Creatine kinase isoenzyme MB relative index as predictor of mortality on extracorporeal membrane oxygenation support for postcardiotomy cardiogenic shock in adult patients.

OBJECTIVE: Extracorporeal membrane oxygenation (ECMO) has been used as initial, biventricular circulatory support for patients with severe postcardiotomy cardiogenic shock (PCS). Due to its aggressiveness and limited weaning quote, concerns have been raised about maintenance of ECMO support regarding duration. However, it is frequently hazardous for physicians to make an individualized decision, whether and when discontinuation of ECMO support should be considered. We tried to find measurable values during ECMO support that could predict the patient mortality on ECMO support. METHODS: During a 9-year period, 32 patients (mean age 55.4+/-11.9; ranging from 30 to 75 years) with ECMO support for postcardiotomy cardiogenic shock were included in this study. RESULTS: Eighteen patients died without weaning (group I, 56.25%), while 14 patients could be weaned off the ECMO support (group II, 43.75%). In the group II, six patients (18.75%) died later in the postoperative course and eight patients (25%) survived to be discharged from hospital. The overall survival of all 32 patients at 30 days was 31.25% (n=10). At a follow-up period of 3.88+/-1.58 years, the overall survival rate was 12.5% (n=4). Mean duration of ECMO support was 2.7+/-1.7 days. The following variables were significantly different between the two groups: blood lactate level and the level of MB isoenzyme of creatine kinase (CK-MB) 48 h after ECMO initiation (p<0.01, p=0.001) as well as the CK-MB relative index as the ratio of CK-MB to total CK (p<0.001). Logistic regression identified that only the CK-MB relative index 48 h after ECMO initiation was associated with mortality on ECMO support (p=0.011, odds ratio=1.219, 95% confidence interval: 1.046-1.421). CONCLUSION: For adult non-transplantation patients with postcardiotomy cardiogenic shock, the CK-MB relative index 48 h after ECMO initiation can be a predictor of mortality on ECMO support. This might be a useful tool for considering a patient either for discontinuation of ECMO support or further treatment.     

Extracorporeal membrane oxygenation for infant postcardiotomy support: significance of shunt management

BACKGROUND: After repair of complex congenital heart defects in infants and children, postcardiotomy cardiac failure requiring temporary circulatory support can occur. This is usually accomplished with the use of extracorporeal membrane oxygenation (ECMO). ECMO management of patients with single-ventricle physiology and aorto-pulmonary shunts can be particularly challenging. We retrospectively reviewed our experience with postcardiotomy support with particular attention to those children with single-ventricle palliation. METHODS: Thirty-five consecutive children (age 1 to 820 days, median 19 days) out of 1,020 patients (3.4%) required mechanical support (ECMO) after repair of congenital cardiac lesions from February 1994 to April 1999. Twenty-five patients underwent two ventricle repairs and 10 patients had single-ventricle palliation. Various parameters analyzed included strategies of shunt management, presence of presupport cardiac arrest, and timing of support initiation. RESULTS: Overall hospital survival for these 35 patients was 61%. There were four additional late deaths. Hospital survival was the same for those patients in whom support was initiated for failure to wean from cardiopulmonary bypass in the operating room versus those patients in whom support was initiated after successful separation from cardiopulmonary bypass (6 of 10 vs 15 of 25 or 60% survival). In those patients with shunt-dependent pulmonary circulation, survival was significantly improved in those patients in which the aorto-pulmonary shunt was left open (4 of 5 with open shunt vs 0 of 4 with occluded shunt (p = 0.048). CONCLUSIONS: The ability to readily implement postcardiotomy support is vital to the management of children with complex congenital cardiac disease. Overall survival can be quite satisfactory if support is employed in a rational and expedient manner. In patients with single-ventricle physiology and aorto-pulmonary shunts, leaving the shunt open during the period of support can result in markedly improved outcomes.     

