complication rates were analyzed. Patients in the two groups showed a similar incidence of vascular-related complications, such as acute lower limb ischemia, major bleeding, severe hematoma, pseudoaneurysm, and arteriovenous fistula [20% versus 18.2%, p=.896]. The incidence of groin infection and delayed healing was significantly higher in the surgical removal group [3.3% versus 36.4%, p=.014]. Percutaneous decannulation of veno-arterial extracorporeal membrane oxygenation with the Perclose ProGlide device is a feasible and safe technique that simplifies the decannulation process, shortens the hospitalization duration, and lowers the potential risk of groin infection and delayed wound healing.

Abstract 9439: Invasive Evaluation of Left Ventricular Hemodynamics with Veno-Arterial Extracorporeal Membrane Oxygenation

Introduction: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a frequently used hemodynamic support strategy, but considerable debate exists about its hemodynamic effects. We evaluated changes in left ventricular (LV) function, volumes, and work in patients treated with VA-ECMO using invasive LV catheterization and three-dimensional echocardiographic volumes. Methods: In this case series, patients underwent evaluation due to persistent vasoplegia or poor LV function despite treatment with VA-ECMO. Hemodynamic parameters were reported as medians with interquartile ranges. Paired comparisons were done to evaluate hemodynamics at the baseline (highest) and lowest tolerated levels of VA-ECMO support. Results: Six patients aged 53.5 (41.8, 57.8) years were included. Three patients received VA-ECMO for refractory cardiogenic shock and three patients for extracorporeal cardiopulmonary resuscitation. The baseline LV ejection fraction was 22.1% (19.0%, 24.7%). The baseline and lowest VA-ECMO flows were 4.0 (4.0, 4.0) L/min and 1.0 (1.0, 1.5) L/min, respectively. Compared to the lowest flow, full VA-ECMO support reduced LV end-diastolic volume [116 (90, 153) versus 94 (58, 119) mL, p=0.03], LV end-diastolic pressure [16 (12, 24) versus 14 (9,15) mmHg, p=0.03], LV stroke work [2640 (1800, 4275) versus 1953 (759, 2179) mL*mmHg, p=0.03], and pressure-volume area [6864 (4038, 7715) versus 4575 (3142, 5888) mL*mmHg; p=0.046], respectively. The pressure-volume curves at the highest and lowest VA-ECMO flows are represented in blue and red, respectively ( Figure ). Mean arterial pressure and heart rate were similar at the lowest and highest flows (p=0.17 and p=0.60, respectively). All patients were decannulated from VA-ECMO. Four survived the index hospitalization. Conclusion: High flow VA-ECMO support significantly reduced LV end-diastolic volume, end-diastolic pressure, stroke work, and pressure-volume area compared to low flow.

Association Between Body Mass Index and Outcomes in Venoarterial Extracorporeal Membrane Oxygenation

The association between obesity, or elevated body mass index (BMI), and outcomes in patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) has not been well established. Recent studies in patients receiving venovenous ECMO did not detect an association between obesity and increased mortality. The purpose of this retrospective observational study is to evaluate the association between BMI and survival in patients receiving VA-ECMO for cardiogenic shock. All patients >18 years of age supported on VA-ECMO for refractory cardiogenic shock in a single academic center between 2009 and 2019 were included. ECMO outcomes, including successful ECMO decannulation and 30-day survival, were analyzed after stratification according to BMI. Multivariable and univariate logistic regression were used to assess the association between BMI and VA-ECMO outcomes. Of the total patients (n = 355) cannulated for VA-ECMO, 61.7% of the patients survived to ECMO recovery/decannulation, 45.5% of the patients survived to 30 days after ECMO decannulation, and 38.9% of the patients survived to hospital discharge with no statistically significant differences among the BMI groups. Multivariable logistic regression did not reveal any associations between obesity as defined by BMI and survival to ECMO decannulation (odds ratio [OR] 1.07 per 5 unit increase in BMI, 95% confidence interval [CI], 0.86-1.33; P = .57), 30-day survival (OR = 0.91, 95% CI, 0.73-1.14; P = .41) or survival to hospital discharge (OR = 0.95, 95% CI, 0.75-1.20; P = .66). Despite potential challenges to cannulation and maintaining adequate flow during ECMO, this single centered, retrospective observational study did not detect association between BMI and survival to ECMO decannulation, 30-day survival, or survival to hospital discharge for patients requiring VA-ECMO for refractory cardiogenic shock. These data suggest that obesity alone should not exclude candidacy for VA-ECMO.The primary outcome in this retrospective study was survival of the ECMO therapy (survival to ECMO decannulation), defined as surviving >24 hours after decannulation without a withdrawal of care. Secondary outcomes included survival at 30 days and survival to hospital discharge.

Evaluation of Anti-Activated Factor X Activity and Activated Partial Thromboplastin Time Relations and Their Association with Bleeding and Thrombosis during Veno-Arterial ECMO Support: A Retrospective Study.

Background: We aimed to investigate the relationship between anti-activated Factor X (anti-FXa) and activated Partial Thromboplastin Time (aPTT), and its modulation by other haemostasis co-variables during veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. We further investigated their association with serious bleeding and thrombotic complications. Methods: This retrospective single-center study included 265 adults supported by VA-ECMO for refractory cardiogenic shock from January 2015 to June 2019. The concordance of anti-FXa and aPTT and their correlations were assessed in 1699 paired samples. Their independent associations with serious bleeding or thrombotic complications were also analysed in multivariate analysis. Results: The concordance rate of aPTT with anti-FXa values was 50.7%, with 39.3% subtherapeutic aPTT values. However, anti-FXa and aPTT remained associated (β = 0.43 (95% CI 0.4–0.45) 10−2 IU/mL, p < 0.001), with a significant modulation by several biological co-variables. There was no association between anti-FXa nor aPTT values with serious bleeding or with thrombotic complications. Conclusion: During VA-ECMO, although anti-FXa and aPTT were significantly associated, their values were highly discordant with marked sub-therapeutic aPTT values. These results should favour the use of anti-FXa. The effect of biological co-variables and the failure of anti-FXa and aPTT to predict bleeding and thrombotic complications underline the complexity of VA-ECMO-related coagulopathy.

Acute vascular complications of femoral venoarterial ECMO; a single center retrospective study

Abstract Funding Acknowledgements Type of funding sources: None. Backgroud Emergent veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used to provide rapid cardiopulmonary resuscitation in adult patients with refractory cardiogenic shock . Femoral arterial cannulation may result in ipsilateral limb ischemia due to reduced distal blood flow below the insertion point of the cannula .We retrospectively studied adult patients supported with femoral VA-ECMO for cardiogenic shock between 2015 and 2019 at our tertiary care hospital. Results : the study included 65 adult patients supported on femoral VA-ECMO for refractory cardiogenic shock . The studied patients had a mean age of 37.9 ± 14.87 years , mostly males (70.8%) , a mean BSA of 1.77 ±0.27 m2 and a mean BMI of 26.1 ± 6.7 kg/m2 . Twenty one (32.3%) patients developed acute lower limb ischemia. Femoral thrombectomy and angioplasty were done in 20 (30.8% ) patients . Four (6.2%) patients developed limb compartmental syndrome and fasciotomy was done . Amputation of toes was done in one patient . The vascular complications included cannulation site bleeding in 24.6% of patients , femoral arteriovenous fistula in one patient and large pseudoaneurysm after ECMO decannulation and required vascular surgical repair . Three (4.6%) patients developed chronic limb ischemia manifestations after hospital discharge . The patients who developed acute limb ischemia had significantly frequent AKI (&amp;lt;0.001) without significant use of haemodialysis (p = 0.07) and longer ICU stay (p = 0.028) compared to the patients without limb ischemia. The hospital mortality occurred in 29 (44.6%) patients without significant difference between the patients with and without acute limb ischemia. The occurrence of acute limb ischemia was significantly correlated with failed percutaneous femoral cannulation (p = 0.039 ) while there was no significant statistical correlation between the cut-down technique and occurrence of limb ischemia(p = 0.053). The occurrence of femoral cannulation site bleeding was significantly correlated with failed percutaneous cannulation (p = 0.001 ) and cut-down technique (p = 0.001) . Conclusion : Acute vascular complications are frequent after femoral VA-ECMO. Failed percutaneous femoral cannulation has been, in this study identified as the most important risk factor for acute limb ischemia and cannulation site bleeding. Recommendation: A careful approach during femoral cannulation is recommended to prevent occurrence of acute limb ischemia and femoral cannulation site bleeding. Abstract Figure. Cannulation approaches of VA-ECMO .