When to discontinue extracorporeal membrane oxygenation for postcardiotomy support

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has demonstrated limited success in adult postcardiotomy shock. The goal of this study was to determine when to discontinue ECMO for postcardiotomy support. METHODS: During a 7-year period ECMO was used in 51 postcardiotomy patients, of whom 16 (31%) weaned and 8 (16%) survived. RESULTS: Patients in the heart transplant group were more likely to wean compared with patients in the non-heart transplant group (p = 0.03). Patients aged greater than 65 years (p = 0.04) or with ejection fractions of less than 30% after 48 hours of ECMO (p < 0.001) were less likely to wean. Time on ECMO was significantly longer for survivors in the heart transplant group (101.3 +/- 7.5 hours) compared with survivors in the non-heart transplant group (28.3 +/- 11.9 hours, p < 0.001). CONCLUSIONS: After 48 to 72 hours, consideration should be given to discontinuing ECMO, either by moving to an implantable ventricular assist device or by withdrawal of support, except in those patients with heart transplants. In the latter, both severe postoperative pulmonary hypertension and reperfusion injury may take as long as 120 hours to reverse.     

Extracorporeal membrane oxygenation support for adult postcardiotomy cardiogenic shock

BACKGROUND: Postcardiotomy cardiogenic shock occasionally develops in patients who have undergone cardiac procedures. We report our experience using extracorporeal membrane oxygenation (ECMO) in adult patients with postcardiotomy cardiogenic shock, and analyze the factors that affected outcomes for these ECMO patients. METHODS: We retrospectively reviewed the medical records of ECMO patients. RESULTS: From August 1994 to May 2000, 76 adult patients (48 men, 28 women; mean age, 56.8+/-15.9 years) received ECMO support for postcardiotomy cardiogenic shock at the National Taiwan University Hospital. The mean ECMO blood flow was 2.53+/-0.84 L/min. The cardiac operations included coronary artery bypass grafting (n = 37), coronary artery bypass grafting and valvular operation (n = 6), valvular operation alone (n = 14), heart transplantation (n = 12), correction of congenital heart defects (n = 3), implantation of a left ventricular assist device (n = 2), and aortic operations (n = 2). Fifty-four patients received ECMO support after intraaortic balloon pumping, but 22 patients directly received ECMO support. Two patients were bridged to heart transplantation and two bridged to ventricular assist devices. Thirty patients died on ECMO support. The causes of mortality included brain death (n = 3), refractory arrhythmia (n = 2), near motionless heart (n = 2), acute graft rejection (n = 1), primary graft failure (n = 1), uncontrolled bleeding (n = 5), and multiple organ failure (n = 16). Twenty-two patients were weaned off ECMO support but presented intrahospital mortality. The cause of mortality included brain death (n = 1), sudden death (n = 4), and multiple organ failure (n = 17). Twenty patients were weaned off ECMO support and survived to hospital discharge. During the follow-up of 33+/-22 months, all were in New York Heart Association functional status I or II except two cases of late deaths. Among the ECMO-weaned patients, "dialysis for acute renal failure" was a significant factor in reducing the chance of survival. CONCLUSIONS: The ECMO provided a satisfactory partial cardiopulmonary support to patients with postcardiotomy cardiogenic shock, and allowed time for clinicians to assess the patients and make appropriate decisions.     

Long-term outcomes of patients undergoing extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock

Purpose

Postcardiotomy cardiogenic shock is still associated with a poor prognosis. We reviewed patients undergoing extracorporeal membrane oxygenation (ECMO) support for postcardiotomy cardiogenic shock and assessed their long-term outcomes.

Methods

The subjects were 47 patients who received ECMO support for cardiogenic shock after open heart surgery. We analyzed the long-term survival and risk factors for early or late death.