Outcomes following venoarterial extracorporeal membrane oxygenation in children with refractory cardiogenic disease

Retrospective analysis was performed at an affiliated university children's hospital with consecutive patients receiving a venoarterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock from July 2007 to May 2018. Fifty-six patients underwent VA-ECMO for refractory cardiogenic shock with the median age of 39.0 (1.5, 103.5)months were included. Median ECMO duration was 87h, and the median length of hospital stay was 22days. Successful ECMO weaning rate was 68%. Thirty-day mortality in this cohort was 39% (22/56), among which the mortality of fulminant myocarditis and postcardiotomy cardiogenic shock (PCS) were 23% (6/26) and 52% (12/23), respectively. Multivariate Cox proportional hazard regression analysis identified prolonged prothrombin time (PT) > 6s and elevated lactate level 24h after ECMO initiation were associated with 30-day mortality.Conclusions: Pediatric VA-ECMO for refractory cardiogenic shock appears to be a satisfactory salvage therapy to various fatal diseases in this retrospective study. Prolonged PT > 6s and elevated lactate level 24h were significant predictors of 30-day mortality. What is Known: • VA-ECMO is a salvage therapy for refractory cardiogenic shock in pediatrics. What is New: • Prothrombin time > 6s was a significant predictor of 30-day mortality. • Elevated lactate level 24h was a significant predictor of 30-day mortality.

Venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock post-cardiac arrest.

To describe the characteristics, outcomes, and risk factors associated with poor outcome of venoarterial extracorporeal membrane oxygenation (VA-ECMO)-treated patients with refractory shock post-cardiac arrest. We retrospectively analyzed data collected prospectively (March 2007-January 2015) in a 26-bed tertiary hospital intensive care unit. All patients implanted with VA-ECMO for refractory cardiogenic shock after successful resuscitation from cardiac arrest were included. Refractory cardiac arrest patients, given VA-ECMO under cardiopulmonary resuscitation, were excluded. Ninety-four patients received VA-ECMO for refractory shock post-cardiac arrest. Their hospital and 12-month survival rates were 28 and 27%, respectively. All 1-year survivors were cerebral performance category 1. Multivariable analysis retained INR>2.4 (OR 4.9; 95% CI 1.4-17.2), admission SOFA score>14 (OR 5.3; 95% CI 1.7-16.5), and shockable rhythm (OR 0.3; 95% CI 0.1-0.9) as independent predictors of hospital mortality, but not SAPS II, out-of-hospital cardiac arrest score, or other cardiac arrest variables. Only 10% of patients with an admission SOFA score>14 survived, whereas 50% of those with scores≤14 were alive at 1year. Restricting the analysis to the 67 patients with out-of-hospital cardiac arrest of coronary cause yielded similar results. Among 94 patients implanted with VA-ECMO for refractory cardiogenic shock post-cardiac arrest resuscitation, the 24 (27%) 1-year survivors had good neurological outcomes, but survival was significantly better for patients with admission SOFA scores<14, shockable rhythm, and INR≤2.4. VA-ECMO might be considered a rescue therapy for patients with refractory cardiogenic shock post-cardiac arrest resuscitation.

Percutaneous Venoarterial Extracorporeal Membrane Oxygenation for Refractory Cardiogenic Shock Is Associated with Improved Short- and Long-Term Survival.

Mortality due to refractory cardiogenic shock (RCS) exceeds 50%. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has become an accepted therapy for RCS. The aim of our study was to evaluate outcomes of patients with RCS treated with percutaneous VA-ECMO (pVA-ECMO). Retrospective review of patients supported with VA-ECMO at our institution in 2012-2013. Clinical characteristics, bleeding, vascular complications, and outcomes including survival were assessed. A total of 37 patients were supported with VA-ECMO for RCS. The majority of VA-ECMO (76%) was placed in the catheterization laboratory. Nearly half (49%) of the patients presented with acute myocardial infarction. Seven patients (19%) underwent insertion of pVA-ECMO in the setting of cardiopulmonary resuscitation with mechanical chest compression device. Median duration of support was 5 days. Index hospitalization, 30-day, and 1-year survival were 65%, 65%, and 57%, respectively. Survival rate for discharged patients was 87.5% with a median follow-up of 450 days. Refractory cardiogenic shock supported with pVA-ECMO is associated with an improved survival in patients with a traditionally poor prognosis.

Abstract 15668: Mechanical Circulatory Support With Veno-Arterial Extracorporeal Membrane Oxygenation for Refractory Cardiogenic Shock in Elderly Patients: Results From the Extracorporeal Life Support Organization (ELSO) Registry

Introduction: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for refractory acute cardiogenic shock is increasingly applied in adult patients. Patient age, however, represents still a controversial issue and data about VA-ECMO in elderly patients have been poorly reported in this setting. Hypothesis: The Extracorporeal Life Support Organization (ELSO) Registry was analysed to assess the in-hospital outcome of elderly patients (≥ 70 years) undergoing VA-ECMO because of acute refractory cardiogenic shock. Methods: Mean age of the total adult patient cohort (n=5,408) was 53.0±15.7 years (range 18-91 years). The elderly group included 735 patients (13.6%), with a mean age of 75.2±4.4 years, with pre-ECMO cardiac-related surgical or interventional procedures performed in 134 cases (18.9%). The mean duration of VA-ECMO in this group was 100.7± 90.9 hours (as compared to 137.7±146.1 hours, in younger group)(p&lt;0.001). Results: Overall survival to hospital discharge was 41.4% (2,657/5,408), with 30.5% (224/735) in the elderly, and 43.1% (2,016/4,673) in younger patients (p&lt;0.05), respectively. In terms of complications, older patients showed higher rates (p&lt;0.001) of bleeding, of infection, acute renal failure, renal replacement therapy, and need of inotropic drugs. Conclusions: Despite higher mortality and morbidity rates as compared to younger subjects, elderly patients undergoing VA-ECMO for refractory cardiogenic shock have still an acceptable outcome in such a challenging clinical scenario, indicating that patient age should not represent an absolute contraindication in the therapeutic decision-making.

Abstract 17229: Survival after Veno-arterial Extracorporeal Membrane Oxygenation Support is Dependent on Underlying Etiology of Cardiogenic Shock

Introduction: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an emerging therapy for refractory cardiogenic shock (CS); however, characteristics of patients most likely to benefit from this therapy remain to be determined. We hypothesized that the underlying etiology of CS and patient specific characteristics predict survival to discharge. Methods: We compared outcomes in patients supported with VA-ECMO for refractory CS resulting from (1) acute myocardial infarction (AMI; with or without revascularization); (2) acute pulmonary embolism (PE); (3) acute cardiomyopathy; (4) chronic cardiomyopathy; (5) post-cardiotomy; and (6) other etiologies of shock. Chi-square analysis was used to identify predictors of survival to discharge after VA-ECMO. Results: From 2009-2013, 102 patients were initiated on VA-ECMO for refractory CS. The average age was 52 ±15 (mean ± SD) years old with 71 (70%) males. Overall, 39 (38%) patients survived to discharge. In the cohort, 22 patients were post-cardiotomy and 5 (23%) of those survived to discharge. Of the 80 patients without prior cardiotomy, survival to discharge was 27% (8/30) after AMI, 64% (9/14) after PE, 75% (6/8) with acute cardiomyopathy, 50% (5/10) with chronic cardiomyopathy, and 39% (7/18) with other CS etiologies. Survivors were younger (45 ±13 vs 56 ±14, p = 0.0002) and none of the 24 patients over the age of 64 years old survived to discharge. There was a significant difference in survival when comparing etiologies of shock (p = 0.012 by Chi-square comparison among etiologies). There was no significant difference in survival by gender. Conclusions: Survival in patients with refractory CS requiring VA-ECMO may depend on age and underlying etiology of shock. Further research into predictors of survival after institution of VA-ECMO is warranted.