Results

Twenty-nine patients were weaned off ECMO support, but 15 of these patients died during their hospital stay. An independent predictor of mortality during ECMO support was incomplete sternum closure (OR 4.089, 95 % CL 1.003–16.67, p = 0.049) and a predictor of mortality after weaning off ECMO was more than 48 h of support (OR 8.975, 95 % CL 1.281–62.896, p = 0.027). Fourteen patients were discharged from hospital, but seven of these patients died during the follow-up period owing to cardiac events (n = 2) or non-cardiac causes (n = 5). The actuarial survival rates were 34.0 % at 30 days, 29.8 % at 1 year, and 17.6 % at 10 years.

Conclusion

Although postcardiotomy cardiogenic shock requiring ECMO support is associated with high morbidity and mortality, the long-term survival rate is acceptable.     

Extracorporeal membrane oxygenation for adult cardiac support: the Allegheny experience.

BACKGROUND: A mix of cardiac assist options is necessary to meet the diverse indications for cardiac support in a comprehensive heart failure program. At our institution, an adult extracorporeal membrane oxygenation (ECMO) system comprising a centrifugal pump and hollow fiber membrane oxygenator is used for short-term and temporary cardiac assist. METHODS: Between December 1991 and August 1997, 82 adult cardiac patients were supported on ECMO. Indications for cardiac assist included postcardiotomy cardiogenic shock (PCCS, 55 patients), high-risk cardiology intervention (27 patients), perioperative cardiac graft failure (4 patients), and emergency cardiac resuscitation (6 patients). Data for analysis were collected by prospective completion of standardized ECMO report forms and retrospective review of hospital charts. RESULTS: The ECMO system was inexpensive to operate, uncomplicated to implant, and adaptable for diverse indications. Survival in PCCS was 20 of 55 patients (36%), with an increased survival rate of 56% (18 of 32 patients) in patients with PCCS after isolated coronary bypass. Catheter-based revascularizations were successfully performed in 26 of 27 (96%) high-acuity patients temporarily supported by ECMO, and 23 of 27 patients (85%) survived to discharge. Survival in the cardiac graft failure group was 2 of 4 (50%). No patient supported on ECMO for cardiac resuscitation survived. CONCLUSIONS: ECMO provides good cardiopulmonary and end-organ support; survival rates are similar to or higher than those seen with centrifugal pump support in comparable patient populations.     

Pediatric cardiac extracorporeal membrane oxygenation in congenital heart disease: the cardiologist's view

Abstract: There is no doubt that extracorporeal membrane oxygenation (ECMO) as a powerful therapeutic modality in critically ill newborn infants and older children with congenital heart disease has implications for the pediatric cardiologist. His responsibilities as consultant in the intensive care unit include screening for unsuspected cyanotic heart disease in neonatal candidates referred for ECMO and appraisal of surgical repair in postcardiotomy patients as well as assessment of postoperative hemodynamics and detection of complications during perfusion. A close cooperation between intensive care specialists and other appropriate specialists (pediatric cardiologists, cardiac surgeons, and anesthesiologists) is required for the process of decision making prior to initiation of postoperative ECMO in the individual patient with congenital heart disease. Long-term survival, morbidity, cerebrovascular complications, and neurodevelopmental sequelae of these near miss children remain a critical issue. Furthermore, there is a strong need for professional psychosocial support of affected parents, both in the hospital and after discharge.     

Mechanical bridge with extracorporeal membrane oxygenation and ventricular assist device to heart transplantation

The aim of this study was to evaluate the effect of double bridges with extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VADs) in clinical heart transplantation. Between May 1994 and October 2000, 134 patients underwent heart transplantation at the National Taiwan University Hospital. Ten patients received ECMO or VAD support as bridges to transplantation. The ages ranged from 3 to 63 years. The indications included cardiac arrest under cardiopulmonary resuscitation in 2 and profound cardiogenic shock refractory to conventional therapy in 8 patients. Usually ECMO was first set up as rescue therapy. If ECMO could not be weaned off after short-term (usually 1 week) support, suitable VADs (HeartMate or Thoratec VAD) were implanted for medium-term or long-term support. Five patients received ECMO support as emergency rescue for 2 to 9 days, and then moved to Thoratec VAD for 8, 49, and 55 days, respectively, or centrifugal VAD for 31 days, or HeartMate VAD for 224 days. They all survived. The survival rate of double bridges with ECMO and VAD was 100%. In postcardiotomy cardiogenic shock, circulatory collapse from acute myocardial infarction or myocarditis, ECMO is the device of choice for short-term support. If heart transplantation is indicated, VADs should replace ECMO for their superiority as a bridge to heart transplantation. Our preliminary data of double bridges with ECMO and VAD revealed good results and were reliable and effective bridges to transplantation.     

Concurrent Implantation of Intra‐Aortic Balloon Pump and Extracorporeal Membrane Oxygenation Improved Survival of Patients With Postcardiotomy Cardiogenic Shock

The aim of this study is to report the combined application of extracorporeal membrane oxygenation (ECMO) with intra‐aortic balloon pumping (IABP) in postcardiotomy cardiac shock (PCS). A total of 60 consecutive patients who received both ECMO and IABP (concomitantly 24 hours) for PCS from February 2006 to March 2017 at Fuwai Hospital were included in our study. Clinical characteristics of the patients were collected retrospectively and compared between survivors and non‐survivors. Logistic regression analysis was used as predictors for survival to discharge. The study cohort had a mean age of 51.4±12.7 years with 75% males. ECMO was implanted intra‐operatively in 38 (63%) patients and post‐operatively in 22 (37%) patients. ECMO was implanted concurrently with IABP in 38 (63%) patients. Heart transplantation (38%) and coronary artery bypass graft (33%) were the main surgical procedures. ECMO was weaned successfully in 48% patients, and the rate of survival to discharge was 43%. Survivors showed less bedside ECMO implantation (12% vs. 41%, P=0.012) and more concurrent implantation of ECMO with IABP (81% vs. 50%, P=0.014). Concurrent implantation of IABP with ECMO (OR=0.177, P=0.015, 95% CI: 0.044‐0.718) was an independent predictor of survival to discharge. As for complications, the rate of renal failure (59% vs. 15%, P=0.001) and multiple organ dysfunction syndrome (29% vs. 0, P=0.003) was higher in patients who failed to survive to discharge. Patients who had heart transplantation had a better long‐term survival than others (P=0.0358). In summary, concurrent implantation of ECMO with IABP provides better short‐term outcome for PCS and combined application of ECMO with IABP for PCS after heart transplantation had a favorable long‐term outcome.     

Extracorporeal membrane oxygenation for the treatment of postcardiotomy shock

Use of extracorporeal membrane oxygenation (ECMO), one of an increasing variety of mechanical circulatory support strategies, was first used close to 50 years ago. For decades, it was mostly applied to the pediatric population. However, during the past several years, its use has dramatically increased as therapy for pulmonary and cardiac failure in the adult. In particular, ECMO is being used more and more for postcardiotomy shock. Unfortunately, despite its increased application in this setting, improved outcomes have been hard to come by. Improved results must be grounded on an approach that honors the tenets of myocardial recovery, minimizing the work done by the heart during the recovery period. Left ventricular decompression should be a tenet of ECMO support in the setting of postcardiotomy shock, universally applied if we are to see any significant improvement in our results. Furthermore, the point is made that surgeons should play a leadership role in the immediate counseling of patients' families to assure realistic expectations on their part. To address the need for family support during this very difficult time, ECMO centers should design a programmatic approach to care for patients and their families so as to provide them with education, guidance, and emotional support.     

How an undiscovered extensive peripheral pulmonary venous thrombosis destroyed a heart transplant: a case report

This report details a recent experience with a 56-year-old man affected by an incompetent mitral valve due to Barlow's disease. The patient underwent a mitral valve repair and extracorporeal membrane oxygenator (ECMO) assistance due to postcardiotomy cardiogenic shock. During the ECMO assistance he experienced a left atrial thrombosis. A few days later, being unaware of the pulmonary vein thrombosis, we transplanted the patient, who ultimately died due to multiorgan failure and coagulopathy. This article highlights both the vain experience with ECMO and the uselessness of heart transplant, to avoid in the future an irresponsible waste of donor organs, as occurred in the current case.     

Outcomes and factors associated with early mortality in pediatric postcardiotomy veno‐arterial extracorporeal membrane oxygenation

Mortality and morbidity of children received veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) support after cardiac surgery remain high despite remarkable advances in medical management and devices. The purpose of this study was to describe outcomes and risk factors of applying VA‐ECMO in the surgical pediatric population. We retrospectively analyzed 85 consecutive pediatric patients (aged <18 years) who received postcardiotomy VA‐ECMO from January 2010 to December 2018. Median (IQR) age at ECMO implantation in this cohort was 12.7 (6.4, 43.2) months, median weight was 8.5 (6.0, 12.8) kg, mean ECMO duration was 143.2 ± 81.6 hours and mean hospital length of stay was 48.4 ± 32.4 days. Seventy‐five patients (88.2%) were indicated for postcardiotomy cardiogenic shock. The successful ECMO weaning rate was 70.6% and in‐hospital mortality was 52.9%. The most common diagnosis was transposition of great arteries (n = 18, 21.2%), while acute kidney injury occurred most often (n = 64, 75.3%). Multivariate logistic regression analysis showed that thrombocytopenia, hemolysis, and nosocomial infection were positively correlated with in‐hospital mortality. Multivariate Cox proportional hazard regression analysis presented that thrombocytopenia significantly increased the 180‐day mortality in patients with successful weaning. Therefore, multiple factors had adverse effects on prognosis. Patient selection and procedures from ECMO implantation to weaning need to be closely monitored and performed in a timely manner to improve outcome.     

Rescue extracorporeal membrane oxygenation in children with refractory cardiac arrest

We describe our experience with extracorporeal cardiopulmonary resuscitation (CPR) using extracorporeal membrane oxygenation (ECMO) in children with refractory cardiac arrest, and determine predictors for mortality. ECMO support was instituted on 42 children, median age 0.7 years (1 day-17.8 years), median weight 7.05 (range 2.7-80) kg who suffered refractory cardiac arrest (1992-2008). Patients were postcardiotomy (n=27), or had uncorrected congenital heart diseases (n=3), cardiomyopathy (n=3), myocarditis (n=2), respiratory failure (n=3), or had trauma (n=4). Cannulation site was the chest in all except for three neonates who were cannulated through the neck vessels and two children who had femoral cannulation. ECMO was successfully discontinued in 17 patients. Primary cause of mortality was neurological injury. Pre-ECMO CPR duration for survivors against those who died was a mean of 35±1.3 min vs. a mean of 46±4.2 min. Age, weight, sex, anatomic diagnosis, etiology (surgical vs. medical) were not significant predictors of poor outcome. Prolonged CPR and high-dose inotropes are significant predictors of mortality. Rescue ECMO support in children with refractory cardiac arrest can achieve acceptable survival and neurological outcomes.     

Heparin-coated adult ECMO vs. ventricular assist devices: a decision analysis modeling approach

Postcardiotomy failure requiring ventricular assist occurs in about 1% of adult patients undergoing cardiac surgical procedures. One method of support is a short-term ventricular assist device. This incurs the cost of the device, which is substantial, and allows for reduced anticoagulation in the first 24 hours. Another option is a heparin-coated extracorporeal membrane oxygenation (ECMO) circuit. This also allows for reduced anticoagulation and can support the lungs if necessary. The use of a heparin-coated ECMO circuit requires 24-hour monitoring, but the cost of disposables is considerably less than the cost of ventricular assist devices. This decision analysis uses a Markov model to evaluate the relative outcomes and costs associated with selection between these modalities of support. Data from the past 5 years of patients who received postcardiotomy support will be used to develop the Markov model. The hypothesis is that supporting the patient on heparin-coated ECMO before instituting ventricular assistance will reduce cost and allocate resources in a more cost-effective manner. The model was used to determine the optimal economic time for initiation of ventricular assist devices in postcardiotomy patients. The total costs associated with support begin to level out between postoperative days 6 and 10 using an Abiomed BVS5000 ventricular assist device. The largest decline in costs occurs after postoperative day 3. This model suggests that patients should be supported on heparin-coated ECMO for 2-3 days to evaluate their potential for recovery before instituting more expensive ventricular assist devices.     

Extracorporeal Membrane Oxygenation Support for Postcardiotomy Cardiogenic Shock

Abstract: Extracorporeal membrane oxygenation (ECMO) has had promising results in life-threatening respiratory failure and postcardiotomy cardiogenic failure. From October 1994 to October 1995, 18 patients received 19 ECMOs at National Taiwan University Hospital for severe cardiogenic shock after cardiac surgery. They included patients receiving cardiac massage or repeated bolus injections of norepinephrine to maintain blood pressure (n = 10), patients who could not be weaned off cardiopulmonary bypass after several attempts despite in-traaortic balloon pumping and maximal doses of catecholamine (n = 7), and patients with progressive intractable cardiogenic shock after cardiac surgery. Venoarterial ECMO was set up via femoral artery (17 or 19 Fr cannula) and vein (19 or 21 Fr) in all patients except 2 infants. No left heart drainage was performed in any of the patients. The heparin-coated circuit (with Carmeda Bio-active Surface) was used in the last 13 patients to reduce bleeding. Ten (52.6%) of the 19 cases could be smoothly weaned off ECMO, and 6 (33.3%) of the 18 patients were discharged from the hospital in good condition. Four (80%) of the 5 patients after valvular surgery and all 3 heart transplant patients could be weaned off ECMO successfully with the survival rate being 60% and 67%, respectively. Complications included leg ischemia (n = 3), bleeding (n = 4), renal failure (n = 3), and tube rupture (n = 1). The inability to wean off ECMO was caused by multiple organ failure (n = 5), sepsis (n = 2), tube rupture (n = 1), and dysfunction of the ECMO system (n = 1). The major cause of multiple organ failure was hesitation to set up ECMO. Our preliminary results confirmed the effect of ECMO in postoperative cardiogenic shock.     

Documento de consenso SEDAR/SECCE sobre el manejo de ECMO

ECMO is an extracorporeal cardiorespiratory support system whose use has been increased in the last decade. Respiratory failure, postcardiotomy shock, and lung or heart primary graft failure may require the use of cardiorespiratory mechanical assistance. In this scenario perioperative medical and surgical management is crucial.Despite the evolution of technology in the area of extracorporeal support, morbidity and mortality of these patients continues to be high, and therefore the indication as well as the ECMO removal should be established within a multidisciplinary team with expertise in the area.This consensus document aims to unify medical knowledge and provides recommendations based on both the recent bibliography and the main national ECMO implantation centers experience with the goal of improving comprehensive patient care.     

Have Changes in ECMO Technology Impacted Outcomes in Adult Patients Developing Postcardiotomy Cardiogenic Shock?

Extracorporeal membrane oxygenation (ECMO) technology has undergone several advancements over the last decade. We sought to compare current ECMO technology to older ones to determine how these technological improvements have impacted outcomes in patients suffering from postcardiotomy cardiogenic shock (PCS). Between 2005 and 2010, 49 patients received ECMO as support for PCS following elective cardiac surgery. Patients were divided into three groups. Group 1 (Gp 1, n = 11) patients received a Biomedicus pump with an Affinity oxygenator, Group 2 (Gp 2, n = 11) patients received a Biomedicus pump with a Quadrox D oxygenator, and Group 3 (Gp 3, n = 27) patients received a Rotaflow pump with a Quadrox D oxygenator. Groups were compared with regards to adverse events and ability to wean. Adverse event analysis showed no statistically significant difference between groups in incidence of stroke (p = 0.08), renal failure (p = 0.88), or bleeding requiring reexploration (p = 0.10). Changes in technology did little to improve weaning rates from ECMO (Gp 1 = 63.6%, Gp 2 = 45.5%, and Gp 3 = 55.6%). Similar trends were detected in hospital survival (Gp 1 = 27.3%, Gp 2 = 27.3%, and Gp 3 = 33.3%). Technology did impact oxygenator durability with Gp 1 requiring seven (63.6%) oxygenator exchanges compared to zero (0.0%) in Gp 2 and two (7.4%) in Gp 1. While advancements in ECMO technology have resulted in improved oxygenator durability, outcomes in patients requiring such support for PCS continue to be poor.     

心脏外科手术后体外膜肺治疗50例

目的 总结50例成人心脏外科术后体外膜肺治疗的临床经验,并尝试确定院内死亡的预测因子.方法 2004年至2008年,50例心脏外科术后病人接受体外膜肺治疗.记录病人基本资料,体外膜肺建立时的临床特征,并发症及院内死亡比例,以逻辑回归计算院内死亡的预测因子.结果 38例病人脱机,33例出院,生存比例66%.经逻辑回归计算,体外膜肺建立前的乳酸水平为院内死亡的预测因子.结论 体外膜肺可治疗心脏手术后顽固性心源性休克及呼吸功能异常.

Abstract：

Objective Extracorporeal membrane oxygenation is a cardiopulmonary supportive therapy. Since 2004, our institution has adopted venoarterial ECMO for adult patients who otherwise could not be weaned from cardiopulmonary bypass and patients experiencing postcardiotomy cardiogenic shock and/or pulmonary dysfunction unresponsive to conventional treatment algorithms. In this study, we reviewed our experience with ECMO support and tried to identify measurable values which might predict in-hospital mortality. Methods From January 2004 through December 2008, 50 of 21,298 adult patients received VA ECMO. We retrospectively analyzed clinical records of these 50 consecutive patients. Demographics, preoperative measurements, clinical characteristics at the time of ECMO implantation, ECMO related complications and in-hospital mortality were collected. Logistic regression analyses were performed to investigate predictors of mortality. A p value ≤0. 05 was accepted as significant. Results Mean ECMO duration was ( 110 ± 17 ) hours. 38 patients were weaned from ECMO and 33 patients survived upon discharge. The overall survival was 66%. In univariate analyses, duration of ECMO support, receiving cardiopulmonary resuscitation prior to ECMO setup, ECMO setup in ICU, pre-ECMO plasma lactate level, infection, lower limbs ischemia, renal failure, experiencing at least one ECMO related complications were all associated with in-hospital death. In a multiple logistic regression adjusted for other factors mentioned above, blood lactate level before initiation of ECMO was a risk factor associated with in-hospital mortality (OR 1. 27 95% CI 1. 042-1. 542 ). To evaluate the utility of pre-ECMO lactate in predicting mortality, a conventional receiver operating characteristic curve was produced. Sensitivity and specificity were optimal at a cut-off point of 12.6 mmol/L, with an AUC of 0. 752. The positive and negative predictive values were 73.3% and 83.9% respectively. Conclusion ECMO is a justifiable alternative treatment for postoperative refractory cardiac and pulmonary dysfunction which could rescue more than 60 percent of otherwise fatal patients. Patients with pre-ECMO lactate above 12.6mmol/L are at higher risks for in-hospital death. Evidence based therapy for this group of high risk patients is needed.     

Utility of extracorporeal membrane oxygenation for early graft failure following heart transplantation in infancy.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is widely used for postcardiotomy cardiogenic shock in children. However, the efficacy of ECMO for early post-heart transplant graft failure in infants has not been reported. Our aims were to determine: (1) the utility of ECMO in infants with severe donor-heart dysfunction, (2) predictors for requiring ECMO, and (3) the long-term outcome of surviving ECMO patients. METHODS: All infants (age < 6 months at listing) undergoing heart transplantation were reviewed. Diagnostic categories were hypoplastic left heart syndrome (HLHS) and non-HLHS (complex congenital heart disease and cardiomyopathies). Continuous and categorical comparisons were by Wilcoxon's rank sum test and Fisher's exact test respectively. RESULTS: 14 (12 HLHS, 2 non-HLHS) of 63 (46 HLHS, 17 non-HLHS) infants were placed on ECMO. Ten patients (71%) were successfully weaned from ECMO and 8 (57%) were discharged alive. All ECMO hospital survivors remain alive (mean follow-up 36.2 +/- 21.4 months, range 13.1-77.6 months). Mean duration of ECMO support was 68 hours in weaned patients vs 144 hours (p = 0.19) in nonweaned patients, and 64 hours in survivors vs 123 hours (p = 0.35) in nonsurvivors. ECMO deaths were due to sepsis (n = 3), intractable pulmonary hypertension (n = 2), and intracranial bleed (n = 1). Neurologic deficits occurred in 2 survivors. Median ICU and hospital stays for ECMO survivors were 29 and 33 days vs 7 (p = 0.0003) and 9 (p = 0.0004) days for non-ECMO patients. Age listed, age transplanted, wait time, body weight, donor/recipient weight ratio, total ischemia time, and diagnosis did not predict the need for ECMO. CONCLUSIONS: (1) ECMO is useful for post-heart transplant circulatory support in infants with early graft failure. (2) All survivors were weaned in fewer than 4 days. (3) Three-year survival of ECMO hospital survivors has been high, but neurologic complications are prevalent.     

Variables associated with in-hospital and postdischarge outcomes after postcardiotomy extracorporeal membrane oxygenation: Netherlands Heart Registration Cohort

ObjectivesExtracorporeal membrane oxygenation (ECMO) for postcardiotomy cardiogenic shock has been increasingly used without concomitant mortality reduction. This study aims to investigate determinants of in-hospital and postdischarge mortality in patients requiring postcardiotomy ECMO in the Netherlands.MethodsThe Netherlands Heart Registration collects nationwide prospective data from cardiac surgery units. Adults receiving intraoperative or postoperative ECMO included in the register from January 2013 to December 2019 were studied. Survival status was established through the national Personal Records Database. Multivariable logistic regression analyses were used to investigate determinants of in-hospital (3 models) and 12-month postdischarge mortality (4 models). Each model was developed to target specific time points during a patient's clinical course.ResultsOverall, 406 patients (67.2% men, median age, 66.0 years [interquartile range, 55.0-72.0 years]) were included. In-hospital mortality was 51.7%, with death occurring in a median of 5 days (interquartile range, 2-14 days) after surgery. Hospital survivors (n = 196) experienced considerable rates of pulmonary infections, respiratory failure, arrhythmias, and deep sternal wound infections during a hospitalization of median 29 days (interquartile range, 17-51 days). Older age (odds ratio [OR], 1.02; 95% CI, 1.0-1.04) and preoperative higher body mass index (OR, 1.08; 95% CI, 1.02-1.14) were associated with in-hospital death. Within 12 months after discharge, 35.1% of hospital survivors (n = 63) died. Postoperative renal failure (OR, 2.3; 95% CI, 1.6-4.9), respiratory failure (OR, 3.6; 95% CI, 1.3-9.9), and re-thoracotomy (OR, 2.9; 95% CI, 1.3-6.5) were associated with 12-month postdischarge mortality.ConclusionsIn-hospital and postdischarge mortality after postcardiotomy ECMO in adults remains high in the Netherlands. ECMO support in patients with higher age and body mass index, which drive associations with higher in-hospital mortality, should be carefully considered. Further observations suggest that prevention of re-thoracotomies, renal failure, and respiratory failure are targets that may improve postdischarge outcomes.